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10:00 a.m. CDT
Coordinator At this time I’d like to thank all parties for holding. Your lines will
remain on listen-only until the question and answer session of today’s
conference. Today’s conference is also being recorded. At this time I’d
like to turn the call over to Ms. Jeanne Brennan.
J. Brennan Thank you. Hi, everyone. Thanks again for being on today’s call. Before
we start I just want to restate who is speaking on today’s call and provide
full titles and spellings of their names. First we’ll have Dr. Allen Dietrich
who is Professor of Community and Family Medicine at Dartmouth
Medical School and is the co-chair of the MacArthur Initiative on
Depression and Primary Care at Dartmouth and Duke.
We also have Dr. Charles Engel, who is Director of the Deployment
Health Clinical Center at Walter Reed Army Medical Center, and is also
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faculty at the Uniformed Services University. Dr. Engel is also a
lieutenant colonel.
We also have Dr. Laurie Garduque, who is the Director of Research for
the Program on Human and Community Development at the MacArthur
Foundation.
Just let me know if you have any questions about the spellings after the
call. You can reach me by e-mail. Again, it’s Jeanne Brennan. But at this
point, I’ll turn the call over to Dr. Allen Dietrich.
A. Dietrich Thank you, Jeanne, and good morning. I’m Allen Dietrich of Dartmouth
Medical School, co-chair of the MacArthur Foundation Initiative on
Depression and Primary Care. As Jeanne said, I’m joined here today by
Dr. Charles Engel of the Walter Reed Army Medical Center and the
Uniformed Services University, and Laurie Garduque, Director of
Research for the Program on Human and Community Development at the
John D. and Katherine T. MacArthur Foundation.
We’re very pleased to be here today to discuss a paper that will be
appearing in this week’s British Medical Journal. The paper describes a
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clinical trial that we think represents a big step forward for patients with
depression, and for the clinicians who care for them.
You may know that the World’s Health Organization has estimated that
depression was the fourth highest cause of disability and premature death
worldwide in 1990, and will be the second highest cause by 2020.
Over the past two decades medical science has made great strides in
understanding depression. New drugs and therapies are more effective
than ever in treatment. Unfortunately, the stigma of mental illness
continues to influence attitudes toward this condition.
There’s a startling proportion of adults and children with mental illness
who do not receive treatment. Primary care is a prime portal to get people
into treatment, especially for those reluctant to access, or unwilling of
their need for mental health services. At this time few programs
nationwide are expressly organized to integrate mental health services and
primary care.
The MacArthur Foundation’s Initiative on Depression and Primary Care
has been charged with making a difference nationally in the primary care
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management of depression. To that end we have developed the Re-
Engineering Systems for Primary Care Treatment of Depression project,
known as RESPECT-Depression for short.
The components of the RESPECT approach of care are not unique but
rather the product of a wide range of recent research by many investigators
and institutions nationally and internationally. The essential components
include prepared primary care clinicians and practices, telephone care
management, and closer relationships between mental health and primary
care clinicians.
Professionals work together through these three components and provide
more systematic patient education, promotion of patient self-management,
and monitoring of suicide risk. Especially important is supporting
modification of the management plan if the patient’s symptoms are not
improving.
Starting in February 2002, we conducted a clinical trial of the RESPECT-
Approach. Five healthcare organizations in the United States - three large
medical groups and two health plans - and 60 of their affiliated practices
took part in the trial. Four hundred patients diagnosed with depression, in
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beginning or modifying treatment, were randomly assigned to either the
RESPECT- Depression Approach or to usual care.
Results: Sixty percent of patients responded to the RESPECT-Approach
within six months. Ninety percent rated their care as good or excellent.
Remission rates were up by almost 40% over usual care. Response rates
were up by nearly 30%, and patients who ranked their care as good or
excellent, was up over 20%.
Other studies have found benefits from enhanced care programs for
depression patients. However, many of the participating practices have
found that they can’t afford to continue these programs once the study is
over and the technical and financial support from the research team is
gone.
This study shows us how to better translate enhanced depression care from
the journal page to routine practice in the exam room. The RESPECT-
Approach relies on modest resources and the quality improvement
programs already available to many practices. The significance of all five
organizations participating in the trial has since taken steps to sustain and
expand their use of the approach.
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In the interest of helping more practices to adopt this approach, the
MacArthur Initiative is making the RESPECT- Depression materials
available at no cost. These materials can be downloaded from our Web
site, www.depression-primarycare.org. This is spelled out for you in the
press release.
Before I close, I think it’s important to note that the world today, as you
all know, is filled with uncertainty and anxiety. We know there are real
barriers such as perceived stigma to getting people the help they need to
deal with depression. This approach breaks down those barriers by using
the primary care clinician, the person in the front line of healthcare, to get
people the help they need. Doing this now is more important than ever.
At this point I’d like to call on Lieutenant Colonel Charles Engel, with the
Walter Reed Army Medical Center in the Uniform Services University, to
tell us about the development of a modified RESPECT model to help meet
the post-war needs of returning soldiers and their families.
C. Engel Thanks, Dr. Dietrich. As you may know, soldiers returning home from
war sometimes struggle with depression, posttraumatic stress disorder, and
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other mental health problems. They’re often reluctant or unable to seek
the care of a specialist. This was a central finding among troops returning
from Iraq and Afghanistan in a New England Journal of Medicine article
published in July of this year.
An approach based on the RESPECT-Depression model adapted for use in
military primary care holds enormous promise. The RESPECT model
could improve early access to needed services, improve the effectiveness
of those services, and reduce stigma by locating the care in a primary care
setting.
Deployment Health Clinical Center, whose mission it is to improve post-
deployment health care in the U.S. military, is actively working with the
RESPECT team to tailor a modified program that will help meet the
comprehensive post-war primary care needs of returning soldiers and their
families. We’re also planning a feasibility project at Fort Bragg, North
Carolina this fall.
A. Dietrich Thank you, doctor. I’d also like you to hear a few words from Laurie
Garduque, Director of Research for the Program of Human and
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Community Development at the MacArthur Foundation. She will tell us a
bit about why this work is so important.
L. Garduque Thank you, Dr. Dietrich, and good morning. The MacArthur Foundation
recognizes that mental health is critical to an individual’s healthy
development and well-being and central to his or her ability to function in
school, in the workplace, and in the community. Improving the quality of
depression treatment and primary care is important for several reasons that
extend beyond our concern for individuals and their families to the larger
society.
First, depression poses a major public health problem. Depressive
disorders affect 19 million American adults; about seven percent of the
population. One in five people will have an episode in their lifetime.
Twice as many women as men are affected, and for half of the individuals
depression will reoccur. Depressive disorders affect one in ten primary
care patients, and most people with depression seek care in primary care.
Depression exacts high personal and social cost. One of the more
prevalent forms of mental illness, depression accounts for over half of all
insurance claims. Effects include decreased functioning in everyday
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activities, impaired work performance, increased mortality when it co-
occurs with other medical conditions, and increased risk of suicide.
In the workplace, depression is associated with decreased productivity,
increased absenteeism, and increased disability. Yet, science has shown
there are cost-effective treatments. The challenge is to close the gap
between science and practice.
The Foundation asked Dr. Dietrich and his colleagues to accelerate
progress in closing the gap to develop a successful, replicable model of
clinical care that would be available and sustainable in community
healthcare settings and ready to take to scale nationally. Now we need to
get the word out that the approach represented by RESPECT is practical
and feasible in a variety of care settings, and that the tools are readily
available.
A. Dietrich Thank you very much, Dr. Garduque. I think we’re now ready to take
some questions.
Coordinator Your first question comes from Byron Spice from the Pittsburgh Post
Gazette. Your line is open.
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B. Spice Thank you. Dr. Dietrich, in this study you’re comparing the RESPECT
model to usual care. Was usual care standardized in some way or did this
vary depending on the provider?
A. Dietrich Usual care was not standardized. It was what the provider usually did
with a patient who was starting or changing their prescription dosage for
medication or was being referred to counseling. It is worth noting that to
participate in a study of this sort, the clinicians have to have a certain level
of confidence in their care, and they have to be willing to cooperate with
the rigors of informed consent and other things.
So we found that our usual care physicians probably perform better than
the national average in terms of providing services for depressive disorder.
But even though this was a high-performing group to begin with, the
RESPECT model was able to boost their outcomes in terms of patient
depression and to achieve superior results in terms of remission, response
to treatment, and patient satisfaction.
These physicians, for the most part, did rely on medications with some
proportion of patients getting counseling as well. They were clinicians
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who had been taught about informed consent and had reviewed for them
the criteria for diagnosing depression. But other than that there was no
standard approach that they were required to take.
B. Spice Is the effect with respect that they have more contact because of the
follow-up calls, or is the number of contacts the same as with usual care
but just different in kind?
A. Dietrich That’s a great question, and I can direct your attention to table three in the
paper and tell you some of the things that it reports. In particular, the
clinicians in the prepared practices that were part of the RESPECT model
were shown by independent evaluators to be more thorough about
evaluating suicide risk, to be more likely to hand the patients patient-
education material about depression, and to be more likely to promote
self-management on behalf of the patient; that is seeking active
opportunities for social contact, doing positive things like exercise and
watching their diet. So those were some of the things that were different
in terms of improved process of care for the clinicians that were working
within the RESPECT model.
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It’s also true that with the RESPECT model patients were much more
likely to get a series of follow-up contacts from the clinician. They had
both more follow-up visits over the three months following the index
visit—following the first visit. And they were also much, much more
likely to get a telephone support call. In this case these telephone support
calls were provided by this telephone care manager who was based within
each of the organizations and who was training to provide a supportive
call to patients.
B. Spice And the role of the psychiatrist, does the psychiatrist at some point step in
if necessary, if the patient is not improving?
A. Dietrich The psychiatrists functioned in several ways. They were in contact every
week through a formal supervision call with the care managers, reviewing
new cases and reviewing follow-up cases. For the most part they
supported the care managers in what they were doing and made sure that
they were following the protocol for care management.
In some cases, although a modest percentage, they had an observation that
they thought should be shared with the primary care clinician. This was
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typically either suggesting an increased dose of the medication or perhaps
a change in medication for patients that weren’t getting better.
In some cases this was conveyed through the care manager in a written
report, and in a few cases the psychiatrist reached out directly to the
primary care clinician and said, “Oh, I see, Dr. Jones, that you’re helping
Mrs. Smith. It looks to me like you might consider the following in terms
of a change in management. What do you think about that?” So the
primary care clinician was always in charge, but what the psychiatrist
brought to the table was supervision for the care management and an
informal resource for primary care clinicians to modify treatment to get a
remission.
B. Spice Thank you.
Coordinator At this time we’re showing no questions.
A. Dietrich Okay. Perhaps we’ll wait another minute or two to see if anybody comes
up with a question that might be appropriate for Dr. Garduque or Dr.
Engel. And I guess, if not, we’ll conclude the call.
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Coordinator At this time I do have a question again from Byron Spice from the
Pittsburgh Post Gazette. Your line is open.
B. Spice Hello again. Dr. Engel, you mentioned something about a trial this fall, I
think at Fort Bragg. Could you tell me more about that?
C. Engel This is a feasibility study. As you know, people who return from war
often develop challenges such as depression, post-traumatic stress
disorder, and other mental health conditions, and primary care is an ideal
place to de-stigmatize that care. They’re reluctant to seek specialty
services in many cases. This was highlighted in the New England Journal
paper published in the first of July.
A lot of the data that was collected in that research was collected in Fort
Bragg. This is a major place where troops are returning. So we’re
interested in looking to see whether a modified version of the RESPECT
model, applied to military primary care in a setting like Fort Bragg where
there’s a high rate of people returning from the war, whether we can
improve outcomes and improve access to services.
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There are a number of unique aspects of military health care, one of which
is that both patients and, in many cases, military providers are rotating in
and out at a higher rate than one would see in civilian primary care
practice. So we’re going forward cautiously.
Right now we’re developing materials to report the intervention that
describe the role of the care manager, the primary care doctor, and the
psychiatrist, the tools that are used to screen for the relevant disorders, and
we’re working with people at Fort Bragg to implement the feasibility
study. And the plan is, in October, that we would implement the
feasibility study at Fort Bragg.
A. Dietrich That’s a great question, Byron. I think the thing that’s important to keep
in mind is that this approach enables patients to obtain excellent
management for depression and other mental health services in primary
care. It enables primary care clinicians to provide it and it enables health
care organizations, even organizations like the Department of Defense in
the military to disseminate and support its use to benefit patients.
C. Engel I would also add, Dr. Dietrich, that I think that it’s the overall flexibility of
the RESPECT program model that makes it a fairly robust candidate to try
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in an unusual and high-pace primary care setting such as the military,
where troops are returning and going to war.
B. Spice Dr. Engel, do you know what percentage of the returning troops are
reporting symptoms of depression?
C. Engel In the paper that was published by Charles Hoge and colleagues in the
New England Journal of Medicine in July, what they found was that
troops returning from Iraq were reporting post-traumatic stress disorder at
about a rate of 17%, and that troops returning from Afghanistan were
reporting post-traumatic stress disorder at a rate of about 13%, a much
lower rate, so this is an important challenge for us.
Again, I think the RESPECT-Depression model has the potential to be
very adaptive and to improve the care of folks that we know will have
these kinds of challenges when they come back. So we’re very
enthusiastic about the use of the RESPECT model.
A. Dietrich Byron, if you have any trouble putting your hands on that Hoge article,
we’re happy to help, and I have to admit that article was an inspiration for
us in RESPECT in getting together with Dr. Engel’s center to see what we
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might do to address the problem that that study identifies so well, and we
think the RESPECT model does offer at least one solution.
B. Spice So you say, Dr. Dietrich, that all of the centers that were involved in this
trial are now implementing this program, or in the process of
implementing this program permanently?
A. Dietrich Yes. They’re sustaining it or, the term is often used, “reinventing” it to
move it out of a standard protocol that had to be similar across all five
organizations to go on and evolve it to fit the particular cultures of the
different organizations. But in all cases it relies on using a standard
monitoring tool, this questionnaire called the PHQ9, that can help
quantitatively assess the patient’s depression severity, and is sensitive to
change over time. It also involves follow-up calls and promotion of self-
management for patients, exercise and what have you, and the use of
patient education materials.
I think in all cases we see those elements continued. The particular way
that the care management follow-up phone calls are provided vary a little
bit across organizations and, actually, we would expect that. I think that
for a program like this to be maintained over the long haul, it needs to be
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modified. The rough edges need to be sanded to have them fit within the
organization. Although, I think that all the places so far have done very
well to maintain the essential elements that had been shown in other
research to make a difference in helping patients get a remission.
B. Spice Thank you.
Coordinator I do have a question from Darrel Regier from the American Psychiatric
Association. Your line is open.
D. Regier Thanks very much. I’m delighted to see the study coming out, and I think
one of the major questions that we would have is how this study and this
protocol might be different than what has been experienced with other
studies, like Juergen Unuetzer’s and the major study with the elderly
population and others in primary care, that actually will make it
sustainable over time, once the study is ended.
I heard the previous discussion about that, but it seems like, in each of
these places, the sites are going to have to maintain a care manager and the
use of the PHQ9 as the essential element. And I was wondering how you
saw the sites being able to deal with the financial issues and the
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organizational issues of sustaining that in the absence of the research
funding?
A. Dietrich Well, excellent question, Dr. Regier. I’ll take a first crack at that and then
I’ll see what Dr. Laurie Garduque would like to add. One of the unique
things about this RESPECT study, Dr. Regier, is that we tried to build,
within the quality improvement infrastructures of each of the five
organizations, the ability to sustain the project over time.
That is, we taught somebody within the quality improvement organization,
who was paid by the organization, to know how to train new clinicians
new practices in the RESPECT model, who knew how to train and support
new care managers when there was turnover, and who knew how to train
and support psychiatrists. So the skills to add new people and to maintain
it over time were purposely built in to the infrastructures of these
organizations.
The organizations that we’ve worked with, for the most part, already have
care management structures that are already dealing with conditions like
diabetes and congestive heart failure. In some of these cases there’s pretty
good data. At least the organizations have confidence that sustaining care
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management services saves money overall because it keeps people out of
the hospital, or keeps people out of trouble.
One of the ways that these organizations that we’re working with have
continued it has been to add the depression skills to these existing care
management programs so that for patients being followed already for
diabetes or congestive heart failure a depression screening and
management component gets added. And for patients that don’t suffer
from other conditions, there’s an infrastructure where the depression
support can get provided without creating something new. So that’s two
of the important things that are unique about this study.
Also the wonderful studies that had been done and recently reported, Dr.
Unuetzer’s study that you mentioned, Dr. Simon’s study, the studies of
Wells and Kayton and others, for the most part they involved more
intensive resources than we’re providing. For example, the Unuetzer
study that you mentioned, which was directed at an older population, had
built in the ability to get either low-cost or no-cost psychotherapy as part
of the plan.
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So, overall, I think that when you line them up those are much more
expensive projects to be able to sustain over time than the services of the
care manager providing a series of 10- to 20-minute calls to patients over
time than the services of an hour-a-week psychiatrist.
One of the studies that has the best economic analysis is the study of Dr.
Simon. He estimated that the cost of providing the kind of services that
we’re talking about here, in terms of telephone support, was on the order
of $80 a patient. Our own number-needed-to-treat studies—you’re
familiar with that concept—around the order of five or six patients need to
have the care manager services to get a remission, who otherwise wouldn’t
have gotten a remission.
So the organizations we’re working with have done the math and they’ve
concluded that supporting care management within their own resources is
feasible, appropriate, improves quality of care, improves patient
satisfaction, and improves clinician satisfaction. That’s not to say that this
is right for every organization at this time, but at least the five
organizations that we’ve worked with were able to sustain this project and
are disseminating it further. Laurie, would you like to add something?
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L. Garduque Let me just add to what Dr. Dietrich has said. It was actually part of the
challenge that the MacArthur Foundation posed for Dr. Dietrich and his
colleagues was to come up with a model that would be likely to be
replicated in a variety of different care settings, as well as in different
regions of the country. So the fact that it demonstrated effectiveness in
these five different healthcare settings in different regions is important in
terms of thinking about how it might spread and be replicated.
In addition, the model that RESPECT represents is not as discordant or
discrepant to what you see, as Dr. Dietrich suggested, to other models that
primary care practices use for managing other chronic conditions. So that
gap between science and practice isn’t as great to close with the
RESPECT model.
I think that’s often why we see it as a failure to sustain or maintain
innovative practices, because the infrastructure isn’t in place once the
research team departs. But it’s also an empirical question and the
foundation has provided funds to the initiative to follow the five
healthcare organizations and to see, in fact, if the take up is sustained and
maintained over time once the research team departs.
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A. Dietrich Dr. Regier, I hope we’re answering your question. I might add that in one
of our organizations, Intermountain Healthcare, there’s one care manager
who’s actually received her 1,000th referral since we started the study back
in 2002. So they’re clearly succeeding and maintaining it. And I think we
can help any of you who are interested in making contacts with some of
the organizations themselves, and clinicians, to find out from people on
the front lines how it can be maintained and how it can work.
D. Regier Yes, I think this is very responsive and I’m delighted that you’ve had the
focus on an intervention that will be sustainable over time. Certainly
integrating it into a care model for other chronic conditions like diabetes
and hypertension and heart disease and the like is an excellent model to
keep it from becoming just a separate effort that requires additional
staffing beyond what might be available.
I think that the major problem is probably disseminating it to the smaller
office practices that don’t have additional staff available and that don’t
already have a preexisting infrastructure of the type that your five
organizations had. But if, in fact, this model can be demonstrated to be
sustained, I think it will be a very nice contribution.
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A. Dietrich Well thank you, Dr. Regier. I also don’t mean to say that there aren’t
some changes in policy in the way healthcare financing is done that
wouldn’t be very helpful in improving depression care, for example, the
notion of primary care clinicians being informally able to consult with a
psychiatrist and have the psychiatrist get paid for it; I think there’s
excellent evidence that that’s justifiable and improves care. There’s no
mechanism to do that yet, as I’m aware.
Also, the notion of care management support calls. I think that, clearly,
just about all the studies that we’ve been talking about over the last few
minutes have included some component of care management and it really
makes a difference in patient outcomes and it would be justified to be able
to bill for it, and there’s no mechanism as of yet.
The issue that you raised, Dr. Regier, about the solo practices: We’re in
the midst of finalizing what I’m thinking of as kind of a do-it-yourself
manual for somebody in an independent practice that does not have the
support of a quality improvement project to institute at least a number of
the elements of the RESPECT model.
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A motivated clinician or practice now could go to our Web site, download
the clinician manual, and could probably implement a half or two thirds of
the RESPECT materials on their own if they wanted to take the time to go
through it.
And this do-it-yourself model that I’m talking about, we’re going to make
it more streamlined so that a clinician or a practice manager could pick up
the elements such as using PHQ9, having internal nursing staff make one
or two follow-up calls, using patient education materials, and have that be
something that clinicians who don’t have the benefit of a quality
improvement program could do it on their own.
D. Regier I would just add one other thing. At a time when there is such interest in
monitoring the use of antidepressant medications, that the use of an
instrument like the PHQ9 that has a specific mention of increases in
suicidal ideation or increased activation, that, in fact, if physicians were
using this kind of instrument on a routine basis they would be able to
address the safety issues that have been raised and will now be raised
again in the hearing at the FDA this coming week.
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A. Dietrich Indeed. Actually one of the more gratifying results that we got from the
independent evaluation offices that were not aware of the point of the
study, were not aware of people’s group assignments, is that patients cared
for in RESPECT projects were much, much more likely to indicate at
three and six months that they had been asked about suicide issues. And
that is an important thing that I think the RESPECT model provides, and
all of the data that we’re reading about, even in the paper over the last few
days, the importance of suicide and monitoring for suicide can’t be
overemphasized. So that’s a real strength of the program.
I think we have time for a few more questions, if there are any.
Coordinator I’m showing no questions at this time.
A. Dietrich Well, we’ve had luck with waiting another minute before we sign off.
Let’s do that again and see if there are any more questions that come to
mind as people either look at the materials in front of them or reflect on
the previous questions in the presentations.
Well I think maybe it’s time to conclude. So I wanted to thank all of you
for your interest and for your questions. We hope, by spreading the word
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about this trial and its related materials that are now available to clinicians,
medical groups, health plans, and employers, more patients will get the
care they need to lead happier, healthier lives.
Thanks again. Have a good day, and if we can help you further, as you
reflect on this call and look at the materials, please be in touch. Were you
going to say any final words, Jeanne?
J. Brennan No, I think we’re all set.
A. Dietrich Thank you very much, everybody, and goodbye for now.