Referral Pathways Research Articles

Women’s experiences of seeking healthcare for abdominal pain in Ireland: a qualitative study

BackgroundEvidence suggests that women’s abdominal pain is more likely to be minimised or dismissed by healthcare professionals than men’s. This can have a detrimental impact on health-related outcomes as well as quality of life. The aim of this study was to explore women’s experiences of seeking healthcare for abdominal pain in Ireland.MethodA qualitative design and opportunity sampling approach were employed in this study. Fourteen women living in Ireland with experience of seeking healthcare for abdominal pain took part in one-to-one semi-structured interviews via video-conferencing software. Data were analysed using reflexive thematic analysis.ResultsFour themes were constructed from the data: [1] “Just Get on with It” – Normalisation and Invalidation; [2] “Bad Enough”? Costs of (Not) Seeking Help; [3] “Fight Your Case,” Fight for Care; and [4] “Out of the Loop” – Systemic Barriers to Care. Perceived invalidation of pain by healthcare professionals was common, as was internalised normalisation of pain. This created challenges when negotiating pain management solutions. Despite functional interference, participants felt their pain needed to reach an extreme level of severity before seeking help. Costs of private healthcare were implicated in delayed help-seeking. Participants felt the onus was on them to fight for care. Social support and information-seeking facilitated participants in this fight while systemic issues were identified as barriers to adequate care. Despite their frustrations, participants expressed empathy for healthcare professionals operating in a flawed system.ConclusionsParticipants described mostly negative experiences of seeking healthcare for abdominal pain, characterised by dismissal of symptoms and internalisation of normative views of women’s pain as less worthy of care. These experiences reinforced participants’ views that self-advocacy is essential to access care for their pain. There are systemic issues at play within the Irish healthcare system that limit women’s ability to access abdominal pain management support. Education and training for healthcare professionals on the Gender Pain Gap and its implications for patient care, as well as clear referral pathways for women presenting with abdominal pain, may help to ensure more equitable healthcare delivery for individuals with abdominal pain in Ireland.

A multidisciplinary diagnostic centre for early detection of cancer in patients with non-specific symptoms: a service evaluation

Background/Aims Symptoms of malignancy are often vague and non-specific, leading to delayed diagnosis and treatment. The multidisciplinary diagnostic centre was established in 2017 to facilitate the shortest and safest route to detecting cancer in such cases. This study aimed to evaluate the service model and work towards a business case for more widespread adoption of the multidisciplinary diagnostic centre service. Methods Data from all patients managed by the service from 2017–21 were collected contemporaneously. After 51 months, service data were examined against the aims of the service, focusing on patient demographic characteristics, main reasons for referral, main diagnostic tests performed, patient outcomes and time from referral to discharge. Results Between 2 February 2017 and 30 April 2021, 899 patients were referred to the centre. Weight loss was the most common reason for referral. During this period, 96 (10.7%) patients were diagnosed with a cancer. Of these diagnoses, 42.9% were made within 28 days of referral, improving to 60.6% in the final year of the service evaluation. Conclusions The multidisciplinary diagnostic centre demonstrates the importance and potential of having a dedicated referral pathway for patients presenting with vague, concerning symptoms.

Codesigning enhanced models of care for Northern Australian Aboriginal and Torres Strait Islander youth with type 2 diabetes: study protocol

IntroductionPremature onset of type 2 diabetes and excess mortality are critical issues internationally, particularly in Indigenous populations. There is an urgent need for developmentally appropriate and culturally safe models of...

“Coming home was a disaster, I didn’t know what was going to happen”: a qualitative study of survivors’ and family members’ experiences of navigating care post-stroke

Purpose Understanding navigational barriers and facilitators has the potential to advance equitable stroke care delivery. The aim of this study was to explore, using a qualitative study, the experiences of stroke survivors and their families as they journey through the stroke care system, both before and during the COVID-19 pandemic. Methods In-depth semi-structured interviews were conducted with 18 stroke survivors and 12 family members during 2021 and 2022. Participants were recruited through voluntary organisations, social media, and stroke support groups. Data analysis followed a systematic process guided by the framework method with steps including familiarisation, coding, framework development, and charting and interpretation. Results The experiences of navigating stroke care were particularly challenging following discharge from hospital into the community. Barriers to stroke care continuity included insufficient appropriate services and information, unsatisfactory relationships with healthcare professionals and distressed mental health. There were particular navigational challenges for survivors with aphasia. Facilitators to effective navigation included having prior knowledge of the health system, harnessing support for care co-ordination, and being persistent. Conclusion Greater support for patient navigation, and person-centred referral pathways, particularly during times of increased pressure on the system, have the potential to improve access to services and wellbeing among stroke survivors.

A Pilot Study to Evaluate a New Hep-GRP Care Pathway to Improve Outcomes Among Canadian Older Adults with Liver Cirrhosis.

Older adults with cirrhosis have complex medical needs that are not satisfied by organ specific management. Interdisciplinary approach may mitigate comorbidity and improve patient satisfaction. A pilot study consisted of dual specialist interdisciplinary referral pathway and mixed virtual care delivery model are prospectively evaluated in older adults (65 years and older) with cirrhosis during the COVID-19 pandemic between September and December 2022. Participant attitudes towards telemedicine were surveyed. 68 participants with cirrhosis were consecutively assessed by hepatology. The mean age was 73 years. 39 (57%) screened positive for one or more geriatric syndrome(s). Comprehensive geriatric assessments were conducted via telemedicine in 18 participants, with additional referrals to physiotherapy and nutritional education. Compared to a historic cohort matched for age, sex, and Child-Pugh class, acute health service utilization measured by ER visits among those received dual specialist interdisciplinary consultation were lowered by 1.11 per patient at three-month follow up period (p = .0006, 95% CI 0.47-1.74). Majority participants (87.6%) preferred telemedicine or mixed method visits. An interdisciplinary approach to older adults with cirrhosis will likely be beneficial, and routine screening for geriatric syndrome may lead to reduced acute health-care utilization in the short term. Telemedicine and virtual screening tools in seniors should be fully explored to improve access to care.

183P Improving timeliness of diagnosis of lung cancer patients through implementation of a web-based lung cancer referral pathway

183P Improving timeliness of diagnosis of lung cancer patients through implementation of a web-based lung cancer referral pathway

The perceptions of palliative care medical practitioners towards oral health: A descriptive qualitative study

Background: Oral health problems are common, but often overlooked, among people receiving palliative care. Aim: To better understand how oral health can be addressed in this population, this study aimed to explore the perceptions of oral health care among medical practitioners who provide palliative care to inform the development of a palliative oral health care program. Design: A descriptive qualitative design was adopted. Setting/participants: A single focus group was conducted with 18 medical practitioners at a palliative care facility in Sydney, Australia. All participants had experience providing palliative care services to clients. The focus group was audio recorded, transcribed and thematically analysed. Results: The results from the inductive thematic analysis identified four themes. The themes highlighted that participants were aware of the oral health needs of people receiving palliative care; however, they also reflected on the complexity in delivering oral health care across the healthcare settings, as well as the challenges around cost, lack of appropriate dental referral pathways, time constraints and limited awareness. Participants also provided recommendations to improve the delivery of oral health care to individuals receiving palliative care. Conclusions: To improve the provision of oral health care in this population, this study highlighted the need for oral health training across the multidisciplinary team, standardised screening assessments and referrals, a collective responsibility across the board and exploring the potential for teledentistry to support oral health care provision.

Pre-existing depression, anxiety and trauma as risk factors for the development of post-traumatic stress disorder symptoms following wildfires

The trauma of wildfires leads to one of the most challenging and treatment resistant mental health conditions-namely-post-traumatic stress disorder (PTSD). Research addressing the contribution of pre-existing mental health conditions to the development of PTSD symptoms following traumatization by wildfires is limited. This study examined whether people with pre-existing diagnoses of anxiety, depression, PTSD, insomnia and nightmares, by a mental health professional, are more likely to develop symptoms of PTSD than those with no previous diagnosis following the trauma of wildfires. A total of 126 wildfire survivors from Australia, Canada and the United States of America completed an online survey. An independent sample t-tests revealed that pre-existing diagnosed conditions of depression, an anxiety disorder and PTSD significantly increased the likelihood of developing PTSD symptoms following traumatization by wildfires (t = −2.51, p = 0.014, 95% CI [-18.91 to −2.20], t = −2.61, p = 0.01, 95% CI [-18.91 to −2.57], t = −2.57, p = 0.012, 95% CI [-22.36 to −2.87] respectively). Practitioners working in communities subjected to wildfires need to run a thorough screening of their patients’ pre-existing mental health conditions to provide the right treatment and referral pathways to those affected by the trauma of wildfires.

A Comparative Analysis of the Demographics and Zip Codes of Patients Seen at the Indiana University Student Outreach Clinic.

Within a small geographic area, Marion County contains a stark spectrum of health outcomes and socioeconomic statuses. The Indiana University Student Outreach Clinic (IUSOC) serves as a safety net provider, offering free health and social services in the Near Eastside neighborhood of Indianapolis. The aim of this study was to characterize the demographics and geographic distribution of the IUSOC's patient population. From January to September 2023, 612 patients visited the IUSOC, and 460 self-identified as Marion County residents. 63.9% of patients were between 45 and 64 years old. 66.8% were Non-Hispanic (NH) Black, and 23.3% were Hispanic. 18.9% spoke Spanish and had limited English proficiency. Based on the Distressed Communities Index (DCI), 58.7% lived in "Distressed" zip codes, indicating economic vulnerability and disparities. The zip code with the greatest number of IUSOC patients had the highest rate of uninsured adults in Marion County. IUSOC patients are primarily middle-aged minorities who live in zip codes with low socioeconomic rankings by DCI. This information can be used to improve community resource referral pathways in the clinic.

Barriers to early diagnosis and management of oral cancer in Latin America and the Caribbean.

This study aimed to explore perceived barriers to early diagnosis and management of oral cancer, as well as potential pathways for improvement in Latin America and the Caribbean (LAC). This cross-sectional study used a self-administered online questionnaire created via the Research Electronic Data Capture platform. The survey was distributed to health professionals trained in Oral Medicine, Oral Pathology, Oral and Maxillofacial Surgery, and Dentists with clinical and academic expertise in oral potentially malignant disorder (OPMD) and oral cancer. Data obtained were systematically organized and analyzed descriptively using Microsoft Excel. Twenty-three professionals from 21 LAC countries participated. Major barriers included the limited implementation of OPMD and oral cancer control plans (17.4%), low compulsory reporting for OPMD (8.7%) and oral cancer (34.8%), unclear referral pathways for OPMD (34.8%) and oral cancer (43.5%), and a shortage of trained professionals (8.7%). Participants endorsed the utility of online education (100%) and telemedicine (91.3%). The survey highlights major perceived barriers to early diagnosis and management of OPMD and oral cancer in LAC, as well as potential avenues for improvement.

Consensus statement on the interhospital transfer of patients with acute aortic syndrome: TRAVERSING Delphi study

BackgroundStandardisation of referral pathways and the transfer of patients with acute aortic syndromes (AAS) to regional centres are recommended by NHS England in the Acute Aortic Dissection Toolkit. The aim...

Evaluating geographical disparities on clinical outcomes following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BackgroundRural Australians typically encounter disparities in healthcare access leading to adverse health outcomes, delayed diagnosis and reduced quality of life (QoL) parameters. These disparities may be exacerbated in advanced malignancies, where treatment is only available at highly specialised centres with appropriate multidisciplinary expertise. Thus, this study aims to determine the association between patient residence on oncological, surgical and QoL outcomes following cytoreductive surgery (CRS) and hyperthermic intra-peritoneal chemotherapy (HIPEC).MethodsA retrospective analysis was conducted on consecutive patients undergoing CRS and HIPEC at Royal Prince Alfred Hospital from January 2017 to March 2022. On the basis of their postcode of residence, patients were stratified into metropolitan and regional groups. Data encompassing demographics, oncological, surgical and QoL outcomes were compared. Statistical analysis included chi-square test, t-tests and Kaplan–Meier survival curves.ResultsAmong the 317 patients, 228 (72%) were categorised as metropolitan and 89 (28%) as regional. Metropolitan patients presented higher rates of recurrence (61.8% versus 40.0%, p = 0.014) and shorter overall mean survival [3.8 years (95% CI: 3.44–4.09) versus 4.2 years (95% CI: 3.76–4.63), p = 0.019] compared with regional patients. No other statistically significant differences were observed in oncological, surgical and QoL outcomes.ConclusionsMost oncological, surgical and QoL parameters did not differ by geographical location of patients undergoing CRS and HIPEC for peritoneal malignancies at a high-volume quaternary referral centre. Observed differences in recurrence and survival may be attributed to the selective nature of surgical referrals and variable follow-up patterns. Future research should focus on characterising referral pathways and its influence on post-operative outcomes.

Diagnosis and Treatment of Vernal Keratoconjunctivitis: A Qualitative Study of Caregiver, Patient, and Clinician Experience in the United States.

To better understand the patient journey and challenges in the diagnosis and treatment of patients with vernal keratoconjunctivitis (VKC). This qualitative study assessed the experience of caregivers of children with VKC (n = 7) and of clinicians who treat VKC (n = 16) in the United States. The structured interviews were conducted to identify key "pain points", obstacles, and trends on the path to diagnosis. Like an earlier study conducted in the United Kingdom, this study found low awareness of the nature and severity of VKC among U.S. caregivers and non-specialist providers, and a tendency among young patients and their caregivers to downplay initial symptoms. Medical intervention was delayed as caregivers treated symptoms with over-the-counter medications; 88% (14 of 16) of specialists reported frequent misdiagnosis and mistreatment by pediatricians and primary care providers who were initial points of care. Time to appropriate referral ranged from 1 to 2 weeks to 3 months, in part due to convoluted referral pathways that were universal points of frustration for caregivers and specialists. Limited awareness of VKC remains a barrier to timely identification and management of this rare but disruptive ocular surface disease. Caregivers underestimate symptom severity, pediatricians and primary care providers often misdiagnose VKC as allergy or infection, and referrals to appropriate specialists are delayed until symptoms are severe. Early identification is essential to improving the diagnostic journey and treatment of VKC. [J Pediatr Ophthalmol Strabismus. 2024;61(4):252-256.].

What are the triggers for palliative care referral in burn intensive care units? Results from a qualitative study based on healthcare professionals' views, clinical experiences and practices.

Burns are a global public health problem, accounting for around 300,000 deaths annually. Burns have significant consequences for patients, families, healthcare teams and systems. Evidence suggests that the integration of palliative care in burn intensive care units improves patients' comfort, decision-making processes and family care. Research is needed on how to optimise palliative care referrals. To identify triggers for palliative care referral in critically burned patients based on professionals' views, experiences and practices. Qualitative study using in-depth interviews. All five Burn Intensive Care Units reference centres across Portugal were invited; three participated. Inclusion criteria: Professionals with experience/working in these settings. A total of 15 professionals (12 nurses and 3 physicians) participated. Reflexive thematic analysis was performed. Three main triggers for palliative care referral were identified: (i) Burn severity and extension, (ii) Co-morbidities and (iii) Multiorgan failure. Other triggers were also generated: (i) Rehabilitative palliative care related to patients' suffering and changes in body image, (ii) Family suffering and/or dysfunctional and complex family processes, (iii) Long stay in the burn intensive care unit and (iv) Uncontrolled pain. This study identifies triggers for palliative care in burn intensive care units based on professionals' views, clinical experiences and practices. The systematisation and use of triggers could help streamline referral pathways and strengthen the integration of palliative care in burn intensive care units. Research is needed on the use of these triggers in clinical practice to enhance decision-making processes, early and high-quality integrated palliative care and proportionate patient and family centred care.

Intimate Partner Violence Detected during Abortion-Related Visits: A Systematic Review of Screenings and Interventions.

To perform a systematic review of screening tools and interventions focused on reducing adverse health outcomes associated with intimate partner violence (IPV) at abortion-related visits. Studies were eligible if they included individuals seeking pregnancy options health care services in the United States, screening for or implementation of an intervention for IPV, and were published in English after the year 2000. The primary outcomes were to summarize screening tools, interventions studied, and if interventions led to individuals being connected to IPV-related resources. Secondary outcomes included patient responses to the IPV-related interventions and any other outcomes reported by the studies (PROSPERO #42021252199). Among 4,205 abstracts identified, nine studies met inclusion criteria. The majority (n = 6) employed the ARCHES (Addressing Reproductive Coercion in Health Settings) tool for identification of IPV. Interventions included provider-facilitated discussions of IPV, a safety card with information about IPV and community-based resources, and referral pathways to directly connect patients with support services. For the primary outcome, IPV-related interventions were shown to better inform patients of available IPV-related resources as compared to no intervention at all. For the secondary outcomes, screening and intervening on IPV were associated with improvements in patient perception of provider empathy (i.e., caring about safety) and safer responses by patients to unhealthy relationships. Screening for and intervening on IPV at abortion-related visits are associated with positive outcomes for patient safety and the patient-provider relationship. However, data on effective tools for identifying and supporting these patients are extremely limited. This review emphasizes the unmet need for implementation and evaluation of IPV-specific interventions during abortion-related clinical encounters. · The abortion visit offers a crucial setting to address IPV among a highly affected population.. · This study reviews others that analyzed interventions and associated outcomes for IPV at abortion-related visits.. · Appropriate interventions for IPV can improve patient-provider relationships and connect patients to essential resources..

The socio-economic impacts of artisanal mining on ordinary villagers in Insiza District, Zimbabwe

This study sought to understand how ordinary villagers in the artisanal mining areas of Insiza District, where Emthonjeni Women's Forum implemented a program titled ‘Women as strategic partners in peacebuilding’, are affected by the violence and conflicts emanating from the illegal and artisanal mining in the proximities of their villages. The project sought to strengthen resilience, social cohesion and women's security in socio economic and political conflict as well as strengthening knowledge of local women and traditional leaders on the referral pathways of addressing GBV, including the strengthening of stakeholder coordination in conflict mitigation, transformation and resolution. While men, boys, girls and women all experience violence in varying degrees, it was found that women feel the effects of violence and conflict the most as they experience it as direct victims, and vicariously when their husbands or sons participate in violent activities. This is because they bring their troubles home to the wives or mothers who often have to address the problems or live with the consequences of the men's actions. Gender is often one of the key determinants of what social spaces and opportunities might be available or not available to society or family. Therefore, people's vulnerability is shaped by their gender although other factors may also contribute to it. Most societies are constructed in such a way that women and children have the least power and natural rights and are therefore regarded as weak and powerless. They are especially vulnerable to violence as they are often unable to defend themselves or outrun perpetrators of violence. Lawlessness and violence in wards one and two of Insiza District, as in most parts of the country, are driven mostly by groups of armed young men—often ‘outsiders’, those who are not ordinarily residents of the two wards or from Insiza in general, who appear to act with impunity.

Distilling lessons from home hospital implementation: a narrative scoping review.

Multiple Cochrane Reviews have demonstrated 'hospital at home' (HaH) as a promising healthcare model to be explored, with benefits such as higher care quality, reduced readmissions, shorter lengths of stay, lower cost and greater patient satisfaction. While there have been many reviews focusing on the quantitative clinical outcomes of HaH, there is generally a lack of collation of qualitative insights from stakeholders and lessons learnt from past HaH implementation. We performed a systematic literature search on four databases and included 17 papers involving the provision of acute and/or subacute care by healthcare professionals in patients' homes. Review characteristics and relevant outcomes were extracted from the reported findings and tables in the reviews, and these included stakeholder attitudes and factors contributing to the success of HaH implementation. Factors relating to patients and caregivers included home setup, preference for care and death settings, and support for caregiver. Factors involving the healthcare professionals and intervention included a multidisciplinary care team, accessibility to emergency care and support, training of providers and patients, adequate manpower allocation, robust eligibility and referral criteria, sufficient awareness of the HaH referral pathway, communication and medication management. HaH presents a promising alternative care model, and many of the success factors identified, including the strong push for multidisciplinary single care teams, existing frameworks for data sharing and strong community network, are already present today. As such, Singapore appears to be well positioned to adopt a new care model like HaH.

Exploring the feasibility of a gambling harm screening model in general practice and community service settings in Fairfield: a pilot study.

Gambling is a growing public health issue in Australia. However, limited research has examined the role of primary health care and social services in routine screening for gambling harm in Australia. This research aimed to explore the enablers and barriers to implementing a co-designed gambling screening model in Fairfield, New South Wales - an area with high gambling expenditure. A co-designed gambling screening and referral model for GP and community-based organisations was implemented in Fairfield in 2020. Follow-up interviews were conducted with nine health care professionals who implemented the screening in 130 patients. Thematic analysis generated key barriers and enablers for implementation of this model. Key enablers for the screening model implementation included structural factors (alignment of the screening model with current work), process factors and staffing factors (staff empowerment). However, we also noted process factors as a barrier to implementation, particularly the referral pathway following screening. Other barriers included social and structural factors, such as the complexity of gambling harm and project funding. Embedding routine screening in primary and community care settings can play a role in treating, reducing and preventing gambling-related harm, and reducing stigma in Fairfield and beyond. Additionally, screening models such as this provide health systems with clear evidence on the level of gambling harm in their community (particularly important in culturally and linguistically diverse communities who are underrepresented in research). This evidence is important for addressing system-level drivers of harm and advocating for political reform to reduce the impact of gambling on communities.

'Let's talk about sleep health' within primary care: a qualitative study of patients' willingness to engage in psychological interventions for insomnia.

Cognitive behavioural therapy for insomnia (CBT-I) is recommended as the first-line treatment for insomnia yet remains underutilised in general practice. Understanding patient motivations and barriers to engaging in psychological interventions for insomnia is critical. Theoretical frameworks, such as the theory of planned behaviour, are needed to identify variables related to intentions and behaviour change. To explore key influences that motivate individuals' intention to engage with psychological interventions for insomnia. Qualitative study consisting of an online survey and interviews with 20 community-dwelling participants with insomnia aged 26-75 years residing in Victoria, Australia. Guided by the theory of planned behaviour, reflexive thematic analysis was used to identify factors influencing participants' intention to engage with psychological interventions for insomnia. Participants reported positive attitudes towards psychological interventions for insomnia, stemming from negative beliefs about pharmacological sleep aids and the perceived benefits of a structured and evidence-based intervention. Important others positively influenced participants' intention to engage; however, the GP influence was less consistent and often indirect. Participants believed in the efficacy of psychological interventions, but several barriers hampered their ability to benefit from them. Accessibility was identified as a key facilitator, whereas lack of knowledge and clear referral pathways were the main barriers having an impact on uptake. This study highlights key factors influencing patients' intention to engage in psychological interventions for insomnia as well as opportunities for GPs to support uptake and engagement. Routine conversations about sleep health are essential to reduce the burden of untreated insomnia in the community, and the active promotion of evidence-based psychological interventions is needed.

SWOT analysis of the models used by social enterprises in scaling effective refractive error coverage to achieve the 2030 in SIGHT in Kenya

Uncorrected refractive error has predominantly been delivered through commercial entrepreneurship in Kenya. However, to achieve the 2030 IN SIGHT, integration of other forms of entrepreneurship such as the social entrepreneurship is desirable to supplement the efforts of the dominant commercial entrepreneurship. Therefore, this study intended to undertake a SWOT analysis of the current models used by social enterprises in scaling effective refractive error coverage to achieve the 2030 IN SIGHT in Kenya. A review of the seven national strategic plans for eye health in Kenya was undertaken to get a glimpse on the efforts directed towards uncorrected refractive error in achieving the 2030 IN SIGHT. The review was inclined towards assessing the efforts directed by the strategic plans towards scaling human resource, spectacle provision and refraction points. A SWOT analysis was undertaken based on the financial, impact and the approach report for each model. A key informant interview was conducted with a representative and three to five members of the social enterprise about the model. Thereafter, the modified SWOT analysis based on the review and the interview was presented to the representatives of the social enterprises. Purposive sampling was used to identify seven models used by social enterprises in the delivery of refractive error services in Kenya. Finally, the recommendations were presented to key opinion leaders for an input through a Delphi technique. Out of the seven national strategic plans for eye health reviewed, only the strategic plan 2020–2025 intends to establish optical units within 15 different counties in Kenya. Of the seven models currently utilized by social enterprises, only the Kenya Society for the Blind has integrated the telemedicine concept. On application of mHealth, all of the social enterprises models tend to embrace the approach for screening activities. None of the models has a strengthened referral pathway utilizing telereferral and telemedicine. Out of all the models, only Operation Eyesight Universal, Fred Hollow Foundation and Peek Acuity do not depend on sales of subsidized spectacles for sustainability. Every model has the capacity to propel the delivery of refractive error services depending on its comprehensiveness. However, for the 2030 IN SIGHT to be achieved, models prioritizing human resource through telemedicine integration, service provision across all sectors, awareness creation and enhancing cost efficiency are desirable.