Quality Insights: All right. Well, good good afternoon and welcome to today's Webinar, which is going to focus on the Co. Pd. National Action Plan.
Quality Insights: We're going to get started in just a few minutes. But first I want to go over a couple of housekeeping items.
Quality Insights: First of all, today's participants entered the Webinar in. Listen only mode. If you have a question or a comment during today's call, we just ask that you please type that into either the Q. A feature or the chat box which are located at the bottom of your zoom window.
Dr. Daniel Doyle: You may need to hover your mouse around the bottom of the window to get the icons to appear. Sometimes they disappear on us
Quality Insights: at the end of the program. You'll be directed to an evaluation with some reflective questions. Once completed, you'll be presented with a certificate that you can then fill out and print out as your proof of Webinar of Webinar completion.
Quality Insights: even if you Don't need continuing education credits. We hope that you will still complete the evaluation because it helps. Tell us how we did, and it can help shape our future programming.
Quality Insights: Just wanted to go over a little bit of information about continuing education
Quality Insights: to complete the course learners. We'll need to watch either this live webinar this live 60 min, Webinar, or they can watch the recording, and you'll need to complete the evaluation and reflective questions at the end.
This Webinar has been approved for 1.2 5 contact hours for nursing
Quality Insights: quality insights is accredited as a provider of nursing, continuing professional development by the American nurses. Credentialing centers Commission on Accreditation and Quality insights, and Dr. Doyle have no further disclosures
Quality Insights: just to go over a couple of the learning objectives. After today's Webinar, all learners should be able to identify the need to address primary prevention of Co. Pd. For your patients
explain the need for expanded access to quality assurance for entry and rural areas
Quality Insights: describe the need and value of pulmonary rehabilitation in rural areas and identify the need for care management for persons with chronic lung diseases.
Yeah.
Quality Insights: so we have a lot of great information to deliver today. So without further ado, i'm going to turn things over to Natalie Tapy. She's one of our quality improvement specialists here, quality on sites, and she is going to introduce our guest speaker today. Natalie.
Natalie Tappe: Thank you, Betsy. Welcome. Everyone. I just wanted to give a little history of Dr. Doyle and his background.
Natalie Tappe: Dr. Dan Doyle is the clinical director for the Appalachian Pulmonary Health Project. He formally served as a family physician at New River Health Center, in Fayette County and at Cabin Creek Health Center in Canal County. He helped to fat, found
Natalie Tappe: the New River Health Association of federally qualified Health Center in 1,978, and practice there until 20,
Natalie Tappe: 22 Dr. Doyle graduated from the University of Notre Dame in 1,969 Harvard Medical School, in 1,974 and completed a family medicine residency at the University of Massachusetts, Worcester in 1,977. His teaching and research has focused on
Natalie Tappe: medical education for community health evidence based practice communication skills and pulmonary rehabilitation he is currently the pi for the Palantine Foundation Grant to empower Middle School and High school students with accurate information about the dangers of E. Cigarette use.
Doctor Doyle, I will turn it over to you.
Dr. Daniel Doyle: Thank you, Natalie, and good afternoon, everyone. It's great to be here with you. I want to thank Natalie for inviting me to give this presentation and giving me the opportunity to talk about
Dr. Daniel Doyle: activities that are really important to me.
Dr. Daniel Doyle: I can see that there's about that there are 35 people on this Webinar right now, but I can't see who all you who you all are. So if you want to just
Dr. Daniel Doyle: put in your your name, and kind of where you are. What your organization is. That would be great. Don't have to do it, but it would be nice to see.
Dr. Daniel Doyle: As you can see, the topic today is improving. Copd outcomes starting with prevention.
Dr. Daniel Doyle: And.
Dr. Daniel Doyle: as Natalie said, I
Dr. Daniel Doyle: practice as a family physician for many years in Fayette County and Kanach County.
Dr. Daniel Doyle: and in in most of that time I was taking care of Copd patients. And then for the last 10 years I have really focused a lot on C. O. Pd. And especially making pulmonary rehabilitation more available to our patients in rural areas.
Dr. Daniel Doyle: As I see you putting in your names. I I recognize some names. Hello, everybody. and
Dr. Daniel Doyle: I guess I want to start out by apologizing for telling some of you what you already know. I I know that
Dr. Daniel Doyle: many, many of you are experts about care coordination, and it's part of your daily work. I know that some of you are probably
Dr. Daniel Doyle: nursing home direct nursing directors and nursing homes.
Dr. Daniel Doyle: So again I apologize for telling you things that you already know. But but there will be people hopefully, for whom some of this will be new
Dr. Daniel Doyle: also. I want to apologize for a little bit of alphabet soup, but I think with the the Q. I. N. And the Q. I/O. Probably you guys are kind of used to alphabet soup already. So but i'll try to keep it clear.
Dr. Daniel Doyle: and and especially I want some of you to know that there is such a thing as a Copd National Action plan.
Dr. Daniel Doyle: because, unfortunately, some people have never, never heard of it, and I think it's just important to know about it.
Dr. Daniel Doyle: So, as this Slide says, I want to tell you about 2 programs related to improving C. O. Pd. Outcomes.
Dr. Daniel Doyle: One of them is a national program.
Dr. Daniel Doyle: and it and it's really it's program in the sense of being a plan.
Dr. Daniel Doyle: The Copd National Action plan and kind of the first half of this we'll be talking about that. and then the other one is something here in West Virginia. the Appalachian pulmonary health project.
Dr. Daniel Doyle: although we have had, we have worked with Pennsylvania, and I see Diana carpenter of the Rural Health Redesign project is on on this great.
Dr. Daniel Doyle: and we've also worked some with Kentucky so, but but primarily we're here in West Virginia.
Dr. Daniel Doyle: Next.
Dr. Daniel Doyle: Want to acknowledge these. 123-45-6780rganizations that have been really important in our work. I'm not going to read all the names. except that, speaking of alphabet soup the last one is the coalition for a tobacco-free West Virginia.
Dr. Daniel Doyle: Probably there's people on this call who are part of that and who attend the monthly meetings. and it's a great networking group for trying to have more
Dr. Daniel Doyle: tobacco-free public spaces in our State next
Dr. Daniel Doyle: next.
Dr. Daniel Doyle: So here again, as some of you already know, that there is a very high prevalence of Copd in Appalachia and the South Central Us. Especially here in West Virginia, or or including here in West Virginia, and then we have our own special situation
Dr. Daniel Doyle: of a coal mine. Dust disease, also known as Black Lung
Dr. Daniel Doyle: throughout West Virginia, Southeast, Ohio, and Eastern Kentucky, that
Dr. Daniel Doyle: often overlaps with Copd and and i'm just going to do a little aside here. We've talked about Copd so much for all these years my whole career. But what we're finding more and more is that
Dr. Daniel Doyle: in some ways a lot of people who have the diagnostic label of Copd Don't actually meet the diagnostic criteria.
Dr. Daniel Doyle: And late in my career. We're learning more and more about the importance of interstitial lung disease, which could be a topic for another day.
Dr. Daniel Doyle: The other thing about this slide is, it looks like so many other chronic disease slides that we know about whether it be cardiovascular disease diabetes
Dr. Daniel Doyle: the opiate epidemic Teen pregnancy.
Dr. Daniel Doyle: So we know that we're in an area, and it has to do with social determinants of health
Dr. Daniel Doyle: that has a high prevalence of a number of of diseases, chronic diseases, which is one of the focuses for quality insights
Dr. Daniel Doyle: and for risk factors for chronic disease. And a lot of our work is trying to intervene earlier and earlier
Dr. Daniel Doyle: and not just at end stages of disease, like when people are in the hospital and getting readmitted next.
Dr. Daniel Doyle: So, as I said, the first thing I want to tell you about is that there is such a thing as the Copd National Action plan.
Dr. Daniel Doyle: and we don't really have the setup for people to raise hands because we don't have the gallery view, but I assume i'm I'm pretty sure some of you have heard of it. But my bet is
Dr. Daniel Doyle: that less than a quarter of you have heard of it.
Dr. Daniel Doyle: And the so pediat National Action plan was developed by the National Heart Lung Blood Institute, which is one of the Institutes of the National Institutes of Health.
Dr. Daniel Doyle: It was published in May, 2,017. You can see it has 5. It has, and had 5 main goals. It was developed with a lot of input
Dr. Daniel Doyle: from many different organizations and individuals, and we have with us today somebody who worked on developing that plan, and i'm going to ask her to comment in a minute
Dr. Daniel Doyle: when I get done with this section of the talk. But, as you can see. when it was finally published there were 5 main goals.
Dr. Daniel Doyle: Number one to empower patients. Sounds a lot like some of the Qi, N. Q. I. O. Goals improve, care exactly what you you work to do.
Dr. Daniel Doyle: collect and use public health data. You do some of that
Dr. Daniel Doyle: increase in sustained research, and and probably it's fair To say that Nhlbi's main mission is to is to fund research into heart and lung diseases.
Dr. Daniel Doyle: and they make policy decisions all the time about where to put their focus. and then finally to translate policy into action.
Dr. Daniel Doyle: So there are many ways that these general goals overlap with the mission of quality, insights and other quality improvement organizations around the country.
Dr. Daniel Doyle: It's kind of long. It has 68 pages and 92 sub goals. But when we learned about this in 2,018,
Dr. Daniel Doyle: and when we looked at it and said, Where do we fit in? It was obvious that we fit in primarily in goal 2 to improve care like you.
Dr. Daniel Doyle: And so what I'm going to do in the next couple slides is kind of 0 in on goal 2.
Dr. Daniel Doyle: But remember that overall it has 92 different goals. Some of them are very detailed under these different headings next.
Dr. Daniel Doyle: So what I need there you go.
Dr. Daniel Doyle: So what goal 2 of the Copd National Action plan is is improving diagnosis, treatment and management.
Dr. Daniel Doyle: and you can see they broke it down into 5 sub goals to develop a national guideline. To my knowledge that Hasn't happened. The closest thing we have is the gold guideline, which is an international guideline, gets updated every year.
Dr. Daniel Doyle: and the gold is the global initiative for obstructive lung disease, and my bet is more than half of you are familiar with that. But if you aren't and you're dealing with. C Opd. A lot. Look it up.
Dr. Daniel Doyle: develop a curriculum for health care professionals, and these numbers in parentheses are how many of those 92 sub goals or 92 specific
Dr. Daniel Doyle: action goals fall under this particular subheading.
Dr. Daniel Doyle: Develop a curriculum for health care professionals. There's lots of curricula, but to my knowledge, no central curriculum or none that has been developed specifically out of this plan.
Dr. Daniel Doyle: Develop a clinical decision tree.
Dr. Daniel Doyle: To my knowledge, we don't have that product develop a. A. C. O. Pd. Management plan tool. There are a number of those. Well, a good one is a pocket tool developed by this Copd foundation. That would be something to look for. And also there's a pocket tool that is that you can get from the gold guideline. You can download it, and all those things are free.
Dr. Daniel Doyle: and then finally was improve access and hard to reach areas. And and when we looked at this set it seemed like that's where we especially fit in, and i'll talk more about that in the second. In our second topic, the Appalachian Pulmonary Health Project next.
Dr. Daniel Doyle: So here's here. It gets real detailed.
Dr. Daniel Doyle: So under goal to Section 5. Item B improve access to care with for people with C. O. Pd. Particularly for those in hard to reach areas. And
Dr. Daniel Doyle: and this is something that we've really worked on because we have so many people living in rural areas.
Dr. Daniel Doyle: They can be hours from the closest pulmonary rehab program, and sometimes hours from their primary care, provider or an hour or more. So you you all know about that.
Dr. Daniel Doyle: And so this was something that we thought we should focus on. And then, as you look at the a couple of goals underneath this improving awareness of pulmonary rehab
Dr. Daniel Doyle: that it's covered by insurance.
Dr. Daniel Doyle: trying to get regulation, to facilitate broader access to pulmonary rehab programs outside the hospital setting, and an example of that is right is at least until recently, and and and Grace Anne may be more up on this than I am, at least until recently
Dr. Daniel Doyle: only doctors could order good sign, orders for pulmonary rehab
Dr. Daniel Doyle: and trying to get that change to include nurse position, assistance. because, as you know, in many primary care, sites in our state, they are the main providers, and in some cases they are the only providers.
Dr. Daniel Doyle: and then consider opportunities to identify novel ways, to help health care providers, help health care providers start and maintain pulmonary rehab programs and actually get their patients to pulmonary rehab programs. An example of a novel form is what's called tele rehabilitation.
Dr. Daniel Doyle: And you'll hear a little more about that which is basically telemedicine home based pulmonary rehab next.
Dr. Daniel Doyle: So what has happened in the 5 years or 6 years since this
Dr. Daniel Doyle: C. O. Pd. National Action plan came out
Dr. Daniel Doyle: well in March, 2,018, 5 years ago, and Nhlb. I hosted a national meeting at Nih, in Bethesda to launch the plan and get input from
people all around the country on how to implement it.
Dr. Daniel Doyle: We were there. We actually were invited to present at that conference on our rural pulmonary rehabilitation network here, because we were already 5 years into it.
Dr. Daniel Doyle: December 2021 Nhlb. I hosted an international webinar, on what they call pulmonary tele rehabilitation, or tele-rehab we call it a home-based pulmonary rehab.
Dr. Daniel Doyle: We've we've experimented with and and done home based pulmonary rehab here at a couple of our sites.
Dr. Daniel Doyle: and this particular Webinar had people from all over the world talking about how they use home-based rehab. It's especially used in Australia, where people are
Dr. Daniel Doyle: days from pulmonary rehab. Not just, not just ours. It's been used in Japan. This is something that's been going on around the world for some time last year here in Charleston the Copd Foundation sponsored a
Dr. Daniel Doyle: a forum on Copd readmissions, and i'm almost positive some of you were at that unfortunately I wasn't
Dr. Daniel Doyle: next slide
Dr. Daniel Doyle: and and preparation for this talk, I actually reached out to Nhl. B. I. And got their communications office and got Niall Emory Rich who
Dr. Daniel Doyle: heads their communications office, Mitzi
Dr. Daniel Doyle: and she and and so I asked her, you know. Is there any other things I should tell people about that have come from the Copd National Action plan
Dr. Daniel Doyle: since it was launched, and she suggested that I tell you about these 3 things. and I might ask Natalie to send this slide deck out, because it's a little different from the one you already received.
This slide was added in.
Dr. Daniel Doyle: but they mentioned that they now that they have launched the Copd National Action National Action Plan, community action, tool, and essentially what that is, is a website where you can create an account, and you can actually post activities that you or your organization are carrying out that advance the goals of the Co. Pd. National Action plan.
Dr. Daniel Doyle: and I hadn't seen it before, and so I signed us up today.
Dr. Daniel Doyle: us being partners in Health Network and the Appalachian Pulmonary Health Project. and we should also sign up the Grace and Dorney pulmonary rehabilitation centers?
Dr. Daniel Doyle: She asked. Did I tell you about Nhlbi's? Learn more? Breathe better program? Has a lot of excellent copd education tools in English and Spanish and other languages.
Dr. Daniel Doyle: a lot for patient education and some for provider education. They have a small community subcontract program, 3 grantees last year.
Dr. Daniel Doyle: And then also to mention that the learn more, breathe better program has a number of other resources which are listed here. Next slide.
Dr. Daniel Doyle: One other thing, and and Grace and I will probably comment on this in a minute. Is that partly because of frustration, that the progress on the Copd National Action plan had been so slow, particularly in the area of research.
Dr. Daniel Doyle: Gray-san and her husband, Ted Koppel and their foundation the Dornicopo foundation, organized this national outreach effort sos to get the word out
Dr. Daniel Doyle: that a lot of Copd was under diagnosed.
Dr. Daniel Doyle: What were the experiences of patients, and i'll stop there because i'm hoping Grace Anne will say more, and this is my last slide for part 1 one Copd National Action plan.
Dr. Daniel Doyle: So, grace, and if you're I know you're on, and
Mitzi's going to mute you and give you a chance to comment on what you've heard so far.
Grace Anne Dorney Koppel: Well, Dan, first of all, I applaud your efforts always. and want you to know that I certainly support this this kind of Webinar
Grace Anne Dorney Koppel: broadcast in West Virginia, which. as we all know, has the highest rate of Clpd. In the United States, and over 12% of the population diagnosed.
Grace Anne Dorney Koppel: And if you consider that only half
Grace Anne Dorney Koppel: of those diagnosed with Clp day are represented, the undiagnosed, would bring a quarter of the population
Grace Anne Dorney Koppel: of
Grace Anne Dorney Koppel: West Virginia into the Clp. D. Orbit it's not a great orbit to be in. But I I will comment on first the National Action Plan, which has kind of stalled.
Grace Anne Dorney Koppel: In fact, there was a recent Webinar with the head of of Nhl, Bi Dr. Gary Gibbons and the head of each of the parts
Grace Anne Dorney Koppel: of Nhlb. I. But which is a
Grace Anne Dorney Koppel: lung and sleep and heart.
Grace Anne Dorney Koppel: And
Grace Anne Dorney Koppel: when we got to research plans for
Grace Anne Dorney Koppel: for clpd specifically and for lung disease.
Grace Anne Dorney Koppel: Dr. Kylie, who was head of the Lung division.
Grace Anne Dorney Koppel: says it for the moment it's on pause
Grace Anne Dorney Koppel: and end.
Grace Anne Dorney Koppel: I, who was an attendee, and others from the Clpd Foundation, with whom I'm. Still affiliated. What kind of shock to hear that because we are still the third
Grace Anne Dorney Koppel: killer
Grace Anne Dorney Koppel: of Americans for chronic diseases. It's still heart disease. cancer, clp day.
Grace Anne Dorney Koppel: So i'm hoping that that will change. I know that
Grace Anne Dorney Koppel: Dr. Kylie's artist in the right place, and I use that deliberately. I just hope that the lungs will be in the right place soon, too.
Grace Anne Dorney Koppel: and i'll just make a mention about C. O. P. D. Sos.
Grace Anne Dorney Koppel: I did also refer to
Grace Anne Dorney Koppel: 16 million diagnosed in the United States, and we believe another
Grace Anne Dorney Koppel: 16 million
Grace Anne Dorney Koppel: have Copd and are not diagnosed, and clearly, if we could catch them earlier
Grace Anne Dorney Koppel: in the disease process.
Grace Anne Dorney Koppel: we could achieve much more. and I hope that this campaign, which was joined in by about 18 other organizations as partners
Grace Anne Dorney Koppel: was a success. and I hope soon to reinvigorate it. because I've had some health challenges myself.
Grace Anne Dorney Koppel: so this has not been at the very top of my agenda, but it is moving to that space now.
Grace Anne Dorney Koppel: and I am very proud of what Dr. Doyle and others
Grace Anne Dorney Koppel: have been able to achieve an Appalachia in terms of not only awareness of clpd, but putting boots on the ground
Grace Anne Dorney Koppel: and graduating patients from pulmonary rehab, which actually makes
Grace Anne Dorney Koppel: the greatest difference in their lives, and improves breathlessness.
Grace Anne Dorney Koppel: physical function.
Grace Anne Dorney Koppel: quality of life Better better. I repeat that that any other therapy
Grace Anne Dorney Koppel: and that's from this is national pulmonary rehab week from March the twelfth to the eighteenth.
Grace Anne Dorney Koppel: What I just stated was a direct quote from the Ats pulmonary Rehab assembly that I'm a member of in the National. I hope you have a slide on that, Dan.
Grace Anne Dorney Koppel: to show the benefits of pulmonary rehab included a mortality benefit which is something extraordinary.
Grace Anne Dorney Koppel: So with that I turn it back to you.
Dr. Daniel Doyle: Thanks, Grace, Anne.
Dr. Daniel Doyle: and we're going to talk about Gracie and doorny pulmonary rehab centers and the a Php now. And so I'm. Definitely going to ask you to to chime in again
Dr. Daniel Doyle: next slide.
Dr. Daniel Doyle: So now we're turning from the National action plan, a national effort, an initiative.
Dr. Daniel Doyle: and even if it's stalled, it's good to have a plan.
Dr. Daniel Doyle: We know what we, what we will do and what we can do when we're given the resources to do it. So here in West Virginia we have something called the Appalachian Pulmonary Health Project, and and I have been part of that
Dr. Daniel Doyle: from the beginning, and really the beginning was before there was any Appalachian pulmonary health project. We coined that name in 2,018,
Dr. Daniel Doyle: but 5 years before that were the Gracie and Dorny, pulmonary rehab centers. And really
Dr. Daniel Doyle: she and and Ted were the ones that got this whole ball rolling and got me involved
Dr. Daniel Doyle: next slide.
So so this shows a little bit of that timeline partners in health. And so here comes the alphabet. So
Dr. Daniel Doyle: partners in Health network which some of you are familiar with is based here in Charleston, West Virginia. It's a nonprofit rural health network made up of something like 35 different rural hospitals, Fqh. Cs.
Dr. Daniel Doyle: Ems. Organizations. Cmc. Itself. It has an independent board of Cmc. But it is affiliated with. and it it it's it's mainly health care providers in Central and Southern West Virginia, and they've been around since 1,995
Dr. Daniel Doyle: trying to support all these different rural health providers and link them together in 2,013. We were approached by Grace and Dorney and her husband, Ted Koppel.
Dr. Daniel Doyle: who had a family foundation whose goal was to spread availability to pulmonary rehab. They live in Maryland so, and they knew about, as you just heard Gracie, and talk about the high prevalence of copd morbidity and mortality in this State.
Dr. Daniel Doyle: and they decided that they wanted to reach out and try to make pulmonary rehab more available in West Virginia. They talked to their friend Senator J. Rockefeller, and asked him for some connections, and
Dr. Daniel Doyle: he recommended that they talked to Craig Robinson, administrator of Cabin Creek health Center and in some ways the rest is history.
Dr. Daniel Doyle: and and we start, and that's when the Grace and Dorny pulmonary rehab center started it wasn't until 5 years later, when the the different respiratory therapists who had been needing and I was meeting with them.
Dr. Daniel Doyle: decided that we would expand a bit beyond continue with our pulmonary rehab continue to identify ourselves as gracieand or pulmonary rehab centers, but expand to a a project that included prevention and also care coordination and we named that
Dr. Daniel Doyle: the Appalachian pulmonary health project, and we affiliated ourselves with partners in health Health network largely, so that we would have a a fiscal agent, since we weren't incorporated ourselves
Dr. Daniel Doyle: next slide.
Dr. Daniel Doyle: I think. Click again, Mitzi, because I think I animated this slide. Keep going, so I get all 4 goals. One more great. Well innovation works.
Dr. Daniel Doyle: So we have. So the Appalachian Pulmonary Health Projection plan has 5 main goals. The Appalachian Pulmonary health project of partners in Health Network has 4 main goals to work for the primary prevention of yeah. So we we had spent
our whole careers mostly, and most of our time treating
Dr. Daniel Doyle: the end stages of, but we felt like we wanted to do something for prevention and and intervene at the very root of the problem. And you'll hear about that
to expand access to quality, assured spirometry in rural areas that had been an issue.
Dr. Daniel Doyle: Many doctors off offices, even health centers had no good spirometry. Perhaps a medical assistant had a little handheld spirometer
Dr. Daniel Doyle: that that sheer he could use if the doctor ordered it. But everybody's in a hurry, and so we knew that if we ordered that it would slow her down, and so generally
Dr. Daniel Doyle: any spirometry tended to not be available, and frequently, if it was available, people hadn't really had adequate training and the equipment wasn't that good
Dr. Daniel Doyle: to expand access to pulmonary rehab to our rural areas, and then to provide more care management and better cure management for our patients with chronic lung diseases.
Dr. Daniel Doyle: So i'm going to go through each of these
Dr. Daniel Doyle: next slide.
Dr. Daniel Doyle: Okay. So number one working for primary prevention. How did we do that next slide?
Dr. Daniel Doyle: How did we? And how do we do that? I want to mention that tobacco use is the leading cause of of preventable disease and death in the United States
Dr. Daniel Doyle: I were very aware of lung disease.
Dr. Daniel Doyle: Tobacco uses associated is the cause of not all copd around 70%. There are other causes, especially occupational causes. But tobacco use is the leading cause of preventable disease, and not just for the for lung diseases. But, as you know, for cardiovascular disease for a number of cancers.
Dr. Daniel Doyle: peripheral, peripheral, vascular disease, very important, and nearly all tobacco product use begins during youth and young adulthood.
Dr. Daniel Doyle: so that, knowing that told us that we needed to intervene with the young People, and the logical place to go was school
Dr. Daniel Doyle: to prevent c. Opd. Prevent first use and prevent it in youth and young adults. Next slide
We're going to work with schools
Dr. Daniel Doyle: when we and when we looked at schools and talked to at that point in 2,017 or 2,018, I still was of the mindset that it was about cigarette smoking, but we very quickly learned that we were right on the edge of a vaping epidemic which all of you know about. Because you have kids. They tell you about it.
Dr. Daniel Doyle: Some of you might be school school health nurses. This has been a huge problem.
Dr. Daniel Doyle: and you can see just from 2,018 to 2,019 nationally vaping use in middle schools went from 5% to over 10% more than doubled just in a year.
Dr. Daniel Doyle: and at that time in 2,019 and high schools. It was 27, so we knew that if we wanted to intervene it it was going to be about vaping
Dr. Daniel Doyle: next slide. So our next step was to look for a program or a curriculum
Dr. Daniel Doyle: that worked, and we pretty quickly came to this catch. My breath. Vaping prevention program developed by the University of Texas School of Public Health in Houston
Dr. Daniel Doyle: has 4 forty-minute sessions it's once a week for 4 weeks. It's interactive and hands-on.
Dr. Daniel Doyle: Once we got our our hands on this I actually went and delivered this curriculum myself with health teachers at Eastbank Middle School in Uppercana Valley.
Dr. Daniel Doyle: and and learned about it. It's free to schools with funding from the Cvs Foundation
Dr. Daniel Doyle: next slide
Dr. Daniel Doyle: researchers at the
Dr. Daniel Doyle: University of Texas School of Public Health, and this is primarily Dr. Steven Kelder, but he has a whole team working on this.
I did research on this, and they came up with this interesting infographic which
Dr. Daniel Doyle: the average seventh grade class size in the Us. Is 192 students. And, by the way, there are 18,000 seventh graders in West Virginia, and
Dr. Daniel Doyle: because we have rural areas, I'm. Sure that many seventh grade classes I know that many are less than 192. But in some of our
Dr. Daniel Doyle: bigger schools in our cities. It it could be this or more
Dr. Daniel Doyle: so. 192 students average. If we do nothing 17, we'll start vaping with the catch of my breath program. They found that half of those
Dr. Daniel Doyle: 8 would be prevented, and when they projected that onto the total seventh grade population in the country. That would mean that 152,000 students didn't start.
Dr. Daniel Doyle: and we know that vaping often leads to cigarette use as well, and perhaps other drugs. So some people consider nicotine a gateway.
Dr. Daniel Doyle: and if some of you on the call no, it's a gateway drug. Speak up in in our discussion next slide.
Dr. Daniel Doyle: This is how it has moved to reach many parts of the country since it was developed in Texas. It's not surprising that that this public health measure has been widely applied in Texas.
Dr. Daniel Doyle: so their colors on the left are are where there's greater use.
and a lighter color is less use; but as of 2,019 it had been, it was being used in 49 states, 1,100 schools, and over 300,000 students
Dr. Daniel Doyle: by last year. It was in all 50 states, 5,500 schools, 1.8 million students.
Dr. Daniel Doyle: You can see that there's a little bit of not a red spot, but an orange spot kind of in West Virginia. So this this slide, you know. The very red is where it's being used a lot.
Dr. Daniel Doyle: And then the orange last pink lesson blew. Not at all. And so I think, in a small way we contributed to this reach of the program in our State next slide.
Dr. Daniel Doyle: So then we looked for funding for how to do this, and we we got help from the Palatine foundation of Huntington
Dr. Daniel Doyle: we applied, and we received funding in 2,019, and in the our grain application. Our commitment was to provide this to 4 counties, 10 schools, and 2,400 students.
Dr. Daniel Doyle: It was a two-year grant because of the pandemic and school being stopped in 2,020,
Dr. Daniel Doyle: they allowed us to. They allowed us an extra year, and at the end of that year
Dr. Daniel Doyle: so we would have finished up in 2,021. But Instead, we're actually this is our our final semester right now. We're finishing up this after this spring semester.
Dr. Daniel Doyle: So we we wound up, going for 4 years, and as of December completing 7 of our 8 semesters, we were serving 9 counties, 25 schools, and 7,000 students.
Dr. Daniel Doyle: So, after being sort of stopped in our tracks. We recovered and and feel good about this reach, and are are right now seeking funding to expand the program, and I can say that the West Virginia Bureau of Health is also really interested in expanding this program, and our new commissioner, Matt Christensen.
Dr. Daniel Doyle: I've heard him quoted secondhand a saying that he would like to bring this to all 55 counties next slide.
Dr. Daniel Doyle: So that was that's goal number one of the a Php primary prevention, and I I feel good that we be able, but and actually able to walk our talk on that
Dr. Daniel Doyle: our next 2 goals, expanding access to quality, assert spirometry and expanding access to pulmonary rehab. Really, that's what we started with the gray Sand Dorny pulmonary rehab centers in 2,013. So we've been doing this now for 10 years. That program is going strong. I'll tell you a little bit about it next slide.
Dr. Daniel Doyle: so many of you know. But just to review improving access to quality.
culinary function tests and pulmonary rehabilitation in rural areas. The reason this is important.
Dr. Daniel Doyle: as Grace Anne, already mentioned is pulmonary rehab is it has important benefits. For a long time we've known from
Dr. Daniel Doyle: from
really randomized studies or or control studies.
Dr. Daniel Doyle: that it reduces dysmia. Shortness of breath improves exercise tolerance, and improves quality of life. We also know that it reduces 30 day readmissions after Copd exacerbations.
Dr. Daniel Doyle: That alphabet, soup, acronym is acute exacerbation of
Dr. Daniel Doyle: and as gray Sand mentioned, and she'll scold me for not having that bullet on this slide that it has been now shown to have a mortality benefit, as well to actually reduce mortality with yeah.
Dr. Daniel Doyle: next slide.
Dr. Daniel Doyle: She mentioned how how the great cost effectiveness of pulmonary rehabilitation, and this is the Copd value pyramid developed as a joint project of the London School of Economics and the London Respiratory Team in 2,013,
Dr. Daniel Doyle: and they studied the different Co. Pd. Treatments. the greatest and the measure they used was quality adjusted life, years.
an epidemiologist measure.
Dr. Daniel Doyle: and what they found was that this the single greatest thing for for getting more quality adjusted life years per At that point your British pound
Dr. Daniel Doyle: was actually flu vaccine, and then the next one was smoking cessation support, including nicotine replacement for that. and then came, and then pulmonary rehabilitation came next, and before any of the medications we use, all the inhalers we use, and and
the expensive inhalers that we use.
Dr. Daniel Doyle: And then finally at the top, was telemedicine. So all of these treatments are important and and are cost-effective, but the most cost the right down there near the base of the pyramid, is pulmonary rehabilitation, so the clinical benefits, and also the cost benefits
Dr. Daniel Doyle: of pulmonary rehab are great, and and tend to be underappreciated by my colleagues and
Dr. Daniel Doyle: frontline medical care providers in general. So part of our job is to educate primary care providers about this.
Dr. Daniel Doyle: So in 2,013. I told you about
Dr. Daniel Doyle: Grace Anne and Ted and the Doorney Koppel Foundation, with the help of Senator Rockefeller coming to us and saying, we want to do this? Are Are you up for it? Are you game? And we said, Yes.
Dr. Daniel Doyle: you all know it's hard to say no to a funder. But this was already something we were dealing with, and we knew it was important.
Dr. Daniel Doyle: Honestly, I knew almost nothing about pulmonary rehab. At that point Selimer never referred my patients for it.
Dr. Daniel Doyle: but came and learned about the Cochrane reviews, showing its effectiveness.
Dr. Daniel Doyle: and was enthusiastic to be to learn about this, and to be able to bring it to our patients at New River, in Cabin Creek.
Dr. Daniel Doyle: and so in in the autumn of 2,013, we started with our first 3 sites. With the help of the Dorne Koppel foundation and their funding partners. they definitely had a big
Dr. Daniel Doyle: wanted skin in the game from the local communities. And so
Dr. Daniel Doyle: Craig Robinson wrote the original grant. The grantee was Cabin Creek, but he got additional matching funding from Cmc.
Dr. Daniel Doyle: From the Benetham Foundation. and from the United Mine Workers of America actually Union next slide.
Dr. Daniel Doyle: This was our grand opening at Cabinet Creek, Health Center in Dos. right off the share and exit on I. 77 in November, in November, 2,013. The picture is a little dark, but left to right are Craig Robinson, the CEO of Cabin Creek House Center then, and now
Dr. Daniel Doyle: Kim Tamman, of the Benedham Foundation. That's Cecil Roberts there the President of the United Mine Workers then, and now
Dr. Daniel Doyle: standing to us under Rockefeller, then Grace an then Ted Koppel. So that was
Dr. Daniel Doyle: a big day that was launching the ship next slide.
Dr. Daniel Doyle: This shows the 10 different
Dr. Daniel Doyle: pulmonary rehab sites that are the Grace and dorny pulmonary rehab sites around the State a week. There is one in Eastern Kentucky, and they actually they stopped doing pulmonary rehab for a while, because both our site in Kentucky and in North Carolina
Dr. Daniel Doyle: found that they were having trouble recruiting patients, and it might have been because their sites were kind of out of the way, even even for their patients.
Dr. Daniel Doyle: But then Big Sandy healthcare started again. Recently the other sites I Won't read off all the names, but you can see where they're located around the site. I. We should probably add, C. Amc. To this map, because
Dr. Daniel Doyle: they. They are a central hospital based site, but they are an important partner with us, including in training the original respiratory therapists. At these sites many of these sites did not have respiratory therapists until the great, the dornecopal funding, and that was one of the conditions for the funding was that they hire a respiratory therapist.
Dr. Daniel Doyle: and and that's what allowed us to bring quality pulmonary function testing to those sites because all of them were niosh-certified in doing valid high quality pulmonary function testing, I added, 3 that have just recently joined us.
Dr. Daniel Doyle: Minnie Hamilton, in Calhoun County, Pocahontas memorial in Marlington, and Charles Kennison from there is is on the Webinar with us
Dr. Daniel Doyle: and Montgomery, General Hospital, Montgomery, and Fayette County, next slide
Dr. Daniel Doyle: one of the great things about the great S. And Dority pulmonary rehab centers in West Virginia is that as these new respiratory therapists found new jobs in the Fqhcs, and sometimes in the in the rural hospitals.
Dr. Daniel Doyle: doing education which they loved.
Dr. Daniel Doyle: They kind of created a community among each other. And actually, since the very beginning we have been meeting quarterly
Dr. Daniel Doyle: for them, and primarily those quarterly meetings are a chance for them to talk with each other, share share things that they've learned about supplies, about equipment.
Dr. Daniel Doyle: and it's it's really you know how hard it is to get people to come keep coming to meetings. And and these guys have regularly showed up at meetings, and it's mainly because they love talking to each other. So it's been. This network has
Dr. Daniel Doyle: has been really exciting, and I've been at all the meetings I've been with them all the way
Dr. Daniel Doyle: for them to have the support they need that that peer support that we talk about with doctors that keeps you going in rural areas, and not surprisingly, most of them are from the rural areas. We've got people here from Jackson, General Hospital.
Dr. Daniel Doyle: Boone Memorial Hospital
Dr. Daniel Doyle: from Man Hospital in Logan County, from New River, in Fett County, from Cabin Creek, from Lincoln County.
Dr. Daniel Doyle: from Fake and and and and, as I said, from Pad County, and also from Eastern Kentucky, Big Sandy healthcare. This was their meeting in 2,017 next slide. Since since the pandemic.
Dr. Daniel Doyle: like so many things, we've been meeting virtually. So here's what we've accomplished over these 10 years.
Dr. Daniel Doyle: We've done over a 1,000 pulmonary Rehab intakes since 2,013.
Dr. Daniel Doyle: We've looked at pulmonary rehab is 12 weeks 24 sessions. It takes a lot of commitment
Dr. Daniel Doyle: to be able to finish the whole thing, and what we found is the graduation rate is around 50%.
Dr. Daniel Doyle: So
Dr. Daniel Doyle: a 1,000 intakes. We just were looking at our data this past week. Dr. Mary Emmett, who is also on this call, has been summarizing this and
Dr. Daniel Doyle: Mary. We should probably try to get you to comment as well. But basically what you see here is the steady growth from from 2,013
Dr. Daniel Doyle: up until 2,01819
Dr. Daniel Doyle: peaking around 200 intakes a year for the network, and then the pandemic came and crash. Mostly we stopped doing pulmonary rehab for a few months during this time.
Dr. Daniel Doyle: But then, since then you can see how things have built back up again. We've really worked hard on that, and and are happy to see the recovery of this network next slide.
Dr. Daniel Doyle: And last, but not least, we have a goal that is near and dear to all of your hearts or most of you. which is to provide care management for persons with chronic lung disease.
Dr. Daniel Doyle: and I have one more slide. That shows how we've been doing this
next slide.
Dr. Daniel Doyle: So a lot has happened just in the past year with this.
Dr. Daniel Doyle: and and a lot of that has to do with us, getting a full time coordinator
Dr. Daniel Doyle: for the Appalachian Pulmonary Health Project and Health Network, and was finishing up another project. The accountable health care Communities Project
Dr. Daniel Doyle: of Cms.
Dr. Daniel Doyle: And her name is Hillary Payne, and she might be on this call.
Dr. Daniel Doyle: I know that she and Tom Kuhn, from partners in health, are actually down visiting the Grace and Dorny Pulmonary Rehab center in Mayan, in Logan County today, because one of the things we try to do is get out and visit these sites at least once a year, and sometimes twice a year. But on the care management side
Dr. Daniel Doyle: we've worked Hillary and Tom and I, all, but especially Hillary, have worked a lot with Camc
Dr. Daniel Doyle: Morgan Meeks from division of pulmonary medicine at Cmc. Is on this call. She's been really important in this Dr. Mary Emmett
Dr. Daniel Doyle: and Adam Johnstone is on the call, and he's the one who is responsible for Bullet Number 3 there. The daily Copd Admissions report
Dr. Daniel Doyle: which tells, so we've.
Dr. Daniel Doyle: So a Php. Has worked with Camc to get this report to look at the report we asked Adam to add the Zip code and town where people live so we could look and see where the patients live.
Dr. Daniel Doyle: and then identify which one of our rural sites they would be closest to if they are out from rural areas, our main sites, which which tend to have our patients submitted to Cmc. Or Cap on Creek Boone Memorial, New River Health.
Dr. Daniel Doyle: but we get some patients also from Marone, General from Jackson, General
Dr. Daniel Doyle: So and and and from Lincoln County as well. But so we've been working together a lot over the past year to kind of close the loop between the patients who are admitted
Dr. Daniel Doyle: discharged, and then to get them in touch with their local pulmonary rehab. So it reminds many of you know who Dr. Don Berwick is, and it reminds me of a talk he gave back in 2,019 when he said that hospitals say they're discharging patients. They really mean it.
Dr. Daniel Doyle: A lot of work has been done since then. Many of you are involved in it to make to make sure that discharge is not just dumping people out off the cliff, but that there is follow-up and good transitional care.
Dr. Daniel Doyle: And next slide, which I think says end. Okay. So we have a little over 10 min.
Dr. Daniel Doyle: and
Dr. Daniel Doyle: i'm gonna I'm going to ask Gray Sand to go ahead and comment on
Dr. Daniel Doyle: whatever you would like the the second part, Grayson, and then ask Dr. Mary Emmett to comment as well. And if you don't mind, Nitzi, go back when Dr. Emmett speaks, Go back to that slide that showed
Dr. Daniel Doyle: the the bar graph of all the intakes. But Gracie and go ahead.
Grace Anne Dorney Koppel: Well, first of all. I want to thank you, Dan, because what has been achieved. much of it under your leadership in West Virginia is is is quite amazing and
Grace Anne Dorney Koppel: and very, very gratifying, because. in terms of the 1,000 intakes over this period of time. you have been able to improve the quality of life and functionality
Grace Anne Dorney Koppel: of people living with lung disease.
Grace Anne Dorney Koppel: particularly those with Clpd, and I applaud your efforts.
Grace Anne Dorney Koppel: I do. If you're not going to show the infographic that the Ats Assembly and I worked on for pulmonary Re-head week this week. I will draw one thing to the attention of of those listening.
Grace Anne Dorney Koppel: and that is, we have some new data.
Grace Anne Dorney Koppel: Dr. Marshall, who was published in Jama Open Network.
Grace Anne Dorney Koppel: has completed a study
Grace Anne Dorney Koppel: that $5,721 would be saved per patient
Grace Anne Dorney Koppel: by undertaking timely pulmonary rehab
Grace Anne Dorney Koppel: following a Copd hospitalization.
Grace Anne Dorney Koppel: This would result in a 1 billiondollars saved by medicare annually.
Grace Anne Dorney Koppel: Now.
Grace Anne Dorney Koppel: we we did not have really great cost data.
Grace Anne Dorney Koppel: and that's why you're
Dr. Daniel Doyle: still using the pyramid showing the pulmonary rehab gets more bang for the buck.
Grace Anne Dorney Koppel: But
yeah.
Grace Anne Dorney Koppel: I believe that what You've started with Cmu.
Grace Anne Dorney Koppel: and that is looking at who is being discharged, who has been in a hospital for a copd Exacerbation
Grace Anne Dorney Koppel: is really the way to capture these people. And if you do.
Grace Anne Dorney Koppel: using the leverage of the study that we now have of what the cost savings would be, should be something that everyone in the community is interested in, because it not only does all those wonderful things like help with breathlessness and physical function and quality of life better
Grace Anne Dorney Koppel: than any other therapy, but it also would save money.
Grace Anne Dorney Koppel: So I really do want to underscore that. And again thank you for all your efforts. Thank you. Very soon
Dr. Daniel Doyle: we wouldn't be here without you. Dr. Emmett.
Dr. Daniel Doyle: And hey, could you go back to the Bar Graph slide, please, Mitzi, sure that that's about 3 back
Quality Insights: this one.
Dr. Daniel Doyle: No next next. Yeah.
Quality Insights: Well.
Dr. Daniel Doyle: I think I might be ahead of you. Here is it this one? I'll wait for it to come back toward the end. There, right there.
Mary Emmett: Thank you. Thank you very much for the opportunity to to jump in and just say this documents a great legacy.
Mary Emmett: and this presentation out of papers preserved for po austerity's sake. because it really shows the work that has been done by multiple people across
Mary Emmett: from one company to another continent
Mary Emmett: and across the whole United States. I just want to say that
Mary Emmett: we are in the process of really looking at our data seriously once again. and as you can see from this slide that's up there the Bar graphs the number of intakes that have occurred
Mary Emmett: from 2,013, through 2,022.
Mary Emmett: This bar graph is a result of
Mary Emmett: at each site. When the person comes in and
Mary Emmett: registers for pulmonary we have.
Mary Emmett: and then begins the process that that is what we call it intake. and this represents individual intakes. There may be a few duplicates in it, but we'll eventually get that
Mary Emmett: address as we look more carefully at
Mary Emmett: individual site Data
Mary Emmett: overall. This represents the number of persons
Mary Emmett: that not been touched by the
Mary Emmett: and looking at the clinical indicators that we are considering everyone that we've looked at where a person started the program and completed it has been statistics
Mary Emmett: significant.
Mary Emmett: So it shows a positive impact.
Mary Emmett: I don't know
Mary Emmett: people who are in this program and graduate from
Mary Emmett: any of which they are all right.
Mary Emmett: The the individual pulmonary. We have
Mary Emmett: the other point that I would like to make is that
Mary Emmett: this is again an opportunity that we need to strengthen. The one area is the Ph. Q. 9, which is a
Mary Emmett: on social and
Mary Emmett: psychological indicator of depression.
Mary Emmett: whether it's social related to social activities, unable to get out to them. Engagement with the community engagement with others
Mary Emmett: just being able to move about.
Mary Emmett: We did not have enough free and post assessments in that area to show a statistically significant difference.
Mary Emmett: But the clinical direction is positive.
Mary Emmett: So, in other words, people social life is improving
Mary Emmett: because of.
Mary Emmett: And I really think we need to do a better job of capturing that. So we can focus on the overall them as well as social.
Mary Emmett: and then raise. That makes a great point.
Mary Emmett: Tracking people
Mary Emmett: keep them from being readmitted. The huge cost savings not only to the health care system overall, but
Mary Emmett: many people also pay for a tremendous amount of their care out of their pocket.
Mary Emmett: and so it's a benefit to them as well personally.
Mary Emmett: And Dan made up.
Mary Emmett: We do. We have some duplicates in here, and if we can remove those.
Mary Emmett: it's probably close to about 800
Mary Emmett: total anti experiences overall period of time.
Dr. Daniel Doyle: Thank you, Mary, and we have. We have a couple of minutes left. I'm sorry we don't have more, but there's still some people on, and and
Dr. Daniel Doyle: we'd like to just open it up for other people to comment or ask questions.
Quality Insights: Yes, and i'd like to remind everyone that you can enter questions into either the Q. A. Feature or the chat window, and it looks like we do have a question right. Now, Dr. Doyle.
Quality Insights: this is from Pan-metor, she asks, is cardiac rehab something that those in the late phases of C opd should look into as an intervention.
Dr. Daniel Doyle: Pulmonary rehab is is similar to, but not exactly the same as cardiac. We have cardiac rehab Medicare reimbursees cardiac rehab at about twice the rate, that it reimburses pulmonary rehab, which is one of the reasons why cardiac rehab is more available than pulmonary rehab.
Dr. Daniel Doyle: I would say that people in the late stages of Gopd should start with pulmonary rehab
Dr. Daniel Doyle: they would you? You're not medicare eligible for cardiac rehab, unless you have a qualifying condition. And there could be people on the line in this call who actually know the exact criteria, and if so, speak up.
Dr. Daniel Doyle: But you have to have had some sort of recent either cardiac event or cardiac intervention like you just had bypass surgery. You're just in the hospital with Chf.
Dr. Daniel Doyle: You just you had a recent stent placement, or mi.
Dr. Daniel Doyle: So, pam. I hope that answers your question to to recap what they should look into as pulmonary rehab
Dr. Daniel Doyle: and cardiac rehab. If they have a qualifying condition.
Dr. Daniel Doyle: That's it.
Quality Insights: Okay, it looks like we have another question. This is from Tim Ritz. He says, we know about the blue marble program. What other Mobile or at home services are available for pulmonary rehab, if any
Dr. Daniel Doyle: Hi, Tim! So Tim Ritz is the leader of one of our Grace and Dorny pulmonary rehab centers. He's been he's a respiratory therapist. He's at Jackson, General Hospital.
Dr. Daniel Doyle: He's been with it the project since something like 2,015,
Dr. Daniel Doyle: and tim I don't there are others
Dr. Daniel Doyle: I don't know. I have not had any experience with others. but
Dr. Daniel Doyle: you know, if I were, if I were trying to figure that out. I I I'd go to my Google search, and and if you do the work, please present it at one of our quarterly meetings that's a great topic for one of our on what we call Rt. Quarterly meetings of a Php. But simple answer is, the blue marble
Dr. Daniel Doyle: program is the only one I know of. But there are others.
Quality Insights: Okay.
Quality Insights: I am not seeing any other questions at this time. A couple of comments in the chat
Quality Insights: related to the question if I didn't know if you wanted to speak to those Dr. Doyle.
Dr. Daniel Doyle: Let's see. I'm going to the end here. Nice. Let's see, Gracie, and says important to note anyone who has respiratory symptoms
Dr. Daniel Doyle: is eligible for pulmonary rehab. Oh, Grace, An, said Tim, several pr virtual trials are in progress. I am part of nih monitoring of the trial. So
Dr. Daniel Doyle: so
Dr. Daniel Doyle: after that after that conflict that international conference in 22 December 2,021,
Dr. Daniel Doyle: I guess in hlb I and I did fund some trials of home-based pulmonary rehab what they call tele-rehab
Dr. Daniel Doyle: and a good way to figure that out to see what's going on around the world is to go to Google Scholar or to pubmed. I've I've been familiar with projects in in Australia, in France, in Japan.
Dr. Daniel Doyle: in Canada.
Dr. Daniel Doyle: But those aren't things, Tim, that are available to us right here.
Dr. Daniel Doyle: Gracie, and mentions that there's one going on at University of Alabama.
Dr. Daniel Doyle: Pam Meter says it does. Okay, Great: yeah. Recent: Chf: Event: Thank you for the presentation.
Dr. Daniel Doyle: Thank you. Luanne and Christopher for being with us.
Dr. Daniel Doyle: and that's all I see, you see. And I'd i'd love to go on, but I know that you meant that you try to be done it, too. So
Quality Insights: we did, and I. I want to Thank you, Dr. Doyle, for your time today. This has been excellent information, and I wanted to also remind everyone
Quality Insights: to please fill out the evaluation that will pop up when you exit this Webinar today there will be a recording of today's Webinar that will be shared on our website. I'll put the specific page that that will be on in the chat right now
Quality Insights: for everyone to see.
Quality Insights: And there we go. You should be able to see that now. So I wanna again. Just thank everyone for attending today, Dr. Doyle. Thank you, Grace, and thank you, Dr. Emma. Thank you.
Quality Insights: And everyone have a wonderful afternoon.