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Kinds of Health Administration Selected AbstractsPredictors of injury-related and non-injury-related mortality among veterans with alcohol use disordersADDICTION, Issue 10 2010Sylwia Fudalej ABSTRACT Aims To describe the association between alcohol use disorders (AUDs) and mortality and to examine risk factors for and all-cause, injury-related and non-injury-related mortality among those diagnosed with an AUD. Setting Department of Veterans Affairs, Veterans Health Administration (VHA). Participants A cohort of individuals who received health care in VHA during the fiscal year (FY) 2001 (n = 3 944 778), followed from the beginning of FY02 through the end of FY06. Measurements Demographics and medical diagnoses were obtained from VHA records. Data on mortality were obtained from the National Death Index. Findings Controlling for age, gender and race and compared to those without AUDs, individuals with AUDs were more likely to die by all causes [hazard ratio (HR) = 2.30], by injury-related (HR = 3.29) and by non-injury-related causes (HR = 2.21). Patients with AUDs died 15 years earlier than individuals without AUDs on average. Among those with AUDs, Caucasian ethnicity and all mental illness diagnoses that were assessed were associated more strongly with injury-related than non-injury-related mortality. Also among those with AUDs, individuals with medical comorbidity and older age were at higher risk for non-injury related compared to injury-related mortality. Conclusions In users of a large health-care system, a diagnosis of an AUD is associated significantly with increased likelihood of dying by injury and non-injury causes. Patients with a diagnosis of an AUD who die from injury differ significantly from those who die from other medical conditions. Prevention and intervention programs could focus separately upon selected groups with increased risk for injury or non-injury-related death. [source] Comparison of costs and utilization among buprenorphine and methadone patientsADDICTION, Issue 6 2009Paul G. Barnett ABSTRACT Aims Buprenorphine is an effective alternative to methadone for treatment of opioid dependence, but economic concerns represent a barrier to implementation. The economic impacts of buprenorphine adoption by the US Veterans Health Administration (VHA) were examined. Design Prescriptions of buprenorphine, methadone treatment visits, health-care utilization and cost, and diagnostic data were obtained for 2005. Findings VHA dispensed buprenorphine to 606 patients and methadone to 8191 other patients during the study year. An analysis that controlled for age and diagnosis found that the mean cost of care for the 6 months after treatment initiation was $11 597 for buprenorphine and $14 921 for methadone (P < 0.001). Cost was not significantly different in subsequent months. The first 6 months of buprenorphine treatment included an average of 66 ambulatory care visits, significantly fewer than the 137 visits in methadone treatment (P < 0.001). In subsequent months, buprenorphine patients had 8.4 visits, significantly fewer than the 21.0 visits of methadone patients (P < 0.001). Compared to new methadone episodes, new buprenorphine episodes had 0.634 times the risk of ending [95% confidence interval 0.547,0.736]. Implementation of buprenorphine treatment was not associated with an influx of new opioid-dependent patients. Conclusion Despite the higher cost of medication, buprenorphine treatment was no more expensive than methadone treatment. VHA methadone treatment costs were higher than reported by other providers. Although new buprenorphine treatment episodes lasted longer than new methadone episodes, buprenorphine is recommended for more adherent patients. [source] Use of Outpatient Care in Veterans Health Administration and Medicare among Veterans Receiving Primary Care in Community-Based and Hospital Outpatient ClinicsHEALTH SERVICES RESEARCH, Issue 5p1 2010Chuan-Fen Liu Objective. To examine differences in use of Veterans Health Administration (VA) and Medicare outpatient services by VA primary care patients. Data Sources/Study Setting. VA administrative and Medicare claims data from 2001 to 2004. Study Design. Retrospective cohort study of outpatient service use by 8,964 community-based and 6,556 hospital-based VA primary care patients. Principal Findings. A significant proportion of VA patients used Medicare-reimbursed primary care (>30 percent) and specialty care (>60 percent), but not mental health care (3,4 percent). Community-based patients had 17 percent fewer VA primary care visits (p<.001), 9 percent more Medicare-reimbursed visits (p<.001), and 6 percent fewer total visits (p<.05) than hospital-based patients. Community-based patients had 22 percent fewer VA specialty care visits (p<.0001) and 21 percent more Medicare-reimbursed specialty care visits (p<.0001) than hospital-based patients, but no difference in total visits (p=.80). Conclusions. Medicare-eligible VA primary care patients followed over 4 consecutive years used significant primary care and specialty care outside of VA. Community-based patients offset decreased VA use with increased service use paid by Medicare, suggesting that increasing access to VA primary care via community clinics may fragment veteran care in unintended ways. Coordination of care between VA and non-VA providers and health care systems is essential to improve the quality and continuity of care. [source] Comparing Safety Climate between Two Populations of Hospitals in the United StatesHEALTH SERVICES RESEARCH, Issue 5p1 2009Sara J. Singer Objective. To compare safety climate between diverse U.S. hospitals and Veterans Health Administration (VA) hospitals, and to explore the factors influencing climate in each setting. Data Sources. Primary data from surveys of hospital personnel; secondary data from the American Hospital Association's 2004 Annual Survey of Hospitals. Study Design. Cross-sectional study of 69 U.S. and 30 VA hospitals. Data Collection. For each sample, hierarchical linear models used safety-climate scores as the dependent variable and respondent and facility characteristics as independent variables. Regression-based Oaxaca,Blinder decomposition examined differences in effects of model characteristics on safety climate between the U.S. and VA samples. Principal Findings. The range in safety climate among U.S. and VA hospitals overlapped substantially. Characteristics of individuals influenced safety climate consistently across settings. Working in southern and urban facilities corresponded with worse safety climate among VA employees and better safety climate in the U.S. sample. Decomposition results predicted 1.4 percentage points better safety climate in U.S. than in VA hospitals: ,0.77 attributable to sample-characteristic differences and 2.2 due to differential effects of sample characteristics. Conclusions. Results suggest that safety climate is linked more to efforts of individual hospitals than to participation in a nationally integrated system or measured characteristics of workers and facilities. [source] The Impact of Private Insurance Coverage on Veterans' Use of VA Care: Insurance and Selection EffectsHEALTH SERVICES RESEARCH, Issue 1p1 2008Yujing Shen Objective. To examine private insurance coverage and its impact on use of Veterans Health Administration (VA) care among VA enrollees without Medicare coverage. Data Sources. The 1999 National Health Survey of Veteran Enrollees merged with VA administrative data, with other information drawn from American Hospital Association data and the Area Resource File. Study Design. We modeled VA enrollees' decision of having private insurance coverage and its impact on use of VA care controlling for sociodemographic information, patients' health status, VA priority status and access to VA and non-VA alternatives. We estimated the true impact of insurance on the use of VA care by teasing out potential selection bias. Bias came from two sources: a security selection effect (sicker enrollees purchase private insurance for extra security and use more VA and non-VA care) and a preference selection effect (VA enrollees who prefer non-VA care may purchase private insurance and use less VA care). Principal Findings. VA enrollees with private insurance coverage were less likely to use VA care. Security selection dominated preference selection and naïve models that did not control for selection effects consistently underestimated the insurance effect. Conclusions. Our results indicate that prior research, which has not controlled for insurance selection effects, may have underestimated the potential impact of any private insurance policy change, which may in turn affect VA enrollees' private insurance coverage and consequently their use of VA care. From the decline in private insurance coverage from 1999 to 2002, we projected an increase of 29,400 patients and 158 million dollars for VA health care services. [source] Case-Mix Adjusting Performance Measures in a Veteran Population: Pharmacy- and Diagnosis-Based ApproachesHEALTH SERVICES RESEARCH, Issue 5 2003Chuan-Fen Liu Objective. To compare the rankings for health care utilization performance measures at the facility level in a Veterans Health Administration (VHA) health care delivery network using pharmacy- and diagnosis-based case-mix adjustment measures. Data Sources/Study Setting. The study included veterans who used inpatient or outpatient services in Veterans Integrated Service Network (VISN) 20 during fiscal year 1998 (October 1997 to September 1998; N=126,076). Utilization and pharmacy data were extracted from VHA national databases and the VISN 20 data warehouse. Study Design. We estimated concurrent regression models using pharmacy or diagnosis information in the base year (FY1998) to predict health service utilization in the same year. Utilization measures included bed days of care for inpatient care and provider visits for outpatient care. Principal Findings. Rankings of predicted utilization measures across facilities vary by case-mix adjustment measure. There is greater consistency within the diagnosis-based models than between the diagnosis- and pharmacy-based models. The eight facilities were ranked differently by the diagnosis- and pharmacy-based models. Conclusions. Choice of case-mix adjustment measure affects rankings of facilities on performance measures, raising concerns about the validity of profiling practices. Differences in rankings may reflect differences in comparability of data capture across facilities between pharmacy and diagnosis data sources, and unstable estimates due to small numbers of patients in a facility. [source] Potentially Inappropriate Prescribing in Elderly Veterans: Are We Using the Wrong Drug, Wrong Dose, or Wrong Duration?JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 8 2005Mary Jo V. Pugh PhD Objectives: To identify the extent of inappropriate prescribing using criteria for proper use developed by the Agency for Healthcare Research and Quality (AHRQ) and dose-limitation criteria defined by Beers, as well as to describe duration of use and patient characteristics associated with inappropriate prescribing for older people. Design: Retrospective national Veterans Health Administration (VA) administrative database analysis. Setting: VA outpatient facilities during fiscal year 2000 (FY00). Participants: Veterans aged 65 and older having at least one VA outpatient visit in FY00 (N=1,265,434). Measurements: Operational definitions of appropriate use were developed based on recommendations of an expert panel convened by the AHRQ (Zhan criteria). Inappropriate use was identified based on these criteria and inappropriate use of drugs per Beers criteria for dose-limitations in older people. Furthermore, duration of use and patient characteristics associated with inappropriate use were described. Results: After adjusting for diagnoses, dose, and duration, inappropriate prescribing decreased from 33% to 23%. Exposure to inappropriate drugs was prolonged. Pain relievers, benzodiazepines, antidepressants, and musculoskeletal agents constituted 61% of inappropriate prescribing. Whites, patients with psychiatric comorbidities, and patients receiving more medications were most likely to receive inappropriate drugs. Women were more likely to receive Zhan criteria drugs; men were more likely to receive dose-limited drugs Conclusion: For the most part, the Zhan criteria did not explain inappropriate prescribing, which includes problems related to dose and duration of prescriptions. Interventions targeted at prescriptions for pain relievers, benzodiazepines, antidepressants, and musculoskeletal agents may dramatically decrease inappropriate prescribing and improve patient outcomes. [source] Veterans' perceptions of care by nurse practitioners, physician assistants, and physicians: A comparison from satisfaction surveysJOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS, Issue 3 2010Dorothy Budzi DrPH (Quality Manager/Performance Improvement Coordinator) Purpose: To examine the differences in patient satisfaction with care provided by nurse practitioners (NPs), physician assistants (PAs), and physicians in the Veterans Health Administration (VHA) system. Data source: Secondary data was obtained from the VHA's Survey of Healthcare Experience of Patients (SHEP), a monthly survey designed to measure patient satisfaction. Descriptive statistics were calculated and categorical variables were summarized with frequency counts. Conclusions: Of the 2,164,559 surveys mailed to the veterans, 1,601,828 (response rate 64%) were returned. The study found that satisfaction scores increased by 5% when the number of NPs was increased compared to 1.8% when the number of physicians was increased and slightly increased or remained the same when the number of PAs was increased. Physician to PA/NP ratio was 7:3. Implications for practice: The VHA is the largest healthcare system and the single largest employer of NPs and PAs in the country. This study shows that a majority of the primary care clinic patients prefer to see NPs as compared with PAs and physicians. Besides clinical care, NPs focus on health promotion, disease prevention, health education, attentiveness, and counseling. Physicians and PAs should be educated on these characteristics to promote patient satisfaction and expected outcomes. [source] Occupational blood exposure among unlicensed home care workers and home care registered nurses: Are they protected?AMERICAN JOURNAL OF INDUSTRIAL MEDICINE, Issue 7 2009FAAN, J. Lipscomb PhD Abstract Background Little is known about the risk of blood exposure among personnel providing care to individual patients residing at home. The objective of this study was to document and compare blood exposure risks among unlicensed home care personal care assistants (PCAs) and home care registered nurses (RNs). Methods PCAs self-completed surveys regarding blood and body fluid (BBF) contact in group settings (n,=,980), while RNs completed mailed surveys (n,=,794). Results PCAs experience BBF contact in the course of providing care for home-based clients at a rate approximately 1/3 the rate experienced by RNs providing home care (8.1 and 26.7 per 100 full time equivalent (FTE), respectively), and the majority of PCA contact episodes did not involve direct sharps handling. However, for PCAs who performed work activities such as handling sharps and changing wound dressings, activities much more frequently performed by RNs, PCAs were at increased risk of injury when compared with RNs (OR,=,7.4 vs. 1.4) and (OR,=,6.3 vs. 2.5), respectively. Conclusion Both PCAs and RNs reported exposures to sharps, blood, and body fluids in the home setting at rates that warrant additional training, prevention, and protection. PCAs appear to be at increased risk of injury when performing nursing-related activities for which they are inexperienced and/or lack training. Further efforts are needed to protect home care workers from blood exposure, namely by assuring coverage and enforcement of the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard [Occupational Safety and Health Administration. 1993. Frequently Asked Questions Concerning the Bloodborne Pathogens Standard. Available at: http://www. osha.gov/pls/oshaweb/owadisp.show_document?p_table=INTERPRETATIONS &p_id=21010#Scope. Accessed May 30, 2008]. Am. J. Ind. Med. 52:563,570, 2009. © 2009 Wiley-Liss, Inc. [source] Metal and non-metal miners' exposure to crystalline silica, 1998,2002AMERICAN JOURNAL OF INDUSTRIAL MEDICINE, Issue 7 2006James L. Weeks ScD Abstract Background Crystalline silica is well known to cause silicosis and other diseases. Exposure is common in the mining industry and consequently, the US Mine Safety and Health Administration (MSHA) evaluates miners exposure to silica to determine compliance with its exposure limit. Methods MSHA exposure measurements were obtained for the 5-year period from 1998 to 2002 and average exposure was calculated classified by occupation and by mine. Evaluation criteria were whether average values exceeded MSHA's permissible exposure limit or the limit recommended by the National Institute for Occupational Safety and Health (NIOSH), whether there was a risk of exposure to freshly fractured silica, and whether there was a risk of a high rate of exposure to silica. Results Miners in certain jobs are exposed to silica above permissible and recommended exposure limits. Some miners may also be exposed at a high rate or to freshly fractured silica. Conclusions Known dust control methods should be implemented and regular medical surveillance should be provided. Am. J. Ind. Med. 49:523,534, 2006. © 2006 Wiley-Liss, Inc. [source] Hypersensitivity pneumonitis due to metal working fluids: Sporadic or under reported?AMERICAN JOURNAL OF INDUSTRIAL MEDICINE, Issue 6 2006Amit Gupta MD Abstract Background Occupational exposure to metal working fluids (MWF) is common with over 1.2 million workers in the United States involved in machine finishing, machine tooling, and other metalworking operations. MWF is a known cause of hypersensitivity pneumonitis (HP). Recent reports of outbreaks of hypersensitivity HP secondary to exposure to MWF are reported. Design Cases were identified through the Occupational Disease surveillance system in the State of Michigan and from referrals for evaluation to the Division of Occupational and Environmental Medicine at Michigan State University (MSU). Each patient underwent a clinical examination including an occupational history, lung function studies, radiographic imaging, and in some cases lung biopsies. Following the diagnosis of definite HP, an industrial hygiene investigation was carried out, which included a plant walk-through, and review of the "Injury and Illness" log. Air monitoring and microbial sampling results were reviewed. Results As part of Michigan's mandatory surveillance system for occupational illnesses, seven cases of suspected HP were identified in 2003,2004 from three facilities manufacturing automobile parts in Michigan. Each plant used semi-synthetic MWFs, and conducted a MWF management program including biocide additions. Two facilities had recently changed the MWF before the cases arose. Growth of mycobacteria was found in these two MWFs. Breathing zone samples for particulates of two employees in plant A (two cases) ranged from 0.48 to 0.56 mg/m3. In plant B (four cases), two employees' sampling results ranged from 0.10 to 0.14 mg/m3. No air sampling data were available from plant C. Conclusion Hypersensitivity pneumonitis due to exposure to MWFs is under-recognized by health care providers, and current surveillance systems are inadequate to provide a true estimate of its occurrence. HP arose from environments with exposures well below the Occupational Safety and Health Administration (OSHA) permissible exposure limit (PEL) for MWF, and in one case from exposures well below the National Institute of Occupational Safety and Health (NIOSH) recommended exposure limit (REL). The sporadic nature of reports of HP in relationship to MWF probably represents a combination of workplace changes that cause the disease and inadequate recognition and reporting of the disease when it does occur. Physician awareness of HP secondary to MWF and an effective medical surveillance program are necessary to better understanding the epidemiology and prevention of this disease. Am. J. Ind. Med. 2006. © 2006 Wiley-Liss, Inc. [source] More evidence of the need for an ergonomic standardAMERICAN JOURNAL OF INDUSTRIAL MEDICINE, Issue 4 2004Jeff Biddle Abstract Background In 1999, the Occupational Safety and Health Administration (OSHA) proposed regulations designed to reduce work related inquiries by limiting worker exposure to "ergonomic risk factors." Congress subsequently overturned the regulations. We provide additional evidence on earnings losses attributable to musculoskeletal disorders (MSDs), and thus on the need for an ergonomic standard. Methods Regression techniques are used to analyze data from a survey of injured workers that has been matched to employer-reported earnings data covering pre- and post-injury periods, and to workers' compensation claims records. Results MSDs lead to large and persistent earnings losses. Cost estimates used by OSHA to justify the 1999 EPS are corroborated. Losses are greatest among workers who file workers compensation claims, but nonclaimants also have losses. Conclusions Earnings losses and lost productivity associated with work-related MSDs are substantial and an ergonomic standard could be cost effective. Am. J. Ind. Med. 45:329,337, 2004. © 2004 Wiley-Liss, Inc. [source] Preliminary findings on OSHA's refinery NEP ,PROCESS SAFETY PROGRESS, Issue 2 2010James Lay P.E. Abstract On June 7, 2007, the US Occupational Safety & Health Administration initiated a Petroleum Refinery Process Safety Management (PSM) National Emphasis Program (Refinery NEP) in response to a large number of fatal or catastrophic incidents in the petroleum refining industry. The program's intent is to inspect all refineries under federal jurisdiction within 2 years using a newly developed inspection protocol. This article briefly describes the inspection protocol, progress in completing the inspections, and review findings from this NEP and other PSM inspections conducted since 1992. Data on which paragraphs of the PSM standards were most frequently cited is included. Published 2009 American Institute of Chemical Engineers Process Saf Prog, 2010 [source] Comment on "Outcomes of DATA Certification Trainings for the Provision of Buprenorphine Treatment in the Veterans Health Administration"THE AMERICAN JOURNAL ON ADDICTIONS, Issue 4 2009MPhil, Melvin D. Small MD No abstract is available for this article. [source] Mortality and Revascularization Following Admission for Acute Myocardial Infarction: Implication for Rural VeteransTHE JOURNAL OF RURAL HEALTH, Issue 4 2010Thad E. Abrams MD Abstract Introduction: Annually, over 3,000 rural veterans are admitted to Veterans Health Administration (VA) hospitals for acute myocardial infarction (AMI), yet no studies of AMI have utilized the VA rural definition. Methods: This retrospective cohort study identified 15,870 patients admitted for AMI to all VA hospitals. Rural residence was identified by either Rural-Urban Commuting Area (RUCA) codes or the VA Urban/Rural/Highly Rural (URH) system. Endpoints of mortality and coronary revascularization were adjusted using administrative laboratory and clinical variables. Results: URH codes identified 184 (1%) veterans as highly rural, 6,046 (39%) as rural, and 9,378 (60%) as urban; RUCA codes identified 1,350 (9%) veterans from an isolated town, 3,505 (22%) from a small or large town, and 10,345 (65%) from urban areas. Adjusted mortality analyses demonstrated similar risk of mortality for rural veterans using either URH or RUCA systems. Hazards of revascularization using the URH classification demonstrated no difference for rural (HR, 0.96; 95% CI, 0.94-1.00) and highly rural veterans (HR, 1.13; 0.96-1.31) relative to urban veterans. In contrast, rural (relative to urban) veterans designated by the RUCA system had lower rates of revascularization; this was true for veterans from small or large towns (HR, 0.89; 0.83-0.95) as well as veterans from isolated towns (HR, 0.86; 0.78-0.93). Conclusion: Rural veterans admitted for AMI care have a similar risk of 30-day mortality but the adjusted hazard for receipt of revascularization for rural veterans was dependent upon the rural classification system utilized. These findings suggest potentially lower rates of revascularization for rural veterans. [source] Integration of safety technologies into rheumatology and orthopedics practices: A randomized, controlled trial,ARTHRITIS & RHEUMATISM, Issue 7 2008Gautam R. Moorjani Objective To identify and integrate new safety technologies into outpatient musculoskeletal procedures and measure the effect on outcome, including pain. Methods Using national resources for patient safety and literature review, the following safety technologies were identified: a safety needle to reduce inadvertent needlesticks to heath care workers, and the reciprocating procedure device (RPD) to improve patient safety and reduce pain. Five hundred sixty-six musculoskeletal procedures involving syringes and needles were randomized to either an RPD group or a conventional syringe group, and pain, quality, safety, and physician acceptance were measured. Results During 566 procedures, no accidental needlesticks occurred with safety needles. Use of the RPD resulted in a 35.4% reduction (95% confidence interval [95% CI] 24,46%) in patient-assessed pain (mean ± SD scores on a visual analog pain scale [VAPS] 3.12 ± 2.23 for the RPD and 4.83 ± 3.22 for the conventional syringe; P < 0.001) and a 49.5% reduction (95% CI 34,64%) in patient-assessed significant pain (VAPS score ,5) (P < 0.001). Physician acceptance of the RPD combined with a safety needle was excellent. Conclusion As mandated by the Joint Commission and the Occupational Safety and Health Administration, safety technologies and the use of pain scales can be successfully integrated into rheumatologic and orthopedic procedures. The combination of a safety needle to reduce needlestick injuries to health care workers and the RPD to improve safety and outcome of patients is effective and well accepted by physicians. [source] End-of-life care for older cancer patients in the Veterans Health Administration versus the private sector,,§¶CANCER, Issue 15 2010Nancy L. Keating MD Abstract BACKGROUND: Treatment of older cancer patients at the end of life has become increasingly aggressive, despite the absence of evidence for better outcomes. We compared aggressiveness of end-of-life care of older metastatic cancer patients treated in the Veterans Health Administration (VHA) and those under fee-for-service Medicare arrangements. METHODS: Using propensity score methods, we matched 2913 male veterans who were diagnosed with stage IV lung or colorectal cancer in 2001-2002 and died before 2006 with 2913 similar men enrolled in fee-for-service Medicare living in Surveillance, Epidemiology, and End Result (SEER) areas. We assessed chemotherapy within 14 days of death, intensive care unit (ICU) admissions within 30 days of death, and >1 emergency room visit within 30 days of death. RESULTS: Among matched cohorts, men treated in the VHA were less likely than men in the private sector to receive chemotherapy within 14 days of death (4.6% vs 7.5%, P < .001), be admitted to an ICU within 30 days of death (12.5% vs 19.7%, P < .001), or have >1 emergency room visit within 30 days of death (13.1 vs 14.7, P = .09). CONCLUSIONS: Older men with metastatic lung or colorectal cancer treated in the VHA healthcare system received less aggressive end-of-life care than similar men in fee-for-service Medicare. This may result from the absence of financial incentives for more intensive care in the VHA or because this integrated delivery system is better structured to limit potentially overly aggressive care. Additional studies are needed to assess whether men undergoing less aggressive end-of-life care also experience better outcomes. Cancer 2010. © 2010 American Cancer Society. [source] Prescription-related illness , a scandalous pandemicJOURNAL OF EVALUATION IN CLINICAL PRACTICE, Issue 4 2004Hugh McGavock BSc MD FRCGP Abstract Prescribed drugs are now a major cause of morbidity and mortality, particularly in the elderly. The extent of this pandemic is described and its likely causes in primary care are identified: unnecessary prescribing, imprecise diagnosis, inadequate undergraduate and postgraduate education in pharmacology and therapeutics, the uncritical application of evidence-based medicine, the outstanding development of new drugs and their sometimes unjustified promotion. Urgent action is recommended under seven headings, by health administration, epidemiologists, medical educators and prescribing doctors. [source] | ||||||||||