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Geriatric adults represent an increasing proportion of emergency department (ED) users, and can be particularly vulnerable to acute illnesses. Health care providers have recently begun to focus upon the development of quality indicators to define a minimal standard of care.
The original objective of this project was to develop additional ED-specific quality indicators for older patients within the domains of medication management, screening and prevention, and functional assessment, but the quantity and quality of evidence was insufficient to justify unequivocal minimal standards of care for these three domains. Accordingly, the authors modified the project objectives to identify key research opportunities within these three domains that can be used to develop quality indicators in the future.
Each domain was assigned one or two content experts who created potential quality indicators (QI) based on a systematic review of the literature, supplemented by expert opinion. Candidate quality indicators were then reviewed by four groups: the Society for Academic Emergency Medicine (SAEM) Geriatric Task Force, the SAEM Geriatric Interest Group, and audiences at the 2008 SAEM Annual Meeting and the 2009 American Geriatrics Society Annual Meeting, using anonymous audience response system technology as well as verbal and written feedback.
High-quality evidence based on patient-oriented outcomes was insufficient or non-existent for all three domains. The participatory audiences did not reach a consensus on any of the proposed QIs. Key research questions for medication management (3), screening and prevention (2), and functional assessment (3) are presented based upon proposed QIs that the majority of participants accepted.
In assessing a minimal standard of care by which to systematically derive geriatric QIs for medication management, screening and prevention, and functional assessment, compelling clinical research evidence is lacking. Patient-oriented research questions that are essential to justify and characterize future quality indicators within these domains are described.
The Society for Academic Emergency Medicine (SAEM), with participation from the American College of Emergency Physicians (ACEP), created the SAEM Geriatric Task Force in 2005 largely to improve the care delivered to geriatric emergency department (ED) patients. The task force identified topics in the ED management of older adults (i.e., those aged 65 years and older) that are essential to their health and well-being, and for which there are important gaps in the quality of care that they receive. With the understanding that there are many areas for which quality must be improved, the goal was to select a small number of important areas to initiate the identification of quality indicators (QIs) for the emergency care of older adults.
In various medical settings, patients frequently receive inadequate health care.1 The ED is no exception, and errors of omission and commission have been reported.2,3 Emergency medicine (EM) occurs in a unique milieu of time-pressured diagnostic uncertainty within a frequently crowded space.4,5 Despite a constellation of problems, including nursing shortages, information overload, liability concerns, increasing ambulance diversions, uncompensated care, and bioterrorism preparedness, EM must focus on quality improvement because patients deserve competent care and the public demands it. Within the ED environment, older adults more often fail to receive appropriate diagnostic and therapeutic interventions compared to younger populations.6–10 Aging adults were recognized as a disproportionate challenge to EM physicians two decades ago, but changes within graduate medical education have been slow to evolve.11–13 Because the proportion of patients receiving care in U.S. EDs who are older will continue to increase for decades, age-specific quality improvements specifically designed to mitigate these deficits are essential and long overdue.14–17
The Assessing Care of Vulnerable Elders (ACOVE) investigators recently developed a comprehensive set of primary care focused quality assessment tools for high-risk community-dwelling adults over age 65 years. They used the RAND appropriateness method to develop evidence-based, patient-centric quality of care indicators using systematic literature reviews and expert group consensus.18 ACOVE investigators reported that vulnerable community-dwelling older adults do not routinely receive acceptable levels of care in inpatient and outpatient settings, even though higher quality care is associated with improved survival.19,20 Investigators have since expanded the list of QIs for primary care to 26 conditions with 392 QIs covering 14 different interventions, ranging from history, physical exam, screening, and diagnostic testing to referrals, surgery, and physician visits.18,21 Terrell et al. used similar methods to develop EM-specific QIs for cognitive assessment, pain management, and transitional care.22 Although the original objective of this project was to develop additional ED-specific QIs for older patients within the domains of medication management, screening and prevention, and functional assessment, the quantity and quality of evidence was insufficient to justify unequivocal minimal standards of care within these domains. We therefore modified the project objectives to identify key research questions within these three domains that are necessary to answer before evidence-based QIs can be offered to the practicing community.
This project occurred over a three-year period from 2006 through 2009 (Figure). The task force first conducted literature reviews and Delphi-type surveys among its members to identify major deficiencies in the emergency care of geriatric adults involving conditions that are important for the seniors’ health and well-being. Six target conditions were identified by this process (described below). The next step was to construct QIs to address these deficiencies, which then were vetted across multiple groups of heterogeneous geriatric health care providers. The initial set of QIs was published for three conditions: cognitive assessment, pain management, and transitional care.22 A similar process (described in detail below) was conducted for the remaining three conditions: medication management, screening and prevention, and functional assessment. However, the quantity and quality of evidence to support proposed QIs for these three conditions was found to be low. Further, feedback from the audiences that vetted the proposed QIs indicated that some of the proposed QIs seemed unreasonable, and that the others were not yet validated to the extent that they could be used in quality-improvement projects. For these reasons, the task force determined that recommending QIs in these three areas was premature. However, both the task force and the vetting audiences believed that work to establish evidence-based QIs was worthwhile, based on clear evidence of inadequate care in these areas. Therefore, the final step was to transform the QIs that the vetting audiences felt were reasonable into research priorities that could provide validated QIs for subsequent quality improvement efforts.
The task force identified content experts for each target condition (medication management, KH and AG; screening and prevention, CRC; and functional assessment, STW and KS). The content experts created potential QIs using IF-THEN statements, following the ACOVE quality indicator approach.18 The “IF” statement determines whether a patient is eligible for the QI, and “THEN” describes the care process that should or should not be performed. A QI is considered to have been satisfied if the medical record indicates that a patient is offered or receives the care required by the QI (e.g., timely administration of aspirin for an acute myocardial infarction). The QI is excluded from application to the patient if the patient has a documented contraindication to the indicator (e.g., allergy to aspirin). The QI is not met if the medical record 1) demonstrates that the patient meets inclusion criteria, AND 2) does not indicate that the patient was offered the care required by the indicator, AND 3) has no documentation that the care item was contraindicated or refused by the patient. The QIs in this project were designed to be used with ED medical records as the data source.
The five content experts conducted systematic reviews for their target conditions. They searched for relevant English language articles in MEDLINE, Cumulative Index to Nursing & Allied Health Literature (CINAHL), and The Cochrane Library using appropriate subject headings and text words for each condition. Search terms are provided in Data Supplement 1. For each search, all titles and abstracts (if available) were reviewed to screen for potentially relevant articles. Full texts of potentially relevant articles were examined for possible inclusion. Content experts examined all references within relevant articles for studies that might meet inclusion criteria. After critically reviewing all applicable articles, each content expert developed a critical summary of the literature and a preliminary list of QIs. For the medication management indicators, the authors also performed a limited analysis of the ED component of the National Hospital Ambulatory Medical Care Survey (NHAMCS) to identify the medications most commonly prescribed to older patients discharged from the ED (see DS 1 for details).
Four groups sequentially evaluated the proposed QIs: the full SAEM/ACEP Geriatric Task Force (n = 19), the SAEM Geriatric Interest Group (unique n = 28), an audience at the 2008 SAEM annual meeting (n = 31), and audience members at a workshop at the 2009 American Geriatrics Society (AGS) annual scientific meeting (n = 37). The meeting programs described the workshops as interactive. Audience members were informed that they would help contribute to developing the QI agenda. The QIs were modified after each evaluation, based on consideration of each group’s responses. First, the literature summaries and proposed QIs were distributed to the 19 members of the 2007–2008 Task Force. Recipients were instructed to critically review the preliminary QIs and provide feedback to the task force chair (LWG) or the appropriate content expert, but to avoid replying to all of the task force members so that all comments would be independent. All feedback received by the chair was forwarded to the appropriate content experts.
The content experts revised the QIs in response to task force members’ suggestions. In the second stage of development, the revised indicators were distributed to the members of the SAEM Geriatric Interest Group. Again, recipients were asked to reply only to the chair or the content expert. The indicators were revised based on the new comments.
Third, the revised working set of medication management, screening, and functional assessment QIs were presented at an interactive didactic session at the 2008 SAEM annual meeting using individualized electronic response cards for all members of the audience.23 The 31 participants included physicians (89% of group, including 13% residents), nurses (3%), and social workers (3%). The majority of participants practiced in the United States (81%) or Canada (8%). The session’s goal was to draw on the expertise of this group to refine the QIs for use by clinicians, researchers, educators, and administrators. The session began with a background presentation on the nature of QIs. The content experts presented their sets of proposed QIs and the basis for inclusion of each. A discussion with the audience occurred after each presentation followed by anonymous electronic voting for each QI with three options: accept, reject, or modify. The QIs were revised based on these discussions. Further discussion followed the anonymous voting.
The next step was to present the three sets of QIs at a workshop during the 2009 AGS annual meeting. There were 37 consenting participants in the audience, including physicians (80%), nurses (3%), social workers (3%), and non-physician gerontologists (14%). The majority of participants practiced in the United States (76%) or Canada (9%). Similar to the SAEM meeting, each set of QIs was presented separately and feedback from the audience was elicited. The group discussion informed modification of QIs, resulting in the final version presented in this article. The description of the QIs in Data Supplement 2 represents the original wording as presented to the various audiences, whereas the QIs presented in the body of the manuscript represent the final wording.
Audience members at each meeting were asked to use their Turning Point (Turning Technologies LLC, Youngstown, OH) handheld devices to approve, reject, or modify the proposed QI. The voting results (DS 2) were presented on the screen and further discussion followed.
The evidence for improved patient-centric outcomes was non-existent or of low quality for each domain. In addition, the diverse participatory audiences failed to achieve a consensus for most of these proposed measures. Therefore, rather than present QIs without sufficient supporting evidence, we decided to use results from this multi-stage process to identify key research questions that could be used to construct validated QIs for use in subsequent quality improvement initiatives.
In the sections that follow, the key research questions for the three domains are reported separately. For each condition, we provide a brief description of the pertinent literature, the proposed research questions that will inform the development of future QIs, and the rationale for each research recommendation.
Adverse drug events are a common cause of ED visits and hospitalizations.24–26 As older patients take more medications, they are at increased risk to suffer from these events.27 While some adverse events cannot be prevented, many can be avoided.28 As over 50% of patients over the age of 65 years who are seen in an ED receive a prescription for a new medication,27 decreasing adverse drug events due to prescriptions provided in the ED is a reasonable objective that is likely to improve patient outcomes.
We sought to suggest QIs that would be relevant to EM by targeting medications that are frequently prescribed to patients discharged from the ED, and that are common causes of adverse drug events. We selected four medications that were commonly prescribed (based on NHAMCS data), and that are frequent cases of adverse drug events (based on the literature review).24,25,29 For these medications, we identified an intervention (such as monitoring, checking for interactions, or adding a protective agent) that would be expected to decrease the rate of adverse events from that medication. One of these interventions (early follow-up renal function monitoring following prescription of loop diuretics) was not accepted during the SAEM presentation, so it is not included in the research questions listed below.
Rationale: Warfarin is one of the most common causes of adverse drug events.25,26 At least 13 of the top 20 medications that are most commonly prescribed to older patients discharged from the ED have an interaction that potentially inhibits or potentiates the anticoagulant effects of warfarin30 (details available from the authors on request).
Rationale: Lorazepam is the 28th most commonly prescribed medication to patients older than age 65 years who are discharged from the ED. Benzodiazepines are a common cause of adverse drug events,25,26 and several studies have reported an increased risk of falling in older patients who are prescribed short- and long-acting benzodiazepines.31–34 Furthermore, benzodiazepines are frequently prescribed for conditions where there are little data for efficacy (such as vertigo, muscle spasm, and acute anxiety), or for conditions where the need for emergent treatment is questionable (insomnia).35–38 The one condition where benzodiazepines are clearly the drug of choice is alcohol withdrawal, and it is likely that older patients with alcohol withdrawal will require admission to the hospital. As the use of benzodiazepines is questionable for most other conditions, a careful assessment of risks and benefits will help assure that the medications are used appropriately.
Rationale : Non-steroidal anti-inflammatory drugs (NSAIDS) are the fourth most common category of medications prescribed to patients older than 65 years who are discharged from the ED, and account for approximately 12% of adverse drug event admissions.25,26 The relative risk of GI complications increases dramatically in patients older than 70 years.39 Several studies have shown that gastroprotective agents (proton pump inhibitors or misoprostol) decrease the risk of GI bleeding, and a Cochrane review recommends the use of these gastroprotective agents with NSAIDS for high risk patients.40,41
Compared with younger populations, older adults use emergency services more frequently with greater illness-related urgency and ED recidivism.42 Age-associated pathology such as cognitive dysfunction, fall risk, and frailty is prevalent and often unrecognized.33,43,44 ED-based case-finding has demonstrated no effect on overall service use, but does reduce nursing home admissions while improving patient satisfaction and increasing the recognition of occult cognitive impairment.45–47 Several tools have been validated to identify a subset of older adults at risk for short-term functional decline including the Triage Risk Screening Tool (TRST), Identification of Seniors at Risk (ISAR), and the Brief Risk Identification for Geriatric Health Tool (BRIGHT).47–49
The SAEM Preventive Services working group had previously identified falls prevention and pneumococcal vaccination for individuals over age 65 years as geriatric-specific interventions of potential value to older ED patients.50 Because 27% of geriatric adults fall at least once every year, emergency physicians will be evaluating many fall-related injuries.33 However, in the United States, fall patients frequently fail to prompt ED-based risk assessment or secondary prevention.51 In a similar fashion pneumococcal vaccination is a simple intervention, but non-immunized patients rarely receive the vaccine while in the ED.52,53 Furthermore, discharged patients do not routinely obtain outpatient vaccinations, nor do admitted patients.54,55
Rationale: Falls are the leading cause of traumatic mortality in older adults, costing the United States alone $19 billion annually.56,57 The AGS/British Geriatrics Society “Prevention of Falls in Older Persons” guidelines provide eleven summary recommendations for screening and assessment, including routine questions about the presence and frequency of falls, ambulation difficulties, and a multifactorial fall risk assessment for those who perform poorly on standardized gait testing.58 Although these guidelines represent the initial stages of enhancing fall-prevention efforts by decreasing variability, they are not well-suited for emergency care for several reasons. First, ED-specific fall risk stratification instruments have yet to be validated.59,60 Many of the individual risk factors and functional assessment screens that are associated with increased fall risk in other settings are either impractical or inaccurate for ED populations to identify older adults most likely to fall.60 Second, the guidelines suggest that “the health professional or team conducting the fall risk assessment should directly implement the intervention, or should assure that the interventions are carried out by other qualified health care professionals.” This is impractical in the crowded ED without round-the-clock access to traditional falls prevention support services. More importantly, very little high-quality evidence exists to demonstrate effectiveness for ED-initiated falls interventions.61 In addition, complicated interventions that span multiple specialties and entail home- or lifestyle-based modifications are difficult to initiate and sustain from the ED. Therefore, emergency clinicians cannot be confident that even if high-risk fallers were identified, fall-risk programs can be implemented and falls can be reduced.
The effect of ED-based falls prevention initiatives will need to assess a variety of outcomes at the patient, family, and community levels in evaluating cost-benefit trade-offs. The diminished quality of life resulting from fear of falling is less apparent than the medical expense and physical deterioration associated with injurious falls, but are also important to study.62 Some ED-based multidisciplinary secondary prevention interventions have reduced fall rates, but results were inconsistent and fall-related injuries were not reduced.63–66
Rationale: One-half of pneumonia patients discharged from the hospital are re-hospitalized or die from a vaccine-preventable infection within five years.67 Nonetheless, the majority of geriatric ED patients are not immunized against seasonal influenza.53,68 In older adults, widespread influenza vaccination practices can reduce all-cause mortality by 40% to 50% annually, with the most marked impact on the 65 to 69 years age-group.69,70 The American College of Physicians Advisory Committee on Immunization Practices recommends that all persons over age 65 years should receive an annual influenza vaccination.71 Similarly, vaccination against pneumococcal bacteremia in older adults is cost-effective,72,73 but most older patients in the ED remain unvaccinated for pneumococcus.68,74–76 However, evidence suggests that ED-based pneumococcal vaccinations are feasible, desirable, and acceptable for both health care providers and patients.54,68,73,75–78
The reasons why older adults are not routinely vaccinated against pneumococcal or influenza infections in the ED are likely related to perceptions of effectiveness, risk aversion, and the limits of emergency care.53 Whereas tetanus vaccination effectiveness approaches 100%, lower-quality evidence suggests that pneumococcal vaccination does not prevent pneumonia, but may reduce illness severity and bacteremia.67,79–81 On the other hand, influenza vaccination is 70% to 90% effective in preventing influenza-like illness related death.82 Another barrier to ED-based vaccinations for pneumococcus is that it needs be administered only once, and emergency staff may be wary about the risks and costs of duplicate administration.53 This impediment would not apply to influenza, though, and would not explain why most EDs do not screen for immunization status. As regards to the scope of emergency practice in comparing exemplary tetanus vaccination rates with less stellar influenza and pneumococcus rates, clinicians probably view tetanus boosters for high-risk wounds as secondary prevention, whereas influenza or pneumococcal vaccines are primary prevention and therefore beyond the role of the ED.53
Functional assessment of older adults has been recognized as an important aspect of the Geriatric Emergency Care Model described by the SAEM Geriatric Emergency Medicine Task Force in the early 1990s.83 Those authors recommended assessment of activities of daily living, instrumental activities of daily living, and direct evaluation of function using performance tests.83–85 The AGS’s research agenda setting process recommended development and testing of feasible and valid methods of functional assessment in older ED patients, followed by clinical trials to determine whether detection and management of the functional decline improves patients’ outcomes.86–88
General themes identified from review of these articles, book chapters, and expert opinion included the following: functional decline may be the only presenting symptom for numerous serious diseases;89–92 older patients with subacute medical conditions often present when their medical symptoms affect their function;90 injuries commonly result in functional decline;93–97 emergency physicians often do not address function in their evaluation of older ED patients;89,95,98 and the minimum functional abilities needed for discharge are the ability to transfer and ambulate, unless 24 hour care is available.84,85 For these reasons, we consider functional assessment a necessary portion of the history, examination, and disposition of older patients with acute illness and injury, rather than a case-finding or screening process.
Rationale: Rutschmann and colleagues found that older ED patients with functional decline and no specific medical complaint (referred to as presenting for “home care impossible”) had an acute medical problem in 51% of cases. All of those with acute medical problems were not triaged to a level commensurate with their illness severity, often due to poor recognition of neurological symptoms and atypical clinical presentations.89
Rationale: Wilber and colleagues found that older patients with subacute medical symptoms have poor baseline functional status (only 22% were completely independent), commonly have functional decline as a result of their illness (74%), and this functional decline often contributes to their reason for the ED visit (79%).90
Rationale: Functional decline is common in older ED patients with acute injuries, occurring in 23% to 51%.93,95,99 These studies show that the rate of functional decline is highest in the immediate post-injury period.93,95,99 The “Get Up and Go” test, whereby the clinician observes a patient arising from a chair, taking several steps, and sitting down, is recommended and easily performed in the ED.84 The ability to transfer and ambulate is crucial for the performance of other critical activities of daily living, including eating and drinking, and toileting.
Emergency providers have an obligation to provide the very best care that they can and to remedy care deficiencies whenever possible. Older patients and other vulnerable populations present issues that pose additional challenges to EM professionals delivering care. Additionally, health care quality has become an overarching focus for government, third party payers, and regulatory agencies. However, the ED is a high stress, high acuity, decision-dense environment with finite resources, in conjunction with limited ability to control patient volume. Further, high variability in the quality of care is the norm in today’s medical environment, and EM is no exception.100–102 Improving quality in such an environment is challenging, and focusing energy and resources on high-yield quality improvement efforts is essential. QIs offer one approach to improve the average quality of care, but QIs must be based on the highest quality evidence, and engender broad-based multidisciplinary support.103,104 The QIs proposed by Terrell et al.22 had, for the most part, reasonable evidence backing them and reasonable agreement at the end of the process. The QIs in this article did not achieve this level of agreement, and we identified the research questions that developed from the process. While the majority of EM quality measures use time-based metrics, the indicators described by both Terrell et al. and our group focus on processes rather than specific structures or outcomes.105
Some of the proposed QIs were rejected by our expert audiences (summarized in DS 2). These audiences represented a broad spectrum of physician and non-physician health care providers in emergency and geriatric settings across academic and community-based settings. Rejected QIs included assessment of prognostic risk using validated tools such as ISAR or TRST,47–49,106,107 comprehensive geriatric assessment in the ED,108 and depression screening.109–112 The various audiences also rejected the concept of EDs that only care for geriatric adults modeled after the pediatric ED.14
If subsequent trials demonstrate efficacy, then future studies will also need to ascertain if these measures are cost-effective and what unintended consequences result from their implementation.113,114 We expect that research on our identified priorities will likely identify further refinements to these and future QIs to enhance their external validity and universal feasibility.113,115,116 For example, no single practitioner could or should be expected to accomplish all of these quality measures during a typical ED encounter. Atypical approaches such as non-physician, non-nurse personnel (volunteers, pre-medical students) trained to administer simple screening tools can be used to perform some of these processes during prolonged ED evaluations.117
The initial set of indicators was developed by emergency physicians with interest and expertise in these domains. Potential biases in developing these research priorities were minimized by using the broad opinion base of the SAEM Geriatric Task Force and Interest Group, SAEM annual meeting attendees, and AGS annual meeting attendees. Nonetheless, our consensus process may have underrepresented practicing community physicians. An additional limitation of our process was that we excluded potential QIs based upon consensus voting without ascertaining specific reasons why certain proposals were rejected. Despite our rigorous methods and divergent audiences, there is a lack of high-quality research to support the originally proposed QIs. Future research will enhance the applicability of QIs for these conditions.
Three domains for potential quality indicators in the emergency medical care of geriatric adults were evaluated by diverse audiences in a systematic fashion. Participants concluded that these three domains had insufficient high-quality evidence to support quality indicators. High-priority research questions that require an analysis of patient-oriented outcomes are described to shape and prioritize future research as minimal standards of care are shaped for geriatric ED quality indicators.
The SAEM Geriatric Task Force included experts in geriatric emergency care from either or both the Society for Academic Emergency Medicine and the American College of Emergency Physicians. Task Force Members included Jeanne M. Basior, MD, University at Buffalo, KaleidaHealth Buffalo General Hospital; Christopher R. Carpenter, MD, MS, Washington University; Michael Cassara, DO, North Shore University Hospital; Jeffrey Caterino, MD, Ohio State University; Kathleen J. Clem, MD, Loma Linda University; James A. Espinosa, MD, University of Medicine and Dentistry of New Jersey; Neal Flomenbaum, MD, Weill Cornell Medical College; Lowell W. Gerson, PhD (Chair), Northeastern Ohio Universities College of Medicine, Summa Health System; Adit A. Ginde, MD, MPH, University of Colorado Denver School of Medicine; Theresa M. Gunnarson, MD, Regions Hospital; Kennon Heard, MD, University of Colorado School of Medicine; Teresita M. Hogan, MD, Resurrection Medical Center; Fredric M. Hustey, MD, Cleveland Clinic Lerner College of Medicine; Jason A. Hughes, MD, University of Iowa; Ula Hwang, MD, MPH, Mount Sinai School of Medicine; Sean P. Kelly, MD, Beth Israel Deaconess Medical Center; C. Eve D. Losman, MD, University of Michigan; Heather M. Prendergast, MD, University of Illinois at Chicago; Arthur B. Sanders, MD, University of Arizona; Manish N. Shah, MD, MPH, University of Rochester; Kirk A. Stiffler, MD, Northeastern Ohio Universities College of Medicine, Summa Health System; Jeffrey Tabas, MD, San Francisco General Hospital; Kevin M. Terrell, DO, MS, Indiana University; Scott Wilber, MD, MPH, Northeastern Ohio Universities College of Medicine, Summa Health System; and Robert Woolard, MD, Texas Tech University HSC SOM, El Paso. Seth Landefeld, MD, University of California, San Francisco, and Douglas K. Miller, MD, Indiana University were American Geriatric Society liaisons with the Society for Academic Emergency Medicine.
This project was funded by an award from the American Geriatrics Society as part of the Geriatrics for Specialists Initiative, which is supported by the John A. Hartford Foundation.
Drs. Carpenter, Ginde, Heard, and Wilber were supported by Dennis W. Jahnigen Career Development Awards, which are funded by the American Geriatrics Society, the John A. Hartford Foundation, and Atlantic Philanthropies.
Dr. Carpenter was supported by the Washington University Goldfarb Patient Safety award.
Dr. Heard was supported by Award Number K08DA020573 from the National Institute on Drug Abuse.
The content is solely the responsibility of the authors and does not necessarily represent the official views of the supporting societies and foundations or the funding agencies.