Local Audit Research Articles

Governance of maternity services: Effects on the management of perinatal deaths and bereavement services

Background: External inquiries are carried out following adverse maternal/perinatal events, to examine the care provided and make recommendations to improve it. Clinical governance ensures that organisations promote high-quality care and are accountable for the care they provide, thus contributing to its improvement.Objective: This study examined how Irish perinatal bereavement services and the management of perinatal deaths (including events leading up to the deaths) were affected by developments in maternity services governance as described in ten Irish enquiry reports published over 14 years (2005–18).Methods: Two clinicians collected data from the ten enquiry reports by using a specifically designed review tool. Thematic analysis was carried out, following the steps of familiarising, coding, identifying, grouping and revising themes.Findings: Seven main themes were identified: workforce, leadership, management of risk, work environment, hospital oversight, national documents, data collection. Eight reports noted shortcomings in staffing levels, with a workforce that was under-resourced, and at times carried excessive workloads. The absence of 24/7 midwifery-shift leaders in maternity units resulted in problems with care at times not being escalated appropriately. The absence of a widely-owned, understood strategic plan for the management of the maternity services was mentioned in the reports from 2013.Conclusions and implications for practiceThe National Bereavement Care Standards were published in 2016 to address deficiencies identified in the enquiry reports and to standardise perinatal bereavement care across Irish maternity units. Though the first Irish Maternity Strategy (2016–26) was published in 2016, its implementation is incomplete. Inconsistencies remain in the definition and collection of national perinatal data, as well as concerns regarding the lack of local audit activities on pregnancy outcomes. Greater focus on hospital oversight, implementation of national documents and reliable data collection is required. To be effective and initiate positive changes in clinical services, documents such as incident reviews, national strategies and national reports including inquiries, need to include realistic recommendations with clear timelines and responsibilities for implementation.

Improvements and Shortcomings in Emergency Oxygen Prescribing: A Quality Improvement Initiative at an Acute Tertiary Care Hospital

Oxygen is one of the most commonly used yet poorly prescribed drugs. The 2015 British Thoracic Society (BTS) emergency oxygen audit highlighted the national shortcomings in oxygen prescribing and administration. A 2017 local audit at the Royal Sussex County Hospital, Brighton, UK, continued to demonstrate poor compliance with the BTS Oxygen Prescribing Guidelines in all areas audited. This study carried out yearly reaudits in November 2018 and 2019 to objectively measure the impact of implementing trust-wide and local interventions (July 2018 and August 2019).Intervention 1 included introduction of the National Early Warning Score (NEWS2) scale and redesigning drug charts with tick-boxes for target oxygen saturations. Intervention 2 included mandatory junior doctor teaching on safe oxygen prescribing, ‘oxygen safety’ posters on audited wards, and reminders at handover for staff to measure and document oxygen saturations.Following Intervention 1, all patients with valid oxygen prescriptions had a specified target saturations range. Intervention 2 ensured all patients had actual saturations within their prescribed target range, and 99% had oxygen saturations documented with sufficient frequency for their NEWS2 score. These were huge improvements from previous audits, during which a significant proportion of patients were at risk of hypercapnia, and those over- or underoxygenated were left unrecognised for hours. Despite improvements, 14% of patients continued to use oxygen without valid prescriptions in 2019, and drug charts were inconsistently signed for during drug rounds.Although the implemented changes enabled drastic improvements for patient safety and quality in oxygen use, future work should ensure oxygen is always treated as a drug with suitable prescription and documentation.

134 Quantitative Assessment of Visual Function for Pituitary Macroadenomas: A Practical Scoring Algorithm

Abstract Introduction There is a myriad of existing terms by which visual capacity is recorded. The lack of a standardised categorisation of observations commonly results in ambiguities. We report the utility of a visual function score (VFS) in patients managed by transsphenoidal surgery. Method A VFS (expressed as a percentage) with a maximum score of 20 was calculated for each eye using the Snellen VA (40% weighting: score 0-8) and Humphrey Allergan 30-2 automated visual field (60% weighting: score 0-12). Results 280 patients (560 eyes) underwent transsphenoidal pituitary adenoma resections with complete pre- and post-operative visual function assessment. Mean age 56 years; 56.4% male. 26.1% were treated by endoscopic technique and 73.9% were treated by microscopic technique. Pre-operative vision was normal in 38.0% eyes. All these had full post-operative vision. In patients with pre-operative visual loss (347 eyes), the mean pre-operative VFS rose from 70.8% to 87.5% post-operatively. 43.8% eyes attained full post-operative vision, 28% improved, and 25.6% remained unchanged. 9 patients (2.6%) had worse immediate post-operative vision. Conclusions The VFS is a convenient single measure of visual function that may facilitate local and national audit of transsphenoidal surgery. Studies are planned to correlate this with patient reported visual quality of life measures.

264 Intertrochantic Hip Fracture Fixation at Musgrove Park Hospital

Abstract Background Hip fractures, the commonest fragility fracture in the UK, carry a 6.7% 30-day mortality. NICE-CG124 guide advises extramedullary implants for trochanteric (AO3.1A1/2) and intramedullary nails for subtrochanteric fractures. We carried out a retrospective study on the use of cephalomedullary nails (CMN) at MPH to determine compliance with CG124. Method National Hip Fracture Database (NHFD) from 2019 was reviewed. Trust records were used for fracture type, surgery, and reasons for deviation from CG124. Results 201 fractures were identified. NHFD revealed 38 A3 fractures of which 36 underwent CMN, one SHS and one non-operative management. Of 163 A1/A2 fractures, 33 received CMN and 130 CHS. Only 77% of the NHFD data was correct. Further analysis revealed 18 CMNs were used for AO1/2 injuries. All had justifiable reasons for deviation from CG124, although not documented. Conclusions There is scope to improve accuracy of NHFD data. Deviation from guidelines may be appropriate but reasons must be documented and, when appropriate, discussed with patient. Similar nationwide inaccuracy can have significant implications for research based upon NHFD data. To prevent input of incorrect data, our recommendations include: Consultant to confirm AO grade during trauma meetings Reason CMN used for AO1/2 fractures to be documented Monthly local NHFD data audit

678 An Audit of TRUS Biopsy Sepsis Within A District General Hospital Setting

Abstract Introduction Transrectal ultrasound (TRUS) biopsy is the standard investigation of suspected prostate cancer within the United Kingdom. TRUS biopsy has significant risks of associated complications, the most serious being sepsis. An audit was designed to evaluate the rate of sepsis following TRUS biopsy within a district general hospital setting. Method All men who underwent TRUS biopsy over a four-month period between October 2019 and January 2020 were retrospectively reviewed. Standard rate of sepsis for benchmarking was identified as 0.8% as quoted in the European Association of Urology (EAU) prostate cancer guidelines. Results 88 men underwent TRUS biopsy between October and January. Three cases of TRUS biopsy sepsis requiring hospital admission were identified. The rate of sepsis determined was 3.4%. The average length of stay for the cases was 4.7 days. Oral co-trimoxazole was used as the empirical antibiotic prophylaxis pre-procedure in all. Conclusions The rate of sepsis was higher than the figure quoted in EAU guidelines. Routine local audit for TRUS sepsis is necessary to maintain standards and efficacy of prophylaxis, as well as the accurate counselling of patients on the expected risks of the procedure. Consideration should be given to targeted antibiotic prophylaxis based on pre-biopsy rectal swabs.

541 Investigation of Suspected Prostate Cancer In UK; Evaluation of Local Practice and Feasibility of Moving Towards MRI As First Line Investigation – Re-Audit Following Change of Radiology Staffing

Abstract Introduction NICE recommends MRI as first-line investigation for suspected clinically localised prostate cancer (PCa); previous local audit findings suggest this to be safe and feasible to implement. Recent retirement of radiology staffing however had resulted in MRIs being reported by teleconsultation radiology service. There were concerns on whether this may lead to more missed significant PCa. We performed a re-audit on our prostate MRI and biopsy to assess if this is indeed the case. Method All patients with suspected PCa who have had prostate MRI and biopsy simultaneously from April-August 2019 were retrospectively analysed. Results 222 men were included. 36% of patients with negative MRI had positive biopsies; within this group 25% had significant disease (Gleason grade group ≥2). Compared with our previous audit, specificity for significant PCa has increased (from 34% to 46%), but with a reduced negative predictive value (from 97% to 91%). Conclusions If we are to implement MRI as first-line triage for potential subsequent biopsy, it would result in more men not going for a biopsy (from 18% to 25%), a reduction in diagnosis of non-significant PCa (from 21% to 36%), but at an expense of increase in missed significant PCa (from 3% to 9%).

P061 Patient experience of telephone helpline service during the COVID-19 pandemic

Background/Aims The rheumatology telephone helpline is a nurse-led essential service that provides reliable medical advice, social and psychological support to help patients cope with the disease. An efficient service is especially important during the COVID-19 pandemic as a significant proportion of rheumatology patients are ‘shielding’ because of immunosuppression and their underlying chronic rheumatological conditions. The pandemic resulted in several drastic changes to the rheumatology department at United Lincolnshire Hospital Trust (ULHT), such re-deployment of staff to the frontline. We performed a local audit to assess patient satisfaction and fulfilment of expectations with the helpline during the lockdown and identify areas of improvement to provide an effective helpline service. Methods Patients accessed the helpline by leaving a message over the phone and fifty patients were selected using random sampling. We designed a questionnaire in adherence to RCN guideline. After their query was resolved and obtaining their consent, we assessed their experience by calling them. We analysed the subject of the query and the outcome of the call retrospectively. We aimed to determine if they were psychologically supported, satisfied with the response time and overall, how the query was resolved. We explored their feedback and alternative choices had the helpline not been available. Results A significant proportion (40%) of queries were regarding worsening symptoms of rheumatological conditions. Some of these queries were in context of COVID-19. 35% of the queries were medications related. 94% of the calls were attended within 48 hours. Of 50 patients, 88% (44/50) were satisfied with the response time, 82% (41/50) were satisfied with the overall service, and 88% (44/50) felt they were psychologically supported. 94% (47/50) of the respondents have said that they will call the helpline again if required. Had the helpline not been available, 64% (32/50) patients would have visited their GP and 10% (5/50) would have attended A&E. Nearly 29% of the outcome of the queries were verbal advice alone without further consultations. Other major outcomes were appointment with doctors and prescription renewals. Patient feedback allowed us to identify issues involving communication between patients, GPs and the rheumatology department. Conclusion The helpline continued to be highly appreciated by the patients. It plays a crucial role in alleviating patients’ medical and psychological concerns and maintaining continuity of care. During the pandemic, there is an increased necessity to access an effective helpline. Several important changes were made to streamline the information on the trust’s rheumatology web page. We also amended the voice message to better triage patients. A rheumatology helpline template was added for record keeping through the digital dictation system. This will allow the department to communicate with GPs within 48 hours of response; to alert them regarding changes in medications or other management recommendations. Disclosure A.T. Devarakonda: None. S. Obaid: None. C. Faqihinejad: None.

Achievements and challenges during the development of an advance care planning program

A nationwide program to promote preparation of advance care plans (AC Plans) was introduced in Canterbury, New Zealand, in 2013. The program was developed by local facilitators who provided support and organised education seminars and an accredited training program for health-care professionals. Information and templates for an AC Plan were available to these professionals and the community on local health-care websites and secure online systems designed to allow plans to be viewed across all health-care sectors. The number of AC Plans prepared has increased steadily, although people in minority ethnic populations or in the most deprived socioeconomic quintile are less likely to have a plan. While nurses have become the predominant group guiding people through the process of preparing an AC Plan, the involvement of staff in residential care homes has remained low. Local audit showed that 82% of people with an AC Plan died in a community setting, frequently their preferred place of death.

P99 Quantitative Assessment of Visual Function for Pituitary Macroadenomas: A Practical Scoring Algorithm

Abstract Background There is a myriad of existing terms by which visual capacity is recorded. The lack of a standardised categorisation of observations commonly result in ambiguities. We report the utility of a visual function score (VFS) in patients managed by transsphenoidal surgery. Methods A VFS (expressed as a percentage) with a maximum score of 20 was calculated for each eye using the Snellen VA (40% weighting: score 0-8) and Humphrey Allergan 30-2 automated visual field (60% weighting: score 0-12). Results 280 patients (560 eyes) underwent transsphenoidal pituitary adenoma resections with complete pre and post-operative visual function assessment. Mean age 56 years; 56.4% male. 26.1% were treated by endoscopic technique and 73.9% by microscopic technique. Pre-operative vision was normal in 38.0% eyes and had full post-operative vision. In patients with pre-operative visual loss, the mean pre-operative VFS rose from 70.8% to 87.5% post-operatively. 43.8% eyes attained full post-operative vision, 28% improved, and 25.6% remained unchanged. 9 patients (2.6%) had worse immediate post-operative vision. Discussion The VFS is a convenient single measure of visual function that may facilitate local and national audit of transsphenoidal surgery. Studies are planned to correlate this with patient reported visual quality of life measures

The future of the regulatory space in local government audit: A comparative study of the four countries of the United Kingdom

AbstractThis paper compares audit regulatory space in local government between the U.K.’s four countries – England, Northern Ireland, Scotland, and Wales. It addresses current arrangements and practices, their historical background, and rationales for regulation in order to derive lessons for the future of public audit. It draws on the notion of regulatory space as extended through new audit spaces that specifically include public audit. The study is based on interviews with audit professionals and policy makers in each country, extensive documentation review, and observation. The comparison is structured by four themes: ‘Organisation and fragmentation’ concerns how the system is accredited and imbued with institutional capital. ‘Independence and competition’ addresses the independence of accounting firms and auditors, ‘audit scope’ reporting, and ‘inspection’ the assessments and rankings that have become part of public audit. The four countries exhibited similar emphasis on financial audit and reporting. They treated performance and fairness aspects differently.

Does Client Cyber-Breach Have Reputational Consequences for the Local Audit Office?

SYNOPSISWe examine whether the public disclosure of a client cyber-breach hurts the reputation of the engagement office of the incumbent auditor. Prior research suggests that alleged client misconduct (even if unrelated to accounting) can hurt the auditor's reputation and bargaining position vis-à-vis other clients. In contrast, in a client cyber-breach, the client is the victim of misconduct rather than perpetrator of the misconduct. Still, for the 100 largest breaches during 2005–2018, we find evidence of a loss in the perceived value of the audit for the non-breach clients of that local audit office. For our sample of all breaches during 2005–2018, our results indicate a decline in the bargaining position for the incumbent audit office. We contribute to the literature by documenting that the negative effects of a cyber-breach are not limited to the breached client but spillover to the local audit office.

Local audit of empiric antibiotic therapy in bacteremia: A retrospective cohort study.

It is unclear if a local audit would be useful in providing guidance on how to improve local practice of empiric antibiotic therapy. We performed an audit of antibiotic therapy in bacteremia to evaluate the proportion and risk factors for inadequate empiric antibiotic coverage. This retrospective cohort study included patients with positive blood cultures across 3 hospitals in Hamilton, Ontario, Canada during October of 2019. Antibiotic therapy was considered empiric if it was administered within 24 hours after blood culture collection. Adequate coverage was defined as when the isolate from blood culture was tested to be susceptible to the empiric antibiotic. A multivariable logistic regression model was used to predict inadequate empiric coverage. Diagnostic accuracy of a clinical pathway based on patient risk factors was compared to clinician's decision in predicting which bacteria to empirically cover. Of 201 bacteremia cases, empiric coverage was inadequate in 56 (27.9%) cases. Risk factors for inadequate empiric coverage included unknown source at initiation of antibiotic therapy (adjusted odds ratio (aOR) of 2.76 95% CI 1.27-6.01, P = 0.010) and prior antibiotic therapy within 90 days (aOR of 2.46 95% CI 1.30-4.74, P = 0.006). A clinical pathway that considered community-associated infection as low risk for Pseudomonas was better at ruling out Pseudomonas bacteremia with a negative likelihood ratio of 0.17 (95% CI 0.03-1.10) compared to clinician's decision with negative likelihood ratio of 0.34 (95% CI 0.10-1.22). An audit of antibiotic therapy in bacteremia is feasible and may provide useful feedback on how to locally improve empiric antibiotic therapy.

46 Promoting Advance Care Planning of Patients with Parkinsonism in the Community

Abstract Introduction NICE guideline recommends that all patients with Parkinson’s disease should be reviewed every 6–12 months and offered opportunities to discuss Advanced Care Planning (ACP) (1, 2). There is evidence demonstrating that Advanced Care Plans results in shorter length of stay in the last year of life and lower hospital costs (2, 3). A local baseline audit showed that Advanced Care Planning was not performed adequately. Methods A local baseline audit on community care home patients with Parkinsonism was completed in February 2018. A community-based Parkinson’s clinic was commenced in June 2018. Patients with parkinsonism who were unable to attend hospital clinics due to underlying frailty, neuropsychiatry and physical issues, were reviewed. At each visit, advice was provided on medicines management and there were discussions around Advance Care Planning. A re-audit was completed in August 2019. Patient’s Electronic Patient Records were scrutinised to evaluate progress and identify those who had died. Data was analysed using Microsoft Excel. Results The initiative contributed directly to end of life care in 7/17 patients. Parkinson’s disease medications were rationalised in 11/17 (64.70%). 14/17 (82.35%) had a community-based Do Not Resuscitate order completed. Conclusions The community Parkinson’s clinic service promoted Advance Care Planning in patients with Parkinsonism. This service provides specialist input in frail older people with Parkinsonism who were unable to attend hospital clinic, promoting end of life choices around where they wished to die and avoiding unnecessary hospitalisation in the final stages of their life.

LONG TERM CONDITIONS AND MENTAL HEALTH: AN AUDIT OF LOCAL DATA

Objective: Studies have shown that mental health is affected by poor physical health, with people living in the deprived area are the most affected. Community Pharmacists potentially have a new role in supporting people with mental illness and dementia to manage their medications. The aim of this local audit was to compare the local population to the national and global population, to inform the development and provision of local pharmacy mental health screening services, to support patients diagnosed with long-term conditions.
 Methods: This project was designed as an audit of anonymised local data, to inform the development of services offered by community pharmacies to improve adherence to therapy amongst patients diagnosed with long-term conditions in the Black Country, UK. It forms part of a larger study granted ethical approval by the Health Research Authority in 2018. It was carried out against the background of the Covid-19 epidemic. A total of 652 patients pharmacy records were reviewed between March and April 2020. No patient identifiers were included in the reviewed data.
 Results: This means that the results of this analysis might not be applicable to the entire local population outside the 31-90 y of age range.
 Conclusion: It is was demonstrated during COVID-19 that pharmacists are well-positioned as easily accessible health care facilities to support patients, especially when the other NHS facilities are stretched or closed. Community pharmacies are in a position to offer large-scale screening programs such as self-completed anxiety, depression and cognitive function screening surveys and refer to general practitioners for further investigations. It is also recommended that the New Medicines Service include mental health disorder patients prescribed pharmacological therapy and to allow the pharmacists appropriate access to medical records to facilitate safe, integrated and effective patient care.

Potentially preventable antepartum stillbirths in a high-resource setting: a prospective audit-based study

ObjectivesThe primary objective was the identification of sub-standard care in antepartum stillbirths in Emilia-Romagna Region (Italy), hence the number of potentially preventable cases. Secondly, we seek to evaluate any association between inadequate care and either risk factors for stillbirth or causes of death. Study DesignThis study was based on prospectively-collected data in an institutional stillbirth audit project, involving all 29 hospital with a maternity unit in Emilia-Romagna Region. For each stillbirth occurred in the area from 2014 to the first semester of 2019 the same diagnostic workup was performed and a clinical record with data about mother and stillborn was completed. Every case was discussed in a multidisciplinary local audit to assess both the cause of death and the quality of care. Two aspects of care quality were evaluated: clinical management and women’s access to care. Data were then reviewed by the Regional Audit Group. ResultsElements of inadequate care were identified in 56 out of 524 (10.7 %) fetal deaths. Non-Italian women and pregnancies with fetal growth restriction had double the risk of having received inadequate care during pregnancy, compared to Italian women (aOR 2.0, 95 % CI 1.1–3.6) and a normally developing fetus (aOR 2.0, 95 % CI 1.1–4.1), respectively. Women whose stillbirth was caused by maternal disorders were at higher risk for inadequate care compared to women who had stillbirth explained by other cause (aOR 5.89, 95 %CI 2.2–15.4). Sub-optimal clinical management and barriers to access to care were observed to equal extents. Inappropriate ultrasound monitoring was the most frequent suboptimal care element. ConclusionsAbout one out of ten stillbirths was potentially preventable. Interventions to reduce stillbirth occurrence in our high-resource setting should focus on appropriate diagnosis and management of maternal disorders and fetal growth restriction, as well as improving access to antenatal care.

Ownership of local corporations and audit committee diligence: An empirical evidence from an emerging economy

This study examines whether local corporate ownership is associated with audit committee diligence among 431 listed manufactured firms in Saudi Stock Exchange (Tadawul) for the period 2012-2019. Using the complementary hypothesis, this study expected that there is a positive relationship between local corporate ownership and audit committee diligence. The Pooled OLS regression shows that local corporate ownership is positively associated with audit committee diligence. The findings reported by this study have implications for regulators, companies’ management, auditors, and creditors in a manner that they would gain a deeper understanding on how the local corporate ownership impacts the audit committee diligence.

A nationwide surveillance system to reduce perinatal death cases in Italy: implementing apopulation-based pilot project.

to describe the methodology of a pilot perinatal mortality surveillance system (SPItOSS) aimed to improve quality of care and prevent avoidable perinatal severe morbidity and mortality in three Italian regions. population-based surveillance project monitoring incident cases of stillbirths, born dead ≥ 28 weeks of gestation and live births dying within 7 days. Local multidisciplinary audits in obstetric and neonatal units were conducted to assess causes of each death. A selection of deaths was also discussed by experts in regional and national Confidential Enquiries to assess causes and avoidability. The WHO perinatal mortality definition and the ICD-PM classification were adopted to codify perinatal deaths. health professionals working in any obstetric and neonatal unit in Lombardy (Northern Italy), Tuscany (Central Italy), and Sicily (Southern Italy), accounting for 32.3% of births in Italy. Data collection started on 01.07.2017 and ended on 30.06.2019. obstetric and neonatal units' participation rate in the participating regions, facility structural organisation description, health professionals' training course participation, estimate of perinatal death rates, clinical audits and Confidential Enquiries rates. health professionals from all obstetric and/or neonatal units (N. 138) joined the pilot project. Overall, 830 incident perinatal deaths were reported; 699 underwent a facility-based clinical audit, and 94 selected cases were analysed in detail through regional and national Confidential Enquiries. Among the latter, 16.0% were assessed as avoidable deaths. Interregional differences related to the facility structural organisation were identified. SPItOSS was efficient in identifying and analysing incident cases of perinatal deaths and detecting improvable aspects of care and avoidable perinatal deaths. The next objective is to extend the surveillance at the national level, considering that stable funding and a higher number of participating healthcare professionals and experts will be needed.

The effectiveness of local government financial statement audit by public accounting firm

The effectiveness of local government financial statement audit by public accounting firm

A Machine Learning Approach to Analyze and Support Anti-Corruption Policy

Can machine learning support better governance? In the context of Brazilian municipalities, 2001-2012, we have access to detailed accounts of local budgets and audit data on the associated fiscal corruption. Using the budget variables as predictors, we train a tree-based gradient-boosted classifier to predict the presence of corruption in held-out test data. The trained model, when applied to new data, provides a prediction-based measure of corruption that can be used for new empirical analysis or to support policy responses. We validate the empirical usefulness of this measure by replicating and extending some previous empirical evidence on corruption issues in Brazil. We then explore how the predictions can be used to support policies toward corruption. Our policy simulations show that, relative to the status quo policy of random audits, a targeted policy guided by the machine predictions could detect almost twice as many corrupt municipalities for the same audit rate. Similar gains can be achieved for a politically neutral targeting policy that equalizes audit rates across political parties.

Could the minimization of opportunity prevent fraud? An empirical study in the auditors’ perspective

Fraud prevention is the best effort to solve fraud problems. Minimizing opportunities can be one of the factors that needs to be considered to prevent fraud. This research aimed to analyze the effect minimization opportunity, which consists of several variables, specifically methods of prevention and detection of fraud, internal control, management policy and management integrity, to the prevention of fraud in point of view of the auditors of the Audit Board of the Republic of Indonesia and the local government internal auditors. Data collected by using a questionnaire. Usable sample consisted of 79 respondents. Data were tested using PLS. The research result declared that internal control is an effective factor to minimize opportunities to prevent fraud. Another finding from the study was that fraud prevention and detection methods were not able to reduce fraud. Instead, the fraud prevention and detection methods have a positive effect on the likelihood of fraud. The important thing that needs to be considered in future research is that the distribution of questionnaires to internal and external auditors can be carried out proportionally so that the perceptions of each party can be tested and compared.