scholarly journals Understanding and Information in Cancer Patients: The Impact of a Cancer Symposia on Patient Knowledge

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 6011-6011
Author(s):  
Leslie J Padrnos ◽  
Qing Wu ◽  
Robyn M Scherber ◽  
Donald W. Northfelt ◽  
Joseph R. Mikhael ◽  
...  
Keyword(s):  
Risk Factors ◽  
Health Care ◽  
Side Effects ◽  
Cancer Patients ◽  
Cancer Diagnosis ◽  
Disease Risk ◽  
Symptom Burden ◽  
Screening Tests ◽  
Patient Centered ◽  
The Impact

Abstract Background: Patients diagnosed with cancer experience a significant influx of health care information while continuing to demonstrate understanding deficit regarding their disease and health. This knowledge deficit can negatively impact a patient’s acute and long term health care experience. By identifying patient information deficits and needs, health care providers may be better able to provide targeted education to patients and families. Aims: The aim of this study is to evaluate the impact of a patient centered cancer symposium on knowledge level, reported symptom burden, and desired information from a broad population of cancer patients. Methods: Surveys were distributed to the attendees of the third annual Mayo Clinic “Living with Cancer” patient symposium in January 2014. While 700 individuals registered for the event, only individuals with a past or present cancer diagnosis were asked to participate. Surveys included demographic data in addition to a questionnaire evaluating disease comprehension, symptom burden, desired information and desired role in the health care decision making process. Results: 75 patients completed the pre-intervention and post-intervention survey. There were slightly more female participants (60.2%). Disease types included 40% hematologic malignancies, 27% breast cancer, 20% prostate cancer and 13% other. The majority of patients were greater than 3 years from cancer diagnosis (62%). Baseline Patient Understanding: Most respondents reported understanding their disease quite a bit (54%) or very much (30%). Respondents reported the majority of their knowledge regarding their disease came from their oncologist (56%), oncology nurse (24%), previous symposiums (22%), or the internet (15%). Most respondents reported “quite a bit” or greater comprehension of screening tests (75%), monitoring disease response to treatment (70%), monitoring disease recurrence (70%), treatment options (67%) and treatment side effects (73%). There was no consensus among participants regarding understanding or limiting risk factors, symptoms associated with disease relapse, fatigue and pain management, navigating the health care system, financial considerations, or confidence in their primary care physician’s involvement in their cancer or post-cancer care. A large proportion of attendees reported “quite a bit” or greater desire for increased information/understanding regarding their disease (83%), risk factors (83%), nutrition (80%), screening tests (69%), and management of fatigue (69%) and stress (68%). Knowledge Improvement Durable at 3 months: There was improvement in 18 of 20 areas of self-reported knowledge. This was noted in increased percentage of respondents reporting “quite a bit” or greater comprehension, especially in areas of disease risk factors(55%pre vs 63%post), disease side effects(55%pre vs 63%post), and health care navigation(53%pre vs 69%post). The reported desire for “quite a bit” or more increased understanding on various topics did decrease post symposium regarding their disease(87.9% pre vs 68.9%post), disease risk factors(86.3%pre vs 64.0%post), screening tests(74.7%pre vs 63.3%post), and nutrition(78.4%pre vs 64.9%post)(all p<0.05). There was no significant decrease in the desire for increased understanding managing stress and fatigue. Summary: Demonstrated in this study, individuals choosing to attend a patient-centered cancer symposium, seek to improve an already solid knowledge base. Study participants indicate a significant desire for increased information on all topics, even those with sufficient level of knowledge reported. This indicates that some cancer patients’ thirst for knowledge is difficult to quench, and may benefit from recurrent education opportunities. The improvement in almost all topics assessed indicates a patient centered symposium is an effective method to provide information to patients regarding the spectrum of cancer health management. Disclosures No relevant conflicts of interest to declare.

Identification and Characterization of Recurrent Venous Thrombosis In Cancer Patients

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 3328-3328
Author(s):  
Catherine Weber ◽  
Nelly G. Adel ◽  
Elyn Riedel ◽  
Gerald A. Soff
Keyword(s):  
Risk Factors ◽  
Lung Cancer ◽  
Overall Survival ◽  
Cancer Patients ◽  
Cancer Diagnosis ◽  
Hazard Ratio ◽  
Older Age ◽  
Recurrent Thrombosis ◽  
Recurrent Vte ◽  
The Impact

Abstract Abstract 3328 Background: Venous thromboembolism (VTE) is a common cause of morbidity and mortality in cancer patients. Standard of care for treatment is Low Molecular Weight Heparin, but recurrence of VTE remains a concern. We performed a retrospective analysis of our institutional experience, to characterize the patients who had a recurrence of VTE while on therapeutic doses of Dalteparin. Objectives: 1. To determine the VTE recurrence rate for cancer patients on therapeutic Dalteparin. 2. To elucidate potential risk factors for recurrence. 3. To determine the impact of recurrent VTE on overall survival. Methods: Patients beginning treatment for VTE with dalteparin between 1/1/2008 and 12/10/ 2009 were retrospectively identified through the hospital's electronic medical records system and cases of recurrent VTE were characterized. Overall survival was estimated using the Kaplan-Meier method and the influence of VTE recurrence on overall survival was analyzed as a time-dependent covariate using a Cox proportional hazards model. Results: 1,392 patients, treated for VTE with dalteparin were included in this study. 34 recurrent VTE episodes were identified. The overall incidence of recurrent thrombosis by six months was 2.3% (95% CI: 1.7%-3.3%). Older age was significantly associated with recurrence (p=0.04). Lung cancer patients had a significantly elevated risk of recurrence (5.6%, p=0.03). No other cancer types were associated with a significant trend to increased recurrent VTE rates. The incidence of recurrent VTE was higher among females compared to males (3.0% vs. 1.6%), although this trend was not statistically significant (P = 0.08). After adjusting for gender, sex and cancer diagnosis, developing a recurrent VTE was associated with a 3.0-fold hazard ratio of death (<0.0001). Conclusions: The rate of recurrent VTE in cancer patients at MSKCC is low in comparison with previously published reports. However, we identified both older age and lung cancer diagnosis as statistically significant risk factors for recurrent VTE. Females also experienced a higher rate of recurrent thrombosis when compared to males, although this result was not statistically significant. The hazard ratio for death was three times that for a patient with recurrent thrombosis when compared to one without subsequent VTE, suggesting recurrence of VTE remains an important influence on cancer-associated mortality. Disclosures: No relevant conflicts of interest to declare.

Association of baseline cardiovascular risk factors and health care utilization and costs in elderly breast cancer patients enrolled in SWOG clinical trials.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. 11508-11508
Author(s):  
Dawn L. Hershman ◽  
Cathee Till ◽  
Jason Dennis Wright ◽  
Melissa Kate Accordino ◽  
Riha Vaidya ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Risk Factors ◽  
Clinical Trials ◽  
Cancer Patients ◽  
Healthcare Costs ◽  
Disease Risk ◽  
Breast Cancer Patients ◽  
Increased Risk ◽  
Clinical Records ◽  
The Impact

11508 Background: Cardiovascular-disease risk factors (CVD-RFs) increase the risk of cardiac events in women undergoing chemotherapy. Less is known about the impact of CVD-RFs on healthcare utilization and costs. Methods: We examined breast cancer patients treated uniformly on SWOG clinical trials from 1999-2011. We identified baseline diabetes, hypertension, hypercholesterolemia, and coronary artery disease (CAD) by linking trial records to Medicare claims; obesity was identified using clinical records. The outcomes were emergency room visits (ER), hospitalizations and costs. Multivariable logistic and linear regression were used. Results: Among the 708 patients included in the analysis, 160 (22.6%) experienced 234 separate hospitalizations, and 193 (27.3%) experienced 311 separate ER visits. Diabetes, hypertension, hypercholesterolemia, and CAD were all associated with increased risk of hospitalizations and ER visit. Hypertension had the strongest association, with more than a threefold risk of hospitalization for those with hypertension compared to those without (OR [95% CI], 3.16 [1.85-5.40], p<0.001). For those with ≥3 CVD-RFs, the risk of hospitalization was greater compared to 0 or 1 CVD-RFs (OR [95% CI], 2.74 [1.71-4.38], p<0.001). Similar results were seen for ER visits. In the first 12 months after trial registration, patients with diabetes ($38,324 vs $30,923, 23.9% increase, p=0.05), hypercholesterolemia ($34,168 vs $30,661, 11.4% increase, p=0.02), and CAD ($37,781 vs $31,698, 19.2% increase, p=0.04) had statistically significantly higher total healthcare costs. Additionally, those with 2 significant CVD-RFs ($35,353 vs. $28,899, 22.3% increase, p=.005) had higher total healthcare costs. Conclusions: Our study demonstrates that the presence of both CVD-RFs and ER visits and hospitalizations are frequent among elderly BC patients. The risk of ER visits and hospitalizations is higher among patients with CVD-RFs, and increases with the number of RFs. Better management of CVD-RFs and more aggressive symptom management may be required to reduce both physical and financial toxicities to elderly patients undergoing BC therapy.

scholarly journals Risk Factors and Clinical Outcomes of Cancer Patients with Clostridium difficile Associated Diarrhea Co-infected with a Second Enteropathogen

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S362-S363
Author(s):  
Harika Yalamanchili ◽  
Andrew Chao ◽  
Eduardo Yepez Guevara ◽  
Samuel L Aitken ◽  
Micah Bhatti ◽  
...  
Keyword(s):  
Risk Factors ◽  
Health Care ◽  
Cancer Patients ◽  
Clinical Symptoms ◽  
Care Facility ◽  
Health Care Facility ◽  
Exact Test ◽  
Increased Risk ◽  
Clostridium Difficile Associated Diarrhea ◽  
The Impact

Abstract Background Cancer patients are at an increased risk for C. difficile infection (CDI) which is often identified along with other enteropathogens. The impact of co-infections on outcomes has not been established in this population. We compared the risk factors and clinical characteristics of patients with CDI monoinfection (CDIM) and patients coinfected with bacterial (CDIB) or viral (CDIV) enteropathogens. Methods Adult patients presenting with primary or recurrent CDI (n = 88) identified on a two-step GI multiplex assay (Biofire) followed by toxin A/B EIA, were classified into CDIM (n = 66), CDIB (n = 12), and CDIV (n = 10) groups. Demographic and clinical data were collected and risk factors and outcomes compared by Fisher’s exact test, ANOVA, and the Kruskal–Wallis test. CDI severity was determined using Zar’s criteria, presence of bacteremia, and ICU stay. Results During the study period, 2,017 diarrheal samples were submitted to the microbiology laboratory. An enteric pathogen was identified in 311 (15%) patients. CDI was identified in 88 cases of which 22 (25%) had a second pathogen. CDIM was found in 66 (21%), CDIB in 12 (4%), and CDIV in 10 (3%) subjects. The most common co-pathogens identified were diarrheagenic E. coli in the CDIB group (9/12, 75%) and norovirus in the CDIV group (8/10, 80%). Groups were similar in terms of demographics, number of recurrences, health care acquisition, co-morbidities, disease severity, serum creatinine at presentation, presence of toxin by EIA, and mortality. Patients with CDIM were more likely to have a recent hospitalization than the CDIB group (44/66 67% vs.. 3/12 25%, P = 0.01). Clinical symptoms at presentation were similar for the three groups except for nausea which was more common in the CDIV group when compared with CDIM (8/10, 80% vs. 25/66, 38%; P = 0.02). The use of proton pump inhibitors was similar in the three groups. There was however, a higher proportion of patients taking GABA-like drugs within 90 days among the CDIB patients (10/12, 83%) than the group with CDIM (26/66, 40%) P = 0.01. Conclusion In CDI cancer patients, co-infection with other enteropathogens is common. Patients with CDIB were less likely to have a recent admission to a health care facility. The use of GABA-like drugs was associated with a higher risk of bacterial co-infection. Disclosures All authors: No reported disclosures.

scholarly journals Psychological and Behavioral Predictors of Vaccine Efficacy: Considerations for COVID-19

2021 ◽  
pp. 174569162198924
Author(s):  
Annelise A. Madison ◽  
M. Rosie Shrout ◽  
Megan E. Renna ◽  
Janice K. Kiecolt-Glaser
Keyword(s):  
Risk Factors ◽  
Side Effects ◽  
Vaccine Efficacy ◽  
Psychological Factors ◽  
Behavioral Interventions ◽  
Vulnerable Groups ◽  
Behavioral Risk Factors ◽  
Behavioral Risk ◽  
Vaccine Response ◽  
The Impact

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine candidates are being evaluated, with the goal of conferring immunity on the highest percentage of people who receive the vaccine as possible. It is noteworthy that vaccine efficacy depends not only on the vaccine but also on characteristics of the vaccinated. Over the past 30 years, a series of studies has documented the impact of psychological factors on the immune system’s vaccine response. Robust evidence has demonstrated that stress, depression, loneliness, and poor health behaviors can impair the immune system’s response to vaccines, and this effect may be greatest in vulnerable groups such as the elderly. Psychological factors are also implicated in the prevalence and severity of vaccine-related side effects. These findings have generalized across many vaccine types and therefore may be relevant to the SARS-CoV-2 vaccine. In this review, we discuss these psychological and behavioral risk factors for poor vaccine responses, their relevance to the COVID-19 pandemic, as well as targeted psychological and behavioral interventions to boost vaccine efficacy and reduce side effects. Recent data suggest these psychological and behavioral risk factors are highly prevalent during the COVID-19 pandemic, but intervention research suggests that psychological and behavioral interventions can increase vaccine efficacy.

scholarly journals The impact of socio-demographic factors on the survival of cancer patients in Zimbabwe

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Idika E. Okorie ◽  
Ricardo Moyo ◽  
Saralees Nadarajah
Keyword(s):  
Risk Factors ◽  
Survival Analysis ◽  
Marital Status ◽  
Cancer Patients ◽  
Hazard Rate ◽  
Significant Risk ◽  
Demographic Factors ◽  
Female Cancer Patients ◽  
Socio Demographic Factors ◽  
The Impact

AbstractWe provide a survival analysis of cancer patients in Zimbabwe. Our results show that young cancer patients have lower but not significant hazard rate compared to old cancer patients. Male cancer patients have lower but not significant hazard rate compared to female cancer patients. Race and marital status are significant risk factors for cancer patients in Zimbabwe.

Abstract 14772: Effects of Reallocating Time in Different Physical Activity Intensities and Sleep on Cardiovascular Disease Risk Factors in Asian American Women: A Cross Sectional Modeling Study

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Chorong Park ◽  
Britta A Larsen ◽  
Yuhe Xia ◽  
Simona Kwon ◽  
Victoria V Dickson ◽  
...  
Keyword(s):  
Physical Activity ◽  
Risk Factors ◽  
Asian American ◽  
Disease Risk ◽  
Asian American Women ◽  
American Women ◽  
Wear Time ◽  
Wrist Actigraphy ◽  
Substitution Models ◽  
The Impact

Introduction: Physical activity (PA), sedentary behavior (SB) and sleep form the finite 24-hour day; changes to one behavior result in changes to the others. Little is known about how shifting the balance of time spent in these behaviors affects cardiovascular (CV) risk factors. The purpose of this study is to model the effects of changes in PA, SB and sleep on body mass index (BMI), waist circumference (WC) and blood pressure (BP) in Asian American women, who have elevated CV risk. Methods: Normotensive middle-aged Asian American women completed 7 days of hip and wrist actigraphy monitoring (Actigraph, GT3X and GT9X) to assess 24-hour activity. Total sleep time was identified using the Cole-Kripke algorithm with sleep diaries, and moderate-to-vigorous PA (MVPA), light PA and SB were classified by Freedson’s cut-points from wake time. Isotemporal substitution models were used to test effects of replacing 30 mins of each behavior with the others on BMI, WC and BP adjusting for age, education and comorbidity. Results: Data from 75 women were included (age=61.4±8.0, 57% college educated, median comorbidities=1[IQR=0-2]). On average, their days were composed of 0.5 hrs MVPA, 6.2 hrs light PA, 10 hrs SB and 5.3 hrs sleep (2.1 hrs non-wear time). In partition models, where all behaviors were entered simultaneously, more MVPA and sleep were associated with lower BMI and WC. In isotemporal substitution models that held total wear time constant (Table 1), replacing 30 mins SB with an equal amount of MVPA or sleep decreased BMI by 1.7 and 0.6 and WC by 4.1 and 1.2 cm. Replacing 30 mins light PA with MVPA or sleep decreased BMI by 1.9 and 0.9 and WC by 4.5 and 1.6 cm. None of the modeled behavior changes affected BP. Conclusion: These findings suggest that substituting 30 mins of SB or light PA with MVPA or sleep could significantly reduce Asian American women’s BMI and WC. Future studies should test the impact of behavioral interventions that promote these changes on CV risk in Asian American women.

Impact of cancer on the risk of unplanned 30-day readmissions.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 6581-6581
Author(s):  
Alexander Qian ◽  
Edmund Qiao ◽  
Vinit Nalawade ◽  
Nikhil V. Kotha ◽  
Rohith S. Voora ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Cancer Diagnosis ◽  
Hospital Admissions ◽  
Reference Group ◽  
Cancer Site ◽  
Cancer Type ◽  
Logistic Regression Models ◽  
Increased Risk ◽  
Initial Hospitalization ◽  
The Impact

6581 Background: Hospital readmission are associated with unfavorable patient outcomes and increased costs to the healthcare system. Devising interventions to reduce risks of readmission requires understanding patients at highest risk. Cancer patients represent a unique population with distinct risk factors. The purpose of this study was to define the impact of a cancer diagnosis on the risks of unplanned 30-day readmissions. Methods: We identified non-procedural hospital admissions between January through November 2017 from the National Readmission Database (NRD). We included patients with and without a cancer diagnosis who were admitted for non-procedural causes. We evaluated the impact of cancer on the risk of 30-day unplanned readmissions using multivariable mixed-effects logistic regression models. Results: Out of 18,996,625 weighted admissions, 1,685,099 (8.9%) had record of a cancer diagnosis. A cancer diagnosis was associated with an increased risk of readmission compared to non-cancer patients (23.5% vs. 13.6%, p < 0.001). However, among readmissions, cancer patients were less likely to have a preventable readmission (6.5% vs. 12.1%, p < 0.001). When considering the 10 most common causes of initial hospitalization, cancer was associated with an increased risk of readmission for each of these 10 causes (OR range 1.1-2.7, all p < 0.05) compared to non-cancer patients admitted for the same causes. Compared to patients aged 45-64, a younger age was associated with increased risk for cancer patients (OR 1.29, 95%CI [1.24-1.34]) but decreased risk for non-cancer patients (OR 0.65, 95%CI [0.64-0.66]). Among cancer patients, cancer site was the most robust individual predictor for readmission with liver (OR 1.47, 95%CI [1.39-1.55]), pancreas (OR 1.36, 95%CI [1.29-1.44]), and non-Hodgkin’s lymphoma (OR 1.35, 95%CI [1.29-1.42]) having the highest risk compared to the reference group of prostate cancer patients. Conclusions: Cancer patients have a higher risk of 30-day readmission, with increased risks among younger cancer patients, and with individual risks varying by cancer type. Future risk stratification approaches should consider cancer patients as an independent group with unique risks of readmission.

scholarly journals Impact of Extended-Spectrum β-Lactamase Production on Treatment Outcomes of Acute Pyelonephritis Caused by Escherichia coli in Patients without Health Care-Associated Risk Factors

2015 ◽  
Vol 59 (4) ◽  
pp. 1962-1968 ◽  
Author(s):  
Sun Hee Park ◽  
Su-Mi Choi ◽  
Dong-Gun Lee ◽  
Sung-Yeon Cho ◽  
Hyo-Jin Lee ◽  
...  
Keyword(s):  
Risk Factors ◽  
Escherichia Coli ◽  
Health Care ◽  
Treatment Outcomes ◽  
Acute Pyelonephritis ◽  
Esbl Production ◽  
Content Type ◽  
E Coli ◽  
Extended Spectrum ◽  
The Impact

ABSTRACTExtended-spectrum β-lactamase-producingEscherichia coli(ESBL-EC) is increasingly identified as a cause of acute pyelonephritis (APN) among patients without recent health care contact, i.e., community-associated APN. This case-control study compared 75 cases of community-associated ESBL-EC APN (CA-ESBL) to 225 controls of community-associated non-ESBL-EC APN (CA-non-ESBL) to identify the risk factors for ESBL-EC acquisition and investigate the impact of ESBL on the treatment outcomes of community-associated APN (CA-APN) caused byE. coliat a Korean hospital during 2007 to 2013. The baseline characteristics were similar between the cases and controls; the risk factors for ESBL-EC were age (>55 years), antibiotic use within the previous year, and diabetes with recurrent APN. The severity of illness did not differ between CA-ESBL and CA-non-ESBL (Acute Physiology and Chronic Health Evaluation [APACHE] II scores [mean ± standard deviation], 7.7 ± 5.9 versus 6.4 ± 5.3;P= 0.071). The proportions of clinical (odds ratio [OR], 1.76; 95% confidence interval [CI], 0.57 to 5.38;P= 0.323) and microbiological (OR, 1.16; 95% CI, 0.51 to 2.65;P= 0.730) cures were similar, although the CA-ESBL APN patients were less likely to receive appropriate antibiotics within 48 h. A multivariable Cox proportional hazards analysis of the prognostic factors for CA-APN caused byE. colishowed that ESBL production was not a significant factor for clinical (hazard ratio [HR], 0.39; 95% CI, 0.12 to 1.30;P= 0.126) or microbiological (HR, 0.49; 95% CI, 0.21 to 1.12;P= 0.091) failure. The estimates did not change after incorporating weights calculated using propensity scores for acquiring ESBL-EC. Therefore, ESBL production did not negatively affect treatment outcomes among patients with community-associatedE. coliAPN.

scholarly journals The pattern of Comorbidities and Associated Risk Factors among Colorectal Cancer Patients in Spain: CoMCoR study

2019 ◽  
Author(s):  
Miguel Angel Luque-Fernandez ◽  
Daniel Redondo-Sánchez ◽  
Miguel Rodríguez-Barranco ◽  
Ma Carmen Carmona-García ◽  
Rafael Marcos-Gragera ◽  
...  
Keyword(s):  
Colorectal Cancer ◽  
Risk Factors ◽  
Surgical Treatment ◽  
Cancer Patients ◽  
Cancer Diagnosis ◽  
Web Application ◽  
Stage Iv ◽  
Chronic Obstructive ◽  
Limited Information ◽  
Colorectal Cancer Patients

AbstractColorectal cancer is the second most frequently diagnosed cancer in Spain. Cancer treatment and outcomes can be influenced by tumor characteristics, patient general health status and comorbidities. Numerous studies have analyzed the influence of comorbidity on cancer outcomes, but limited information is available regarding the frequency and distribution of comorbidities in colorectal cancer patients, particularly elderly ones, in the Spanish population. We developed a population-based high-resolution cohort study of all incident colorectal cancer cases diagnosed in Spain in 2011 to describe the frequency and distribution of comorbidities, as well as tumor and healthcare factors. We then characterized risk factors associated with the most prevalent comorbidities, as well as dementia and multimorbidity, and developed an interactive web application to visualize our findings. The most common comorbidities were diabetes (23.6%), chronic obstructive pulmonary disease (17.2%), and congestive heart failure (14.5%). Dementia was the most common comorbidity among patients aged ≥75 years. Patients with dementia had a 30% higher prevalence of being diagnosed at stage IV and the highest prevalence of emergency hospital admission after colorectal cancer diagnosis (33%). Colorectal cancer patients with dementia were nearly three times more likely to not be offered surgical treatment. Age ≥75 years, obesity, male sex, being a current smoker, having surgery more than 60 days after cancer diagnosis, and not being offered surgical treatment were associated with a higher risk of multimorbidity. Patients with multimorbidity aged ≥75 years showed a higher prevalence of hospital emergency admission followed by surgery the same day of the admission (37%). We found a consistent pattern in the distribution and frequency of comorbidities and multimorbidity among colorectal cancer patients. The high frequency of stage IV diagnosis among patients with dementia and the high proportion of older patients not being offered surgical treatment are significant findings that require policy actions.

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