Implementation of VA Womens Health Patient Aligned Care Teams WH-PACTs
Phase: NA
Conditions: Patient-centered Medical Home Implementation
Sponsor: VA Office of Research and Development

 
 
Implementation of VA Women’s Health Patient Aligned Care Teams WH-PACTs 
 
PI: Elizabeth M Yano, PhD MSPH 
 
January 15, 2014 

Study Protocol and Statistical Analysis Plan 
 
Background 
Women Veterans’ (WVs) numerical minority in Veterans Health Administration (VA) 
healthcare settings has created logistical challenges to delivering gender-sensitive comprehensive 
primary care (PC). Women commonly must access an array of VA and non-VA providers, 
usually requiring multiple separate visits, to achieve the same basic level of care which male 
veterans can achieve through a single onsite PC visit [1–3]. The VA has invested in a variety of 
resources intended to improve WVs’ care, establishing women’s health clinics, designating 
Women’s Health (WH) PC providers with the requisite training/experience, and contracting with 
non-VA obstetrics and gynecology services. Despite these investments, WVs’ quality of care in 
VA continues to lag behind that of male veterans [4]. Contributing to these outcomes is the lack 
of gender sensitivity prevalent in many VA care settings, which may be linked to low WV 
retention rates in VA care [5, 6].  
The VA has undertaken a major initiative to transform care through mandated 
implementation of Patient Aligned Care Teams (PACTs), which hold promise for addressing 
many of the gaps in WVs’ care. The PACT model is based on the concept of patient-centered 
medical homes (PCMHs), widely endorsed by PC professional societies and shown to improve 
quality of care and patient, provider, and staff satisfaction, while reducing costs [7, 8]. PACT 
focuses on development of high-performing “teamlets” comprised of PC providers, nurses, and 
administrative support who together manage care of a defined panel of patients. These teamlets 
operate within a larger team that includes, for example, pharmacists, social workers, mental 
health (MH) providers, and dietitians, and link to specialists and hospital care in their medical 
“neighborhood.” Through these teams/teamlets, PACT aims to achieve improvements in 
accessibility, continuity, coordination, and comprehensiveness using team-based care that is 
patient-driven and patient-centered [9]. These improvements, in turn, should translate into better 
chronic illness care and prevention and lower costs.  
However, how VA should adapt this major reorganization to meet the needs of special 
populations, such as WVs, is yet to be fully worked out. The PACT model itself does not include 
specific accommodations for gender-specific care or improved gender sensitivity. Current WV 
care is also out of step with PACT priorities and emphasis on “one-stop shopping” for care [10]. 
For example, WVs are more likely to be outsourced to the community for gender-specific 
services now than they were 10 years ago, and, while the number of women’s clinics is up, over 
40 % do not deliver comprehensive PC [3]. Therefore, improving VA PC alone or “beefing up” 
women’s clinics is unlikely to achieve what an integrated WH-PACT model must reconcile to 
mprove care for WVs and thereby reduce persistent gender disparities in VA care [11, 12].  
 
Research aims 
We propose to use evidence-based quality improvement (EBQI) in the context of the 
Chronic Care Model to develop and test achievement of WH-PACT in a cluster randomized trial 
[13, 14]. EBQI is a systematic approach to developing local research-clinical partnerships to 
produce tailored, evidence-based care models or redesigns [15]. The resulting WH-PACT 
redesign will make use of local WH resources (e.g., women’s clinics, designated providers), 
while linking them to the broader PACT initiative and medical center resources. We will also 
explore the extent to which receiving care that meets WH-PACT tenets translates into higher 

value (better quality, lower costs) for individual WVs, evaluate local implementation, and 
develop tools for sustaining and spreading WH-PACT. Our aims are: 
 
1. To assess the effectiveness of EBQI for developing a WH-PACT model using a cluster 
randomized trial design. WH-PACT model achievement includes (a) PACT features 
(accessible, continuous, coordinated, team-based, patient-driven, and patient-centered), 
(b) comprehensive WH care (PC, gender-specific care, and integrated MH), and (c) 
gender-sensitive care delivery. We will (a) survey providers/staff on achievement of WH-
PACT model attributes, (b) survey WV patients on WH-PACT model care experiences, 
and (c) analyze WH-PACT achievement (e.g., continuity) using secondary data. 
2. To examine impacts of receipt of WH-PACT concordant care on WVs’ outcomes. We 
will explore impacts on quality of chronic disease care and prevention, health status, 
utilization and costs. 
3. To evaluate the processes of EBQI-supported WH-PACT implementation. We will assess 
pre-post practice contexts; document EBQI activities and their relationship to 
provider/staff and team actions and attitudes; document WH-PACT implementation; and 
examine barriers and facilitators to EBQI -supported WH-PACT implementation using 
mixed methods (e.g., semi-structured interviews, brief progress narratives). 
4. To develop implementation and evaluation tools for use in EBQI-supported WH-PACT 
model adaptation, implementation, sustainability, and spread to additional VA facilities. 
 
Methods/design 
 
Setting, site selection, trial design, and participants  
The VA healthcare system is currently organized into 21 regional Veterans Integrated 
Service Networks (VISNs), with administrative and clinical authority over VA medical centers 
(VAMCs) and their affiliated programs in geographically distinct regions of the USA [16]. Study 
sites are members of the VA Women’s Health Practice-Based Research Network (WH-PBRN), a 
37-VAMC network spanning 17 VISNs and comprising over 270 geographically distinct sites of 
care and nearly 600 designated WH providers [17]. Together, PBRN facilities serve over 
100,000 WVs (about one third of WVs seen in VA) and span diverse patient populations. We 
identified five VISNs with three or more WH-PBRN sites; we excluded one that was already 
participating in a VISN-wide EBQI stepped-wedge trial. We approached leadership at the other 
four VISNs and their WH-PBRN member site leads about study participation. All agreed to 
participate. One VISN dropped out ahead of randomization, which was replaced with a VISN 
that had two WH-PBRN sites; we then worked with VISN leadership to identify a third non-
PBRN VAMC, which subsequently joined the WH-PBRN (since the trial began, the WH-PBRN 
has expanded to 60 VAMCs in 20 of 21 VISNs). VAMCs participating in the trial span nine 
states (Connecticut, Illinois, Iowa, Massachusetts, Minnesota, North Dakota, Pennsylvania, West 
Virginia, and Wisconsin).  
This study is designed as a parallel two-arm, cluster randomized controlled trial (cRCT), 
blocked on VISN (Fig. 1). We randomly assigned the 12 VAMCs to EBQI or usual PACT 
implementation in an unbalanced 2:1 ratio within VISN, supporting appraisal of variations in 
EBQI implementation in the context of differences of VISN geography, resources, and oversight 
(Fig. 1). No site stratification or matching criteria were used. The study biostatistician used 
www.randomization.com with a randomized permuted block of three (simple block of three 

VAMCs within each VISN) and a seed of 15,356 to start the random allocation sequence. The 
eight intervention VAMCs will engage in EBQI, while the four control VAMCs will receive 
standard PACT and WH care delivery handbooks and guidance that all VA facilities receive. The 
study biostatistician assigned the VAMCs to EBQI or control, while the study PI (EMY) enrolled 
and launched EBQI with the resulting eight VAMCs. 
Local quality improvement (QI) teams, their WH and PC leaders, and VAMC facility 
leadership, as well as VISN leaders and other key stakeholders (e.g., national VA partners), will 
be the focus of this study, given their varying levels of responsibility for WH, primary care, and 
PACT implementation. Outcomes for the PC providers and WVs seen in each participating 
VAMC’s primary care/PACT programs, whether sited in a women’s clinic or general primary 
care clinic, will also be examined.  
 
Ethical approval and informed consent 
The VA supports a large number of Institutional Review Boards (IRBs) across the USA 
among chiefly academically affiliated VAMCs, in addition to a Central IRB (cIRB) for multisite 
research. While this study represents a 12-VAMC cluster randomized trial, the cIRB determined 
that participating sites were not engaged in research (i.e., the intervention is QI, and all research 
activities are performed centrally at the Principal Investigator’s site in the VA Greater Los 
Angeles (GLA) Healthcare System), permitting the use of the local GLA IRB. Evaluation and 
data collection activities are submitted serially to the GLA IRB for review as discrete human 
subject research component projects (e.g., patient survey component, provider/staff survey 
component). Two components involved contractors at local affiliates (teamlet interviews with 
UCLA, provider/staff survey with RAND Health), whose IRBs also reviewed and approved their 
respective activities. The study is registered with ClinicalTrials.gov (NCT02039856). 
 
VA partnerships 
This study is one of the five inter-related projects that together comprise a WH-focused 
research-clinical partnership funded by VA Health Services Research and Development 
(HSR&D) Service under the Collaborative Research to Enhance and Advance Transformation 
and Excellence (CREATE) initiative [18]. Central to CREATE is the involvement of policy 
and/or practice partners in the design, conduct, and dissemination of study results, with an 
emphasis on implementation and spread of successful strategies. Within the VA Office of Patient 
Care Services, Women’s Health Services (WHS) is the WH CREATE’s primary partner, with 
close involvement of Mental Health Services (MHS) in assessing within- and across-project 
mental health analyses and themes. The WH CREATE is also advised by an Executive Steering 
Committee, comprised of WHS and MHS partners, representatives in national VA clinical 
quality reporting, regional network leadership, public affairs, WH clinical care delivery, WH 
policy, and implementation science and economics, as well as WVs who use the VA for care. 
 
Conceptual framework for application of EBQI 
This study is guided conceptually and practically by the Chronic Care Model (CCM) 
[19]. Developed more than a decade ago, the CCM has been widely adopted to help guide 
clinical QI initiatives in the context of practices or teams in the USA and abroad [20]. The CCM 
depicts the health system linked with complementary community resources, while providers and 
teams within each healthcare organization (regardless of size) aim to deliver care that is 
characterized by consistent, evidence-based assessment, treatment, and follow-up, with clinical 

decision support (often via information technology) and support for patient self-management 
[21]. Applied to EBQI, local QI teams work on improvement plans that consider 
one or more CCM elements.  
The CCM is a particularly strong fit for QI around medical homes, with an easy 
crosswalk to PACT goals. For example, for care coordination, PACT teamlets should link 
patients with community resources to facilitate referrals and respond to social service needs; 
provide care management services for high-risk patients; integrate behavioral health and 
specialty care through structured collaboration, co-location, or referral protocols; track and 
support patients when they obtain services outside the practice; follow up with patients within a 
few days of an emergency room visit or hospital discharge; and communicate test results and 
care plans to patients/families [22].  
Addressing CCM elements, however, requires substantial stakeholder buy-in, local 
knowledge and skills in QI, availability of needed technical support, and continual guidance. 
Previous research has shown that evidence-based programs require adaptation to organizational 
values, needs, and resources prior to dissemination [23]. More structured than continuous quality 
improvement (CQI), which has had mixed results, EBQI is a systematic approach to developing 
a multilevel research-clinical partnership approach to QI, using top-down/bottom-up features to 
engage senior organizational leaders and local QI teams in implementing improvements in the 
context of prior evidence, provider behavior change methods, and local practice structure and 
resources [24]. National strategic directives serve as guides, while regional expert panels set 
innovation design priorities [25]. Local interdisciplinary QI teams design and implement local 
activities, while researchers serve as technical experts and guides. EBQI also uses team-based 
CQI methods to help teams structure their aims and measures and conduct plan-do-study-act 
(PDSA) cycles, in addition to convening topic-focused workgroups with research/clinical 
expertise with periodic across-site meetings for training and sharing data and lessons learned. 
EBQI’s value-added contribution is an emphasis on (a) applying objective evidence, with (b) 
theory review and synthesis integrated into aspects of innovation design and implementation, (c) 
valid and reliable measurement, and (d) formal measurement feedback to stakeholders at all 
levels [26]. Effectively applied to a series of VA implementation studies [27–29], EBQI uses 
well-established implementation strategies, such as local priority setting among key stakeholders, 
adaptation of the evidence to local context (practice tailoring), audit-and feedback of QI data to 
support rapid cycle improvements, and practice facilitation to support implementation into 
practice [30]. 
 
EBQI implementation strategies applied to WH-PACT and hypotheses 
In this study, we propose to use EBQI to convene multilevel stakeholder panels 
(presenting panels with evidence on factors associated with improved WH care in the context of 
national VA WH policy); facilitate local practice QI team design meetings, while providing QI 
training/ education and iterative QI data feedback; and sponsor within and across-practice QI 
collaboration calls (Fig. 2). We will continually foster coverage of CCM elements. We 
hypothesize that the initial results of EBQI will be the specification of the design choices for 
WH-PACT implementation, conduct of local QI activities, and improved provider/staff (and 
team) QI orientation, WH knowledge and attitudes, and gender awareness. We further 
hypothesize that EBQI will lead to higher achievement of WH-PACT (more practices achieve 
more features) in EBQI vs. control practices (aim #1). We anticipate that practice context (e.g., 
local leadership support, pre-EBQI factors) will moderate the relationships between EBQI and 

implementation of WH-PACT. We will then explore the extent to which receipt of WH-PACT 
concordant care (PACT features, comprehensive WH care, gender sensitive care delivery) is 
associated with improved WH-PACT outcomes (aim #2).  
For aim #3 (processes), we will document EBQI activities among intervention practices 
and examine barriers and facilitators to WH-PACT achievement in all participating practices. 
For aim #3, we will also rely on Diffusion of Innovation theory [31, 32] to frame our assessment 
of EBQI-supported WH-PACT adaptation, implementation, and sustainability, considering, for 
example, the trialability, complexity, and relative advantage of EBQI supported WH-PACT, as 
well as concordance between WH-PACT achievement and CCM principles. Aim #4 (tools) will 
build on our conceptual model and benefit from our practical experience implementing evidence-
based care models [15].  
In this study, EBQI implementation will focus on six main activities: (1) conduct of four 
VISN-level interdisciplinary stakeholder planning meetings using expert panel techniques to 
come to consensus on PACT QI priorities for women Veterans (“QI roadmaps”); (2) 
development and training of a local QI champion and QI team members at EBQI-assigned 
VAMCs to pursue one or more QI projects from the “roadmaps”; (3) formative feedback from 
patient, provider, staff, and practice survey data; key stakeholder and teamlet interview data; and 
utilization and cost-related administrative data; (4) ongoing practice facilitation and expert 
review and feedback on local QI proposals and progress; (5) monthly across-intervention VAMC 
calls to facilitate collaboration and spread of effective QI innovations; and (6) technical work 
groups designed to provide additional evidence-based support in priority areas (Table 1). 
 
Evaluation 
As shown in Fig. 3, we have planned a comprehensive approach to evaluating the 
processes and outcomes of EBQI for tailoring PACT to the needs of WVs. Baseline data 
collection (as well as 12-month follow-up in the case of the patient surveys) will be used for 
formative feedback to EBQI-assigned VAMCs. Table 2 provides an overview of the data 
sources, samples, and measures planned for each evaluation component. 
 
Sample size calculation and power analysis 
We based our power calculations on the study’s unequal (2:1) intervention-to-control 
ratio and clustered sample design. To detect a moderate (0.20) effect size between WVs at 
intervention and control sites, we considered data from the Primary Care Satisfaction Survey for 
Women’s Care Coordination and Comprehensiveness scale, [33] with 12 practices (8 
intervention-to-4 control sites), cluster adjustment (ICC = 0.03) [34], and two-tailed 5 % 
significance level. Based on these parameters, we will target enrollment of a minimum of 40 
WVs at each of the 12 study sites over the 2-year period (baseline to 24-month follow-up), for a 
total of 480 WVs who complete a baseline and at least one of the two follow-up surveys (12- 
and/or 24-month). To achieve this target, we will create a baseline sample of 6665 WVs who 
have received PC or WH care at one of the study’s 12 participating sites during the 12-month 
period prior to the baseline survey (555 per site). Allowing for a conservative 20 % response rate 
and 40 % attrition over the 2-year period, we aim to enroll 111 WVs at each of the 12 sites at 
baseline, for a total of 1333 interviews at the completion of the first wave. 
 
 
 

Primary outcome measures 
The primary outcome measure, focused on achievement of the PACT model of care for 
WVs, will include changes in levels of achievement of individual PACT features: access, 
continuity, care coordination, team-based care, patient-driven care, patient-centeredness, 
comprehensiveness (including gender-specific services and integrated MH), and gender 
sensitivity (Fig. 2). These measures will be examined at the practice, provider/ staff, and patient 
levels and investigated qualitatively using the key stakeholder and teamlet interviews. 
 
 
Secondary outcome measures 
Secondary outcome measures include WH-PACT outcomes that should result from 
achievement of the full PACT model, including improvements in quality of care and health 
status, and reductions in utilization and costs. For quality of care, we will examine chronic 
disease quality (e.g., process measures such as foot sensation exams or eye exams among 
diabetics) and preventive practice (e.g., women’s breast and cervical cancer screening and 
gender-neutral prevention, such as influenza immunizations and colorectal cancer screening). We 
will determine whether total annual costs per patient and utilization by type of care (e.g., primary 
care, specialty care, hospitalizations, emergency department visit rates) have changed in EBQI 
vs. routine PACT implementation VAMCs and based on level of WH-PACT achievement. We 
anticipate, however, that acute and emergency care may be too rare in our practice populations to 
have the power to detect differences over time, so these analyses will be exploratory.  
We will also examine impacts on provider and staff WH knowledge and attitudes, QI 
orientation/culture, and gender awareness, as well as changes in practice contextual factors as a 
result of EBQI exposure (e.g., changes in leadership support, local resources applied to WH and 
primary care QI, training). 
 
Statistical analyses 
We will use multivariate regression to determine EBQI effectiveness, adjusting for 
covariates, clustering, and enrollment and attrition weights at the patient and provider/staff 
levels. The primary regressor of interest is being at an EBQI vs. routine PACT implementation 
site. We will examine the potential moderating effects of practice context and provider/staff 
knowledge/attitudes. Patient-level controls will include sociodemographic characteristics, health 
status, comorbidity, and utilization. Adjustment for clustering will be performed using Stata v13. 
We will evaluate goodness-of-fit using Mallow’s statistic (Cp). We will use multiple imputation 
methods to address missing data patterns among covariates, although CATI procedures will 
significantly reduce item non-response in the patient survey, and the web-survey methods will do 
the same for the provider/staff surveys. Hot deck imputation will be used for imputation of 
missing values within scales as needed. To address the potential for response bias, patient and 
provider/staff survey data will be weighted to the inverse of the probability of selection based on 
available characteristics in the administrative data used to randomly sample them. We will use 
factor analysis and cluster analysis using PACT features (e.g., access), comprehensive women’s 
health care (e.g., gender-specific care availability), and gender-sensitive care delivery (e.g., 
availability of same-gender providers or gender-aware providers) for WH-PACT achievement 
variable creation.  
All semi-structured interviews will be audio-recorded and transcribed, and qualitative 
analysis will be conducted using ATLAS.ti version 7. Interview domains are noted in Table 2. 

Initially, a top-level codebook will be developed for the baseline interviews based on the 
interview guide. The codebook will then be elaborated based on emergent themes using a 
constant comparison analytic approach, adjusting as each round of interviews is reviewed. 
Interviews will be compared within and across facilities and over time. In baseline key 
stakeholder and teamlet transcripts, we will conduct targeted coding of PACT-related 
knowledge, attitudes, beliefs, and experiences; expectations of WH-PACT’s effectiveness; and 
practice contextual factors that influence how care is delivered (and changed) locally. In follow-
up key stakeholder transcripts, we will identify factors that facilitated and/or impeded EBQI and 
WH-PACT achievement and strengths/ weaknesses of the WH-PACT model as implemented.  
 
Trial timeframe 
The WH-PACT trial is planned from March 2013 through February 2017 (Fig. 1). Phase 
1 network-level stakeholder panel meetings occurred as half-day in-person meetings from May 
to August 2014. Phase 2 local QI launched at all eight EBQI-assigned VAMCs in October 2014. 
Baseline key stakeholder interviews in all participating VISN and VAMC followed within days 
of each respective network-level meeting, followed by teamlet interviews at EBQI sites only 
within one quarter of each meeting. Provider and staff surveys were fielded to PC and WH 
providers and staff in all participating VAMCs starting September 2014, while baseline patient 
surveys were launched in January 2015, yielding formative feedback in the following year. EBQI 
will run for 24 months from launch of local QI teams, followed by 24-month follow-up interview 
and survey waves. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Figure 1: Consort flow diagram for cluster randomized controlled trial of evidence-based quality 
improvement  
 
Figure 2: Evidence-based quality improvement (EBQI) conceptual model  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Table 1: Core components of evidence-based quality improvement (EBQI) implementation 
strategy  
 
EBQI component 
Activities 
Example product(s)  
Conduct of VISN-level 
interdisciplinary 
stakeholder planning meetings 
to 
develop “QI roadmaps” 
Modified Delphi panel meetings 
with materials on PACT and 
panel ratings in advance of an in-
person presentation of aggregated 
pre-panel ratings for review and 
moderated discussion and 
consensus development on top 
priorities for QI in context of 
feasibility of implementation and 
local resources 
Panel materials 
• Panel rating form 
• Summary of women Veterans’ 
research 
• VISN-level gender differences 
in patient ratings of care 
• Local practice and patient 
population characteristics 
VISN-level QI roadmaps 
• Brief panel presentation 
summary 
• Brief summary of top VISN 
priorities for QI for PACT for 
women Veterans 
• Brief summary of top-rated 
topics requiring technical 
support (e.g., care coordination 
between VA and non-VA 
providers) 
• Oversight and communication 
plans 
Development, training, and 
support of 
local QI champions and QI 
team 
members 
In-person training of 1–2 local QI 
champions at the parent study 
site in Los Angeles 
• National PC and WH leadership 
endorsement 
• Review VISN QI roadmaps and 
planned QI projects across 
intervention sites 
• Review approaches to QI 
• Breakout groups on applying 
QI methods/tools to project 
plans 
• Across-team debriefing 
• Formative feedback from key 
stakeholder interviews 
• Breakout groups on applying 
EBQI principles to WH-PACT 
QI projects 
• Training on EBQI formative 
feedback reports and Technical 
Work Groups 
• Exemplar session on using 
EBQI to improve PACT team 
functioning 
• Q&A panel with EBQI experts 
Training materials (reader, 
slidesets, breakout exercises, in-
person expert EBQI project 
consultations) 
Follow-up technical consults on 
local QI plans (with QI/system 
redesign consultant by 
email/phone) 

on lessons learned from prior 
projects 
• Training on local QI project 
documentation 
Formative feedback of local QI 
data 
• Feedback of baseline and 12-
month survey data from women 
Veterans seen in participating 
VAMC primary care clinics 
• Feedback of baseline PACT 
provider and staff survey 
findings 
• Feedback of key themes from 
baseline interviews of VISN, 
VAMC and practice-level key 
stakeholders 
• Feedback of key themes from 
baseline interviews of PACT 
teamlet members in 
participating VAMCs 
• Feedback of VA quality 
measures and patient survey 
data by gender for participating 
VAMCs
Site-level formative feedback 
reports with comparisons to 
VISN and all participating 
VAMCs 
Ongoing practice facilitation 
and expert 
review/feedback on local QI 
proposals 
and progress 
• Regular EBQI team contacts 
with local QI teams by 
telephone and email 
• Troubleshooting of local 
problems using VISN 
oversight/communication plans 
• Intermittent policy contacts 
(e.g., identify/disseminate key 
policy documents, obtain 
national guidance)
Structured local QI project 
proposals (templated) 
Structured expert feedback 
(email and telephone summaries) 
Facilitation or across-site 
collaboration 
and spread of effective QI 
innovations 
EBQI team-moderated monthly 
calls with 1+ representative per 
intervention VAMC 
Verbal summaries of local QI 
project progress (including 
shared materials across sites) 
Aggregated across-site 
formative feedback (from 
multiple data sources, e.g., 
patient surveys)
Technical work groups 
designed to 
provide additional evidence-
based 
support in priority areas 
VISN-level stakeholder panel 
meeting (above) used to also rate 
priority areas in which expert 
evidence-based consultation and 
support would be useful—work 
groups will be convened among 
national experts in clinical care 
and research in selected priority 
areas
Mini-systematic reviews in 
priority area(s) 
Practice scans of WH-PBRN 
site leads to identify best 
practices at other VAMCs 
 

Figure 3: Evaluation components of the Women’s Health PACT trial.   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Legend: PC, primary care; WH, women’s health; CATI, computer-assisted telephone interviews 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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