Healthcare Without Walls


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Professor Stanton Newman
Professor of Health Psychology and Dean of the School of Health Sciences, City University, London

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Healthcare Without Walls

  1. 1. Healthcare  without  Walls  –  transforming  the  way   services  are  delivered   Stanton  P  Newman,     School  of  Health  Sciences   City  University  London  
  2. 2. STRUCTURE  OF  TALK  •           Purpose(s)  of  TH  
  3. 3. Background  -­‐  AssisEve  Technologies  Telehealth  (TH):  The  remote  exchange  of  data  between  a  paEent  and  health  care  professional(s)  to  assist  in  the  diagnosis  and  management  of  a  health  care  condiEon(s).    Examples  include  blood  pressure  monitoring,  blood  glucose  monitoring  and  medicaEon  reminders.      
  4. 4. Range  of  TeleHealth  Technologies  FIXED   Home  telephone   E  mail   Web  or  TV  -­‐  informaEon  and  interacEon   Online  support  group   Passive  telemonitoring  systems  without  feedback  PORTABLE   Mobile  Phone  (calls  &  SMS)   PDA  (Calls,  SMS,  Data,  Picture  &  Video  informaEon)    
  5. 5. ID168,  W,  77  yrs,  COPD  
  6. 6. PenetraEon  :  84.5  %      10  Year  Growth  336.8  %  
  7. 7. The  range  of  purposes  for   introducing  Telehealth  
  8. 8. Outcomes  at  the  individual  level  –  the  parEcipant  Ability  of  the  person  with  the  chronic  condiEon  to:   Beaer  manage  their  symptoms,  treatment,  and  the   physical  and  psychosocial  consequences  of  their  condiEon       to  appropriately  monitor  their  condiEon  and  seek  help  at   appropriate  Emes   Maintain  independence  over  their  lives  (includes   caregivers)   maintain  quality  of  life  and  psychological  well  being  in  the   face  of  the  chronic  condiEon   Make  the  appropriate  behavioural  changes  to  play   increased  role  in  the  management  of  their  condiEon   8  
  9. 9. Key  Psychological  processes”  Ability  of  the  person  with  the  chronic  condiEon  to:   Feel  more  in  control  of  their  symptoms,  treatment,  and   the  physical  and  psychosocial  consequences  of  their   condiEon       to  feel  empowered  and  supported     to  have  adequate  knowledge  and  informaEon  regarding   the  condiEon     To  feel  confident  in  their  ability  to  deal  with  the  cogniEve   and  behavioural  changes  required  to  adapt  to  the   demands  and  impact  of  the  condiEon     9  
  10. 10. Key  clinical  &  system  outcomes  for  the   introducEon  of  telehealth  Ability  of  the  programme  to:   reduce  symptoms  and  clinical  indices  of  the  condiEon       to  reduce  health  &  social  care  uElisaEon  and  costs   to  promote  health  &  social  care  integrated  working   1 0  
  11. 11. MulEplicity  of  processes  &  outcomes  for   telehealth  intervenEons   Proximal   Distal   Health Behaviour Responsibility Knowledge Clinical State Care change Utilisation Patient & Taking Reduce carer appropriate Beliefs Adherence Costs dependencyParticipation actionOrganisational System re- Change Confidence Attendance Isolation organisation Change Quality ofProfessional Empowerment Disability Life behaviour Independence 1 1  
  12. 12. Issues  to  address  in  scaling  up        Telehealth  
  13. 13. OrganisaEonal  Issues  Even  with  “excellent  evidence”  translaEonal  of  evidence  into  pracEce  is  complex  and  requires  organisaEonal  change  at  a  number  of  levels.     Service  innovaEon  needs  to  seen  to  be  compaEble  with  needs   values,  norms  and  ways  of  working  within  the  organisaEon.     RelaEve  power  and  interest  (professional  &  financial)  will   influence  likely  adopEon   Perceived  ownership  of  innovaEon  requires  careful   management   Ongoing  training  &  support  for  hcps  a  necessity     1 3  
  14. 14. Behaviour  and  ways  of  working  Good  example  of  translaEonal  research  Majority  of  translaEonal  research  has  involved  technologies  not  a  service  innovaEon  involving  “human  capital”     “A  novel  set  of  behaviours,  rouEnes  and  ways  of  working,   which  are  directed  at  improving  health  outcomes,   administraEve  efficiency,  cost  effecEveness  or  user   experience  ………….”          Greenhalgh  et  al  2004     1 4  
  15. 15. Professional  Issues  Professional  ways  of  working  ingrained  and  onen  defended.    Rewards  associated  with  acEvity/skills  embedded  in  organisaEon    Flexible  working  not    hallmark  of  many  health  care  professions  Hierarchy  well  established  Costs  of    retraining  require  support  and  perceived  loss  of    funding  to  other  areas   1 5  
  16. 16. Professional  concerns  Concerns  over  clinical  responsibility  and  liability  Reimbursement  on  fee  for  service  is  disincenEve  
  17. 17. Health  Care  professional  paEent  relaEonship    CHF  Telehealth/telephone  &  Nursing  PracEce  Removes  on  of  the  key  features  of  nursing  pracEce  –      proximity  (vision  &  touch)    providing  support  (including  family)    Support  for  behaviour  change/self  management    TEMPORAL  ISSUE:  Coming  to  know  the  paEent  appears  to  take  place  parEcularly  during  face-­‐to-­‐face  contacts  at  the  beginning  of  the  care  trajectory.    If  relaEonships  with  paEents  are  well-­‐established,  ‘seeing  the  paEent’  becomes  less  important  and  a  first  assessment  of  the  seriousness  of  paEents’  complaints  can  be  done  by  phone.  
  18. 18. CHF  Telehealth/telephone  &  Nursing  PracEce  ReducEon  in  vision  removes  stereotypes  driven  by  visual  presence  Removes  rapid  judgements  based  on  vision   Emphasis  on  auditory  clues  and  capacity  to  listen     Others  who  can  give  support  to  paEents’  self-­‐care   tend  not  to  be    acEvely  enrolled  in  providing  or  supporEng   care.  
  19. 19. CHF  Telehealth/telephone  &  Nursing  PracEce  Telemonitoring  transforms  self-­‐care  into  an  obligaEon.    If  daily  measurements  not  received  then  reminders  sent.  Introduces  a  daily  surveillance  of  paEents’  health  condiEon  that  enables  quality  control  over  the  paEent’s  self-­‐care.    The  increased  temporal  nearness  to  paEents  facilitates  a  form  of  care  in  which  paEents  receive  immediate  care  (medicaEon  or  hospital  admission)  in  a  case  of  medical  crisis.  QuesEon  as  to  what  this  does  to  the  relaEonship  between  paEent  and  health  care  professional  
  20. 20. Different  forms  of  care  in  face-­‐to-­‐face  and     telehealth-­‐care  services  for  heart-­‐failure  paEents  Face-­‐to-­‐face  services        Telehealth-­‐care  services  Physical  proximity          Digital  proximity  –  intermiaent  monitoring        –  daily  monitoring  –  open  communicaEon        –  protocol-­‐driven  communicaEon  –  medical  intervenEons  and  advice      –  control  and  advice  –  nurse  as  counsellor        –  nurse  as  surveillant  –  psycho-­‐social  care  through  dialogue    –  psycho-­‐social  care  through  video  –  self-­‐care  as  opEon        –  self-­‐care  as  obligaEon  Contextualised,          Individualised,  Personalised  care  that        Immediate  care  that  consEtutes  heart  failure  as  illness      ConsEtutes  heart  failure  as  disease  
  21. 21. Telehealth  -­‐  Evidence  Base  
  22. 22. Telehealth  -­‐  ExisEng  Evidence  Base  limited  by  Methodology  &  short  term   follow  up  •   CriEcisms  of  the  literature:      -­‐  pilot  projects    -­‐  short-­‐term  outcomes,  do  not  assess  long-­‐term  or                                            rouEne  use  of  technologies    -­‐  studies  do  not  meet  robust  evaluaEon  criteria                                      (Bensink  et  al  2006;  Barlow  et  al  2007;  Whiaen  et  al  2007)  
  23. 23. The  Evidence  Base  as  a  Barrier   Some  posiEve  paEent  reported  outcomes  (QoL)  not   sufficiently  persuasive  to  those  who  retain  clinical  and   managerial  responsibility  for  paEent  care     To  demonstrate  clinical  benefits  in  some  condiEons   requires  years  of  follow  up.  Few  studies  perform  long  term   follow  up  to  demonstrate,  enduring  behaviour  change  or     clinical  benefits  &  reducEons  in  morbidity  &  mortality     2 3  
  24. 24. The  Quality  of  Evidence  as  a  Barrier   Davalos  et  al  2009  
  25. 25. Overall  Aim  of  WSD  EvaluaEon  Aim:  to  provide  a  comprehensive  evaluaEon  of  the  addiEon  of  telecare  and  telehealth  to  whole  systems  re-­‐design.    Project  planned  to  assess  up  to  6,000  individuals  and  up  to    660  carers  with  a  variety  of  methods  and  levels  of  analysis.  
  26. 26. WSD  EvaluaGon  Cluster  RCT  design   Group  A   Group  B   Group  C   Group  D   Social  Care  needs   Social  Care  needs   receive  usual  care   Social  Care  needs   Social  Care  needs   receive  usual  care   receive  telecare   receive  telecare   (CONTROL  GROUP)   (CONTROL  GROUP)   LTCs  receive  usual  care     LTCs  receive  usual  care  LTCs  receive  telehealth   LTCs  receive  telehealth   (CONTROL  GROUP)   (CONTROL  GROUP)  
  27. 27. Total  Numbers  recruited   Target  5721     Recruited:  5831     1200  IntervenEon   Control   1117   1111   Control   IntervenEon   2881   2949   1057   49%   51%   1010   1000   800   775   760   600   Newham   1535   Cornwall   400   26%   2228   38%   200   Kent   2067   36%   0   Cornwall   Kent   Newham  
  28. 28. Total  Numbers  recruited   1750   1625   1605   Control   IntervenEon   1500   1324   1276   1250  TeleCare   2600   TeleHealth   1000   45%   3230   55%   750   500   250   0   TeleHealth   TeleCare  
  29. 29. Is  Telehealth  for  all  Onen  assumed  that  Telehealth  is  applicable  to  all  individuals.  Significant  proporEon  reject  telehealth  ApplicaEon  of  Telehealth  and  Telecare  may  be  less  appropriate  to  some  individuals  -­‐  favour  more  paternalisEc  approach    ApplicaEon  of  Telehealth  more  appropriate  in  condiEons  that  require  significant  monitoring  (e.g.diabetes,  CHF).   3 0  
  30. 30. •  “Our  assump*on  that  all  those  who  were   eligible  would  want  the  technology  proved   to  be  the  biggest  challenge  in  the   recruitment  process.”    (MarEn  Scarfe,   Project  Director  Newham)  hap://  december_2009_wsd.html  
  31. 31.  WSD  :  Key  qualitaEve  themes  from  those  not  wanEng  to  trial  the   equipment  •  PercepEons  of  health,  self-­‐care  and   dependency  •  Views  on  technology  and  operaEonal  factors  •  ExpectaEons  and  experiences  of  changes  in   service  provision  and  use  
  32. 32.  Non-­‐parEcipants:  Threats  to  health,    self-­‐ care  and  independence  •  “I  think  you  feel  like  youre  not  in  control  of  your   life…  from  how  he  explained  it,  you  tended  to  have   to  do  your  blood  test  every  single  day…  I  try  to  be  a   bit  more  relaxed  and…  I  just  felt  it,  it  did  put  a  bit   more  pressure  on  me…”      (ID31,  W,    61  yrs,  Diab)  
  33. 33. •  “I  stood  at  my  front  door  the  other  day  and  I   thought,  really,  truly,  this  worlds  not  for  me  now,   its  too  complicated,  …  you  dont  speak  to   anybody,  you  get  buaons  you  push  and  press.    Ive   got  a  mobile  phone  but  I  wouldn’t  even  know   how  to  use  it.”    (ID27,  W,  79,  diab)  
  34. 34. •  “…we  have  such  good  contact  with  our  district   nurses  and  our  supporEng  teams  around  us.  I  mean,   Ive  only  got  to  phone  the  hospice  and  somebody   will  come  out…weve  got  so  many  contacts  around   us.”      (wife  of  ID134,  M,  70  yrs,  COPD)  
  35. 35. Withdrawal  from  using   telehealth  &  telecare?  Withdrawal  reason     Telecare  N  (%)   Telehealth  N  (%)  Deceased     155  (5.85%)   164  (5.08%)  Physical  or  mental  illness     24  (0.92%)   50  (1.55%)  ResidenEal  or  nursing  care   68  (2.62%)   13  (0.40%)  No  longer  wishes  to  be  in  the  control  group     58  (2.23%)   69  (2.14%)  No  longer  wishes  to  be  in  the  intervenEon  group  and   19  (0.73%)   211  (6.53%)  rejects  the  equipment  aner  trying  for  a  period    No  longer  wishes  to  share  data   0   6  (0.19%)  No  longer  wishes  to  parEcipate  as  quesEonnaire  is  too   7  (0.27%)   8  (0.25%)  onerous    Moved  out  of  area  to  non-­‐parEcipaEng  GP  pracEce     19  (0.73%)   33  (1.02%)  Absence  from  home  or  loss  of  contact       10  (0.38%)   12  (0.37%)  Problem  with  equipment  (e.g.  equipment  broken,  no   3  (0.12%)   11  (0.34%)  longer  working,  misused)    No  reason  given     8  (0.31%)   15  (0.46%)  
  36. 36. Significant predictors of withdrawal from Telehealth1.  ParEcipants  in  the  intervenEon  group  more  likely  to   withdraw  2.  Older  age  categories  increased  the  odds  of   withdrawal  3.  Non-­‐white  BriEsh  ethnic  group  less  likely  to  withdraw  4.   More  co-­‐morbid  condiEons  greater  chance  of   withdrawal  
  37. 37. Why  withdraw  from  using   telehealth  &  telecare?  Withdrawal  reason     Telecare  N  (%)   Telehealth  N  (%)  Deceased     155  (5.85%)   164  (5.08%)  Physical  or  mental  illness     24  (0.92%)   50  (1.55%)  ResidenEal  or  nursing  care   68  (2.62%)   13  (0.40%)  No  longer  wishes  to  be  in  the  control  group     58  (2.23%)   69  (2.14%)  No  longer  wishes  to  be  in  the  intervenGon  group  and   19  (0.73%)   211  (6.53%)  rejects  the  equipment  aQer  trying  for  a  period    No  longer  wishes  to  share  data   0   6  (0.19%)  No  longer  wishes  to  parEcipate  as  quesEonnaire  is  too   7  (0.27%)   8  (0.25%)  onerous    Moved  out  of  area  to  non-­‐parEcipaEng  GP  pracEce     19  (0.73%)   33  (1.02%)  Absence  from  home  or  loss  of  contact       10  (0.38%)   12  (0.37%)  Problem  with  equipment  (e.g.  equipment  broken,  no   3  (0.12%)   11  (0.34%)  longer  working,  misused)    No  reason  given     8  (0.31%)   15  (0.46%)  
  38. 38. Differences by long term condition TH participants receiving telehealth kit for minimum 90 days- WSD 2.5   6   strongly  agree   2.0   1.5   5   moderately  agree   1.0   0.5   4   mildly  agree   *  p  <  0.05   0.0   *  p  <  0.05   -­‐0.5   3   mildly  disagree     -­‐1.0   -­‐1.5   2   moderately  disagree   -­‐2.0   -­‐2.5   1   strongly  disagree   -­‐3.0   increased   privacy/ care  personnel   kit  as   enhanced  care   saEsfacEon   accessibility   discomfort     concerns   subsEtuEon  COPD   1.358   4.858   0.664   a,b   4.164 -­‐1.667   a   1.833 -­‐1.154   2.346   -­‐0.066   3.434   1.867   5.367   a       b  Diabetes   4.743   1.243   4.382 0.882   2.150 -­‐1.350   2.498   -­‐1.002   3.112   -­‐0.388   5.137   1.637   b       a,b  Heart  Failure   4.752   1.252   3.949 0.449   1.966 -­‐1.534   2.496   -­‐1.004   3.385   -­‐0.115   5.266   1.766  
  39. 39. Predictive validity of acceptability: TH participants receiving telehealth kit for minimum 90 days- WSD 2.5   6   strongly  agree   2.0   1.5   5   moderately  agree   **  p  <  0.001   1.0   0.5   4   mildly  agree   **  p  <  0.001   p  >  0.05   **  p  <  0.001   0.0   **  p  <  0.001   **  p  <  0.001   -­‐0.5   3   mildly  disagree     -­‐1.0   -­‐1.5   2   moderately  disagree   -­‐2.0   -­‐2.5   1   strongly  disagree   -­‐3.0   increased   care  personnel   enhanced  care   privacy/discomfort     kit  as  subsEtuEon   saEsfacEon   accessibility   concerns  Completed   1.3720   4.872 .7192   4.219 -­‐1.6232   1.877 -­‐1.1103   2.390 -­‐.0926   3.407 1.8599   5.360Rejected  Kit   3.740 .2400   2.917 -­‐.5833   2.767 -­‐.7333   2.811 -­‐.6889   2.544 -­‐.9556   4.411 .9111  
  40. 40. PotenEal  for  cost  savings  resulEng  from  the  introducEon  of  telehealth  
  41. 41. What  is  the  proposiEon  Widespread  introducEon  for  all  health  care  recipients  SelecEve  introducEon  for  those  in    a.Remote  and  difficult  to  access  environments    b.  SelecEve  condiEons  that  require  close  monitoring    c.  SelecEve  condiEons  and  age  groups  that  are  high      health  care  users  Purpose:    a.  savings  in  reduced  health-­‐care  uElizaEon,  fewer      face-­‐to-­‐face  visits  improve  health  care  outcomes    c.  reduce  inconvenient  travel  for  paEents    d.increase  convenience  of  health  care  professionals    e.  to  change  the  culture  of  health  care    
  42. 42. What  severity  level  to  target  Reducing  other  health  care  costs  such  as  transport  &  GP  visits  may  not  show  short  term  cost  reducEons  in  many  condiEons    ExcepEon  is  in  those  condiEons  that  have  a  high  frequency  of  hospital  visits  e.g.  heart  failure  Re  hospitalizaEon  rate  is  very  high  (2%  within  2  days,  20%  within  1  month,  and  50%  within  6  months)  Seto  et  al  2008  SystemaEc  review:  Cost  reducEons.  were  mainly  aaributed  to  savings  from  reduced  hospitalizaEon  with  telemonitoring  compared  to  usual  care  
  43. 43. When  to  introduce  Telehealth  into  the   health  service   Increasing  care  need     older   Current  policy  –perceived  greater  economic  return   ReducEon  in  hospitalisaEon.   But  older  and  less  tech  savy   But  fails  to  change  the  culture  and  train  and     integrate  telehealth  into  standard  care   Early  change  the  culture  and  train  and     integrate  telehealth  into  standard  care.   Younger  &  more  tech  savy   Greater  possibility  of  establishing  cultural  change   Liale  care  need     younger  
  44. 44. Costs  as  a  Barrier   savings  in  reduced  face  to  face  visits   Low  TH  costs   High  face  to  face  visit  costs  High  TH  costs  Low  face  to  face  costs   Cusack  et  al  2008   The  iniEal  cost  of  the  telemonitoring  equipment  may  be  an   obstacle  to  widespread  use  of  telemonitoring  for  HF  and  other   chronic  disease  management  
  45. 45. Possible  savings  in  Specific  Environments  SimulaEon  of  cost  savings  in  4  se{ngs  in  USA   1.  emergency  departments,     2.  prisons  (correcEonal  faciliEes),     3.  nursing  home     4.  physician  offices  savings  achieved  via  a  reducEon  in  transfers  of  paEents,  prisoners  and  nursing  home  residents  to  and  between  emergency  departments  and  physician  offices.  savings  in  reduced  health-­‐care  uElizaEon,  specifically  from  fewer  face-­‐to-­‐face  physician  office  and  emergency  department  visits  and  from  a  reducEon  in  duplicate  and  unnecessary  tesEng   Cusack  et  al  2008  
  46. 46. Possible  savings  in  Specific  Environments  Area   No  of  instances   Cost  Saving  Transport  –  emergency  room   850,000   $537  mil  Transport  –  Prisons  to  ER   40,000   $60.3  mil  Prison  physician  visits   $210  mil  Transport    Nursing  home  -­‐ER   387,000   $327  mil  Nursing  Home  physician  visits   6.87  mil   $479  mil   NATIONAL  IMPLEMENTATION   $4.28  bil   Cusack  et  al  2008  
  47. 47. What  are  the  range  of  costs  that  need  to  be  taken  into   account   Fixed  costs:  Equipment  etc  (capital  costs),  depreciaEon,   faciliEes  (e.g.  call  centre).     Variable  costs:  Maintenance  and  repairs,  installaEon,  admin   support,  training  etc     Unintended  Costs  :  Increased  surveillance  leads  to  beaer   detecEon  and  potenEally  increased  costs  of  care  .  
  48. 48. VA  RetrospecEve  matched  comparison  group  study  of   TelerehabilitaEon     LAMP:  (Low  ADL  Monitoring  Programme)   Technologies  to  promote  independence  &  skills  to  remain   living  at  home     Programme  targets  people  with  mulEple  co-­‐morbidiEes  &  in   this  study  with  funcEonal  deficits   Matched  control  group  –  techniques  to  avoid  selecEon  bias   Bendixen et al 2009
  49. 49. VA  RetrospecEve  matched  comparison  group  study  of   TelerehabilitaEon  –  Cost  Differences  at  12  months     Bed  Days   Clinic  Visits   Emergency   Nursing   Total   room  Visits   Home   Admission   LAMP   -­‐  $804,268   +  $890,814   +  $415   -­‐  $2,414   +  $44,537  CONTROLS   -­‐  $677,732   +  $220,458   -­‐  $4082   -­‐  $15,470   -­‐  $476,824   Bendixen  et  al  2009  
  50. 50. Saving  Lives  &  Improving  care  does  not  necessarily  imply  a   cost  saving     The  net  effects  of  improving  care  and  reducing  mortality  may   be  to  increase  costs   e.g.  heart  failure:   Improvements  in  the  diagnosis  and  treatment  of  MI  led  to  an   increasing  number  of  paEents  surviving  with  a  damaged   myocardium  who  may  subsequently  be  at  risk  of  developing   heart  failure.  
  51. 51. Increasing  numbers  with  heart  failure  partly  because  of   improved  care     1.  Heart  failure  is  essenEally  a  disease  of  the  elderly  .  Ageing  populaEon   will  lead  to  increase  in  HF   2.  MI  common  and  rates  of  survival  increasing  -­‐  heart  failure  is  an   inevitable  sequel  in  a  significant  proporEon  of  survivors.     1.  Base-­‐case  esEmate  (post-­‐MI  heart  failure  accounts  for  20%  of  heart   failure  cases):     1.  Direct  healthcare  costs  -­‐  £125–181  million     2.  Nursing  home  costs  of  £27  million;     2.  Upper  esEmate  (post-­‐AMI  heart  failure  accounts  for  50%  of  the  total):   1.  Direct  healthcare  costs  of  £313–453  million     2.  Nursing  home  costs  of  £68  million.  
  52. 52. Do  we  know  how  it   works  
  53. 53. Different  models  of  how  TH  works  will  have  cost   implicaEons  Is  all  the  informaEon  required  for  management  sent  to  the  health  care  professional  for  a  decision     PotenEally  disempowering   Changes  relaEonship  of  HCP  to  surveillance   Unlikely  to  increase  self  care     5 6  
  54. 54. Is  InformaEon  sufficient  1.)  The  implicit  model  of  TH  underlying  most  studies  2.)  A  simple  model  of  TH  including  self-­‐care  as  a  mediaEng   variable  3.)  An  elaborated  model  of  TH  including  self-­‐care  and  its   cogniEve  precursors  as  mediaEng  variables     Knowledge a   b   c   a   a   Self-care f   b   QoL/ Clinical Telehealth Behaviour Outcomes d   e   Self-efficacy
  55. 55. Conclusions  and  recommendaEons  re  scaling  up  Be  clear  about  the  desired  objecEves/outcomes  and  the  Emeline  for  their  realisaEon    Plan  and  manage  the  organisaEonal  change  required    Engage  professionals  and  address  concerns  InsEtute  training  early  on  in  process  Present  advantages  to  potenEal  parEcipants  –  use  clinicians  PotenEally  select  parEcipants  Be  clear  if  and  when  any  cost  savings  will  be  realised  Assess  processes  &  outcomes  so  as  to  drive  improvements  to  the  service   5 8  
  56. 56. Thank  you