Effect Of Health Information Technology Research Articles

Information Technology, Improved Access, and Use of Prescription Drugs

Abstract We estimate the effects of health information technology designed to improve access to medication while limiting overuse through easier prescription renewal and improved information provision. We focus on benzodiazepines, a commonly prescribed class of mental health and insomnia medications, which are highly effective but potentially addictive. We study the staggered rollout of a nationwide electronic prescribing system over four years in Finland and use population-wide, individual-level administrative data sets. We find that e-prescribing increases average benzodiazepine use due to increased prescription renewals. The increase is most pronounced for younger patients. E-prescribing can improve the health of elderly patients and may help to balance the access-overuse trade-off. Without additional monitoring for addiction in place, it may, however, also have unintended health consequences for younger patients, who are more likely to develop mental and behavioral health disorders.

Effect of health information technology (HIT)-based discharge transition interventions on patient readmissions and emergency room visits: a systematic review.

To systematically synthesize and appraise the evidence on the effectiveness of health information technology (HIT)-based discharge care transition interventions (CTIs) on readmissions and emergency room visits. We conducted a systematic search on multiple databases (MEDLINE, CINAHL, EMBASE, and CENTRAL) on June 29, 2020, targeting readmissions and emergency room visits. Prospective studies evaluating HIT-based CTIs published as original research articles in English language peer-reviewed journals were eligible for inclusion. Outcomes were pooled for narrative analysis. Eleven studies were included for review. Most studies (n = 6) were non-RCTs. Several studies (n = 9) assessed bridging interventions comprised of at least 1 pre- and 1 post-discharge component. The narrative analysis found improvements in patient experience and perceptions of discharge care. Given the statistical and clinical heterogeneity among studies, we could not ascertain the cumulative effect of CTIs on clinical outcomes. Nevertheless, we found gaps in current research and its implications for future work, including the need for a HIT-based care transition model for guiding theory-driven design and evaluation of HIT-based discharge CTIs. We appraised and aggregated empirical evidence on the cumulative effectiveness of HIT-based interventions to support discharge transitions from hospital to home, and we highlighted the implications for evidence-based practice and informatics research.

Improved efficiency of coding systems with health information technology.

This study aimed to investigate the impact of health information technology (IT) on the Case Mix Index (CMI). This study was a retrospective cohort study using hospital financial data from the Office of Statewide Health Planning and Development (OSHPD) in California. A total of 309 unique hospitals were included in the study for 7 years, from 2009 to 2015, resulting in 2,135 hospital observations. The effects of health information technology (IT) on the Case Mix Index (CMI) was evaluated using dynamic panel data analysis to control endogeneity issues. This study found that more health IT adoption could lead to a lower CMI by improving coding systems. Policy makers, researchers, and healthcare providers must be cautious when interpreting the effect of health IT on the CMI. To encourage the adoption of health IT, the cost savings and reimbursement reductions resulting from health IT adoption should be compared. If any profit loss occurs (i.e., the cost savings is less than reimbursement reduction), more incentives should be provided to healthcare providers.

Health Information Technology Investments, Patient Experience, and Hospital Bad Debt

ABSTRACT In this study, we examine the effect of health information technology (HIT) investments on hospital bad debt via improved patient experience. Using data from California Hospital Reports and Definitive Healthcare, we first expect and find that HIT investments decrease hospital bad debt. Next, following Baron and Kenny's (1986) approach and the bootstrap approach of Zhao, Lynch, and Chen (2010), we study whether patient experience mediates the relationship between HIT investments and hospital bad debt. We find that HIT improves patient experience which, in turn, reduces bad debt at hospitals. Taken together, our findings provide evidence that patient experience is important as a means to affect the relationship between HIT investments and hospital bad debt.

Abstract PO-262: Achieving health equity in cancer preventive services: NIH Workshop insights on barriers and the effectiveness of evidence-based interventions and strategies

Abstract Background: Evidence-based guidelines for preventive services are developed by expert groups such as the U.S. Preventive Services Task Force (USPSTF) to help Americans stay healthy. Despite the proven value of evidence-based preventive services (e.g., screenings, provider counseling, and preventive medications), implementation by providers and uptake by patients vary, contributing to disparities in disease burden and life expectancy. The NIH convened a workshop with multidisciplinary and multisector participants in June 2019 to assess the available scientific evidence on achieving health equity in the use of clinical preventive services for three leading causes of death: diabetes, heart disease, and cancer. Methods: The workshop was framed around five key questions (KQ) and included a systematic evidence review, speaker presentations, and public discussion. KQ 1-2 considered the effects of barriers on the part of providers and patients to adopting and implementing evidence-based preventive services, and how they contribute to health disparities. KQ 3-5 addressed the effectiveness of health information technology and health care organization interventions to reduce disparities in preventive services use. An unbiased, independent panel of experts considered the scientific evidence in addition to speaker and audience perspectives to develop a report of findings and recommendations for addressing disparities in the use of ten clinical preventive services recommended by the USPSTF. Results: Overall, the need for more research on the effects of barriers was identified. However, compared with heart disease and diabetes, the barriers to adopting preventive services for breast, cervical, and colorectal cancer screening have received greater attention. While patient navigation was shown to be effective in increasing cancer screening rates, strategies for bundling preventive services and implementing health information technologies require more study. The importance of addressing unmet basic needs related to health and enhancing community resources to reduce disparities were recurring themes throughout the workshop. Lastly, there were implications for more research in cancer dissemination and implementation. Conclusion: Chronic diseases, including heart disease, cancer, and diabetes, are responsible for seven of every ten deaths in the U.S. each year. Greater use of proven clinical preventive services could avert the loss of millions of life-years. Achieving health equity in preventive services is feasible, but requires efforts at the patient, provider, healthcare organization, and community levels, and greater attention to addressing social determinants of health. Citation Format: Antoinette Percy-Laurry, Richard Berzon, Jennifer Croswell, Carrie Klabunde, Melissa Green Parker, LeShawndra Price, Pamela Thornton, Kate Winseck, Xinzhi Zhang. Achieving health equity in cancer preventive services: NIH Workshop insights on barriers and the effectiveness of evidence-based interventions and strategies [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-262.

The Effect of Health Information Technology on Time and Cost Saving in Remote areas of Iran

The present study aims at investigating the effect of health information technology on time and cost saving in the perspective of users of teaching hospitals in in remote areas of Iran. This is an applied study with a descriptive-analytical and cross-sectional method conducted on users of hospitals in remote areas of Iran using stratified random sampling. Data collection instrument was a selfmade questionnaire, the face validity and reliability of which were confirmed by Cronbach’s alpha 0.94. Data were collected in person and analyzed by SPSS software V. 21 and descriptive and analytical statistics. Based on the Chi-square test results, there was a significant relationship between the effects of health information technology on time saving as well as cost saving. The results of Kruskal-Wallis test showed no significant relationship between education level, age and work experience and time and cost saving as well. User satisfaction is one of the most important aspects of the success of information systems, therefore, it is recommended that senior managers pay attention to the individual aspects of the employees working in the organization, provide them with necessary training before implementing the information systems, and involve them in the decisions in using such technologies.

Improving the Effectiveness of Health Information Technology: The Case for Situational Analytics.

Health information technology has contributed to improvements in quality and safety in clinical settings. However, the implementation of new technologies in health care has also been associated with the introduction of new sociotechnical hazards, produced through a range of complex interactions that vary with social, physical, temporal, and technological context. Other industries have been confronted with this problem and have developed advanced analytics to examine context-specific activities of workers and related outcomes. The skills and data exist in health care to develop similar insights through situational analytics, defined as the application of analytic methods to characterize human activity in situations and identify patterns in activity and outcomes that are influenced by contextual factors. This article describes the approach of situational analytics and potentially useful data sources, including trace data from electronic health record activity, reports from users, qualitative field data, and locational data. Key implementation requirements are discussed, including the need for collaboration among qualitative researchers and data scientists, organizational and federal level infrastructure requirements, and the need to implement a parallel research program in ethics to understand how the data are being used by organizations and policy makers.

A regulatory perspective on the influence of health information technology on organisational quality and safety in England.

Health information technology can transform and enhance the quality and safety of care, but it may also introduce new risks. This study analysed 130 healthcare regulator inspection reports and organisational digital maturity scores in order to characterise the impact of health information technology on quality and safety from a regulatory perspective. Although digital maturity and the positive use of health information technology are significantly associated with overall organisational quality, the negative effects of health information technology are frequently and more commonly identified by regulators. The poor usability of technology, lack of easy access to systems and data and the incorrect use of health information technology are the most commonly identified areas adversely affecting quality and safety. There is a need to understand the full risks and benefits of health information technology from the perspective of all stakeholders, including patients, end-users, providers and regulators in order to best inform future practice and regulation.

Increased health information technology investment decreases uncompensated care cost: A study of Texas hospitals.

Many previous research studies have demonstrated that investing in health information technology (IT) in a hospital setting has potential benefits, including eliminating duplicate or unnecessary tests and adverse drug events, conserving healthcare provider time and effort by making information more readily available, and reducing cost by increasing efficiency or productivity metrics. However, the effect of health IT on uncompensated care has not been reported yet. The objective of this study was to examine the effect of health IT investment on uncompensated care provided by hospitals. The general linear model (GLM) with log link and normal distribution was used to estimate the association between health IT spending and the provision of uncompensated care using Texas American Hospital Association (AHA) data from 2004 to 2010. The total health IT investment was significantly and negatively associated with the provision of uncompensated care. When health IT investment was increased by 10%, the provision of uncompensated care was reduced by 2.7%. Health IT investment was also significantly and negatively associated with bad debt. When health IT investment was increased by 10%, bad debt was decreased by 3.2%. Health IT investment was negatively associated with the provision of uncompensated care. This means that health IT could reduce administrative burden and improve efficiency of tracking patient insurance status and billings.

Effects of health information technology and health information exchanges on readmissions and length of stay

IntroductionThis study explored the effects of HIT/HIE on the outcomes and quality of care for diabetes, asthma, acute myocardial infarction, congestive heart failure, and hip and knee fracture. 30 day readmissions and average length of stay were used as measures of quality of care. MethodsThis study used the HIMSS IT database, coupled with the American Hospital Association (AHA) Hospital survey data and the CMS outpatient and skilled nursing facility Medicare claims data from 2006–2012, along with the standard Medicare file of patient claims for 2006–2012 as the control cohort. Using heirarchical clustering analysis methods, we construct HIT scores for measures of HIT and HIE implementation and penetration across 32 measures of HIT adoption. The scores are then used as the coefficient of interest using fixed effects methods and multinomial regressions, controlling for hospital and patient characteristics, as well as time-invariant factors. ResultsThis study finds that those institutions with the highest HIT scores for specific measures of clinical decision support, continuity of care documentation and clinical discharge and summary care documentation showed modest and statistically significant reduction in 30 day readmissions, with no effects on length of stay. DiscussionThis study has major implications for the future of HIT/HIE in coordinating care across disparate entities. Initiatives aimed at improving care coordination, fostering health ecosystems, and reducing costs associated with unnecessary readmissions and length of stay and stand to benefit from this research in that it highlights tangible areas where HIT/HIE participation may be beneficial to achieving improved health.

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

BackgroundThe NHS policy of constructing multispecialty community providers (MCPs) rests on a complex set of assumptions about how health systems can replace hospital use with enhanced primary care for people with complex, chronic or multiple health problems, while contributing savings to health-care budgets.ObjectivesTo use policy-makers’ assumptions to elicit an initial programme theory (IPT) of how MCPs can achieve their outcomes and to compare this with published secondary evidence and revise the programme theory accordingly.DesignRealist synthesis with a three-stage method: (1) for policy documents, elicit the IPT underlying the MCP policy, (2) review and synthesise secondary evidence relevant to those assumptions and (3) compare the programme theory with the secondary evidence and, when necessary, reformulate the programme theory in a more evidence-based way.Data sourcesSystematic searches and data extraction using (1) the Health Management Information Consortium (HMIC) database for policy statements and (2) topically appropriate databases, including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Applied Social Sciences Index and Abstracts (ASSIA). A total of 1319 titles and abstracts were reviewed in two rounds and 116 were selected for full-text data extraction. We extracted data using a formal data extraction tool and synthesised them using a framework reflecting the main policy assumptions.ResultsThe IPT of MCPs contained 28 interconnected context–mechanism–outcome relationships. Few policy statements specified what contexts the policy mechanisms required. We found strong evidence supporting the IPT assumptions concerning organisational culture, interorganisational network management, multidisciplinary teams (MDTs), the uses and effects of health information technology (HIT) in MCP-like settings, planned referral networks, care planning for individual patients and the diversion of patients from inpatient to primary care. The evidence was weaker, or mixed (supporting some of the constituent assumptions but not others), concerning voluntary sector involvement, the effects of preventative care on hospital admissions and patient experience, planned referral networks and demand management systems. The evidence about the effects of referral reductions on costs was equivocal. We found no studies confirming that the development of preventative care would reduce demands on inpatient services. The IPT had overlooked certain mechanisms relevant to MCPs, mostly concerning MDTs and the uses of HITs.LimitationsThe studies reviewed were limited to Organisation for Economic Co-operation and Development countries and, because of the large amount of published material, the period 2014–16, assuming that later studies, especially systematic reviews, already include important earlier findings. No empirical studies of MCPs yet existed.ConclusionsMultidisciplinary teams are a central mechanism by which MCPs (and equivalent networks and organisations) work, provided that the teams include the relevant professions (hence, organisations) and, for care planning, individual patients. Further primary research would be required to test elements of the revised logic model, in particular about (1) how MDTs and enhanced general practice compare and interact, or can be combined, in managing referral networks and (2) under what circumstances diverting patients from in-patient to primary care reduces NHS costs and improves the quality of patient experience.Study registrationThis study is registered as PROSPERO CRD42016038900.FundingThe National Institute for Health Research (NIHR) Health Services and Delivery Research programme and supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.

The Effectiveness of Health Information Technology on Promoting Medication Adherence in Adults with Diabetes Mellitus Type 2: A Systematic Review Protocol

The objective of this review is to identify the effectiveness of health information technology on promoting medication adherence in adults with diabetes mellitus type 2. More specifically, the review questions are: What is the effectiveness of health information technology on promoting medication adherence in adults with diabetes mellitus type 2? What is the effectiveness of health information technology for enhancing medication adherence in adults with diabetes mellitus type 2 on quality of life? What is the effectiveness of health information technology for enhancing medication adherence in adults with diabetes mellitus type 2 on hospital readmissions?

Drawing on human factors engineering to evaluate the effectiveness of health information technology.

Drawing on human factors engineering to evaluate the effectiveness of health information technology.

Do health information technology self-management interventions improve glycemic control in medically underserved adults with diabetes? A systematic review and meta-analysis.

The purpose of this systematic review and meta-analysis was to examine the effect of health information technology (HIT) diabetes self-management education (DSME) interventions on glycemic control in medically underserved patients. Following an a priori protocol, 5 databases were searched. Studies were appraised for quality using the Cochrane Risk of Bias assessment. Studies reporting either hemoglobin A1c pre- and post-intervention or its change at 6 or 12 months were eligible for inclusion in the meta-analysis using random effects models. Thirteen studies met the criteria for the systematic review and 10 for the meta-analysis and represent data from 3257 adults with diabetes (mean age 55 years; 66% female; 74% racial/ethnic minorities). Most studies ( n = 10) reflected an unclear risk of bias. Interventions varied by HIT type: computer software without Internet ( n = 2), cellular/automated telephone ( n = 4), Internet-based ( n = 4), and telemedicine/telehealth ( n = 3). Pooled A1c decreases were found at 6 months (-0.36 (95% CI, -0.53 and -0.19]; I 2 = 35.1%, Q = 5.0), with diminishing effect at 12 months (-0.27 [95% CI, -0.49 and -0.04]; I 2 = 42.4%, Q = 10.4). Findings suggest that medically underserved patients with diabetes achieve glycemic benefit following HIT DSME interventions, with dissipating but significant effects at 12 months. Telemedicine/telehealth interventions were the most successful HIT type because they incorporated interaction with educators similar to in-person DSME. These results are similar to in-person DSME in medically underserved patients, showing that well-designed HIT DSME has the potential to increase access and improve outcomes for this vulnerable group.

Association between Health Information Technology and Case Mix Index.

ObjectivesHealth information technology (IT) can assist healthcare providers in ordering medication and adhering to guidelines while improving communication among providers and the quality of care. However, the relationship between health IT and Case Mix Index (CMI) has not been thoroughly investigated; therefore, this study aimed to clarify this relationship.MethodsTo examine the effect of health IT on CMI, a generalized estimation equation (GEE) was applied to two years of California hospital data.ResultsWe found that IT was positively associated with CMI, indicating that increased IT adoption could lead to a higher CMI or billing though DRG up-coding. This implies that hospitals' revenue could increase around $40,000 by increasing IT investment by 10%.ConclusionsThe positive association between IT and CMI implies that IT adoption itself could lead to higher patient billings. Generally, a higher CMI in a hospital indicates that the hospital provides expensive services with higher coding and therefore receives more money from patients. Therefore, measures to prevent upcoding through IT systems should be implemented.

Texas hospitals with higher health information technology expenditures have higher revenue: A longitudinal data analysis using a generalized estimating equation model.

BackgroundThe benefits of health information technology (IT) adoption have been reported in the literature, but whether health IT investment increases revenue generation remains an important research question.MethodsTexas hospital data obtained from the American Hospital Association (AHA) for 2007–2010 were used to investigate the association of health IT expenses and hospital revenue. The generalized estimation equation (GEE) with an independent error component was used to model the data controlling for cluster error within hospitals.ResultsWe found that health IT expenses were significantly and positively associated with hospital revenue. Our model predicted that a 100 % increase in health IT expenditure would result in an 8 % increase in total revenue. The effect of health IT was more associated with gross outpatient revenue than gross inpatient revenue.ConclusionIncreased health IT expenses were associated with greater hospital revenue. Future research needs to confirm our findings with a national sample of hospitals.

Effects of health information technology on patient outcomes: a systematic review.

To systematically review studies assessing the effects of health information technology (health IT) on patient safety outcomes. The authors employed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement methods. MEDLINE, Cumulative Index to Nursing Allied Health (CINAHL), EMBASE, and Cochrane Library databases, from 2001 to June 2012, were searched. Descriptive and comparative studies were included that involved use of health IT in a clinical setting and measured effects on patient safety outcomes. Data on setting, subjects, information technology implemented, and type of patient safety outcomes were all abstracted. The quality of the studies was evaluated by 2 independent reviewers (scored from 0 to 10). A total of 69 studies met inclusion criteria. Quality scores ranged from 1 to 9. There were 25 (36%) studies that found benefit of health IT on direct patient safety outcomes for the primary outcome measured, 43 (62%) studies that either had non-significant or mixed findings, and 1 (1%) study for which health IT had a detrimental effect. Neither the quality of the studies nor the rate of randomized control trials performed changed over time. Most studies that demonstrated a positive benefit of health IT on direct patient safety outcomes were inpatient, single-center, and either cohort or observational trials studying clinical decision support or computerized provider order entry. Many areas of health IT application remain understudied and the majority of studies have non-significant or mixed findings. Our study suggests that larger, higher quality studies need to be conducted, particularly in the long-term care and ambulatory care settings.

The Effect of Health Information Technology on Health Care Provider Communication: A Mixed-Method Protocol.

BackgroundCommunication failures between physicians and nurses are one of the most common causes of adverse events for hospitalized patients, as well as a major root cause of all sentinel events. Communication technology (ie, the electronic medical record, computerized provider order entry, email, and pagers), which is a component of health information technology (HIT), may help reduce some communication failures but increase others because of an inadequate understanding of how communication technology is used. Increasing use of health information and communication technologies is likely to affect communication between nurses and physicians.ObjectiveThe purpose of this study is to describe, in detail, how health information and communication technologies facilitate or hinder communication between nurses and physicians with the ultimate goal of identifying how we can optimize the use of these technologies to support effective communication. Effective communication is the process of developing shared understanding between communicators by establishing, testing, and maintaining relationships. Our theoretical model, based in communication and sociology theories, describes how health information and communication technologies affect communication through communication practices (ie, use of rich media; the location and availability of computers) and work relationships (ie, hierarchies and team stability). Therefore we seek to (1) identify the range of health information and communication technologies used in a national sample of medical-surgical acute care units, (2) describe communication practices and work relationships that may be influenced by health information and communication technologies in these same settings, and (3) explore how differences in health information and communication technologies, communication practices, and work relationships between physicians and nurses influence communication.MethodsThis 4-year study uses a sequential mixed-methods design, beginning with a quantitative survey followed by a two-part qualitative phase. Survey results from aim 1 will provide a detailed assessment of health information and communication technologies in use and help identify sites with variation in health information and communication technologies for the qualitative phase of the study. In aim 2, we will conduct telephone interviews with hospital personnel in up to 8 hospitals to gather in-depth information about communication practices and work relationships on medical-surgical units. In aim 3, we will collect data in 4 hospitals (selected from telephone interview results) via observation, shadowing, focus groups, and artifacts to learn how health information and communication technologies, communication practices, and work relationships affect communication.ResultsResults from aim 1 will be published in 2016. Results from aims 2 and 3 will be published in subsequent years.ConclusionsAs the majority of US hospitals do not yet have HIT fully implemented, results from our study will inform future development and implementation of health information and communication technologies to support effective communication between nurses and physicians.

Impact of the Electronic Medical Record on Mortality, Length of Stay, and Cost in the Hospital and ICU: A Systematic Review and Metaanalysis.

To evaluate effects of health information technology in the inpatient and ICU on mortality, length of stay, and cost. Methodical evaluation of the impact of health information technology on outcomes is essential for institutions to make informed decisions regarding implementation. EMBASE, Scopus, Medline, the Cochrane Review database, and Web of Science were searched from database inception through July 2013. Manual review of references of identified articles was also completed. Selection criteria included a health information technology intervention such as computerized physician order entry, clinical decision support systems, and surveillance systems, an inpatient setting, and endpoints of mortality, length of stay, or cost. Studies were screened by three reviewers. Of the 2,803 studies screened, 45 met selection criteria (1.6%). Data were abstracted on the year, design, intervention type, system used, comparator, sample sizes, and effect on outcomes. Studies were abstracted independently by three reviewers. There was a significant effect of surveillance systems on in-hospital mortality (odds ratio, 0.85; 95% CI, 0.76-0.94; I=59%). All other quantitative analyses of health information technology interventions effect on mortality and length of stay were not statistically significant. Cost was unable to be quantitatively evaluated. Qualitative synthesis of studies of each outcome demonstrated significant study heterogeneity and small clinical effects. Electronic interventions were not shown to have a substantial effect on mortality, length of stay, or cost. This may be due to the small number of studies that were able to be aggregately analyzed due to the heterogeneity of study populations, interventions, and endpoints. Better evidence is needed to identify the most meaningful ways to implement and use health information technology and before a statement of the effect of these systems on patient outcomes can be made.

Effects of health information technology on malpractice insurance premiums.

ObjectivesThe widespread adoption of health information technology (IT) will help contain health care costs by decreasing inefficiencies in healthcare delivery. Theoretically, health IT could lower hospitals' malpractice insurance premiums (MIPs) and improve the quality of care by reducing the number and size of malpractice. This study examines the relationship between health IT investment and MIP using California hospital data from 2006 to 2007.MethodsTo examine the effect of hospital IT on malpractice insurance expense, a generalized estimating equation (GEE) was employed.ResultsIt was found that health IT investment was not negatively associated with MIP. Health IT was reported to reduce medical error and improve efficiency. Thus, it may reduce malpractice claims from patients, which will reduce malpractice insurance expenses for hospitals. However, health IT adoption could lead to increases in MIPs. For example, we expect increases in MIPs of about 1.2% and 1.5%, respectively, when health IT and labor increase by 10%.ConclusionsThis study examined the effect of health IT investment on MIPs controlling other hospital and market, and volume characteristics. Against our expectation, we found that health IT investment was not negatively associated with MIP. There may be some possible reasons that the real effect of health IT on MIPs was not observed; barriers including communication problems among health ITs, shorter sample period, lower IT investment, and lack of a quality of care measure as a moderating variable.