JMASM 52: Extremely Efficient Permutation and Bootstrap Hypothesis Tests Using R

In this chapter, we study the applications of the bootstrap in two main components of statistical inference: constructing confidence sets and testing hypotheses. Five different bootstrap confidence sets are introduced in Section 4.1. Asymptotic properties and asymptotic comparisons of these five bootstrap confidence sets and the confidence sets obtained by normal approximation are given in Section 4.2. More sophisticated techniques for bootstrap confidence sets have been developed in recent years, some of which are described in Section 4.3. Fixed sample comparisons of various confidence sets are made in Section 4.4 through empirical simulation studies. Bootstrap hypothesis tests are introduced in Section 4.5.KeywordsNominal LevelBootstrap TestEdgeworth ExpansionBootstrap DistributionBootstrap EstimatorThese keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Innovative, inclusive and resource-efficient screening and intervention methods are essential to address motor skill impairment among preschool children and prevent long-term consequences. This study explores the feasibility of implementing a unique motor skill program for preschool children in low-resource rural areas of South Africa, addressing the heightened risk of motor skill impairment in this demographic. Employing a quantitative pre-post quasi-experimental design with convenience sampling, the research involved assessing children using the second edition of the Movement Assessment Battery for Children (MABC-2) to evaluate their motor skills. Key objectives included assessing the program's recruitment, consent, attrition, adherence, and attendance rates, alongside determining its effect on motor skills. Children who scored less than the 5th percentile of the MABC-2 total score were included in the study and schools were randomly assigned to an intervention and control group. The Hopscotch program was facilitated by an occupational therapist over 8 weeks. Two weekly group sessions focused on gross and fine motor skills through obstacle courses, ball games and craft activities. All participants in the groups were re-assessed following the intervention. The control group received the same intervention following the post-assessment. Quantitative attendance checklists were analyzed to determine consent, assent, attrition and attendance rates. The feasibility of the MABC-2 as a data collection instrument and outcome measure was reported according to test completion rate and cost. The initial effect of the program was determined through analysis of the pre-and post-intervention MABC-2 scores using descriptive statistics while independent samples t-test were used to determine statistically significance of between-group differences. The minimal important difference (MID) for MABC-2 scores was considered to determine the clinical significance of the results. The results revealed a high consent rate (98.08%) and a 0% attrition rate, with significant attendance at program sessions (93.75%). While independent samples t-tests indicated no statistically significant differences in motor skill improvements between the intervention and control groups, analysis considering the MID demonstrated clinically significant improvements in overall motor skill proficiency and balance for the experimental group. The cost of the MABC-2 exceeded the planned budget and amounted to 77% of the total study cost. The duration for testing was one school morning for each pre- and post-test when done by five researchers. The study highlights the feasibility of conducting intervention research in low-resource settings. It notes the challenges of using the MABC-2 due to its cost and time requirements and reports on the initial effect of the program on the motor skills of the participants. Statistical significance of positive results was affected by the small sample size; however, the MID was useful in indicating clinical significance of progress made in general motor skill proficiency and balance. The feasibility study provides valuable insights to effectively plan and conduct a research project and implement a school-based motor skill intervention program in a low-resource area.

Introduction: Laryngopharyngeal reflux (LPR) is a very common disease seen in the ENT outpatient department.Reflux symptom index (RSI) and Reflux findings score (RFS) are used to diagnose LPR clinically.The treatment of LPR includes dietary and behavioral modifications for all patients in addition to pharmacotherapy.This study aims to revisit the clinical practices followed in the treatment of LPR and to find out measures that decrease the duration of treatment.Materials and methods: An interventional study was conducted on 50 patients who presented with reflux symptoms.Reflux symptom index and RFS were used to diagnose LPR.Patients started on treatment with the tablet rabeprazole 20 mg twice daily for 6 weeks along with proper counseling regarding lifestyle modification (LSM).Patients were asked to review after 3 weeks and divided into two groups.They were reviewed again at the end of 6 weeks and treatment response was assessed.Patients were divided into two groups with group A having patients who followed the pharmacotherapy and LSM advice without deviation, group B having patients with poor treatment compliance by not following LSM measures.Treatment response was assessed using RSI and RFS.An independent sample t-test was applied to compare the pretreatment and posttreatment RSI and RFS and the results were tabulated.Results: The mean RSI was found to be 12.23 in group A and 12.41 in group B before starting treatment.The mean posttreatment RSI was found to be 6.27 in group A and 8.36 in group B. The mean difference in RSI between the pretreatment and posttreatment values was found to be 5.95 in group A and 4.05 in group B. Independent t-test was applied for the mean difference in RSI and the p-value was found to be 0.002.The mean RFS was 6.73 in group A and 6.77 in group B before starting treatment.The mean posttreatment RFS was 4.09 in group A and 4.55 in group B. The mean difference in RFS was found to be 2.64 in group A and 2.23 in group B. Independent sample t-test was applied for the mean difference in RFS and the p-value was found to be 0.372.Conclusion: Reflux symptom index is found to be a sensitive index of prognosis of LPR and it can be used in monitoring the prognosis of patients undergoing treatment in the outpatient clinic.From our study, we have observed that patients who followed LSM measures effectively had a significant improvement in reflux symptoms sooner than patients who did not follow LSM measures.Lifestyle modifications alone do not suffice in the treatment of LPR.A combination of both, with effective counseling, is needed for the successful treatment of LPR.

Background: Diabetes mellitus is a relative or absolute decrease in insulin production that can cause direct or long-term metabolic disorders. The complications are microanglopathies and macroanglopathies. Diabetic ulcer is one of the side effects. Numerous studies have shown that health education can stop diabetic ulcers from progressing. Methods: This research is a quasi-experimental study with two group pretest-posttest with control design. Respondents were type 2 diabetes mellitus at the Gatak Health Center. The number of respondents consisted of 78 respondents who were divided into 2 groups. In this study there were 78 respondents with type 2 diabetes mellitus who participated, and divided into two groups, namely the intervention group (n = 39) who were given health education about diabetic ulcer prevention and the control group (n = 39) who were not given health education about diabetic ulcer prevention. Data from the results of this study were obtained from filling out questionnaires that had been tested for validity and reliability and analyzed using the Paired Sample t-test and Independent Sample t-test. Data were processed using SPSS. Results: The test results showed that there was a significant difference between the intervention group and the control group in preventing diabetic ulcers with a P=0.000. Conclusion: Data from the results of this study were obtained from filling out questionnaires that had been tested for validity and reliability and analyzed using the Paired Sample t-test and Independent Sample t-test. Data were processed using SPSS. Results: The test results showed that there was a significant difference between the intervention group and the control group in the prevention of diabetic ulcers with a value of P = 0.000. Conclusion: Data from the results of this study were obtained from filling out questionnaires that had been tested for validity and reliability and analyzed using the Paired Sample t-test and Independent Sample t-test. Data were processed using SPSS. Results: The test results showed that there was a significant difference between the intervention group and the control group in preventing diabetic ulcers with a P=0.000. Conclusion: Providing health education to people with type 2 diabetes mellitus in the prevention of diabetic ulcers that there is a significant influence in preventing the occurrence of diabetic ulcers.

Objective To measure RNFL thickness by Frequency-domain optical coherence tomography (OCT) in patients with different stages of primary glaucoma (CACG and POAG),to evaluate the correlation between RNFL thickness and visual field mean defect (MD),to detect RNFL thickness change of early stage primary glaucoma,and to discuss the clinical significance in the early diagnosis of primary glaucoma objectively. Methods Ninety-two subjects of 40 normal and 52 with different stages of primary glaucoma were enrolled in this study.RNFL thickness was measured by Zeiss Cirru HD-OCT,and visual field was tested by Zeiss Humphrey-750.The association between visual field MD and RNFL thickness was evaluated with Pearson correlation coefficients. Results In the normal group,mean RNFL thickness was 112.91±9.36μm; the early period glaucoma group 94.43±7.67μm; the middle period glaucoma group 80.82±10.36μm; the later period glaucoma group 67.86±8.01μm.Visual field MD in each group was-0.88±1.53dB,-4.26±1.83dB,-7.43±2.64dB and -17.06±5.85dB.The differences in mean RNFL thickness and visual field MD between normal and each stage glaucoma group were significant (P ＜0.05) by independent sample t-test.In each stages of glaucoma group,mean RNFL thickness and visual field MD (early period:r =-0.537,middle period:r =-0.615,later period:r=-0.804) correlated significantly (P ＜0.05).In the early period glaucoma group,superior RNFL thickness was 116.32±11.65μm,inferior RNFL thickness 105.58±9.73μm,nasal RNFL thickness 75.40±10.91μm,and temporal RNFL thickness 70.28±13.08μm.In group B,superior RNFL thickness was 140.15±8.79μm,inferior RNFL thickness 137.29±10.07μm,nasal RNFL thickness 90.20±14.19μm,and temporal RNFL thickness 88.43±10.85μm.The difference of superior and inferior RNFL thickness between group A1 and group B had statistical significance tested by independent sample t-test,P ＜0.05; nasal and temporal RNFL thickness between group A1 and group B was tested by independent sample t-test,P ＞0.05,there was no statistical significance difference. Conclusions Frequency-domain OCT detected that the average of RNFL thickness become thinning with the progression of disease in the primary glaucoma patients,have negative correlation with vision MD,it is able to objectively reflect the degree of glaucomatous optic nerve damage.Frequency-domain OCT can show significantly decreased superior and inferior RNFL thickness of the early period primary glaucoma,which shows good ability in distinguishing normal from early period primary glaucomatous eyes. Key words: Optical coherence tomography (OCT); Retinal nerve fiber layer (RNFL); Mean defect (MD); Early diagnosis primary glaucoma

Background: Immune checkpoint inhibitor (ICI) in combination with chemotherapy has become the standard of care for early-stage and first-line metastatic triple-negative breast cancer (TNBC) patients. TNBC disproportionately affected African Americans and Hispanic patients. Previous studies prior to ICI approval in TNBC demonstrated racial disparity with worse outcomes in these groups of patients. However, the impact of race on the outcomes of TNBC patients treated with ICI remains unknown. In this study, we analyzed the National Cancer Database (NCDB) to evaluate the clinical characteristics and outcomes of TNBC patients from different racial groups. Methods: The NCDB patient database from 2004-2017 was used. Continuous variables were summarized using sample mean and standard deviation, and categorical and discrete variables were summarized using count and percentage of patients. Independent samples t-test or ANOVA were used to compare continuous variables, and categorical and discrete variables were compared using a chi-square test. Patient survival by race was calculated using the Kaplan-Meier method. Associations of race with death were evaluated using unadjusted Cox regression models with death as the outcome. Hazard ratios (HRs) were estimated. All statistical tests were two-sided. Statistical analyses were performed using R Statistical Software. Results: A total of 2015 patients were included, consisting of 71.4% White, 19.7% African American, and 8.9% Hispanic. The African American and Hispanic cohorts had more patients < 60 years old than the White cohort, representing 63.9%, 66.1%, and 56.8%, respectively (p = 0.005). African Americans and Hispanics also had more patients with Charlson-Deyo scores above 0 compared to Whites, representing 17.2%, 16.1%, and 10.6% of their respective cohorts (p = 0.003). African Americans and Hispanics tended to receive treatment at academic centers compared to Whites, representing 47.0%, 55.2%, and 34.0%, respectively (p < 0.001). Additionally, a greater proportion of African Americans and Hispanics received treatment in metro areas compared to White patients, representing 93.3%, 96.0%, and 85.5% of their respective cohorts (p < 0.001). There was no significant difference in insurance coverage between races (p = 0.333). In contrast, the different race cohorts presented similar distributions of clinical features, with no significant differences in tumor grade (p = 0.276), tumor size (p = 0.285), lymph node status (p = 0.422), lymphovascular invasion status (p = 0.088), clinical and pathologic staging (p = 0.096), and whether they received chemotherapy (p = 0.230), radiation therapy (p = 0.587), and surgery (p = 0.242). For stage II-III TNBC, there were 538 White, 142 African American, and 62 Hispanic patients who received at least 1 dose of ICI. Using Kaplan-Meier analysis, African American patients (n = 142) had significantly worse overall survival (OS) compared to whites (HR = 1.362, p = 0.012). For patients with Stage IV TNBC receiving ICI, there were 108 Whites, 30 African American, and 12 Hispanic patients. There was a trend toward worse outcomes in African American patients when compared to whites (HR = 1.950, p = 0.210). There was no significant difference in patient survival when comparing Hispanic/other patients with whites in any stage of TNBC while receiving ICI (HR = 0.956, p = 0.777 for Stage II and III; HR = 2.089, p = 0.200 for Stage IV). Conclusion: Despite similar clinical characteristics, African-American TNBC patients receiving ICI had significantly worse outcomes compared to Whites. Future studies are needed to further validate these results and elucidate the biological basis for the racial disparity observed with ICI treatment in TNBC patients. Citation Format: Andrew Liu, Nadine Norton, Keith Knutson, Saranya Chumsri. The impact of race on outcomes of immune checkpoint inhibitor in triple-negative breast cancer patients: NCDB data analysis [abstract]. In: Proceedings of the San Antonio Breast Cancer Symposium 2024; 2024 Dec 10-13; San Antonio, TX. Philadelphia (PA): AACR; Clin Cancer Res 2025;31(12 Suppl):Abstract nr P3-01-03.

BackgroundAnkle Brachial Pressure Index (ABPI) is the ratio of ankle to brachial systolic blood pressure. It is widely used as a non-invasive, relatively simple method for the diagnosis of peripheral...

PURPOSE: Persistent abnormalities in the autonomic nervous system were found in recovered COVID-19 patients with hospitalization. The purpose of the present study was to determine if there was a long-term effect on heart rate variability (HRV) in college men who recovered from COVID-19 without hospitalization. We hypothesized that college men who recovered from COVID-19 without hospitalization will have lower HRV compared with their peers who never acquired COVID-19. METHODS: This study compared 8 college men who recovered from COVID-19 (156.56 ± 57.63 days after infection; CV group) and 8 college men who never acquired COVID-19 (CT group) matched for age (CV: 21.25 ± 1.49 y; CT 21.63 ± 2.44 y), BMI (CV: 24.44 ± 4.40 kg/m2; CT: 25.59 ± 2.96 kg/m2) and physical activity level (6 physically active participants in each group). HRV was obtained from 5 minutes steady ECG in a seated position with controlled respiratory rhythm at 12 breaths per minute. Power spectral density analysis via Fast Fourier Transformation was employed to determine total power (TP), low frequency (LF), high frequency (HF) and LF/HF ratio. The TP, LF and HF were natural log transformed (ln) prior to analysis. Independent samples t-test was used for group comparisons. All analyses were performed using SPSS (Version 27.0) and statistical significance was set at p < 0.05. RESULTS: There was no significant difference in lnTP (CV: 13.94 ± 0.25 ms2; CT: 13.88 ± 0.14 ms2), lnLF (CV: 7.34 ± 0.79 ms2; CT: 7.02 ± 0.49 ms2), lnHF (CV: 7.90 ± 0.50 ms2; CT: 7.43 ± 0.55 ms2) and LF/HF ratio (CV: 0.67 ± 0.35; CT: 0.64 ± 0.31) between groups (p > 0.05 for all comparisons). CONCLUSIONS: The results suggested that college men who recovered from COVID-19 without hospitalization may not have persistent abnormalities in the autonomic nervous system. The small sample size in this study may limit the power to detect the difference in HRV between groups. Further large sample size study is needed to confirm our findings.

Hasil temuan dilapangan bahwa motivasi belajar siswa masih tergolong sangat rendah, hal ini dlihat dari kurang aktifnya siswa saat proses pembelajaran berlangsung. Penelitian ini bertujuan untuk mengetahui keeftifan Jenis penelitian ini adalah penelitian semu (Quasi Eksperimental), dengan rancangan non-equivalent pretes posttest control grup design, Subjek dalam penelitian ini ditentukan dengan teknik random sampling dengan cara diundi, hasil pengundian dengan jumlah siswa 27 sebagai kelas eksperimen dan jumlah siswa 24 sebagai kelas kontrol. Metode pengumpulan data yaitu kuesioner. Analisis data dilakukan dengan independent sample t-test. Hasil independent sample t-test. diperoleh harga t-hitung &gt; t-tabel (30.38 &gt; 2.009) yang menyatakan bahwa H0 ditolak dan H1 diterima. Hal ini dibuktikan dengan hasil rata – rata gain skor motivasi belajar IPA siswa kelompok eksperimen yaitu 0,769 lebih besar daripada kelompok kontrol yaitu 0,225. Dengan demikian dapat disimpulkan terdapat pengaruh yang signifikan penggunaan teknik talking stick berbantuan lagu daerah terhadap motivasi belajar IPA kelas V, sehingga teknik pembelajaran talking stick berbantuan lagu daerah baik untuk diterapkan dalam proses pembelajaran dikelas sebagai upaya untuk meningkatkan motivasi belajar IPA siswa. Melalui teknik pembelajaran talking stick berbantuan lagu daerah akan diajak siswa untuk siap dan aktif dalam pembelajaran sehingga membuat motivasi belajar IPA menjadi meningkat, jika dibandingkan dengan pembelajaran konvensional.

In this study, the relationship between the brain parenchymal density, the cerebral vessel density, the mean corpuscular hemoglobin (MCH) content, the mean corpuscular hemoglobin concentration (MCHC), and the morbidity associated with lacunar infarction of residents living in either the plains or the plateau regions were analyzed and compared for their potential clinical implications. Clinical data from the brain CT scans of individuals living in either the plain or plateau regions (129 each) were collected. Specifically, the CT values for basal ganglia, the middle cerebral artery, and the superior sagittal sinus, along with the number of patients with lacunar infarction, were collected. In addition, the MCH and MCHC values were measured in blood samples collected within 48 h following the CT scans. For statistical analysis, an independent sample t-test, Pearson's correlation test (permutation test), and Chi-squared test were employed. The inhabitants of the plateau had a significantly higher CT value of basal ganglia, the middle cerebral artery, and superior sagittal sinus and also higher levels of MCH and MCHC in the blood (ps < 0.001) than the inhabitants of the plains region. Further, there was a significant positive correlation between the three aforementioned CT values and the MCH and MCHC findings. However, no significant differences were found in the morbidity of lacunar infarction between these two regions (p > 0.05). The inhabitants in the plateau have a significantly higher brain parenchymal density, higher CT value for cerebral vessels density, and higher blood MCH and MCHC levels in comparison with individuals occupying the plains. Concurrently, the parenchymal density and the CT values are shown to be positively correlated with the MCH and MCHC content in the blood.

Two guidelines for nonparametric bootstrap hypothesis testing are highlighted. The first recommends that resampling be done in a way that reflects the null hypothesis, even when the true hypothesis is distant from the null. The second guideline argues that bootstrap hypothesis tests should employ methods that are already recognized as having good features in the closely related problem of confidence interval construction. Violation of the first guideline can seriously reduce the power of a test. Sometimes this reduction is spectacular, since it is most serious when the null hypothesis is grossly in error. The second guideline is of some importance when the conclusion of a test is equivocal. It has no direct bearing on power, but improves the level accuracy of a test.

YouTube video media as a learning support is an audio-visual media that is useful in learning, especially in fine arts subjects today. By utilizing YouTube video media, it helps students to be more effective, interesting, and foster motivation in learning. This study aims to 1) analyze the influence of YouTube video media on students' learning motivation. 2) to analyze the influence of YouTube video media on student learning outcomes. and 3) to analyze YouTube video media together on learning motivation and student learning outcomes, especially in fine arts subjects for class V at MI Raudlatul Falah Turen. This study uses a quantitative approach with a quasi-experimental design. Data collection techniques in this study were questionnaires, test instruments and documentation. The results of this study indicate: 1) the first hypothesis is shown by the Independent Sample T-Test of learning motivation that the sig. (One Sided p) value is 0.000. Because the sig. (One Sided p) value is 0.000 &lt;0.05, Ho is rejected and Ha is accepted, which means there is a significant influence. 2) The second hypothesis of the Independent Sample T-Test test of learning outcomes is that the sig. (One Sided p) value is 0.012. Because the sig. (One Sided p) value is 0.012 &lt;0.05, Ho is rejected and Ha is accepted, which means there is a significant influence. 3) The third hypothesis shows that YouTube video media has an influence on learning motivation and learning outcomes in fine arts subjects with the N-Gain score test of learning motivation of 74.2928 or 74% and learning outcomes of 71.2390 or 71%, both of which are included in the fairly effective category. ABSTRAK Media video YouTube sebagai pendukung pembelajaran merupakan media audio visual yang bermanfaat dalam pembelajaran khususnya pada mata pelajaran seni rupa pada zaman sekarang. Dengan pemanfaatan media video YouTube membantu peserta didik agar lebih efektif, menarik, dan menumbuhkan motivasi dalam belajar. Penelitian ini bertujuan untuk 1) untuk menganalisis pengaruh media video YouTube terhadap motivasi belajar siswa. 2) untuk menganalisis pengaruh media video YouTube terhadap hasil belajar siswa. dan 3) untuk menganalisis media video YouTube secara bersama-sama terhadap motivasi belajar dan hasil belajar siswa khususnya pada mata pelajaran seni rupa kelas V di MI Raudlatul Falah Turen. Penelitian ini menggunakan pendekatan kuantitatif dengan desain quasi eksperimen. Teknik pengumpulan data dalam penelitian ini yaitu angket (kuesioner), instrumen tes dan dokumentasi. Hasil penelitian ini menunjukkan: 1) hipotesis pertama ditunjukkan dengan uji Independent Sample T-Test motivasi belajar bahwa nilai sig. (One Sided p) adalah 0,000. Karena nilai sig. (One Sided p) 0,000 &lt; 0,05 maka Ho ditolak dan Ha diterima yang berarti terdapat pengaruh yang signifikan. Sedangkan 2) hipotesis kedua uji Independent Sample T-Test hasil belajar bahwa nilai sig. (One Sided p) adalah 0,012. Karena nilai sig. (One Sided p) 0,012 &lt; 0,05 maka Ho ditolak dan Ha diterima yang berarti terdapat pengaruh yang signifikan. Dan 3) hipotesis ketiga menunjukkan bahwa media video YouTube memiliki pengaruh terhadap motivasi belajar dan hasil belajar pada mata pelajaran seni rupa dengan uji N-Gain score motivasi belajar sebesar 74,2928 atau 74% dan hasil belajar sebesar 71,2390 atau 71% keduanya termasuk dalam kategori cukup efektif.

406 Racial and Ethnic Differences in Behavioral Risk Factors Among Young Adult Male Emergency Department Patients

Several approaches to hypothesis testing for coefficients in least absolute value regression are compared using a Monte Carlo simulation: likelihood ratio test, Lagrange multiplier test, and three versions of the bootstrap hypothesis test. Factors considered that might influence test performance include the disturbance distribution, the type of independent variable, and the sample size. Overall, the likelihood ratio and the bootstrap tests perform best, with the likelihood ratio test being marginally more powerful. Least absolute value tests are also compared to the standard t test and three versions of the bootstrapped t test for least squares regression.

OBJECTIVE: To compare the mean Melasma Area and Sensitivity Index (MASI) score of combined trichloroacetic acid peel and topical ascorbic acid versus trichloroacetic acid peel alone in the treatment of melasma. MATERIALS AND METHODS: Randomized Controlled Trial study conducted at Department of Dermatology, Combined Military Hospital Multan with 6-months duration. Sample sizewas taken with OpenEpi software through formula for mean difference is used to calculate sample size. Where, Mean MASI score 12-weeks after TCA &amp; ascorbic acid treatment = 9.50±5.31, Mean MASI score 12-weeks after TCA only treatment = 15.10±4.44, Power of the study = 80%, Confidence level = 95%. Sample size was60 (30 in each group).Non-probability consecutive sampling technique was used. Patients aged 20 – 50 years, either male or female gender and diagnosed with Melasma, ≥ 3-months were included.Data analysis was done through SPSS version 23. MASI-score between the two groups was compared using independent sample t-test. Post-stratification independent sample t-test was applied and p value ≤0.05 was taken as statistically significant. RESULTS:A paired t-test was performed to compare the MASI score reduction within each group, and an independent t-test was applied to compare reductions between groups. The results indicate a significantly greater improvement in Group A (p &lt; 0.001).Group A showed a greater reduction in MASI scores (48.1%) compared to Group B (15.6%).The treatment effect was significant across all Fitzpatrick skin types.The addition of ascorbic acid to TCA peel resulted in superior improvement in melasma treatment. These findings suggest that combining TCA peel with topical ascorbic acid significantly enhances treatment outcomes compared to TCA peel alone. CONCLUSION: Our study confirms that the combination of TCA peel and topical ascorbic acid is significantly more effective in treating melasma compared to TCA peel alone. These findings support the routine use of combination therapy for improved patient outcomes.