**Transcript of Cyberseminar**

**Timely Topics of Interest**

**2013 Under Secretary's Award in Health Services Research**

**Hayden Bosworth, PhD**

**June 18, 2013**

**2013 Under Secretary's Award in Health Services Research**

**June 18, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact:**Hayden.Bosworth@va.gov*

Moderator:Excellent. So we have Dr. Jesse, the Principal Under Secretary for Health, and he will now introduce Dr. Bosworth. Thank you, Dr. Jesse.

Dr. Robert L. Jesse:So this introduction is, I think, more of an acknowledgement for those of you who have not heard. I am making these remarks on behalf of Dr. Petzel, who could not be here. He is tied up over at the White House. 

But what I want to say is that really is a bit of a celebration and an honor for me to be here to congratulate Dr. Bosworth on receiving this year’s Under Secretary’s Award for Outstanding Achievement in Health Service’s Research. This is the highest honor that a VA Health Services Researcher can get and you will hear more about the work he has been doing in the Cyberseminar today, but fundamentally the work he is doing is really there to improve chronic disease care in VA and it is impressive. And I think it is very much the essence of how VA will transition ourselves into a model of much more patient-driven care. In addition to his accomplishments as a researcher and scientist, Hayden is also an exceptional colleague, teacher and mentor, and I think we are very fortunate to have him on our team. So I just wanted to take a moment to make sure that everybody on the call is aware of this great achievement and I think it is a great framing of what will be a wonderful Cyberseminar. So, Hayden, thanks for all that you do to improve the health of our nation’s Veterans, and I am just incredibly pleased and honored and I cannot think of anybody more deserving of this prestigious award. So with that said, I am just anxious to have you get started off; and if you all take a moment sometime to send him your congratulations as well, I am sure they will be well received. So thank you, and Hayden, it is all yours.

Moderator:Thank you kindly, Dr. Jesse. And at this time, I would like to turn it over to Dr. Bosworth. Are you ready to show your screen?

Dr. Hayden Bosworth:I am. Thank you.

Moderator:Great.

Dr. Hayden Bosworth:Dr. Jesse, thank you so much for the introduction. I am here to talk about my journey so far with Research, Moving from Effectiveness with Implementation and How We Can Continue to Improve Outcomes for Veterans. 

I would first like to acknowledge our Veterans and the Veterans Health Administration for all the support to carry out this work, also as well as Dr. Petzel; Dr. Jesse; Dr. Atkins, director of HSR&D; Ms. Seekins, who is the medical center director of the Durham VA hospital; the chief of staff here, Dr. John Shelburne; and the Associate Chief of Staff for Research, Dr. John Whited; as well as the VISN; friends and all of the colleagues with whom I have had the honor to work. Fortunately, I have been awarded the Career Scientist’s Award through the VA for this work.

So just to give a general overview of where we are coming from, I do not think its any surprise that we have an epidemic of poor lifestyle and chronic diseases. I incorporate medication non-adherence into this model as far as behaviors; but non-adherence costs approximately $300 billion and about 50 percent of patients do not take their medication.

Obviously there are aspects of alcohol abuse; obesity, which is a continuing, ongoing problem within our Veterans and in the U.S. population; as well as smoking. So all these issues combine to impact chronic illness, and chronic illness contributes to the majority of the U.S. health expenditures. This is estimated to be about $1.25 trillion.

For the first time we are looking at a cohort of our population where the life expectancy essentially is actually declining. If you look at the 1990s and on, the life expectancy continued to increase. But we may be, for the first time, looking at a decrease here.

Among our VA population, 72 percent have one or more chronic health conditions and generally, what we are seeing is that they are slightly sicker than the U.S. adults with more comorbidities. 

So within that context, our goal, what we are focusing on, is chronic disease management. We are trying to improve chronic disease, and this is important as the VA strives to meet the demands of both the bimodal distribution of the aging Veteran cohorts as well as care for younger Veterans that are entering the healthcare system.

Some of the things we are trying to focus on are how much can we off-load on primary care visits, so how much can be done outside of the primary care setting and perhaps in individuals’ homes. We are examining new models of care, increasing access. We are looking at how we can support performance incentive goals and in general improve quality measures, and how do we assess quality.

As a psychologist, I still believe in theoretical frameworks and this is a model that helps us identify where we are working and what are we focusing on. In general, just quickly one could look at the patient characteristics where we have individuals understanding the perceived risk and the benefits of whatever the treatment is and the disease, cognition, the memory, conductive reason, understanding the disease—what do I do if I have to take medication twice a day? Is that two pills in the morning or is that every 12 hours? Understanding that is an important aspect of cognition.

Coping and stress of daily activities, chaos, all influence how one engages in their health behaviors.

Literacy is a big issue that we have looked at and find that about 25 to 30 percent of our primary care setting here is functionally illiterate, which means that basically they are reading at an eighth grade or less reading level. They have challenges with even understanding the New York Times or the back of a Tylenol bottle, and so how do we address those issues?

Comorbidities, side effects and mental health are all aspects that we consider.

And then there are also the provider characteristics. How are they communicating with individuals? The intensity of therapy, beliefs about therapy, following guidelines and medication regimen. And then there are also the policy, community and medical environment.

So it is similar to the chronic care model. There are multi levels that need to be considered and these are some of the ways that we conceptualize where we are focusing on the programs that I will talk about just shortly.

So one of the things for us that we have done is how do we personalize and tailor intervention programs? I just want to clarify the difference between tailoring and targeting, my interpretation.

Targeting is in communications that are developed to appeal to certain subgroups. Those may be by race or gender. And then once you have targeted that in those programs, then you can tailor the material to different levels or different levels of motivation, different cultural issues and things along those lines. 

So the idea is how can we personalize the information as much as possible so that it is relevant for individuals in identifying what are the important or key characteristics to target and what do we want to tailor on. And that is what I will talk a little bit more about shortly.

Just to give you an overview, programs that we have been doing within different disease states and conditions as well as different behaviors and educations, we have developed about 80 different diseases and conditions, implementing in both the VA and other non-VA healthcare systems, predominantly Medicaid and lower capitated systems that resemble similarly to the VA. But just to frame how we look at the targeting and tailoring and some of the issues that we focused on, quickly I will just go over and then I will dig a little deeper into some specific trials and how we have moved from the trials to implementation and why we do that.

But in general our early work is based upon a couple of effectiveness trials and I will highlight some of these. I will point out also the non-clinician. Always early on in my career I struggled with well, how am I going to help patients? I do not see them on a day-to-day basis per se. I realized that perhaps while I may not have as much of the in-person connection with an individual as our nurses, pharmacists and our physicians, we still can perhaps touch and improve outcomes for a number of individuals.

And so across these seven trials that our local site has conducted that I have been involved with or have led, we have been able to interact with over 3,500 individuals. I highlighted some of the issues regarding minority retention rates and things along those lines because I do think one of the other issues is not only providing targeted and tailored information, but ensuring that we are also engaging patients and ensuring that they stay within the context and they are finding it beneficial. And within that context, if you look, we have been generally confined, depending upon the intensity of the programs, approximately 75 to higher retention rates for our programs. Most of the early trials that we have done were within the context of cardiovascular disease as well as some osteoarthritis and hyperlipidemia.

So if I was to start transitioning from these specific trials, I will briefly give an overview and then talk about how we are moving towards implementation, because I do think that this is the role and direction that HSR&D is moving towards.

One of our first trials was the Veterans Study to improve the Control of Hypertension, The V-STITCH Study. This was funded through the VA.

This was a randomized controlled trial testing a nurse-administered, telephone intervention designed to improve BP control. This was conducted in primary care clinics here at Durham and we enrolled patients with hypertension on medication. It was a 24-month intervention every other month.

In general, our characteristics were what we would typically see in a primary care setting here in Durham. The majority were male. We had 40 percent African Americans and about 25 percent were reporting inadequate income, which means that at the end of the month, they did not have adequate funding to pay all their bills.

Just highlighting the overall intervention, this was also an opportunity to highlight some of our opportunities to collaborate. I was presenting the Nurse Intervention, but the VA is such a wonderful place that we were able to work with Dr. Mary Goldstein at Stanford to use her Athena Decision support; there was a provider component to all this. I am not going to focus on that at the moment, but it should indicate the opportunity that we have in the VA to collaborate, which I do not think is easy to do outside the VA setting.

So it was in the context of this program. If you look at the baseline, about 44 percent of the individuals at the time had blood pressure controls, and then through the nurse intervention there was an improvement of about 21 percent and an overall impact of about 13 percent.

So we were excited by the findings; but I think one of the things that we also learned was to put it into the context. And so within the context, the majority of the patients completed most of the phone calls. This time when we started this program, it was mostly didactic, and so there was not a lot of the tailoring and the targeting, as I mentioned earlier. But the average phone call was three minutes every other month was what we achieved.

And I think the other important thing is we conduct these trials and we move towards implementation, but what we need to do is understand the cost implications as well as the resource allocation. I think this is what I find one of the more important parts of this study.

What we did was estimate what was the number of panels of individuals that a nurse could potentially see using s similar program. This was for the 560 if you look and that was estimating upwards of 20 to 25 minutes to include the review of the records. This was 15 minutes and then this was if it was back down to about 10 minutes or so. And then what the direct costs were back when we conducted the study.

The other important part of all this is that this data was useful for us to then, when we implemented a similar program within the context of Medicaid, which is ongoing at the moment and while the stakeholders are more important that a) that it work and then b) once it works, what was the panel sizes that they could see, what were the resources, that was the most important information from their perspective. Subsequently, this program is ongoing and continues to be used within the context of Medicaid in North Carolina.

So in summary for The VSTITCH Study, it was a brief telephone intervention that improved blood pressure control by 21 percent at 24 months. It was almost a 13 percent relative to the non-behavioral group. We did not see an increase in clinic utilization and it seemed to be relatively cost effective.

This led us to move towards the HINTS study. This is a Hypertension Intervention Telemedicine Study through again a collaboration with Dr. Goldstein using her Athena Decision support for hypertension, but now incorporating home blood pressure monitoring. This was a VA study as well. 

This was an 18-month trial. We enrolled almost 600 individuals. About half were African Americans. The slight variation on the study was that we started identifying people who were more in need of these programs, so people who over the last 12 months had poor blood pressure control; and so these were not just individuals that had hypertension. We focused mostly on the role of home blood pressure monitoring. It was not in management, but the nurses using Athena, Mary Goldstein’s program, made recommendations and then the providers were able to incorporate and make those med changes.

So again changing the roles, utilizing resources more efficiently. And in this case, it is really using nurses to follow a decision support system that was developed and tested with backups from the physicians trying to increase the reach of the healthcare providers to patients.

In terms of just looking at the results, our population, as I mentioned, approximately half were African American. About 92 percent were male. We had almost 40 percent over the low literacy level; this is less than a ninth grade reading level; and about 20 percent had inadequate income.

In general, if we looked at individuals who had poor blood pressure control at baseline, we saw about a 15-point change in systolic blood pressure at 12 months and then subsequently about an eight-point difference at 18 months.

Then again, imagine what our stakeholders are looking for and how can we provide information to them. This is a followup analysis of this trial and what we wanted to look at was what the sustainability of the program after the program was ended.

So we generally limit our followups to whatever our funding opportunities are, but what we do not necessarily know is what happens when you turn off the intervention and what are the long-term implications.

If you look at these data, you can see that at baseline, there was not too much of a difference. The green line is the combined arm, which is the nurse. The implement intervention was then management. And the 18-month here was at the conclusion of the trial and subsequently the results continued for another 18 months. So I think kind of exciting results indicating that a little bit of the intervention can continue effects and perhaps looking back at whether or not boosters are necessary; but potentially the costs are even better if we were to look at further than the actual trial.

So one of the things too is that I think as researchers, we oftentimes want to look at the actual data, and if you look at what most of our analyses are, they are typically correlation matrix and we are providing summary scores. I think the role of our colleagues that do the qualitative research and mix methods are absolutely essential as well as to incorporate what are the patients’ perspectives and opinions about that. 

So this is a non-scientific review, but what we did was look at a couple of individuals that were in the program. If you look here, just to give it a kind of a feel, here is an individual with a baseline of 136/101, here in the program decreased to 116/85. That is a decrease systolic of 20 and a diastolic of 16. I think most of us would claim that that is a pretty substantial improvement.

And then the individual person that reported that do you think your blood pressure changed and this person responded, “Yes, it changed. I was having BP readings greater than 200/100 sometimes; greater at the hospital and now they are much lower.” And then we asked him what was particularly helpful: “It was really concern that made me want to do better and I am more involved in my own care and felt I was part of the process.”

And then here we have an African American woman who is 48, similar improvement in blood pressure. And this person wrote, “This study made me more aware of blood pressure medications, what they do.” And we asked what of all the topics discussed, what was the most helpful: basically knowing about blood pressure and how to monitor and keep an eye on it, an emphasis on eating properly, losing weight, exercising, watching cholesterol and preventing myocardial infarctions and strokes. 

So again just peppering in a little bit of the patients’ perspective. 

But at the beginning of the day when I wake up, I always need to think about what are we trying to do and who are our stakeholders, and these types of data are helpful for me to remind myself that the typical Veteran in the primary care setting is indeed our stakeholder.

So how do we translate these programs into implementation? This is where our group is generally focusing our attention and taking an effectiveness trial where perhaps we may have three or less sites, may have up to about 650 individuals and we are looking at intermediate outcomes, whether blood pressure control, A1C, patient reported, typically we are really underpowered for cost utilization. And so how do we evaluate that to determine what is appropriate for implementation and how do we take these programs and then scale them up to 1,000, 10,000, 20,000, 100,000 people? And I think that is the $64,000 question in thinking about how to do that.

So that led into one of the programs that we have continued and implemented called the HTN IMPROVE, the Hypertension Telemedicine Nurse Implementation Project for Veterans. 

This is an ongoing program and it is going on in three sites. We have been fortunate enough to collaborate with Nashville, Christianne Roumie, and up in Connecticut and here in Durham. This is a behavioral program that is being implemented and each of the sites is providing the resources to implement the program. We will look at nine control sites.

We have conducted Phase I, which is evaluating the barriers and facilitators for implementation. Interestingly, I am sure for those of you who have been doing this type of work, the biggest barrier quite frankly was IT and how to get that support and variations and interpretations of what is research and what is not. So it took a little bit longer at some sites and some were able to get up and going quicker than others.

We are continuing the program. It is a 12-month program and we are continuing to enroll patients into this and eventually we will look at the implementation costs and dissemination. 

The important thing too is that at this point, this was funded through the Stroke RRP, the Rapid Response Projects, and it is just continuing on since then. And so it is not funded through a grant. It is more supported through the infrastructure of the local site.

I will just briefly mention the North Carolina Medicaid Study. I mentioned earlier some of her work, but I want to just highlight some of this work as well. 

Within this context, we took one of our earlier hypertension programs that was conducted with VSTITCH, as I mentioned. This is a self-management program improving lifestyle and medication adherence. Three counties in North Carolina decided that they wanted to support this program. They used existing case managers that were providing care to patients within that context. They also indicated that local sense of motivation and readiness to implement programs can be so key.

So these three case managers that provide care for three counties decided that they wanted to provide these resources and start the program, and basically were able to improve medication session ratios focused on pill refill, and identified the individuals who had poor medication adherence. In the past 12 months there was above the individual 55 percent were refilling their medications for hypertension and diabetes. And then after 12 months of the program, they were able to increase pill refill rates to 77 percent.

So from our perspective, the interesting part was a) they were looking at the outcomes and b) was then circling back and looking at the fidelity: how was it implemented, how can we ensure that there was consistency but yet put in that within a context of an implementation program. And then also, what were the pieces that the stakeholders that were going to continue this program were looking for and how could they identify them.

So one of the key pieces was that they wanted more than just hypertension. They wanted diabetes, and now since then, also chronic kidney disease. And so being mindful of what they were looking for and how it could support them has also provided opportunities for us to continue programs in these communities and evaluate them as they are ongoing.

So some of the challenges I am foreseeing: the scalability I mentioned. I think there is a big difference between going from 600 individuals in potentially three sites to multi-site trials within the context of self-management and what those implications are and the resources to conduct those, but I think those are directions we all need to move forward.

ROI, return on investment, and cost. I think we need to open and broaden our definition of what those define. I think the core in the patient centers moving has helped changes some of those discussions, but I do not think it is just the financial costs. Perhaps it is provider satisfaction that we are helping them increase or support their existing panel sizes and perhaps putting some of the work off and that they are able to focus on certain patients. How do you evaluate that satisfaction? How do you evaluate the satisfaction in the patients? Those are things that I think we still need to define when I mention ROI or return on investment.

I think IT is an ongoing issue. How do we integrate things into our existing medical records and electronic systems and what those processes are? I can tell you that for multiple stakeholders, the more integrated the system, the better off it is. But that is obviously a challenge and something that we all need to continue working on.

And then competing needs. It is one thing when we do a trial and we pay somebody to implement the trial and we can engage that person and the interventions for three years. But it has been definitely for some of the implementation work that may take multiple years. How do we keep them focused on that? The PACT came out shortly after we started HTN-IMPROVE and it took a lot of work to figure out how to avoid competing with the PACT and how do we integrate this within the PACT because that was what the priority was at some of these sites. So always ongoing looking at the competing needs and how do we try to adapt that to try to maximize those.

I think sustainability. We do not want to be seagulls where we peck, do a trial and then leave as the seagulls. So how do we keep these programs moving, continuing and sustaining? Those are real key aspects that we are really constantly looking at. I think some of those ways are involving and engaging the stakeholders from the very beginning so that they have some ownership and feel like there is a way of wanting to continue that. 

One of our programs that we conducted for diabetes in the Medicaid population, after the trial was finished, continued because we had the Medicaid representatives involved with the program from the very beginning, as well as the patients, who wanted the program to continue. So having those types of people be your advocates can be very powerful, I think.

Again, just some of the evaluation aspects: identifying partners, and those partners may change over time, and engaging them; how do we integrate this into the regular work of the clinic; and then trying to define how we measure success.

Where is the future? Chronic disease management is growing in prevalence and I think that particularly as we get younger Veterans, thinking of prevention as well. We need to do that and I think the VA is a wonderful place to do that type of work now.

I think that self-management is the intersection between behavior and social contextual environment, so it is doing a better job of understanding the context the individuals are in.

I think that there are increasing needs for sophistication of analyses and methodologies, particularly as we move away from randomized controlled trials, envisioning how do we use quasi-experimental designs to truly evaluate what is going on and get a sense of what is working. And so I think the designs are going to be continuing to push the direction where analyses and methodologies go.

The ability to work in an interdisciplinary/multidisciplinary environment. I have been really fortunate to work within the VA and have multiple colleagues represent multiple fields and learning from their perspectives. But I think the challenge, too, is learning to ensure that we are all using the same language and terms, so that we all can communicate adequately.

Again just reiterating I think ensuring we provide our stakeholders what they need, knowing who those stakeholders area, and understanding that.

And then I think continuing to invest in our future, which I think is truly important given the financial challenges that we are finding. But I still think that this is more of a reason to continue investing in our future.

To that end, I just highlight some of the individuals that I have been recently able to mentor and have the privilege—and if you have an opportunity to see or talk to some of these people, they are quite amazing and I think they are going to be the faces of the VA already and will continue to be.

Some of these faces may look familiar to some of you who have been in the VA for a while. Dr. Eugene Oddone and Dr. Morris Weinberger, who I believe are truly my mentors and I think at one point I just point out that no matter where someone is in their career, I think it is always useful and beneficial to have mentors. The people that I have started off mentoring that are now my colleagues are Kelli Allen and Corrine Voils and David Edelman and George Jackson and Steve Grambow and Maren Olson. So a wide variety of individuals with different backgrounds that I think just increase our ability to improve our reach to Veterans.

My research team that, if it was not for them, I do not think I would have been able to do any of this work. So I have been very fortunate to have people that have been with me for upwards of 15 years now. 

And then it is always too remember what gets you not only up in the mornings, but sometimes keeps you up at night, but these are my two boys. The oldest on the left is Benjamin and my youngest, Joshua, and then my wife and my two children. So I want to just acknowledge their support over the 15 plus years I have been privileged to work within the VA.

And then just local people. And then since it is an opportunity to do the Cyber Seminar, I just wanted to point out the opportunity to work with such great people across the country, and I am sure I have missed some people here and I apologize. But these are the people I have had an opportunity to collaborate with on multiple occasions and it has just been a pleasure.

So to that end, thank you very much for your attention and I am very privileged to have received the Under Secretary Award.

Moderator:Thank you kindly, Dr. Bosworth, not just for your research, but for addressing the field today. For those of you that joined us after the top of the hour, I just want to let you know that this is the opportunity to ask Dr. Bosworth any questions you may have or send any comments to him. You can do this by using the GoToWebinar dashboard that is located on the right-hand side of your screen. There is a question section with a box that says “Write question for staff here.” Simply type your question or comment into that box and press send. You can have more than one pending at a time, so feel free to submit as many as you would like.

So far, there are no questions from the field, but there are several congratulatory comments. Some are: Congrats, Dr. Bosworth. You set a true example. Thank you for this presentation. It is wonderful to see it play out across the U.S. and several others along those lines. So everyone very much appreciates hearing from you and we will wait to see if any questions regarding your research population in. 

While we wait for those, do you want to give any more comments or concluding comments?

Dr. Hayden Bosworth:I guess the only point I would say is mentorship. It is really – I just put two sentences in there. I think ensuring that we take care of our young, if you will, and supporting them and collaborating with them, is key. And I think commend also HSR&D. I think many of us involved with the CREATES and COINS —there are a little bit of growing pains, but this direction of moving towards more implementation involving stakeholders and also providing infrastructure to collaborate I think are going to be key for the future of the VA. So more opportunities to try to do that type of work are, I think, really important.

Moderator:Thank you. We do have some questions that are now coming in. The first one starts off with a comment: Very nice job. As you continue your work in this area, how will you address care for Veterans who utilize multiple healthcare systems? How can you coordinate care such as medication management across these systems?

Dr. Hayden Bosworth:Boy, that is a $64,000 question. That is a great question and we are trying to address those issues, particularly the medication issues, which is a major focus of what we have been doing lately, medication adherence. I do not have a good answer, quite frankly. It is an issue that we are struggling with and the dual users are I think a major focal point that we really need to put more resources and get a better understanding of who they are and focus on that. But these silos, if there are ways to figure out how to collaborate and share that data in real time, will be very beneficial. I wish I had a better answer.

Moderator:Well, we appreciate your reply. I just want to make a quick announcement. Some people are clicking the hand raise icon to ask a question. I cannot unmute your line, so please type your question in to your GoToWebinar dashboard. The next question is: Thank you for the terrific presentation. Earlier in the presentation, you mentioned some barriers to doing implementation research including, what is research? Are you referring to IRB issues here; and if so, can you expand, offer suggestions, any suggestions?

Dr. Hayden Bosworth:Yes. So that is the great—thank you for paying attention. I think I was probably underlining two interpretations. I think IRB from our experience, is defined slightly different at each institution. And sometimes that is our role is to try to provide our recommendation, but let the local IRB make that decision. Obviously, there is a central IRB. I think our experience lately is that IRBs have definitely got a better sense of the implementation. But in the case of that example, which was in the context of HTN-IMPROVE, which is at three sites, it has been very challenging from an IT perspective, to consistently utilize and implement the program that we have created with one site envisioning it as research, the other two sites envisioning that it is implementation in healthcare. And it took over a year through a lot of persistence on our end to work within the local site and let them dictate and feel comfortable with the way they wanted to interpret it and provide different options for them. And then I think eventually they came around and realized that it is quality indicators and it is implementation. And part of that was when they realized that it is an opportunity to improve the outcomes for their patients and there is no consenting, there is no randomization. It became a little bit more clear. But basically, we were working with IT people trying to define themselves what research is. That is not a great place to be, but I think that is where collectively we can keep pushing that envelope and explaining in detail and defining these things so that we are all in the same place.

Moderator:Thank you very much for that reply. That was an excellent question. Well, we have a few more congratulatory comments that have come in, all with the same sentiments: Thank you very much; we are happy to hear from you; and great presentation. At this time, that was the last pending question, and once again, I want to thank you so very much for taking the time to address the field today and offer my congratulations to this honor of receiving the USH award. Would you like to wrap it up with anything?

Dr. Hayden Bosworth:It has been an honor and thank you so much for your attention.

Moderator:Great. Thank you. And thanks to our attendees for joining us; and as Dr. Jesse mentioned at the beginning, please feel free to send Hayden your congratulations. I am sure they would be very much appreciated. And with that, this does conclude today’s HSR&D Cyber Seminar. Thank you for joining us today. Bye-bye.

Dr. Hayden Bosworth:Thank you.

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