Quality Improvement Study Research Articles

A Quality Improvement Study for Cervical Cancer Screening: Estimating the use of cotesting versus Reflex HPV testing at the time of screening

Abstract Introduction/Objective The recommendations for cervical cancer screening have changed over the years. One of the major changes include inclusion of HPV testing in the screening protocols. A brief scan of our lab data indicated that during the period of Jan-Oct 2023, a small group of women over the age of 30 have not been co-tested. While cytology alone is acceptable, it is less sensitive than other recommended screening options. Therefore, the quality of care these women receive is acceptable but not preferred. We aim to quantify those cases, find reasons why HPV testing was not ordered, and estimate the usage of reflex HPV testing. Methods/Case Report A retrospective analysis was performed of patients screened for cervical cancer with pap testing over 10 months (Jan - Oct 2023) at Geisinger Medical Laboratories. Out of 32849 patients screened for cervical cancer, we identified 546 cases without HPV testing. A chart review of the cases was performed, followed by sending a survey to the respective providers to find out when they prefer reflex HPV testing over cotesting. Results (if a Case Study enter NA) Data analysis showed that 546 out of 32849 cases were screened without co- testing by 102 providers. These providers checked the “HPV if ASCUS” option in the HPV permission section of the cytology requisition form. These cases were diagnosed as Negative for Intraepithelial Lesion on a pap test. We sent a survey to the providers, and responses showed that the reflex HPV testing option is used for patients younger than 30 years by 90% of the providers. Only 10% of providers use cytology alone due to cost issues for patients over 30. Most providers (60%) do not want the reflex testing option to be removed from the HVP permission section. Conclusion The majority of the women above 30 years of age are screened for cervical cancer with co-testing, but a small group (1.6%) is tested with cytology alone mainly due to cost-benefit hence compromising on the sensitivity of the screening test. We recommend the following changes to our cytology requisition form. If the provider selects HPV Reflex testing, the HPV test should be performed in the following scenarios: a) The pap test’s final diagnosis is NIL, and the patient is between ages 30-64. b) The pap test’s final diagnosis is ASCUS, and the patient is between ages 21 and 64. c) The pap test’s final diagnosis is LSIL; the patient is non-pregnant and between ages 25 and 64. Modifying the HPV Reflex option will improve the quality of our patient care and align our practices with current recommendations.

Co-design of a nurse handover tool to optimise infection control and antimicrobial stewardship in a low resource setting intensive care unit: A nurse led collaboration

Background The quality of intensive care unit (ICU) nursing handover impacts patient safety, including infection prevention and control (IPC) and antimicrobial stewardship (AMS) practices. We report a co-designed quality improvement study using a visual, structured nurse handover tool in a low resource setting. Methods The study was conducted with clinical nurses in an 8-bed medical ICU at a tertiary hospital in South Africa. Using a participatory action research (PAR) framework and visual participatory methods, the handover tool development had three phases: data collection, journal club, and co-design. To engage busy nurses and create real-time discussions and input, 7-minute focussed sessions in the ICUs using large-scale graphics to facilitate were used. Qualitative data were thematically analysed. Results Between September – October 2022, baseline data were collected from 16 handovers (46 patient discussions over 4 hours). The tool was co-designed through 18 contact sessions involving 31 nurses (April–June 2023). Variation was observed in patterns of handover structure (sequence of what was presented) and content (type and the level of detail of information provided). An evidence-based visual tool was co-designed to identify and manage key patient care risk factors. The tool included a structured section to report on IPC and AMS. Nurses reported the visual prompts to be beneficial to ensuring consistent inclusion of critical information in handovers. Conclusions An innovative approach involving ICU nurses in co-designing a visual handover tool resulted in a structured method for systematically reporting patient care risk factors, body systems, IPC, and AMS. Implementation and dissemination in this unit, and expansion to other units, is underway to promote sustainable change in nursing clinical practices.

Adherence to Preoperative Fasting Guidelines in Elective Surgical Patients.

Preoperative fasting is recommended by international guidelines as a means to minimize the risk of aspiration of gastric content during induction of anesthesia or surgery. Prolonged preoperative fasting is, however, discouraged due to the associated side effects such as dehydration and electrolyte imbalance, which can negatively impact recovery after surgery. An initial quality improvement study revealed poor implementation of the best practice guidelines on preoperative fasting in three departments of a hospital and an institutional action plan was devised to enforce adherence to these guidelines. This present study aimed to assess compliance with the action plan and for that matter, adherence to international consensus on preoperative fasting in three surgical departments. Adult patients undergoing elective cardiac, thoracic, and vascular surgery at a university teaching hospital were surveyed over four months (September October, November, and December of 2023). Data on the length of preoperative fasting was collected using a standardized questionnaire. A total of 306 patients who were scheduled for elective surgery were included in the study. Of the 306 patients, 139 (45.4%) had vascular surgeries, 108 (35.4%) received cardiac surgeries, and 59 (19.3%) had thoracic surgeries. For clear fluids, the overall median fasting time (Q1, Q3) was 4.5 (2.7, 7.4) hours, and for solid food, 14.5 (12.1, 19.0) hours. Extended abstinence from clear fluids and solid food for more than 12 hours was observed in 43 (14.1%) and 231 (75.5%) instances, respectively, while abstinence from solid food for more than 24 hours was noticed in 40 (13.1%)cases. When compared to patients having operations in the morning, those scheduled for afternoon surgery had longer median fasting periods from clear fluids and solid food, p<0.001: 6.2 (4.0, 12.0) hours vs. 3.4 (2.0, 5.2) hours for clear fluids and 16.7 (12.6, 22.6) hours vs. 13.2 (9.6, 15.2) hours for solid food, respectively. Patients continue to abstain from clear fluids and solid food for extended periods of time, despite the fact that there is worldwide agreement regarding shorter periods of preoperative fasting. Compared to patients undergoing morning surgery, individuals hospitalized for afternoon procedures were more likely to fast for extended periods of time.

Utility of Artificial Intelligence–Generative Draft Replies to Patient Messages

This quality improvement study analyzes the usefulness of patient message replies drafted by artificial intelligence for various health care practitioners.

Development and implementation of autoverification standardization in the adult and pediatric emergency department.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. This project utilized the guidance of the American Society of Health-System Pharmacists (ASHP) autoverification toolkit to refine our health system's approach to autoverification and contribute to the literature regarding appropriate use of autoverification technology in a pediatric and adult emergency department (ED). This single-center quality improvement study was conducted in an academic medical center ED that has 33 pediatric beds and 77 adult beds. A team consisting of clinical pharmacy specialists in emergency medicine, medication safety and informatics personnel, operational managers, and pharmacy leadership was identified to develop and implement autoverification best practices in the ED utilizing practices outlined within the ASHP autoverification toolkit. Before implementation of best practices, defined as the "preoptimization" state, autoverification took place for most medications available in the automated dispensing cabinets (ADCs). By anchoring the autoverification rule on ADC inventory, it was challenging to optimize both inventory practices and autoverification best practices. This project focused on redesigning the autoverification rules in the electronic health record, defined as the "postoptimization" state. In the postoptimization state, autoverification in the ED was updated to better align with regulatory standards. Autoverification metrics and the percentage of orders that autoverified vs required pharmacist verification were analyzed in the preoptimization and postoptimization states. This project utilized the guidance from ASHP's autoverification toolkit to refine our health system's approach to autoverification. High-alert medications (eg, insulin, extended-release opioids, digoxin) were taken off autoverification following implementation. Optimization of autoverification rules allows more orders for high-alert medications to be reviewed by a pharmacist.

Clinical Impact of 3- versus 5-Minute Delay and 30- versus 60-Second Intervals on Unattended Automated Office Blood Pressure Measurements.

Guidelines advise automated office blood pressure (AOBP) with an initial 5-minute delay and multiple measurements at least 60 seconds apart. Recent studies suggest that AOBP may be accurate with shorter delays or intervals, but evidence in clinical settings is limited. Patients referred to one hypertension (HTN) center underwent 24-hour ambulatory blood pressure monitoring (ABPM) and one of four non-randomized, unattended AOBP protocols: a 3- or 5-minute delay with a 30 or 60-second interval, i.e., 3min/30sec/30sec, 3/60/60, 5/30/30 and 5/60/60 protocols. HTN was defined as systolic blood pressure ≥140 or diastolic blood pressure ≥90 mmHg. We compared differences in mean blood pressure and HTN classification between average AOBP and awake-time ABPM by t-tests and Fisher's exact test. Among 212 participants (mean 58.9 years, 61% women, 25% Black), there was substantial overlap in the probability distributions of awake-time ABPM and each of the three AOBP measures. Systolic blood pressure means were similar between the 5/60/60 and 3/30/30 protocols and 5/30/30 and 3/60/60 protocols. The 5/30/30 was associated with a higher proportion of systolic HTN, while the 3/60/60 protocol was associated with a higher proportion of diastolic HTN. There were no significant differences in systolic or diastolic HTN between 5/60/60 and 3/30/30 protocols with respect to awake-time ABPM. In this quality improvement study, the shortest AOBP protocol did not differ significantly from the longest protocol. The time savings of shorter protocols may improve AOBP adoption in clinical practice without meaningfully compromising accuracy.

Effectiveness of telehealth-delivered massed trauma-focused psychotherapy among veterans with posttraumatic stress disorder.

Trauma-focused psychotherapies can be effectively delivered using a massed delivery format. Telehealth treatment for posttraumatic stress disorder (PTSD) using evidence-based interventions has been shown to be as effective as in-person treatment. However, the effectiveness of evidence-based treatments for PTSD over telehealth using the massed delivery format requires further examination. To examine the effectiveness of telehealth massed PTSD treatment, we report on a quality improvement study of 33 veterans (75.8% male; MAge = 42.3, SD = 11.0) who participated in a virtual 4-week massed PTSD program at a Department of Veterans Affairs (VA) medical center. Twenty-seven (81.8%) veterans completed the treatment and reported large reductions in PTSD (d = 1.48) and depressive symptoms (d = 1.08) at Week 4 and at 1-month follow-up (PTSD, d = 1.34; depression, d = 0.70). Results suggested that evidence-based treatment for PTSD can be effectively delivered in a massed format over telehealth in a VA medical setting. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Using QI to develop a sustainable method for titrating taxane infusions to reduce hypersensitivity reactions.

To develop a sustainable three-step method for titrating first and second taxane exposures through integration of best practices in patient and environmental safety; and to evaluate the impact on immediate hypersensitivity rates. A quality improvement study was initiated at a large, NCI-designated comprehensive cancer center in the U.S. to determine a sustainable method of slow, upward titration for reducing taxane-related hypersensitivity reactions. Multidisciplinary collaboration led to the incorporation of best practices for safe preparation and administration of high risk, hazardous drugs. Retrospective data from the electronic health records of 690 patients who received 1221 taxane doses were analyzed. Non-titrated infusions were compared with infusions titrated using a method initially tested for efficacy; and infusions titrated using a method revised for greater compliance with safety standards. Two-sided Fisher's exact tests at a 0.1 level of significance were used to detect differences in the rate of HSR between the three groups. A method of taxane titration that incorporated standardized, preprogrammed infusion rates and tubing primed with inert IV fluid showed a significant reduction in HSR incidence in comparison to non-titrated infusions (6% v. 19%, P = 0.001) and a similar decrease in the rate of HSR (6%) to the initial method previously studied (7%) (P = 0.659) which was not sustainable due to patient and environmental safety concerns. A three-step titration method using standardized, preprogrammed infusion rates and tubing primed with inert IV fluid reduced taxane-related HSRs and was adopted as sustainable practice in ambulatory cancer care.

Evaluating Pediatric Macrolide Allergy Using Direct Graded Oral Challenges

This quality improvement study evaluates the use of direct graded oral challenge to confirm suspected macrolide allergy in children.

8152 Benefits of Inpatient Diabetes Management by a Specialized Diabetes Team

Abstract Disclosure: M. Bojarian: None. A. Ohri: None. C. Buettner: None. Background: Inpatient dysglycemia is associated with poor clinical outcomes such as prolonged length of stay (LOS), increased risk of ICU admission, and in-hospital mortality. The benefits of managing diabetic patients in the hospital with a dedicated diabetes team, as opposed to standard care on episodes of hypoglycemia or hyperglycemia, reduction in LOS, and 30-day readmission rates, remain uncertain. A potential confounder is the likelihood that patients receiving a diabetes consult may be sicker than those without a consult. Given the growing evidence supporting the role of specialized diabetes teams in improving care for diabetes patients, we sought to examine these benefits at our hospital. We plan to address confounding variables through propensity score matching. Objective: To assess whether diabetes patients experience reduced LOS, hypoglycemia, hyperglycemia, and 30-day readmission rates when managed by a specialized diabetes team compared to inpatients managed by a hospitalist team. Material and Methods: This quality improvement study compared LOS, hypoglycemia (glucose &amp;lt;70 mg/dL), hyperglycemia (glucose &amp;gt;180 mg/dL), and 30-day readmission rates in diabetes patients managed by a specialized diabetes team versus a hospitalist team at our hospital between June 2022 and December 2022. Results: 5676 patients with diabetes were admitted between June and December 2022 at our hospital, and a specialized diabetes team managed 417 patients (7.34%). In a preliminary analysis in which no propensity matching was performed yet, the 30-day readmission rate was significantly lower (87,16.6%) in patients who received a diabetes consult compared to patients who did not receive a diabetes consult (320,17.9%). The rate of hypoglycemia was higher (24.4%) in the specialized diabetes consult group than in the non-diabetes consults group (19.9%). Additionally, LOS was longer in patients with a specialized diabetes consult (7.1 vs. 3.1 days), and hyperglycemia (glucose &amp;gt;180 mg/dL) was more prevalent in the specialized diabetes consult group (78.9%) compared to the non-diabetes consult group (39.2%). Conclusion: In this retrospective analysis, patients managed by a specialized diabetes team showed lower readmission rates despite longer hospitalization and increased dysglycemic episodes. This could be attributed to sicker patients receiving diabetes consults, influencing dysglycemia rates. To account for such confounders, ongoing propensity score matching aims to provide a clearer understanding. Reduced readmission rates suggest improved care transitions, potentially resulting in significant cost savings for the healthcare system. Presentation: 6/1/2024

Environmental Outcomes of Reducing Medication Waste by Redispensing Unused Oral Anticancer Drugs

Medications are associated with substantial environmental outcomes, yet frequently end up being unused by patients. Waste-minimizing interventions, such as redispensing of quality-approved oral anticancer drugs remaining unused by patients at home, could reduce the environmental footprint of cancer treatment. To assess the environmental outcomes of redispensing quality-assured oral anticancer drugs and to explore how redispensing could be environmentally optimized. In this quality improvement study, a cradle-to-grave life cycle assessment was performed in the outpatient pharmacy of 4 Dutch hospitals, based on a prospective multicenter trial comprising 1071 patients with a clinical diagnosis of cancer and an active prescription for an oral anticancer drug stored at room temperature from February 1, 2021, to February 1, 2023, with a follow-up of 12 months per patient. Participants received prescribed oral anticancer drugs with additional quality-assurance materials (ie, seal bags and time-temperature indicators), so the pharmacy could redispense quality-assured drugs based on authenticity, appearance, remaining shelf life, and/or adequate storage. The estimated environmental outcomes avoided due to waste reduction (ie, production and transport and incineration of redispensed oral anticancer drugs) corrected for outcomes of process burdens (ie, quality assurance materials), quantified in 3 outcome measures: human health damage (disability-adjusted life-years), ecosystems damage (species × year), and climate change (kg of carbon dioxide equivalent [CO2-eq]) per patient per year. A volunteer sample of 1071 patients (median age, 70 years [IQR, 62-75 years]; 622 men [58.1%]) participated in the intervention. Redispensing oral anticancer drugs was initially associated with an environmental burden, mainly because of the high impact of time-temperature indicators. However, when quality-assurance materials were selectively used for temperature-sensitive oral anticancer drugs (ie, maximum storage temperature of 25 °C), redispensing was environmentally beneficial to human health and ecosystems, providing estimated climate benefits of 1.9 kg (95% CI, 1.4-2.6 kg) of CO2-eq per patient per year. In this quality improvement study, redispensing unused oral anticancer drugs was found to be a suitable strategy to reduce waste and improve environmental sustainability of cancer treatment after process optimization. Redispensing unused oral anticancer drugs could contribute to sustainability of cancer treatment through reduced costs and environmental outcomes.

Safety and Efficacy of Weight-Based MMF (Cellcept) Dosing in Kidney Transplant Recipients: A Quality Improvement Study

Safety and Efficacy of Weight-Based MMF (Cellcept) Dosing in Kidney Transplant Recipients: A Quality Improvement Study

Expedited Main Obstacles of Prekidney Transplant Workup: A Quality Improvement Study

Expedited Main Obstacles of Prekidney Transplant Workup: A Quality Improvement Study

Gaining Insight: Data Needs for Firearm Injury Prevention Researchers

ABSTRACTBetween 1996 and 2018, there was little federally funded research on gun violence, even though it remains a perennial issue, resulting in considerable loss of life. Advocacy and academic groups piece together data to conduct their research, but the U.S. firearms data infrastructure is limited. A current National Institute of Health (NIH)‐funded coordinating center led by researchers at the University of Michigan aims to help confront that problem. This Quality Improvement (QI) study seeks to uncover the information needs of researchers in firearm injury prevention and community‐based interventions through interviews with public health, medical, and criminal justice researchers. Interviews reveal problems associated with existing databases and infrastructures, as well as what researchers need to support their research. We find fragmented data resources and a lag in public health data availability create obstacles to obtaining many datasets. The researchers also describe problems and opportunities for data harmonization across intervention‐focused studies.

Evaluation of the Implementation of Low-Low Hospital Beds With Respect to Fall Frequency and Patient Harms: ARetrospective Analysis.

To identify whether the introduction of low-low hospital beds resulted in changes in the incidence, associated patient harms and event characteristics of bed-related falls where implemented. This retrospective quality improvement study covered 36 months: 18 months pre-intervention and 18 months post-intervention. Our analysis incorporated patient fall data from a hospital in upstate New York. Pre-/post-intervention data covered 18 months on either side of introduction at the units of implementation. Data were sourced from contemporaneously recorded incident reports and the organisation's business intelligence records. Analysis addressed the incidence rate, frequency, patient harm classification and recurrence of bed-related falls, as well as Morse Fall Scale risk classification, patient age, gender and other individualised risk factors. Lastly, we reviewed the presence of individualised interventions, staff assistance during the event, patient census and staffing ratios. Chi-square goodness of fit tests were employed to compare the distribution, and Brunner-Munzel tests the stochastic equality, of the pre- and post-implementation categorical and continuous data. There were no significant differences in the incidence rate of bed-related falls, patient harms or in the need for medical intervention following implementation of the low-low hospital beds. Neither were there any significant differences in the proportion of events resulting in detectable harm or the need for medical intervention post-implementation. The total number of bed-involved falls substantively increased following implementation of the low-low beds, as did the number of events resulting in detectable harms and medical intervention. Among these, substantive increases were noted among events resulting in minor temporary harm and patients referred for diagnostic imaging. The number of events involved patients experiencing recurrent falls of any kind increased significantly post-implementation. We found that the introduction of low-low hospital beds preceded no change in the incidence of bed-related falls, associated patient harms or the need for post-event medical intervention where implemented. While data limitations precluded definitive determination with respect to certain event characteristics, several post-implementation changes, including substantive increases in the number of falls occurring during ingress and egress, may suggest a potential for relationship worthy of future study. Low-low hospital beds are purported to help reduce the occurrence and severity of bed-related falls, both serious problems in inpatient settings. This study describes null outcomes following an implementation of such beds, with implications for adoption in similar settings. We adhered to the relevant Enhancing the Quality and Transparency of Health Research guidelines, specifically following the Standards for Quality Improvement Reporting Excellence standards. No patient or public involvement in the design or conduct of the study. Nurses and medical staff were involved in intervention implementation, data collection and the conception, design and conduct of the study.

Real-World Outcomes of Incurable Cancer Patients Treated with Unlisted Anticancer Treatments in an Academic Center in Quebec, Canada.

Medical oncology is a rapidly evolving field, with new medications being discovered yearly, contributing to increased survival rates. However, accessing drugs in a timely manner can be challenging. In Quebec, Canada, a physician can prescribe an unlisted anticancer treatment through a regulated pathway under exceptional circumstances. We conducted a quality improvement study describing the outcomes of incurable cancer patients receiving unlisted anticancer therapy at the Jewish General Hospital between 2018 and 2019. Though our study did not include a comparator arm, unlisted anticancer therapies were associated with interesting median progression-free survival (11 months) and overall survival (25 months). Moreover, a large proportion of treatments, 44%, were subsequently reimbursed in the province of Quebec. Given the delay in anticancer drug reimbursement, this pathway is essential for timely access to oncology drugs. Such 'special access' programs will likely become increasingly important as precision medicine becomes the standard of practice.

Targeting Community-Based Palliative and Serious Illness Care Resources: Challenges of More Stringent Diagnostic Criteria for Prospective Enrollment.

Background: For patients with serious illnesses, one aim of palliative care services is to reduce the frequency and severity of hospital-based episodes of care. Since hospital-alternative palliative care may consume costly resources, providers need to efficiently target high-intensity services toward those most at risk for such adverse episodes of care. Objective: Our objective was to investigate progressively more restrictive diagnosis-based indications of serious illness as used to prospectively identify patients with higher average rates of hospitalization. Design/Setting: We designed an observational cohort quality improvement study using historical Medicare claims records to evaluate diagnostic inclusion criteria for targeting palliative and serious illness care resources. We first isolated a Seriously Ill Population (SIP) and then defined More SIP and Most SIP subgroups. Measurements: Our primary outcome measure was the 2019 acute-care count of hospitalizations for patients in the SIP, More SIP, and Most SIP subgroups, respectively. Results: The More SIP and Most SIP subgroups exhibited higher hospitalization rates. However, they also excluded progressively more seriously ill patients who did experience hospitalizations. In addition, almost half of the Most SIP subgroup were not hospitalized at all, despite having an average hospitalization rate greater than one. Conclusion:Allocating resources (personnel and services) toward reducing hospitalizations when almost half of the targeted population never goes to the hospital could result in unnecessary expenditures and exclude patients that could potentially benefit. Engaging community-based services to detect changes in status could provide supplemental indications of when and for whom to target palliative care resources.

Impact of a Disease-Focused Electronic Health Record Dashboard on Clinical Staff Efficiency in Previsit Patient Review in an Ambulatory Pulmonary Hypertension Care Clinic.

We aimed to improve the operational efficiency of clinical staff, including physicians and allied health professionals, in the previsit review of patients by implementing a disease-focused dashboard within the electronic health record system. The dashboard was tailored to the unique requirements of the clinic and patient population. A prospective quality improvement study was conducted at an accredited pulmonary hypertension (PH) clinic within a large academic center, staffed by two full time physicians and two allied health professionals. Physicians' review time before and after implementation of the PH dashboard was measured using activity log data derived from an EHR database. The review time for clinic staff was measured through direct observation, with review method-either conventional or newly implemented dashboard-randomly assigned. Over the study period, the median number of patients reviewed by physicians per day increased slightly from 5.50 (interquartile range [IQR]: 1.35) before to 5.95 (IQR: 0.85) after the implementation of the PH dashboard (p = 0.535). The median review time for the physicians decreased with the use of the dashboard, from 7.0 minutes (IQR: 1.55) to 4.95 minutes (IQR: 1.35; p < 0.001). Based on the observed timing of 70 patient encounters among allied clinical staff, no significant difference was found for experienced members (4.65 minutes [IQR: 2.02] vs. 4.43 minutes [IQR: 0.69], p = 0.752), while inexperienced staff saw a significant reduction in review time after familiarization with the dashboard (5.06 minutes [IQR: 1.51] vs. 4.12 minutes [IQR: 1.99], p = 0.034). Subjective feedback highlighted the need for further optimization of the dashboard to align with the workflow of allied health staff to achieve similar efficiency benefits. A disease-focused dashboard significantly reduced physician previsit review time while that for clinic staff remained unchanged. Validation studies are necessary with our patient populations to explore further qualitative impacts on patient care efficiency and long-term benefits on workflow.

Kidney Biopsy Quality Improvement Study

Kidney Biopsy Quality Improvement Study

Quality improvement approach to reduce patient cycle time at a student-run free healthcare clinical network

BackgroundThe University of Florida (UF) Equal Access Clinic Network (EACN) is the largest student-run free healthcare clinic network in Florida. The UF EACN serves those who are underinsured or uninsured...