Unwarranted Practice Variation Research Articles

Developing critical thinking skills for delivering optimal care

Healthcare systems across the world are challenged with problems of misdiagnosis, non-beneficial care, unwarranted practice variation and inefficient or unsafe practice. In countering these shortcomings, clinicians must be able to think critically, interpret and assimilate new knowledge, deal with uncertainty and change behaviour in response to compelling new evidence. Three critical thinking skills underpin effective care: clinical reasoning, evidence-informed decision-making and systems thinking. It is important to define these skills explicitly, explain their rationales, describe methods of instruction and provide examples of optimal application. Educational methods for developing and refining these skills must be embedded within all levels of clinician training and continuing professional development.

A Knowledge Translation Framework for Optimizing Physical Therapy in Patients With Heart Failure.

The American Physical Therapy Association has supported the development of clinical practice guidelines to promote and support evidence-based practice and reduce unwarranted practice variation. Essential to the success of this effort is the generation of knowledge translation, a concept that emphasizes the translation of global knowledge to an application that can be effectively integrated into clinical practice. The Physical Therapy Clinical Practice Guideline for the Management of Individuals with Heart Failure published in the Physical Therapy Journal in January 2020 provides a broad base of knowledge related to evidence-based treatment interventions for patients with heart failure. However, the application and integration of this knowledge in clinical practice need further elucidation. Therefore, this perspective paper aims to serve as a complementary knowledge translation resource to the recently published practice guideline to maximize the utilization of contemporary evidence in clinical practice. This resource provides the physical therapist with practical guidance in the management of patients with heart failure by placing research findings in the context of other knowledge and practice norms that can be applied at the point of care and across the continuum of care. We propose a novel ABCDE (assessment, behavior modification, cardiorespiratory fitness, dosage, and education) practical framework. This clinical paradigm is grounded in ongoing physical therapist assessment throughout the episode of care, along with behavior modification, assessment of cardiorespiratory fitness, appropriate selection and dosing of interventions, and patient education. Examples highlighting the use of this model in patients with heart failure across the continuum of care are provided for application in clinical care.

Optimizing practice guidelines through incorporating patient and family values and preferences

Neonatal care largely follows clinical practice guidelines and position statements developed locally by respective institutions as well as by national and international organizations. One might expect that adoption of clinical guidelines based on best available research evidence would make neonatal care practices mostly uniform. However, wide variation in clinical practice is still noted in neonatal care. Neonatal clinical guidelines are developed almost exclusively by healthcare professionals, with little or no input from families of the infants being cared for. Therefore, such variation in practice may stem not only from how the evidence is interpreted but also how caregivers and families value different outcomes that are affected by particular interventions. Acknowledging and incorporating the variability in patient and family values and preferences in clinical guidelines is an important step towards allowing shared decision making while reducing unwarranted practice variation, and thereby helping clinicians practice family-centered evidence-based medicine.

Is there unwarranted variation in obstetric practice in Australia? Obstetric intervention trends in Queensland hospitals.

Objective The aim of this study was to report on the rates of obstetric interventions within each hospital jurisdiction in the state of Queensland, Australia. Methods This project used a whole-of-population linked dataset that included the health and cost data of all mothers who gave birth in Queensland, Australia, between 2012 and 2015 (n=186789), plus their babies (n=189909). Adjusted and unadjusted rates of obstetric interventions and non-instrumental vaginal delivery were reported within each hospital jurisdiction in Queensland. Results High rates of obstetric intervention exist in both the private and public sectors, with higher rates demonstrated in the private than public sector. Within the public sector, there is substantial variation in rates of intervention between hospital and health service jurisdictions after adjusting for confounding variables that influence the need for obstetric intervention. Conclusions Due to the high rates of obstetric interventions statewide, a deeper understanding is needed of what factors may be driving these high rates at the health service level, with a focus on the clinical necessity of the provision of Caesarean sections. What is known about the topic? Variation in clinical practice exists in many health disciplines, including obstetric care. Variation in obstetric practice exists between subpopulation groups and between states and territories in Australia. What does this paper add? What we know from this microlevel analysis of obstetric intervention provision within the Australian population is that the provision of obstetric intervention varies substantially between public sector hospital and health services and that this variation is not wholly attributable to clinical or demographic factors of mothers. What are the implications for practitioners? Individual health service providers need to examine the factors that may be driving high rates of Caesarean sections within their institution, with a focus on the clinical necessity of Caesarean section.

Differences in Procedural Care of Hemorrhoid Management in Medicare Patients; Unwarranted Variation in Clinical Practice for a Medical-First Problem

Differences in Procedural Care of Hemorrhoid Management in Medicare Patients; Unwarranted Variation in Clinical Practice for a Medical-First Problem

Identifying unwarranted variation in clinical practice between healthcare providers in England: Analysis of administrative data over time for the Getting It Right First Time programme.

The Getting It Right First Time programme aims to reduce variation in clinical practice that unduly impacts on outcomes for patients in the National Health Service (NHS) in England; often termed "unwarranted variation." However, there is no "gold standard" method for detecting unwarranted variation. The aim of this study was to describe a method to allow such variation in recorded practice or patient outcomes between NHS trusts to be detected using data over multiple time periods. By looking at variation over time, it was hoped that patterns that could be missed by looking at data at a single time point, or averaged over a longer time period, could be identified. This was a retrospective time-series analysis of observational administrative data. Data were extracted from the Hospital Episodes Statistics database for two exemplar aspects of clinical practice within the field of urology: (a) use of ureteric stents on first emergency admission to treat urinary tract stones and (b) waiting times for definitive surgery for urinary retention. Data were categorized into 3-month time periods and three rules were used to detect unwarranted variation in the outcome metric relative to the national average: (a) two of any three consecutive values greater than two standard deviations above the mean, (b) four of any five consecutive values greater than one standard deviation above the mean, and (c) eight consecutive values above the mean. For the urinary tract stones dataset, 24 trusts were identified as having unwarranted variation in the outcomes using funnel plots and 23 trusts using the time-series method. For the urinary retention data, 18 trusted were identified as having unwarranted variation in the outcomes using funnel plots and 22 trusts using the time-series method. The time-series method may complement other methods to help identify unwarranted variation.

Design characteristics of studies on medical practice variation of caesarean section rates: a scoping review

BackgroundMedical practice variation in caesarean section rates is the most studied type of practice variation in the field of obstetrics and gynaecology. This has not resulted in increased homogeneity of treatment between geographic areas or healthcare providers. Our study aim was to evaluate whether current study designs on medical practice variation of caesarean section rates were optimized to identify the unwarranted share of practice variation and could contribute to the reduction of unwarranted practice variation by meeting criteria for audit and feedback.MethodsWe searched PubMed, Embase, EBSCO/CINAHL and Wiley/Cochrane Library from inception to March 24th, 2020. Studies that compared the rate of caesarean sections between individuals, institutions or geographic areas were included. Study design was assessed on: selection procedure of study population, data source, case-mix correction, patient preference, aggregation level of analysis, maternal and neonatal outcome, and determinants (professional and organizational characteristics).ResultsA total of 284 studies were included. Most studies (64%) measured the caesarean section rate in the entire study population instead of using a sample (30%). (National) databases were most often used as information source (57%). Case-mix correction was performed in 87 studies (31%). The Robson classification was used in 20% of the studies following its endorsement by the WHO in 2015. The most common levels of aggregation were hospital level (35%) and grouped hospitals (35%) e.g. private versus public. The percentage of studies that assessed the relationship between variation in caesarean section rates and maternal outcome was 9%, neonatal outcome 19%, determinants (professional and organizational characteristics) 21% and patient preference 2%.ConclusionsStudy designs of practice variation in caesarean sections varied considerably, raising questions about their appropriateness. Studies focused on measuring practice variation, rather than contributing to the reduction of unwarranted practice variation. Future studies should correct for differences in patient characteristics (case-mix) and patient preference to identify unwarranted practice variation. Practice variation studies could be used for audit and feedback if results are presented at lower levels of aggregation, and appeal to intrinsic motivation of physicians, for example by including the health effects on mother and child.

National registries: Lessons learnt from quality improvement initiatives in intensive care.

National clinical quality registries (CQRs) are effective tools for improving the outcomes of patients admitted to the intensive care unit (ICU), and are increasingly important as healthcare needs evolve. A high-quality ICU CQR is built from a foundation of common requirements and challenges. First, performance indicators of the structure, process, or outcomes of patient care should measure what is important. Second, high data quality is essential and can be collected and curated through standardized processes. Third, standardized mortality ratio (SMR) is a cornerstone for benchmarking ICU performance, but application requires a comprehensive understanding of its context and potential pitfalls. Fourth, data collection alone is insufficient. Quality improvement comes from closing the feedback loop by identifying and managing unwarranted practice variation. Fifth, the process of improving healthcare is fundamentally a human enterprise, subject to behavioural change, including those that modify performance. Sixth, ICU CQRs must be dynamic to meet the needs of an evolving healthcare system and stakeholders. Finally, these lessons are far from comprehensive. Sharing perspectives on the development of ICU CQRs can help maximise their value as a powerful platform for informing policy development and improving the outcomes of patients admitted to the ICU.

Understanding practice variation with a clinical pathways system: Differences by physician and practice factors, and changes in practice over time.

2079 Background: Clinical oncology pathways aim to support clinical decision-making and reduce unwarranted practice variation across an enterprise. The Dana-Farber Cancer Institute (DFCI) implemented web-based oncology pathways with DFCI-customized content in each disease center and at each of its satellites. Our pre-specified aim was an on-pathway rate of 70-85%. Methods: Treatment decisions were electronically captured as on- or off- pathway. Monthly metrics about usage and on-pathway rate were shared with users on a monthly basis. Physicians were categorized into quintiles based on the calculated on-pathway performance during the first 90 days of each individual’s use of the platform. On-pathway rates were then calculated for days 91-360 to study changes in behavior over time. Physician and practice factors were examined to determine any differences by initial on-pathway quintile classification. Results: 122 physicians were eligible for inclusion in this analysis (minimum 5 navigations in each study period). On-pathway rates showed significant variability in the initial 90-day period: quintile 1 median 100%, quintiles 2-4 80.2%, and quintile 5 50% (Table). In the follow-up period, median on-pathway rates shifted into the pre-specified goal range for all groups. Physicians in quintiles 1 or 5 of initial on-pathway rate were more likely to have fewer total navigations than were physicians in quintiles 2-4 (p=0.003). While no other physician or practice characteristic differed significantly by on-pathway rate group, physicians in the first or last quintile were more likely to be in an academic setting, have a PhD, or navigate fewer pathways. Conclusions: Over time, the deployment of a web-based clinical pathways program resulted in greater uniformity in physician practice, based on on-pathway rate. Familiarity with the pathways platform and its navigation, monthly feedback about usage, and evolution of content over time are some factors that might have played a role. [Table: see text]

Understanding unwarranted variation in clinical practice: a focus on network effects, reflective medicine and learning health systems.

In the past decades, extensive research has been performed on the phenomenon of unwarranted clinical variation in clinical practice. Many studies have been performed on signaling, describing and visualizing clinical variation. We argue that it is time for next steps in practice variation research. In addition to describing and signaling variation patterns, we argue that a better understanding of causes of variation should be gained. Moreover, target points for improving and decreasing clinical variation should be created. Key elements in this new focus should be research on the complex interaction of networks, reflective medicine, patient beliefs and objective criteria for treatment choices. By combining these different concepts, alternative research objectives and new targets for improving and reducing unwarranted variation may be defined. In this perspective, we reflect on these concepts and propose target points for future research.

How Long Will This Take, Doc? Timing from End-of-Life Orders Until Death (QI628)

•Justify use of an order set for withdrawal of life-sustaining treatment in the intensive care unit.•Propose means to reduce unwarranted variation in practice. Withdrawal of life-sustaining treatment (WLST) is a critically important time in the life of a patient and family and presents unique emotional pressure to all involved. The decision to redirect goals of inpatient care to focus on comfort is best supported by clear, evidence-based treatment. Use of an order set in the electronic health record (EHR) can facilitate best care for the dying patient. Assess time from use of a WLST order set to inpatient death with the goal of reducing variation in practice. One-year, single-center, retrospective cohort study across a large, nonprofit health system in central Ohio. All inpatient decedents for whom care measures were entered using an available WLST order set. Primary outcome was timing from orders being entered until death. Secondary analyses included stratification by presence of palliative consultation and by specialty of ordering provider. 690 patients met inclusion criteria. The median time from WLST orders to death was 3.8 hours. Of 690 patients, 312 (45%) received palliative consultation and median time was 3.9 hours; 378 (55%) without palliative consultation had median time of 3.6 hours (not statistically significantly different). There was no statistically significant difference in time from WLST orders to death between the three mutually exclusive groups: orders by palliative provider and palliative consult, orders by nonpalliative provider and palliative consult, and orders by nonpalliative provider and no palliative consult. Timing from use of a WLST order set to inpatient death was consistent with published studies. There were no statistically significant differences in our secondary analyses. We conclude appropriate timing from WLST to death and reduced variation in practice associated with use of an order set. Next steps include order set optimization as well as detailed analysis of medications received.

Clinical practice guidelines for videofluoroscopic swallowing studies: A systematic review

IntroductionClinical practice guidelines (CPGs) are expected to make evidence-based recommendations, thus guiding practice and reducing unwarranted variation. CPGs are particularly helpful in guiding complex procedures such as the Videofluoroscopic Swallowing Study (VFSS) for the assessment of dysphagia, but there is a suspected high level of variability among them. To explore the extent of this variation, this study aimed to systematically identify and appraise all VFSS CPGs available worldwide. MethodsA systematic search of 3 academic databases and other sources was conducted to identify relevant CPGs; independent reviews of each CPG were undertaken by a Speech and Language Therapist and a Radiographer. Both reviewers completed a pre-determined checklist of expected professional content for each CPG. CPGs were then assessed for quality using the Appraisal of Guidance for Research & Evaluation II (AGREE II) instrument. Findings from the professional content review and the methodological quality review were synthesised to inform an assessment of suitability of each CPG to inform clinical practice. ResultsSeven VFSS CPGs were identified worldwide, none of which were co-designed by radiographers or aimed at a radiographer audience. Each differs in their professional content, recommendations, underpinning evidence base and professional focus. Average AGREE ll scores across the quality domains vary considerably, ranging from 93 to 22%. No CPGs scored highly on all six AGREE II domains. ConclusionThere is no standardisation between VFSS guidelines. Six CPGs are not recommended for clinical use; only one of the seven identified CPGs is recommended for use following significant modification. Implications for practiceThe lack of a comprehensive, evidence-based guideline encourages unwarranted variation in clinical practice which potentially compromises clinical care. Further research is needed to define VFSS best practice.

Realistic Medicine: Changing culture and practice in the delivery of health and social care

ObjectiveCurrent models of health and social care services are stretched and do not always suit patients, their carers or the aspirations of the workforce. Realistic Medicine aims to improve patient care by ensuring that people receive appropriate, beneficial, evidence-based care aligned with their personal preferences. This paper builds on a keynote address delivered at ICCH 2018. MethodsWe explore the six core principles of Realistic Medicine: (i) building a personalised approach to patient care; (ii) changing style to shared decision-making; (iii) reducing harm and waste; (iv) tackling unwarranted variation in practice and outcomes; (v) managing risk better; (vi) becoming improvers and innovators in healthcare. ResultsRealistic Medicine is being embedded across Scotland, championed by local and national clinical leaders. There is particular focus on engaging patients around shared-decision making and improving value in healthcare. ConclusionRealistic Medicine is the first example of these principles being articulated clearly and collectively as the essential components of a health and care system’s national improvement strategy. It reflects the care that most professional staff wish to provide. Practice implicationsTo deliver Realistic Medicine, all health and social care professionals must be empowered to work together in teams, networks and in partnership with people.

Variation in rehabilitation setting after uncomplicated total knee or hip arthroplasty: a call for evidence-based guidelines

BackgroundHigh-level evidence consistently indicates that resource-intensive facility-based rehabilitation does not provide better recovery compared to home programs for uncomplicated knee or hip arthroplasty patients and, therefore, could be reserved for those most impaired. This study aimed to determine if rehabilitation setting aligns with evidence regardless of insurance status.MethodsSub-study within a national, prospective study involving 19 Australian high-volume public and private arthroplasty centres. Individuals undergoing primary arthroplasty for osteoarthritis participated. The main outcome was the proportion participating in each rehabilitation setting, obtained via chart review and participant telephone follow-up at 35 and 90 days post-surgery, categorised as ‘facility-based’ (inpatient rehabilitation and/or ≥ four outpatient-based sessions, including day-hospital) or ‘home-based’ (domiciliary, monitored or unmonitored home program only). We compared characteristics of the study cohort and rehabilitation setting by insurance status (public or private) using parametric and non-parametric tests, analysing the knee and hip cohorts separately.ResultsAfter excluding ineligible participants (bilateral surgeries, self-funded insurance, participation in a concurrent rehabilitation trial, experience of a major acute complication potentially affecting their rehabilitation pathway), 1334 eligible participants remained. Complete data were available for 1302 (97%) [Knee: n = 610, mean age 68.7 (8.5) yr., 51.1% female; Hip: n = 692, mean age 65.5 (10.4) yr., 48.9% female]; 26% (158/610) of knee and 61% (423/692) of hip participants participated predominantly in home-based programs. A greater proportion of public recipients were obese and had greater pre-operative joint impairment, but participated more commonly in home programs [(Knee: 32.9% (79/240) vs 21.4% (79/370) (P = 0.001); Hip: 71.0% (176/248) vs 55.6% (247/444) (P < 0.001)], less commonly in inpatient rehabilitation [Knee: 7.5% (18/240) vs 56.0% (207/370) P (< 0.001); Hip: 4.4% (11/248) vs 33.1% (147/444) (P < 0.001], and had fewer outpatient treatments [Knee: median (IQR) 6 (3) vs 8 (6) (P < 0.001); Hip: 6 (4) vs 8 (6) (P < 0.001)].ConclusionsFacility-based programs remain the norm for most knee and many hip arthroplasty recipients with insurance status being a major determinant of care. Development and implementation of evidence-based guidelines may help resolve the evidence-practice gap, addressing unwarranted practice variation across the insurance sectors.

Maximizing quality of life remains an ultimate goal in the era of precision medicine: exemplified by lung cancer.

An ultimate goal of precision medicine in lung cancer treatment is to restore patient health with maximized quality of life (QOL). Results from Mayo Clinic studies show that a significant improvement in fatigue, dyspnea, and pain scales could lead to better overall QOL. Although treatments and guidelines for clinical implementation to alleviate these key symptoms are available, few cancer patients receive adequate therapy, mostly because of limitations in current care delivery systems and unclear clinicians’ roles. For optimal care of lung cancer survivors in different subpopulations, three barriers must be overcome: physicians’ lack of knowledge, unwarranted practice variation, and uncertainty regarding care provider roles. Appropriate culturally adapted, tested and validated tools for QOL measures must be developed, rather than directly translating existing tools between different languages and across cultures or diverse subpopulations. Finally, lack of sensitive, adequate, and relevant tools in measuring health-related QOL (HRQOL) has long been an issue for effective data collection, demanding a global consensus on a set of core components that reflect the needs of all critical parties for the best cure and care, supporting patients to achieve optimal HRQOL.

Associations Among Practice Variation, Clinician Characteristics, and Care Algorithm Usage: A Multispecialty Vignette Study.

The objective was to quantitatively evaluate clinician characteristics associated with unwarranted practice variation, and how clinical care algorithms influence this variation. Participants (142 physicians, 53 nurse practitioners, and 9 physician assistants in family medicine, internal medicine, and cardiology) described their management of 4 clinical vignettes, first based on their own practice (unguided), then using care algorithms (guided). The authors quantitatively estimated variation in management. Cardiologists demonstrated 17% lower variation in unguided responses than generalists (fold-change 0.83 [95% confidence interval (CI) 0.68, 0.97]), and those who agreed that practice variation can realistically be reduced had 16% lower variation than those who did not (fold-change 0.84 [CI, 0.71, 0.99]). A 17% reduction in variation was observed for guided responses compared with baseline (unguided) responses (fold-change 0.83 [CI, 0.76, 0.90]). Differences were otherwise similar across clinician subgroups and attitudes. Unwarranted practice variation was similar across most clinician subgroups. The authors conclude that care algorithms can reduce variation in management.

A Patient Decision Aid for Men With Localized Prostate Cancer: A Comparative Case Study of Natural Implementation Approaches.

There are multiple options for men diagnosed with localized prostate cancer. Patient decision aids (PtDAs) help empower individuals and reduce unwarranted practice variation, but few are used in clinical practice. We compared 2 programs implementing PtDAs for men with localized prostate cancer. This was a comparative case study. Case 1 was a hospital prostate pathway and case 2 was a provincial prostate pathway with 2 locations (2a, 2b). Nurses provided the men with PtDAs and answered questions. Data sources were as follows: (a) 2 years administrative data for men with localized prostate cancer, (b) clinicians survey and interviews, and (c) patients/spouses interviews. Analysis was within and across cases. The PtDA was used with 23% of men in case 1 (95% confidence interval, 19.8%-26.1%) and 98% of men in case 2a (95% confidence interval, 96.5%-99.8%). The pathway was not implemented in case 2b. Men given the PtDA had positive experiences. Many clinicians supported the use of PtDAs, some adapted their discussions with patients, and others did not support the use of PtDAs. To increase use in case 1, participants identified needing a Canadian PtDA available electronically and endorsed by all clinicians. In case 2b, the provincial prostate pathway needed to be implemented. There was variable uptake of the PtDAs between the cases. Men who received the PtDA had positive outcomes. Several strategies were identified to increase or sustain PtDA use. Nurses have a key role in supporting men making decisions about prostate cancer treatment by providing PtDAs, answering questions, and advocating for men's preferences.

A framework for quality measurement in the presurgical care of chronic rhinosinusitis: a review from the Quality Improvement Committee of the American Rhinologic Society.

Quality improvement (QI) in the management of chronic rhinosinusitis (CRS) is garnering increasing attention. Defining frameworks and metrics to assess the quality of key components in CRS management could assist in reducing unwarranted practice variation and increase high-quality care. A panel of the American Rhinologic Society (ARS) QI committee reviewed the literature to determine important presurgical components of CRS care that warrant QI. The evidence was organized into 4 categories: (1) diagnosis, (2) medical management, (3) appropriate patient selection for surgery, and (4) patient-centered discussion. The combination of these categories was used to develop a framework termed the CRS Appropriate Presurgical Algorithm (CAPA). Prior to offering surgery for CRS, the best available evidence support the following quality metrics: (1) a guideline-based diagnosis should be confirmed; (2) appropriate medical management, including a minimum of topical corticosteroid therapy and saline irrigations, should have been attempted (assuming patient tolerance); (3) a computed tomography (CT) scan should be obtained (to confirm the presence of sinus inflammation and for surgical planning); and (4) a patient-centered discussion regarding treatment options for refractory CRS (ie, alternative medical therapies vs surgery vs observation) while focusing on risks and benefits, the need for long-term medical compliance, and understanding of patient preferences and expectations. Defining metrics that assess key components to CRS care prior to offering surgery has the potential to further improve upon an already successful treatment paradigm, reduce unwarranted practice variation, and to ensure that patients are receiving a similar level of high-quality care.

June 2018 Letter to the Editor-in-Chief.

Letter to the Editor-in-Chief of JOSPT as follows: "The Root Method as Fiction: The Original References" with Authors' Response J Orthop Sports Phys Ther 2018;48(6):514-515. doi:10.2519/jospt.2018.0202.

Using Quality Improvement to Tackle Unwarranted Practice Variation.

As health care in the United States moves from quantity to quality, unwarranted practice variation has become a natural target for those wishing to improve care. Variation in provider practice should arise from personalizing care decisions on the basis of each patient’s condition and personal preferences. ‘‘Unwarranted’’ variation refers to variation beyond what would be expected based on patient or population differences1; it is due to non–evidence-based, inappropriate, and/or inefficient health care. Unwarranted variation in pediatrics has been demonstrated since the early 1900s, when Sir Allison Glover2 compared pediatric tonsillectomy rates in geographically and demographically similar areas of England. He showed a >10-fold variation in rates and concluded, “A study of the geographical distribution [of tonsillectomy] in children discloses no correlation between any other factor, such as over-crowding, poverty, bad housing, or climate. In fact it defies any explanation, save that of variation of medical opinion on the indications.”2 Despite broad dissemination of evidence-based guidelines for asthma management,3 unwarranted variation persists in care and outcomes for children treated in emergency departments and/or hospitalized for asthma. Studies have demonstrated wide variation in rates of diagnostic testing (eg, complete blood counts), interventions (eg, intravenous [IV] magnesium sulfate), transfer to ICUs, hospital readmissions, length of stay, and costs, even after correction for patient characteristics.4–7 This variation is largely due to the challenges of integrating guidelines into care, which may take up to 17 …