Linking Clinical and Administrative Data to Inform Performance Measures Regarding Access to Specialist Care for Patients with Rheumatoid Arthritis

IntroductionRheumatoid arthritis (RA) is the most prevalent type of chronic adult inflammatory arthritis and requires timely diagnosis and subsequent access to specialist care and treatment from a rheumatologist. We developed a set of key performance indicators (KPIs) to evaluate access, effectiveness, acceptability, appropriateness and efficiency of care. Objectives and ApproachThe overall objective was to measure performance of a central intake system for referral to rheumatology against the KPIs. We report on one accessibility KPIs: the percentage of patients with new onset RA with at least one visit to a rheumatologist in the first 365 days since diagnosis. We identified a cohort of RA patients using a validated case definition: >16 years, at least 1 RA related hospitalization (ICD-10-CA:M05.x-M06.x) or two RA related physician visits ≥ eight weeks apart within two years (ICD-9: 714.x). The incident case date was date of hospitalization or second physician visit (whichever came first). ResultsThis KPI assessed the proportion of patients seen by a rheumatologist within one year of first RA visit by patients in the RA cohort. 13,914 cases of RA were diagnosed between April 1 2010 and March 31 2016. The percentage of patients with new onset RA with at least one visit to a rheumatologist in the first 365 days since diagnosis increased between fiscal years 2011 and 2015. Of the 2851 incident RA cases in fiscal year 2011, 1490 (53%) met the performance measure compared to 1710 of 2710 (63%) who met the definition in fiscal year 2015. Other KPIs, including wait times, are being evaluated using both clinical and administrative data. Conclusion/ImplicationsBy linking multiple administrative datasets, we are able to measure system performance against a defined KPI and identify opportunities for system improvement. This is the first initiative in Alberta for patients with RA where data from different multi-custodial data repositories have been extracted, linked and analyzed for this purpose.

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Validation of a Case Definition for Pediatric Brain Injury Using Administrative Data

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2016.419 ◽

2017 ◽

Vol 44 (2) ◽

pp. 161-169 ◽

Cited By ~ 3

Author(s):

Jane McChesney-Corbeil ◽

Karen Barlow ◽

Hude Quan ◽

Guanmin Chen ◽

Samuel Wiebe ◽

...

Keyword(s):

Brain Injury ◽

Administrative Data ◽

Predictive Value ◽

External Validation ◽

Secondary Data ◽

Population Based ◽

Case Definition ◽

Case Definitions ◽

Icd 10 ◽

Pediatric Tbi

AbstractBackground: Health administrative data are a common population-based data source for traumatic brain injury (TBI) surveillance and research; however, before using these data for surveillance, it is important to develop a validated case definition. The objective of this study was to identify the optimal International Classification of Disease , edition 10 (ICD-10), case definition to ascertain children with TBI in emergency room (ER) or hospital administrative data. We tested multiple case definitions. Methods: Children who visited the ER were identified from the Regional Emergency Department Information System at Alberta Children’s Hospital. Secondary data were collected for children with trauma, musculoskeletal, or central nervous system complaints who visited the ER between October 5, 2005, and June 6, 2007. TBI status was determined based on chart review. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for each case definition. Results: Of 6639 patients, 1343 had a TBI. The best case definition was, “1 hospital or 1 ER encounter coded with an ICD-10 code for TBI in 1 year” (sensitivity 69.8% [95% confidence interval (CI), 67.3-72.2], specificity 96.7% [95% CI, 96.2-97.2], PPV 84.2% [95% CI 82.0-86.3], NPV 92.7% [95% CI, 92.0-93.3]). The nonspecific code S09.9 identified >80% of TBI cases in our study. Conclusions: The optimal ICD-10–based case definition for pediatric TBI in this study is valid and should be considered for future pediatric TBI surveillance studies. However, external validation is recommended before use in other jurisdictions, particularly because it is plausible that a larger proportion of patients in our cohort had milder injuries.

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P.065 Alzheimer’s disease (AD) and dementias in Canada: First national surveillance data from the Canadian Chronic Disease Surveillance System (CCDSS)

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2017.149 ◽

2017 ◽

Vol 44 (S2) ◽

pp. S29-S29

Author(s):

C Pelletier ◽

C Robitaille ◽

N Gabora-Roth ◽

J Toews

Keyword(s):

Disease Surveillance ◽

Age Groups ◽

Incidence Rates ◽

Case Definition ◽

Administrative Databases ◽

Fiscal Year ◽

Prevalence Rates ◽

Disease Surveillance System ◽

Icd 10 ◽

Group Sex

Background: With a growing and aging population, the number of individuals with AD and dementias and their associated costs are expected to increase in Canada. Up to now, no national mechanism was in place to monitor the epidemiological burden of AD and dementias. This presentation will showcase the first CCDSS data available on these conditions. Methods: Through the CCDSS, a Federal/Provincial/Territorial partnership, health administrative databases are linked to collect data on chronic conditions. Using selected ICD-9(CM)/ICD-10 codes for AD and dementias, the validated case definition implemented to identify relevant cases aged 65+ is:1+ hospitalizations; or3+ physician claims within 2 years, with a 30-day-gap between each claim; or1+ anti-dementia drug prescriptions.Prevalence and incidence rates will be presented by 5-year age group, sex, province/territory, and fiscal year. Results: Overall, incidence and prevalence rates were higher in women. The prevalence rate approximately doubled between 5-year age groups and sex differences tended to widen with age. While aged-standardised data show increasing prevalence rates over time, incidence rates fluctuated but suggest a decline since 2009/10. Conclusions: CCDSS data can be used to monitor the burden of AD and dementias in Canada. This information is important for the assessment of prevention actions and the planning of health care resources.

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Maternal alcohol use, adverse neonatal outcomes and pregnancy complications in British Columbia, Canada: a population-based study

BMC Pregnancy and Childbirth ◽

10.1186/s12884-021-03545-7 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Svetlana Popova ◽

Danijela Dozet ◽

Graham O’Hanlon ◽

Valerie Temple ◽

Jürgen Rehm

Keyword(s):

British Columbia ◽

Risk Factor ◽

Alcohol Use ◽

Pregnancy Complications ◽

Alcohol Exposure ◽

Population Based ◽

Neonatal Outcomes ◽

Fiscal Year ◽

Adverse Neonatal Outcomes ◽

Icd 10

Abstract Background The current study aimed to estimate the prevalence of alcohol use identified as a risk factor during pregnancies by the antenatal care providers, resulting in live births in British Columbia (BC) and to examine associations between alcohol use, adverse neonatal outcomes, and pregnancy complications. Methods This population-based cross-sectional study utilized linked obstetrical and neonatal records within the BC Perinatal Data Registry (BCPDR), for deliveries that were discharged between January 1, 2015 and March 31, 2018. The main outcome measures were alcohol use identified as a risk factor during pregnancy, associated maternal characteristics, pregnancy complications, and adverse neonatal outcomes. Estimates for the period and fiscal year prevalence were calculated. Chi-square tests were used to compare adverse neonatal outcomes and pregnancy complications by alcohol use during pregnancy identified as a risk factor. Logistic regression was used to examine the association between alcohol use identified as a risk factor during pregnancy and adverse neonatal outcomes and pregnancy complications, after adjusting for identified risk factors. Results A total of 144,779 linked records within the BCPDR were examined. The period prevalence of alcohol use during pregnancy identified as a risk factor was estimated to be 1.1% and yearly prevalence was 1.1, 1.1, 1.3 and 0.9% from the 2014/2015 to 2017/2018 fiscal years, respectively. Alcohol use identified as a risk factor was associated with younger maternal age, fewer antenatal visits, being primiparous, a history of mental illness, substance use and smoking. Neonates with alcohol use during pregnancy identified as a risk factor had greater odds of being diagnosed with: “low birth weight (1000-2499g)” (ICD-10: P07.1; aOR = 1.25; 95% CI: 1.01, 1.53), “other respiration distress of newborn” (ICD-10: P22.8; aOR = 2.57; 95% CI: 1.52, 4.07), “neonatal difficulty in breastfeeding” (ICD-10: P92.5; aOR = 1.97; 95% CI: 1.27, 2.92) and “feeding problems, unspecified” (ICD-10: P92.9; aOR = 2.06; 95% CI: 1.31, 3.09). Conclusions The prevalence of alcohol use during pregnancy identified as a risk factor was comparable to previous estimates within the BCPDR. Identified prenatal alcohol exposure was associated with notable differences in maternal and neonatal characteristics and adverse neonatal outcomes. More consistent, thorough screening and prevention efforts targeting alcohol use in pregnancy are urgently needed in Canada.

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Abstract 03: Outpatient Care Preceding Incident Heart Failure (HF) and Implications for Long-Term Outcomes. The Atherosclerosis Risk in Communities (ARIC) Study

Circulation ◽

10.1161/circ.131.suppl_1.03 ◽

2015 ◽

Vol 131 (suppl_1) ◽

Author(s):

Anna Kucharska-Newton ◽

Lloyd Chambless ◽

Ricky Camplain ◽

Carmen Cuthbertson ◽

Patricia Chang ◽

...

Keyword(s):

Outpatient Care ◽

Primary Care Physicians ◽

Fee For Service ◽

Physician Visits ◽

Comorbidity Score ◽

Risk Of Death ◽

Outpatient Visits ◽

Outpatient Physician ◽

One Year ◽

Aric Study

Hypothesis: We hypothesized that outpatient management of patients at risk for a HF hospitalization is associated with lower mortality following an incident HF hospitalization. Methods: Patterns of outpatient visits prior to incident HF hospitalization were assessed among CMS Medicare beneficiaries with continuous fee-for-service eligibility residing during 2003-2006 in four geographic areas of CVD surveillance conducted by the ARIC Study. Incident HF hospitalization was defined as hospitalization with ICD9 code 428.x with no HF hospitalizations in preceding 2 years. Outpatient visits to primary care physicians, general internists, or cardiologists were identified from Carrier files. A comorbidity score was calculated from ICD9 codes at the time of incident HF hospitalization. Cox proportional hazard models adjusted for age, comorbidity score, gender, and race were used to estimate mortality. Results: Mean age among beneficiaries with observed incident HF hospitalization (n=2006; 90.4% white, 45.1% male) was 79.8 years (SD 7.4). Mean comorbidity score was 3.6 (SD 1.9). Mean number of outpatient physician visits occurring in two years preceding the incident HF hospitalization, was 9.6 (SD 9.0); 19.6% beneficiaries had no observed prior outpatient physician visits. Risk of death within one year of incident HF hospitalization was greater among those with no preceding outpatient physician visits as compared to those with at least one physician visit (adjusted HR=1.81 (95% CI 1.50, 2.18); Figure). Adjustment for the presence of an outpatient visit within 2 weeks following the HF hospitalization attenuated the risk of death (HR=1.56 (1.29, 1.89)). Conclusion: Lack of outpatient care in two years prior to a HF-related hospitalization is associated with increased mortality within one year following hospitalization. Further inquiry is warranted to assess whether the association reflects diversity in causes/manifestations of HF, ambulatory care received in ED settings, or benefits associated with outpatient care.

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Comparison of routine blood alcohol tests and ICD-10-AM coding of alcohol involvement for major trauma patients

Health Information Management Journal ◽

10.1177/18333583211037171 ◽

2021 ◽

pp. 183335832110371

Author(s):

Georgina Lau ◽

Belinda J Gabbe ◽

Biswadev Mitra ◽

Paul M Dietze ◽

Sandra Braaf ◽

...

Keyword(s):

Administrative Data ◽

Major Trauma ◽

Blood Alcohol Concentration ◽

Trauma Centre ◽

Trauma Patients ◽

Blood Alcohol ◽

Alcohol Involvement ◽

Preventable Risk Factor ◽

Major Trauma Centre ◽

Icd 10

Background: Alcohol use is a key preventable risk factor for serious injury. To effectively prevent alcohol-related injuries, we rely on the accurate surveillance of alcohol involvement in injury events. This often involves the use of administrative data, such as International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) coding. Objective: To evaluate the completeness and accuracy of using administrative coding for the surveillance of alcohol involvement in major trauma injury events by comparing patient blood alcohol concentration (BAC) with ICD-10-AM coding. Method: This retrospective cohort study examined 2918 injury patients aged ≥18 years who presented to a major trauma centre in Victoria, Australia, over a 2-year period, of which 78% ( n = 2286) had BAC data available. Results: While 15% of patients had a non-zero BAC, only 4% had an ICD-10-AM code suggesting acute alcohol involvement. The agreement between blood alcohol test results and ICD-10-AM coding of acute alcohol involvement was fair ( κ = 0.33, 95% confidence interval: 0.27–0.38). Of the 341 patients with a non-zero BAC, 82 (24.0%) had ICD-10-AM codes related to acute alcohol involvement. Supplementary factors Y90 Evidence of alcohol involvement determined by blood alcohol level codes, which specifically describe patient BAC, were assigned to just 29% of eligible patients with a non-zero BAC. Conclusion: ICD-10-AM coding underestimated the proportion of alcohol-related injuries compared to patient BAC. Implications: Given the current role of administrative data in the surveillance of alcohol-related injuries, these findings may have significant implications for the implementation of cost-effective strategies for preventing alcohol-related injuries.

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Abstract P250: A Strategy for Reliable Identification of Ischemic Stroke, Thrombolytics, and Thrombectomy in Large Administrative Databases

Stroke ◽

10.1161/str.52.suppl_1.p250 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Kori S Zachrison ◽

Sijia Li ◽

Mathew J Reeves ◽

Opeolu M Adeoye ◽

Carlos A Camargo ◽

...

Keyword(s):

Ischemic Stroke ◽

Administrative Data ◽

Administrative Databases ◽

Stroke Patients ◽

Inpatient Hospitalization ◽

Accurate Identification ◽

Stroke Research ◽

Diagnosis Codes ◽

Icd 10 ◽

Icd Codes

Background: Administrative data are frequently used in stroke research. Ensuring accurate identification of ischemic stroke patients, and those receiving thrombolysis and endovascular thrombectomy (EVT) is critical to ensure representativeness and generalizability. We examined differences in patient samples based on different modes of identification, and propose a strategy for future patient and procedure identification in large administrative databases. Methods: We used nonpublic administrative data from the state of California to identify all ischemic stroke patients discharged from an emergency department or inpatient hospitalization from 2010-2017 based on ICD-9 (2010-2015), ICD-10 (2015-2017), and MS-DRG discharge codes. We identified patients with interhospital transfers, patients receiving thrombolytics, and patients treated with EVT based on ICD, CPT and MS-DRG codes. We determined what proportion of these transfers and procedures would have been identified with ICD versus MS-DRG discharge codes. Results: Of 365,099 ischemic stroke encounters, most (87.7%) had both a stroke-related ICD-9 or ICD-10 code and stroke-related MS-DRG code; 12.3% had only an ICD-9 or ICD-10 code, and 0.02% had only a MS-DRG code. Nearly all transfers (99.9%) were identified using ICD codes. We identified32,433 thrombolytic-treated patients (8.9% of total) using ICD, CPT, and MS-DRG codes; the combination of ICD and CPT codes identified nearly all (98%). We identified 7,691 patients treated with EVT (2.1% of total) using ICD and MS-DRG codes; both MS-DRG and ICD-9/-10 codes were necessary because ICD codes alone missed 13.2% of EVTs. CPT codes only pertain to outpatient/ED patients and are not useful for EVT identification. Conclusions: ICD-9/-10 diagnosis codes capture nearly all ischemic stroke encounters and transfers, while the combination of ICD-9/-10 and CPT codes are adequate for identifying thrombolytic treatment in administrative datasets. However, MS-DRG codes are necessary in addition to ICD codes for identifying EVT, likely due to favorable reimbursement for EVT-related MS-DRG codes incentivizing accurate coding.

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Estimating the incidence of first-episode psychosis using population-based health administrative data to inform early psychosis intervention services

Psychological Medicine ◽

10.1017/s0033291718002933 ◽

2018 ◽

Vol 49 (12) ◽

pp. 2091-2099 ◽

Cited By ~ 8

Author(s):

Kelly K. Anderson ◽

Ross Norman ◽

Arlene G. MacDougall ◽

Jordan Edwards ◽

Lena Palaniyappan ◽

...

Keyword(s):

Psychotic Disorder ◽

Administrative Data ◽

Catchment Area ◽

Population Based ◽

First Episode Psychosis ◽

Case Definition ◽

First Episode ◽

Affective Psychosis ◽

Health Administrative Data ◽

Episode Psychosis

AbstractBackgroundDiscrepancies between population-based estimates of the incidence of psychotic disorder and the treated incidence reported by early psychosis intervention (EPI) programs suggest additional cases may be receiving services elsewhere in the health system. Our objective was to estimate the incidence of non-affective psychotic disorder in the catchment area of an EPI program, and compare this to EPI-treated incidence estimates.MethodsWe constructed a retrospective cohort (1997–2015) of incident cases of non-affective psychosis aged 16–50 years in an EPI program catchment using population-based linked health administrative data. Cases were identified by either one hospitalization or two outpatient physician billings within a 12-month period with a diagnosis of non-affective psychosis. We estimated the cumulative incidence and EPI-treated incidence of non-affective psychosis using denominator data from the census. We also estimated the incidence of first-episode psychosis (people who would meet the case definition for an EPI program) using a novel approach.ResultsOur case definition identified 3245 cases of incident non-affective psychosis over the 17-year period. We estimate that the incidence of first-episode non-affective psychosis in the program catchment area is 33.3 per 100 000 per year (95% CI 31.4–35.1), which is more than twice as high as the EPI-treated incidence of 18.8 per 100 000 per year (95% CI 17.4–20.3).ConclusionsCase ascertainment strategies limited to specialized psychiatric services may substantially underestimate the incidence of non-affective psychotic disorders, relative to population-based estimates. Accurate information on the epidemiology of first-episode psychosis will enable us to more effectively resource EPI services and evaluate their coverage.

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The case of inorganic hypersomnia treated with light therapy in the course of schizoaffective disorder

Current Problems of Psychiatry ◽

10.1515/cpp-2016-0002 ◽

2016 ◽

Vol 17 (1) ◽

pp. 17-18

Author(s):

Jolanta Masiak ◽

Elżbieta Masiak ◽

Katarzyna Ziniuk

Keyword(s):

Mental Disorders ◽

Schizoaffective Disorder ◽

Excessive Daytime Sleepiness ◽

Light Therapy ◽

Mood Stabilizers ◽

Definite Evidence ◽

Her Family ◽

Icd 10 ◽

One Year

AbstractAccording to ICD 10, nonorganic hypersomnia is defined as “a condition of either excessive daytime sleepiness and sleep attacks (not accounted for by an inadequate amount of sleep) or prolonged transition to the fully aroused state upon awakening. When no definite evidence of organic etiology can be found, this condition is usually associated with mental disorders”. The severe hypersomnia in the course of schizoaffective disorder is rather a rare phenomenon. The paper presents the case of 41-year-old female patient with severe hypersomnia during the course of the schizoaffective disorder. The course of hypersomnia was severe. The patient slept constantly day and night and was awoken by her family for about three-hour period of time. The duration of hypersomnia was about one year until the onset of treatment. The patient was successfully treated with light therapy that caused gradual resolution of the symptoms of hypersomnia. The patient is also treated as prior to the onset of hypersomnia with antipsychotics and the mood stabilizers for schizoaffective disorder. Since that time there were six-year-period of follow up when the patient was free of any symptoms of hypersomnia.

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Linking education and hospital data in England: linkage process and quality

International Journal for Population Data Science ◽

10.23889/ijpds.v6i1.1671 ◽

2021 ◽

Vol 6 (1) ◽

Author(s):

Nicolás Libuy ◽

Katie Harron ◽

Ruth Gilbert ◽

Richard Caulton ◽

Ellen Cameron ◽

...

Keyword(s):

Ethnic Minority ◽

Statistical Methods ◽

Administrative Data ◽

Hospital Episode Statistics ◽

Hospital Record ◽

Hospital Records ◽

Hospital Episode ◽

One Year ◽

Stage 1 ◽

Deprived Areas

IntroductionLinkage of administrative data for universal state education and National Health Service (NHS) hospital care would enable research into the inter-relationships between education and health for all children in England. ObjectivesWe aim to describe the linkage process and evaluate the uality of linkage of four one-year birth cohorts within the National Pupil Database (NPD) and Hospital Episode Statistics (HES). MethodsWe used multi-step deterministic linkage algorithms to link longitudinal records from state schools to the chronology of records in the NHS Personal Demographics Service (PDS; linkage stage 1), and HES (linkage stage 2). We calculated linkage rates and compared pupil characteristics in linked and unlinked samples for each stage of linkage and each cohort (1990/91, 1996/97, 1999/00, and 2004/05). ResultsOf the 2,287,671 pupil records, 2,174,601 (95%) linked to HES. Linkage rates improved over time (92% in 1990/91 to 99% in 2004/05). Ethnic minority pupils and those living in more deprived areas were less likely to be matched to hospital records, but differences in pupil characteristics between linked and unlinked samples were moderate to small. ConclusionWe linked nearly all pupils to at least one hospital record. The high coverage of the linkage represents a unique opportunity for wide-scale analyses across the domains of health and education. However, missed links disproportionately affected ethnic minorities or those living in the poorest neighbourhoods: selection bias could be mitigated by increasing the quality and completeness of identifiers recorded in administrative data or the application of statistical methods that account for missed links. Highlights • Longitudinal administrative records for all children attending state school and acute hospital services in England have been used for research for more than two decades, but lack of a shared unique identifier has limited scope for linkage between these databases. • We applied multi-step deterministic linkage algorithms to 4 one-year cohorts of children born 1 September-31 August in 1990/91, 1996/97, 1999/00 and 2004/05. In stage 1, full names, date of birth, and postcode histories from education data in the National Pupil Database were linked to the NHS Personal Demographic Service. In stage 2, NHS number, postcode, date of birth and sex were linked to hospital records in Hospital Episode Statistics. • Between 92% and 99% of school pupils linked to at least one hospital record. Ethnic minority pupils and pupils who were living in the most deprived areas were least likely to link. Ethnic minority pupils were less likely than white children to link at the first step in both algorithms. • Bias due to linkage errors could lead to an underestimate of the health needs in disadvantaged groups. Improved data quality, more sensitive linkage algorithms, and/or statistical methods that account for missed links in analyses, should be considered to reduce linkage bias.

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Persistence of neuropsychiatric symptoms associated with SARS-CoV-2 positivity among a cohort of children and adolescents

10.1101/2021.09.28.21264259 ◽

2021 ◽

Author(s):

Victor M Castro ◽

Faith M Gunning ◽

Roy H Perlis

Keyword(s):

New England ◽

Children And Adolescents ◽

Language Processing ◽

Neuropsychiatric Symptoms ◽

Private Insurance ◽

Neuropsychiatric Symptom ◽

Older Children ◽

Primary Analysis ◽

Icd 10 ◽

New Onset

Background: Post-acute sequelae of COVID-19 are common among adults. The prevalence of such syndromes among community samples of children and adolescents remains less well characterized. Method: We identified all individuals age 5-18 across 2 New England health systems who had a positive SARS-CoV-2 PCR test between 3/12/2020 and 4/18/2021 and at least 90 days of follow-up visits documented in electronic health records. We identified neuropsychiatric symptoms in intervals prior to, and following, this testing using a previously-derived set of ICD-10 codes and natural language processing terms. Primary analysis examined sociodemographic features associated with presence of at least one incident (i.e., new-onset) neuropsychiatric symptom between 90 and 150 days after an initial positive test for COVID-19. Results: Among 5058 children (50% female, 2.9% Asian, 6.3% Black, and 63% White; 30% Hispanic; mean age was 12.4 (IQR 8.9-15.6), 366 (7.2%) exhibited at least one new-onset neuropsychiatric symptom between 90 and 150 days following initial SARS-CoV-2 test positivity. The most common incident symptoms at 90-150 days were headache (2.4%), mood and anxiety symptoms (2.4%), cognitive symptoms (2.3%), and fatigue (1.1%). In regression models, older children, girls, those with Hispanic ethnicity, those with public versus private insurance, and those with greater overall burden of medical comorbidity were more likely to exhibit subsequent symptoms. Conclusion: The prevalence of neuropsychiatric symptoms between 3- and 5- months following SARS-CoV-2 test positivity is similar to that observed in the period prior to infection. Prospective controlled studies will be needed to further refine these estimates.

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