Walk-in clinics versus physician offices and emergency rooms for urgent care and chronic disease management

BACKGROUND

Walk-in clinics are growing in popularity around the world as a substitute for traditional medical care delivered in physician offices and emergency rooms, but their clinical efficacy is unclear.

OBJECTIVES

To assess the quality of care and patient satisfaction of walk-in clinics compared to that of traditional physician offices and emergency rooms for people who present with basic medical complaints for either acute or chronic issues.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, six other databases, and two trials registers on 22 March 2016 together with reference checking, citation searching, and contact with study authors to identify additional studies. We applied no restrictions on language, publication type, or publication year.

SELECTION CRITERIA

Study design: randomized trials, non-randomized trials, and controlled before-after studies.

POPULATION

standalone physical clinics not requiring advance appointments or registration, that provided basic medical care without expectation of follow-up. Comparisons: traditional primary care practices or emergency rooms.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane and the Cochrane Effective Practice and Organisation of Care (EPOC) Group.

MAIN RESULTS

The literature search identified 6587 citations, of which we considered 65 to be potentially relevant. We reviewed the abstracts of all 65 potentially relevant studies and retrieved the full texts of 12 articles thought to fit our study criteria. However, following independent author assessment of the full texts, we excluded all 12 articles.

AUTHORS' CONCLUSIONS

Controlled trial evidence about the mortality, morbidity, quality of care, and patient satisfaction of walk-in clinics is currently not available.

Use and characteristics of electronic health record systems among office-based physician practices: United States, 2001-2013

In 2013, 78% of office-based physicians used any type of electronic health record (EHR) system, up from 18% in 2001. In 2013, 48% of office-based physicians reported having a system that met the criteria for a basic system, up from 11% in 2006. The percentage of physicians with basic systems by state ranged from 21% in New Jersey to 83% in North Dakota. In 2013, 69% of office-based physicians reported that they intended to participate (i.e., they planned to apply or already had applied) in "meaningful use" incentives. About 13% of all office-based physicians reported that they both intended to participate in meaningful use incentives and had EHR systems with the capabilities to support 14 of the Stage 2 Core Set objectives for meaningful use. From 2010 (the earliest year that trend data are available) to 2013, physician adoption of EHRs able to support various Stage 2 meaningful use objectives increased significantly. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 authorized incentive payments to increase physician adoption of electronic health record (EHR) systems (1,2). The Medicare and Medicaid EHR Incentive Programs are staged in three steps, with increasing requirements for participation. To receive an EHR incentive payment, physicians must show that they are "meaningfully using" certified EHRs by meeting certain objectives (3,4). This report describes trends in the adoption of EHR systems from 2001 through 2013, as well as physicians' intent to participate in the EHR Incentive Programs and their readiness to meet 14 of the Stage 2 Core Set objectives for meaningful use in 2013.

Risk of redocumenting penicillin allergy in a cohort of patients with negative penicillin skin tests

BACKGROUND

Even though electronic documentation of allergies is critical to patient safety, inaccuracies in documentation can potentiate serious problems. Prior studies have not evaluated factors associated with redocumenting penicillin allergy in the medical record despite a proven tolerance with a penicillin skin test (PST).

OBJECTIVE

Assess the prevalence of reinstating inaccurate allergy information and associated factors thereof.

DESIGN

We conducted a retrospective observational study from August 1, 2012 to July 31, 2013 of patients who previously had a negative PST. We reviewed records from the hospital, long-term care facilities (LTCF), and primary doctors' offices.

SETTING

Vidant Health, a system of 10 hospitals in North Carolina.

SUBJECTS

Patients with proven penicillin tolerance rehospitalized within a year period from the PST.

MEASUREMENTS

We gauged hospital reappearances, penicillin allergy redocumentation, residence, antimicrobial use, and presence of dementia or altered mentation.

RESULTS

Of the 150 patients with negative PST, 55 (37%) revisited a Vidant system hospital within a 1-year period, of whom 21 were LTCF residents. Twenty (36%) of the 55 patients had penicillin allergy redocumented without apparent reason. Factors associated with penicillin allergy redocumentation included age >65 years (P = 0.011), LTCF residence (P = 0.0001), acutely altered mentation (P < 0.0001), and dementia (P < 0.0001). Penicillin allergy was still listed in all 21 (100%) of the LTCF records.

CONCLUSIONS

At our hospital system, penicillin allergies are often redocumented into the medical record despite proven tolerance. The benefits of PST may be limited by inadequately removing the allergy from different electronic/paper hospital, LTCF, primary physician, and community pharmacy records.

The costs of preventing the spread of respiratory infection in family physician offices: a threshold analysis

BACKGROUND

Influenza poses concerns about epidemic respiratory infection. Interventions designed to prevent the spread of respiratory infection within family physician (FP) offices could potentially have a significant positive influence on the health of Canadians. The main purpose of this paper is to estimate the explicit costs of such an intervention.

METHODS

A cost analysis of a respiratory infection control was conducted. The costs were estimated from the perspective of provincial government. In addition, a threshold analysis was conducted to estimate a threshold value of the intervention's effectiveness that could generate potential savings in terms of averted health-care costs by the intervention that exceed the explicit costs. The informational requirements for these implicit costs savings are high, however. Some of these elements, such as the cost of hospitalization in the event of contacting influenza, and the number of patients passing through the physicians' office, were readily available. Other pertinent points of information, such as the proportion of infected people who require hospitalization, could be imported from the existing literature. We take an indirect approach to calculate a threshold value for the most uncertain piece of information, namely the reduction in the probability of the infection spreading as a direct result of the intervention, at which the intervention becomes worthwhile.

RESULTS

The 5-week intervention costs amounted to a total of $52,810.71, or $131,094.73 prorated according to the length of the flu season, or $512,729.30 prorated for the entire calendar year. The variable costs that were incurred for this 5-week project amounted to approximately $923.16 per participating medical practice. The (fixed) training costs per practice were equivalent to $73.27 for the 5-week intervention, or $28.14 for 13-week flu season, or $7.05 for an entire one-year period.

CONCLUSION

Based on our conservative estimates for the direct cost savings, there are indications that the outreach facilitation intervention program would be cost effective if it can achieve a reduction in the probability of infection on the order of 0.83 (0.77, 1.05) percentage points. A facilitation intervention initiative tailored to the environment and needs of the family medical practice and walk-in clinics is of promise for improving respiratory infection control in the physicians' offices.

Safe and secure. How to create an effective OSHA compliance program in your practice

Medical group practice administrators have a responsibility to provide a safe working environment for their employees and patients. You must create an effective Occupational Safety and Health Administration (OSHA) compliance program in your organization. The complexity and diversity of OSHA standards are significant, and developing an effective program requires more than a cut-and-paste approach. This article describes the scope of the task, the steps to take and tools you can use.

A process evaluation of an intervention to improve respiratory infection control practices in family physician offices

OBJECTIVE

To conduct a process evaluation of a short-term intervention by public nurses for physicians to facilitate the incorporation of new respiratory infection control practices in physicians' offices.

DESIGN

Process evaluation.

SETTING

Family physician offices in Ottawa, Ontario, Canada.

PARTICIPANTS

Five public health nurse-facilitators and 53 primary care practices including 143 family physicians.

METHOD

Effectiveness of facilitator training assessed by self-administered questionnaires. Data assessing process of facilitation collected through activity logs and narrative reports. Physicians' satisfaction assessed by post-intervention questionnaire.

MAIN FINDINGS

Facilitators reported that training strongly contributed to their knowledge and skills and all were either satisfied or highly satisfied with their facilitation training. All practices received at least two visits by the facilitator and more than half (51%) were visited three or more times. Facilitators identified the provision of the evidence-based Tool Kit and consensus-building with office staff as key factors contributing to the intervention's success. Of the 45% of physicians who completed the questionnaire (65/143), only 5% reported being somewhat dissatisfied with the intervention, 11% reported the visits were not frequent enough, and 9% thought the visits were too close together. The majority (97%) felt the facilitation program should be available to all family physicians and 98% would continue to use the service if available.

CONCLUSIONS

It is feasible for public health nurses to be trained in outreach facilitation to improve respiratory infection control practices in physicians' offices and this has been widely appreciated by physicians. This model of public health/primary care collaboration deserves further exploration.

The facility's role in office economics: the bottom line

The object of medical practice is to deliver services in a timely manner. To prosper in the current environment, clinicians must stress productivity and efficiency. This article discusses the impact of office space configuration on these factors. Not only is profitability increased, satisfaction improves as providers can spend more face-to-face time with patients, and waits are reduced.

Lower adverse event and mortality rates in physician offices compared with ambulatory surgery centers: a reappraisal of Florida adverse event data

BACKGROUND

A recent study using Florida adverse event data found an increased risk of mortality in offices as opposed to ambulatory surgical centers. A major limitation of Florida adverse event data is the lack of uniform collection of the number of cases performed.

OBJECTIVE

The objective was to reassess the risk of mortality from physician office and ambulatory surgical center procedures using improved estimates of the numbers of cases performed in these settings.

METHODS

Adverse incident reports from March 2000 to March 2003 were obtained from the Florida Board of Medicine. We used data from the National Ambulatory Medical Care Survey and from the Medicare Current Beneficiary Survey to estimate the number of office procedures in Florida for both the general and the Medicare populations. The number of procedures performed and the number of deaths in ambulatory surgical centers was obtained from the Florida Agency of Healthcare Administration for the years 2000 through 2002. These data were used to calculate adverse event and mortality rates.

RESULTS

For physician offices, the adverse event rates and mortality rates calculated per 100,000 procedures from National Ambulatory Medical Care Survey data were 2.1 and 0.41, respectively, and 0.24 and 0.10 using Medicare Current Beneficiary Survey data. For ambulatory surgical centers, the mean adverse event rate was 4.4 and the mean mortality rate was 0.90.

DISCUSSION

Florida's adverse event data do not show higher adverse event rates in physician offices compared with ambulatory surgical centers. Incident reporting and public availability of incidents are important, as is standardization of reporting rules for both adverse events and number of procedures performed in different settings.

Patient Injuries from Surgical Procedures Performed in Medical Offices: Three Years of Florida Data

BACKGROUND

Many state medical boards and legislatures are in the process of developing regulations that restrict procedures in the office setting with the intention of enhancing patient safety. The highest quality data in existence on office procedure adverse incidents have been collected by the state of Florida.

OBJECTIVE

The objective was to determine and analyze the nature of surgical incidents in office-based settings using 3 years of Florida data from March 2000 to March 2003.

METHODS

An incidence study with prospective data collection was performed. Individual reports that resulted in death or a hospital transfer were further investigated by determining the reporting physician's board certification status, hospital privilege status (excluding procedure specific operating room privileges), and office accreditation status.

RESULTS

In 3 years there were 13 procedure-related deaths and 43 procedure-related complications that resulted in a hospital transfer. Seven of the 13 deaths involved elective cosmetic procedures, 5 of which were performed under general anesthesia and 2 of which were performed with intravenous sedation anesthesia. Forty-two percent of the offices reporting deaths and 50% of the offices reporting procedural incidents that resulted in a hospital transfer were accredited by an independent accreditation agency. Ninety-six percent of physicians reporting surgical incidents were board-certified, and all had hospital privileges.

CONCLUSIONS

Restrictions on office procedures for medically necessary procedures, such as requiring office accreditation, board certification, and hospital privileges, would have little effect on overall safety of surgical procedures. These data also show that the greatest danger to patients lies not with surgical procedures in office-based settings per se, but with cosmetic procedures that are performed in office-based settings, particularly when under general anesthesia. Our conclusions are dramatically different from those of a recent study, which claimed a 12-fold increased risk of death for procedures in the office setting.

Hygiene in der Arztpraxis

Nosokomiale Infektionen werden in der Regel als Problem für Spitäler betrachtet. Die ambulante medizinische Versorgung ist aber sowohl für Patienten als auch für Medizinalpersonen ebenfalls nicht ohne Risiko. Fälle iatrogener Infektionen nach invasiven Maßnahmen wie zum Beispiel nach intramuskulären Injektionen werden wiederholt beobachtet und haben auch schon zu Anklagen gegen die involvierten Ärzte wegen vermeintlichen Kunstfehlern geführt. Solche Ereignisse machen deutlich, dass auch Ärzte, die eine eigene Praxis führen, ein Konzept zur Prävention nosokomialer Infektionen in ihrer Praxis benötigen. Dieses Konzept sollte sowohl den Schutz der Patienten als auch des Personals zum Ziel haben und auf die jeweiligen Bedürfnisse der Praxis zugeschnitten sein. Nach Anwendung eines solchen Konzeptes wird es möglich sein, alle Patienten – den Routinepatienten, den Routinepatienten während eines invasiven Eingriffes, den mit einem resistenten Mikroorganismus kolonisierten Patienten, sowie auch den Patienten mit einer Infektionskrankheit – unter Bedingungen zu behandeln, welche das Risiko einer nosokomialen Infektion bei Patienten und Personal möglichst niedrig halten. Die wichtigsten Elemente eines solchen Konzeptes sind schriftliche Richtlinien zur Desinfektion, Sterilisation und zum Personalschutz. Je nach Art der Praxis müssen diese Richtlinien durch weitere ergänzt werden, welche beispielsweise in einer gastroenterologischen Praxis die Aufbereitung von Endoskopen regeln.

Noise in the ambulatory health care setting. How loud is too loud?

A study was conducted to assess noise levels at the Sycamore Primary Care Center, an ambulatory health care facility. It is hypothesized that the building design led to an unusually quiet environment. Noise levels were sampled over a two-week period at two locations within the center, with a range of between 49.2 and 53.2 decibels. A comprehensive literature review failed to find comparison data at other ambulatory care facilities. However, when comparing the results to those of a typical business office environment, the building is unusually quiet. This should result in a positive environment for employees, by increasing productivity and reducing stress.

Alterations in random event measures associated with a healing practice

OBJECTIVE

To determine whether alterations in random events, as measured by a Random event generator (REG), occur in association with a bioenergy healing practice.

DESIGN AND SETTING

Two REGs were set up and run in parallel: one in a bioenergy healer's office and another at a local library as a control. Two multiday sets of data were collected in each setting. A third set was collected in which a reduced amount of attention was placed on the REG by the healer. REG excursions were calculated and compared for (1) overall days in the library and bioenergy healer's office, (2) healing and nonhealing phases in the healing office, and (3) overall excursions during high(sets 1 and 2) and low attention (set 3) by the healer.

RESULTS

The library REG produced excursions outside the 95% confidence interval (CI) on 35 of 61 days (58%), and the REG in the healing practice 47 of 51 days (92%) (mean difference, 34%; 95% CI, 18% to 49%; chi(2) = 16.3, 1 df, p < 0.0005). In the healer's office, 0.6496 excursions per segment for healing phases and 0.6548 excursions per segment for nonhealing phases were shown (t = -1.3, 6794 df, p = 0.182). A comparison with chance expectation derived from Monte Carlo runs showed significantly less mean excursions per segment (t = -7.8, 36625 df, p < 0.0005) for healing phases and no difference in nonhealing phases (t = -0.16, 6309 df, p = 0.872). There was no significant difference in excursions between the high- and low-attention situations in the healing practice.

CONCLUSIONS

In the presence of a healer, an REG produced greater than chance excursions more often than a control REG in a library setting. The healing and nonhealing phases demonstrated inconsistent results. REG deviations were not influenced by the amount of attention directed toward the machine.

[Basic hygienic deficiencies in a medical practice--what to do?--a case report]

A lot of deficiencies in hygienic procedures had been observed in a medical practice on the occasion of a control visit by the Public Health services. Bloodborne infections for the patients could not be excluded. Therefore, this practice was closed by the authorities. After some improvements, the practice was reopened for conservative therapy, whereas operative therapy was still prohibited. Since this verdict was obviously neglected, the operation room was sealed. All these measures were approved by the Administrative Court. This case is reported and discussed with respect to the new infection control law with increased tasks in hygiene control for the Public Health services.

Vaccine storage practices in primary care physician offices: assessment and intervention

PURPOSE

To assess the proportion of primary care physician (PCP) offices meeting vaccine storage guidelines, identify factors associated with low compliance, and evaluate whether a quality improvement (QI) activity improves compliance.

METHODS

We examined compliance with guidelines of 721 PCP offices contracted with a national managed care organization in four cities. A QI activity (educational materials, written feedback, and distribution of thermometers) was conducted at baseline and a follow-up assessment occurred within 3 months.

RESULTS

Baseline compliance was relatively high, with >80% adherence to most guidelines. For example, 89% of offices had a thermometer; and 83% of temperatures were appropriate. Most units did not have vaccines stored in the door or food/biological materials in the unit (80% and 96%, respectively). Almost all vaccines had not expired. Multivariate analysis indicated that practice location, type of physician, participation in vaccine programs, and using guidelines were associated with compliance. For most of the compliance measures, pediatric offices had the highest compliance. Adherence to guidelines improved after the QI activity; the net change between pre- and post-intervention ranged from +1% to +19%. Measurements most impacted included temperature log posted (19% improvement in refrigerator; 16% improvement in freezer) and no vaccine stored in refrigerator door (14% improvement).

CONCLUSIONS

Despite generally high compliance, there are some opportunities for improvement in how PCPs store vaccines. Incorporating an intervention program in existing practice activities can improve storage practices. Further research is needed to determine the possible benefits of targeting interventions to certain types of providers who may be less knowledgeable about recommended guidelines.

Evaluating the design of a family practice healthcare clinic using discrete-event simulation

With increased pressures from governmental and insurance agencies, today's physician devotes less time to patient care and more time to administration. To assist physician clinics in evaluating potential operating procedures that improve operating efficiencies and better satisfy patients, an object-oriented discrete-event simulation model has been constructed using the Visual Simulation Environment (VSE). The research presented herein describes a methodology for determining appropriate staffing and physical resources in a clinical environment using this simulation model. This methodology takes advantage of several simulation-based statistical techniques, including batch means: fractional factorial design: and simultaneous ranking, selection, and multiple comparisons. A clinic effectiveness measure is introduced that captures several objectives within a health care clinic, including profitability and patient satisfaction. An explanation of the experimental design is provided and results of the experimentation are presented. Based upon the experimental results, conclusions are drawn and recommendations are made for an appropriate staffing and facility size for a two physician family practice healthcare clinic.

What impact on PA education? A snapshot of ambulatory care visits involving PAs

This study uses data from the 1997 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey to describe nonfederal physician office, hospital outpatient, and emergency department visits involving physician assistants (PAs). Of an estimated 959 million visits to health care practitioners, 2.55% (an estimated 24,532,000) involved PAs. Diagnoses associated with ambulatory care visits involving PAs included well-infant and well-child examinations and the care of uncomplicated injuries or wounds and respiratory tract infections. On average, 3.1 medications were ordered or provided at a visit with a PA. The problems that PAs address are similar across the 3 ambulatory care settings analyzed, with some expected variation between physician office and emergency department visits. Generally, ambulatory care visits with PAs mirror visits with all health care providers who practice ambulatory care medicine. PA education programs should ensure that students can competently perform the skills needed for typical ambulatory care practice.

Ambulatory surgery outcomes: a survey of office-based delivery

Due to a few well-publicized stories about patient injury and death, office-based ambulatory surgery has recently been thrust upon the forefront of current discussions about clinical outcomes. This has stimulated interest among ambulatory surgery stakeholders, including physicians, patients, and elected officials. An analysis of medical office-based surgical facilities in Florida indicates that office-based surgeons tend to work independently, with limited peer oversight, although as a whole, they professionally subscribe to a high level of ethical standards and offer patients an expected high quality level of clinical expertise. The results did not definitively indicate a relationship between unaccredited medical offices and unacceptable surgical procedures. The paper concludes by offering fifteen medical office standards that can aid in developing office surgery oversight policies.

The American Gastroenterological Association standards for office-based gastrointestinal endoscopy services

The American Gastroenterological Association (AGA) standards for office-based gastrointestinal endoscopy were written in response to market changes in physician reimbursements for many endoscopic procedures that will continue to drive their performance into unregulated physician offices. The AGA believes that patient safety is best protected if these standards are adopted by sites that also comply with state/federal laws for licensure or are certified as an ASC and/or are accredited by a nationally recognized accreditation program (e.g., the Joint Commission on Accreditation of Healthcare Organization's [JCAHO] new Office-Based Surgery Standards). Heretofore, relevant practice standards for the performance of endoscopic procedures in these settings have not been available, a situation that the AGA believes puts patients at risk. These standards have been developed to reduce that risk.

Risk factors for improper vaccine storage and handling in private provider offices

CONTEXT

Preventing loss of vaccine potency during storage and handling is increasingly important as new, more expensive vaccines are introduced, in at least 1 case requiring a different approach to storage. Little information is available about the extent to which staff in private physicians' offices meet quality assurance needs for vaccines or have the necessary equipment. Although the National Immunization Program at the Centers for Disease Control and Prevention (CDC) in 1997 developed a draft manual to promote reliable vaccine storage and to supplement published information already available from the CDC and the American Academy of Pediatrics, the best ways to improve vaccine storage and handling have not been defined.

OBJECTIVES

To estimate the statewide prevalence of offices with suboptimal storage and handling, to identify the risk factors for suboptimal situations in the offices of private physicians, and to evaluate whether the distribution of a new National Immunization Program draft manual improved storage and handling practices.

DESIGN

Population-based survey, including site visits to a stratified, random sample of consenting private physicians' offices. At least 2 months before the site visits, nearly half (intervention group) of the offices were randomly selected to receive a draft CDC manual entitled, "Guideline for Vaccine Storage and Handling." The remainder was considered the control group. Trained graduate students conducted site visits, all being blinded to whether offices were in the intervention or control groups. Each site visit included measurements of refrigerator and freezer temperatures with digital thermometers (Digi-thermo, Model 15-077-8B, Control Company, Friendswood, TX; specified accuracy +/- 1 degrees C). Their metal-tipped probes were left in the center shelf of cold storage compartments for at least 20 minutes to allow them to stabilize. The type of refrigerator/freezer unit, temperature-monitoring equipment, and records were noted, as were the locations of vaccines in refrigerator and freezer, and the presence of expired vaccines. Other information collected included the following: staff training, use of written guidelines, receipt of vaccine deliveries, management of problems, number of patients, type of office, type of medical specialty, and the professional educational level of the individual designated as vaccine coordinator.

PARTICIPANTS

Two hundred twenty-one private physicians' offices known by the Georgia Immunization Program in 1997 to immunize children routinely with government-provided vaccines.

OUTCOME MEASURES

Estimates (prevalence, 95% confidence interval [CI]) of immunization sites found to have a suboptimally stored vaccine at a single point in time, defined as: vaccine past expiration date, at a temperature of </=1 degrees C or >/=9 degrees C in a refrigerator or >/=-14 degrees C (recommended for varicella vaccine) in freezer, and odds ratios (ORs) for risk factors associated with outcomes. We performed chi(2) analysis and Student's t tests to compare the administrative characteristics and quality assurance practices of offices with optimal vaccine storage with those with suboptimal storage, and to compare the proportion of offices with suboptimal storage practices in the groups that did and did not receive the CDC manual.

RESULTS

Statewide estimates of offices with at least 1 type of suboptimal vaccine storage included: freezer temperatures measuring >/=-14 degrees C = 17% (95% CI: 10.98, 23.06); offices with refrigerator temperatures >/=9 degrees C = 4.5% (95% CI: 1.08, 7.86); offices with expired vaccines = 9% (95% CI: 4.51, 13.37); and offices with at least 1 documented storage problem, 44% (95% CI: 35.79, 51.23). Major risk factors associated with vaccine storage outside recommended temperature ranges were: lack of thermometer in freezer (OR: 7.15; 95% CI: 3.46, 14.60); use of freezer compartment in small cold storage units (OR: 5.46; 95% CI = 2.70, 10.99); lack of thermometer in refrigerator (OR: 3.07; 95% CI: 1.15,8.20); and failure to maintain temperature log of freezer (OR: 2.70; 95% CI: 1.40, 5.23). Offices that adhered to daily temperature monitoring for all vaccine cold storage compartments, compared with those that did not, were 2 to 3 times more likely to assign this task to staff with higher levels of training, have received a recent visit from the state immunization program, and be affiliated with a hospital or have Federally Qualified Health Center status. In addition, sites using >1 refrigerator/freezer for vaccine storage were more likely to have at least 1 cold storage compartment outside recommended temperature ranges. We found no significant differences in the data reported above between the intervention group (received copy of the draft manual) and the control group (did not receive copy of draft manual), even when controlling for the annual number of immunizations given or the type of office. (ABSTRACT TRUNCATED)