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Biomedical subjects

P Roderick

Publications and source records attributed to P Roderick.

At least 19 recordsLinked to original sources
PubMed2003

The role of performance indicators in changing the autonomy of the general practice profession in the UK.

Performance indicators (PIs) are widely used across the UK public sector, but they have only recently been applied to clinical care. In doing so, they challenge a previously guarded aspect of clinical autonomy-the assessment of work performance. This "challenge" is specific to a primary care setting and in the general practice profession. This paper reviews the qualitative findings from an empirical study within one English primary care group on the response to a set of clinical PIs relating to general practitioners (GPs) in terms of the effect upon their clinical autonomy. Prior to interviews with GPs, primary care teams received feedback on their clinical performance as judged by indicators. Five themes were crucial in understanding GPs responses: the credibility of PIs, the growing need to demonstrate competence, perceptions of autonomy, the ulterior purpose of PIs, and the identity of the assessor of their performance. PIs are playing a key role in changing the locus of performance assessment along two dimensions: location and expertise. As the locus helps to determine the nature of clinical autonomy, it is likely to have implications for the nature of the general practice profession.

Adult↗
PubMed2003

Inequalities in survival from colorectal cancer: a comparison of the impact of deprivation, treatment, and host factors on observed and cause specific survival.

OBJECTIVE: To investigate whether socioeconomic deprivation is associated with cause specific and all cause survival for colorectal cancer and to what extent this is independent of significant prognostic factors. DESIGN: Prospective cohort. SETTING: The former Wessex Health Region, South West England. PARTICIPANTS: All patients resident in Wessex registered with a diagnosis of colorectal cancer over three years (n=5176). Survival analysis was carried out on those patients with compete data for all factors and a positive survival time (n=4419). OUTCOMES: Death from colorectal cancer and all cause over five year follow up from initial diagnosis. MAIN RESULTS: Deprivation was significantly associated with survival for both outcomes in univariate analysis; the unadjusted hazard ratio for dying from colorectal cancer (most deprived compared with most affluent) was 1.12 (95% CI 1.00 to 1.25) and for all cause was 1.18 (1.07 to 1.30). Significant prognostic factors for both outcomes were age, specialisation of surgeon, Dukes's stage, and emergency compared with elective surgery. Comorbidity and gender were only associated with all cause survival. After adjustment for prognostic factors, the effect of deprivation on both cause specific and all cause mortality was reduced, and it was non-significant for colorectal cancer. However, the most deprived group had consistently worse survival than the most affluent. CONCLUSIONS: Factors associated with survival with colorectal cancer depend on the outcome measure. Socioeconomic deprivation is adversely associated with survival in patients with colorectal cancer. This is strongest for non-colorectal cancer death, partly reflecting higher comorbidity, but it is there for colorectal cancer though not statistically significant. Conclusive evidence of the inequalities by socioeconomic status and underlying reasons needs to come from studies using individual based measures of socioeconomic status and more detail on treatment and host related factors.

Adult↗
PubMed2002

Increasing the sophistication of access measurement in a rural healthcare study.

This paper considers the problem of deriving realistic access measures between population demand and health service locations, in the context of a rural region of England. The paper reviews approaches used in earlier work by the authors and others, and considers new public transport information systems that are now becoming available. An application is presented which incorporates the modelling of both private and public transportation travel times for access to district general hospitals in Cornwall. This information has been assembled from published timetables in order to evaluate the use of more sophisticated access measures that might be used when such data becomes more generally available. The work is set within the context of an ongoing substantive research programme concerned with health outcomes in the rural South West of England.

England↗
PubMed2002

Renal services for people with diabetes in the UK.

Diabetic nephropathy is a serious complication of diabetes that can lead to endstage renal failure (ESRF). It is now the most common cause of ESRF in patients accepted onto renal replacement therapy (RRT) programmes in the UK. Rates of diabetic ESRF are more common in ethnic minority populations. The risk of developing diabetic ESRF is higher in Type 1 diabetes but in absolute terms more patients with Type 2 diabetes develop ESRF and are treated. There is still unmet need for RRT amongst patients with diabetes who develop ESRF. The shortage of organ donors, especially amongst ethnic minorities, means that dialysis is the mainstay of treatment in patients with diabetes and ESRF. This is now largely hospital haemodialysis with an increasing proportion being delivered in satellite units. Demand for RRT from patients with diabetes will increase due to demographic change and the increasing prevalence of diabetes, particularly Type 2, in the population. To meet this challenge closer liaison between those primarily caring for patients with diabetes (primary care physicians and diabetologists) and nephrologists is required to ensure effective surveillance of renal function, to increase early referral and to agree protocols of subsequent care. Continued expansion of high-quality RRT is needed that ensures equity of access with particular targeting in areas with large ethnic minority populations. A national priority must be an increase in the kidney transplant rate.

Continuity of Patient Care↗
PubMed2002

The evaluation of screening policies for diabetic retinopathy using simulation.

AIMS: To develop a model for evaluating screening strategies and to use it to determine the cost effectiveness of varying the screening method and the screening interval. METHODS: A discrete event simulation was designed, validated and run for a population of 500000. Most parameters were derived from peer-reviewed publications. RESULTS: Standard methods of screening save up to 50% of the potential sight years lost. They give up to 85% of the sight years saved by an idealized gold standard programme using mydriatic seven-field photography reported by an ophthalmologist. The mobile camera, used for annual screening and 6-month follow-up after the detection of background retinopathy, had an estimated cost of pound 449200 per year with pound 2842 per sight year saved. It is less efficient to screen Type 2, rather than Type 1 diabetes mellitus patients, but they contributed to almost three-quarters of the sight years saved. CONCLUSIONS: The model can evaluate screening intervals and methods on a national or health authority basis. Results indicate that it appears more cost effective to continue to screen outside an ophthalmology clinic, until treatment is needed. Programmes with annual screening, and more frequent screening for those with background retinopathy, are robust to realistic fluctuations in compliance and screening sensitivity.

Computer Simulation↗
PubMed2002

Late referral for dialysis: improving the management of chronic renal disease.

BACKGROUND: Timely nephrological referral of patients with chronic renal failure (CRF) is important, but referral at a late stage of disease is common. AIM: To investigate whether late referral of patients is avoidable, and where the missed opportunities lie. DESIGN: Prospective ascertainment of new cases and comprehensive review of pre-end stage history. METHODS: Patients admitted to Bristol and Portsmouth renal units for chronic RRT between June 1997 and May 1998 were identified from computer databases. Data were collected from case notes and hospital records, and a self-administered patient questionnaire. Late referral, defined as dialysis within 4 months of first referral to a dialysing nephrologist, was categorized by algorithm as unavoidable or avoidable. RESULTS: Of 250 patients, 96 (38%) were referred late. Forty-three (45%) had definite avoidable reasons: 35 (37%) with raised serum creatinine for a median 3.7 years (IQR 1.5-8.2) before referral, and eight (8%) with risk factors for renal disease but scant assessment of renal function; 12/43 (31%) had a diagnosis of diabetic nephropathy. Late referred patients were less likely to receive standard renal therapies for chronic renal failure, were in a poorer clinical state at start of RRT, and more often required emergency dialysis, compared to patients referred early. Late referrals were as likely from a hospital as a primary care physician. DISCUSSION: A significant proportion of patients are avoidably referred to a dialysing renal unit at a very late stage. Guidelines on referral should be developed by nephrologists, primary and secondary care physicians, and patient groups, and further research is needed into the cost-effectiveness of early referral strategies.

Algorithms↗
PubMed2002

Interrelations between three proxies of health care need at the small area level: an urban/rural comparison.

STUDY OBJECTIVE: To examine the relations between geographical variations in mortality, morbidity, and deprivation at the small area level in the south west of England and to assess whether these relations vary between urban and rural areas. DESIGN: A geographically based cross sectional study using 1991 census data on premature limiting long term illness (LLTI) and socioeconomic characteristics, and 1991-1996 data on all cause premature mortality. The interrelations between the three widely used proxies of health care need are examined using correlation coefficients and scatterplots. The distribution of standardised LLTI residuals from a regression analysis on mortality are mapped and compared with the distribution of urban and rural areas. Multilevel Poisson modelling investigates whether customised deprivation profiles improve upon a generic deprivation index in explaining the spatial variation in morbidity and mortality after controlling for age and sex. These relations are examined separately for urban, fringe, and rural areas. SETTING: Nine counties in the south west of England. PARTICIPANTS: Those aged between 0-64 who reported having a LLTI in the 1991 census, and those who died during 1991-1996 aged 0-74. MAIN RESULTS: Relations between both health outcomes and generic deprivation indices are stronger in urban than rural areas. The replacement of generic with customised indices is an improvement in all area types, especially for LLTI in rural areas. The relation between mortality and morbidity is stronger in urban than rural areas, with levels of LLTI appearing to be greater in rural areas than would be predicted from mortality rates. Despite the weak direct relations between mortality and morbidity, there are strong relations between the customised deprivation indices computed to predict these outcomes in all area types. CONCLUSIONS: The improvement of the customised deprivation indices over the generic indices, and the similarity between the mortality and morbidity customised indices within area types highlights the importance of modelling urban and rural areas separately. Stronger relations between mortality and morbidity have been revealed at the local authority level in previous research providing empirical evidence that the inadequacy of mortality as a proxy for morbidity becomes more marked at lower levels of aggregation, especially in rural areas. Higher levels of LLTI than expected in rural areas may reflect different perceptions or differing patterns of illness. The stronger relations between the three proxies in urban than rural areas suggests that the choice of indicator will have less impact in urban than rural areas and strengthens the argument to develop better measures of health care need in rural areas.

Adolescent↗
PubMed2001

Stroke rehabilitation after hospital discharge: a randomized trial comparing domiciliary and day-hospital care.

OBJECTIVES: To compare the effectiveness and costs of a new domiciliary rehabilitation service for elderly stroke patients with geriatric day-hospital care. DESIGN: Randomized controlled trial. PARTICIPANTS: Stroke patients aged 55+ who required further rehabilitation after hospital discharge or after referral to geriatricians from the community. SETTING: Poole area, East Dorset, a mixed urban/rural area on the south coast of England. MAIN OUTCOMES: Primary-changes between hospital discharge and 6-month follow-up in physical function as measured by Barthel index. Secondary-changes over this period in Rivermead Mobility Index and mental state (Philadelphia Geriatric Centre Morale Scale) and differences in social activity (Frenchay Activities Index) and generic health status (SF-36). Health service and social service cost per patient were compared for the two groups. RESULTS: 180 patients were eligible and 140 (78%) were randomized. The groups were well balanced for age, sex, social class and initial Barthel index. We achieved follow-up in 88% of subjects who were alive at 6 months. We detected no significant differences in patient outcomes, although there was a non-significant improvement in measures of physical function and social activity in the domiciliary group. Domiciliary patients had more physiotherapy time per session and more district nurse time, and made greater use of social service day centres and home helps. Total cost per patient did not differ significantly between the two groups, with reduced health service costs in the domiciliary arm offset by higher social service costs. CONCLUSION: No significant differences were detected in the effectiveness of the two services. Neither service influenced patients' mental state, and their social activity remained low. Total costs were similar. A mixed model of day-hospital and domiciliary care may be most cost-effective for community stroke rehabilitation, but this requires further evaluation.

Aged↗
PubMed2001

A systematic review of the staging performance of endoscopic ultrasound in gastro-oesophageal carcinoma.

BACKGROUND: Endoscopic ultrasound (EUS) may be used for preoperative staging of gastro-oesophageal carcinoma but performance values given in the literature differ. AIMS: To identify and synthesise findings from all articles on the performance of EUS in tumour, node, metastasis (TNM) staging of gastro-oesophageal carcinoma. SOURCE: Published and unpublished English language literature, 1981-1996. METHODS: Data on the staging performance of EUS were retrieved and evaluated. Summary receiver operator characteristic methodology was used for synthesis, and a summary estimate of performance, Q*, obtained. Multiple regression analysis was used to assess study validity and investigate reasons for differences in performance. RESULTS: Twenty seven primary articles were assessed in detail. Thirteen supplied results for staging oesophageal cancer, 13 for gastric cancer, and four for cancers at the gastro-oesophageal junction. For gastric T staging, Q*=0.93 (95% confidence interval (CI) 0.91-0.95) and for oesophageal T staging, Q*=0.89 (95% CI 0.88-0.92). For gastro-oesophageal T staging, including cancers at the gastro-oesophageal junction, Q*=0.91 (95% CI 0.89-0.93). Inclusion of cases with non-traversable stenosis was found to slightly reduce staging performance. For N staging, Q*=0.79 (95% CI 0.75-0.83). In articles that compared EUS directly with incremental computed tomography, EUS performed better. None of the variables assessed in the regression analysis was significant using a Bonferroni correction. Three variables (anatomical location, traversability, and blinding) showed strong relationships for future research and validation. CONCLUSIONS: EUS is highly effective for discrimination of stages T1 and T2 from stages T3 and T4 for primary gastro-oesophageal carcinomas. The failure rate of EUS from non-traversability of a stenotic cancer may be a limitation in some patient groups.

Confidence Intervals↗
PubMed2001

A multilevel analysis of the effects of rurality and social deprivation on premature limiting long term illness.

STUDY OBJECTIVE: To examine the geographical variation in self perceived morbidity in the south west of England, and assess the associations with rurality and social deprivation. DESIGN: A geographically based cross sectional study using 1991 census data on premature Limiting Long Term Illness (LLTI). The urban-rural and intra-rural variation in standardised premature LLTI ratios is described, and correlation and regression analyses explore how well this is explained by generic deprivation indices. Multilevel Poisson modelling investigates whether Customized Deprivation Profiles (CDPs) and area characteristics improve upon the generic indices. SETTING: Nine counties in the south west of England PARTICIPANTS: The population of the south west enumerated in the 1991 census. MAIN RESULTS: Intra-rural variation is apparent, with higher rates of premature LLTI in remoter areas. Together with high rates in urban areas and lower rates in the semi-rural areas this indicates the existence of a U shaped relation with rurality. The generic deprivation indices have strong positive relations with premature LLTI in urban areas, but these are a lot weaker in semi-rural and rural locations. CDPs improve upon the generic indices, especially in the rural settings. A substantial reduction in unexplained variation in rural areas is seen after controlling for the level of local isolation, with higher isolation, at the wider geographical scale, being related to higher levels of LLTI. CONCLUSIONS: This study highlights the need to treat rural areas as heterogeneous, although this has not been the tendency in health research. Generic deprivation indices are unlikely to be a true reflection of levels of deprivation in rural environments. The importance of CDPs that are specific to the area type and health outcome is emphasised. The significance of physical isolation suggests that accessibility to public and health services may be an important issue, and requires further research.

Adolescent↗
PubMed2000

Clinical outcomes, quality of life, and costs in the North Thames Dialysis Study of elderly people on dialysis: a prospective cohort study.

BACKGROUND: Evidence-based health policy is urgently needed to meet the increasing demand for health services among elderly people, particularly for expensive technologies such as renal-replacement therapy. Age has been used to ration dialysis, although not always explicitly, despite the lack of rigorous empirical evidence about how elderly people fare on dialysis. We undertook a comprehensive assessment of outcomes in patients 70 years or over. METHODS: We did a 12-month prospective cohort study of outcomes in 221 patients with end-stage renal failure aged 70 years or over recruited from four hospital-based renal units. We assessed 1-year survival in 125 incident patients (70-86 years) and disease burden (hospital admissions, quality of life, costs) in 174 prevalent patients (70-93 years). FINDINGS: 1-year survival rates were: 71% overall; 80%, 69%, and 54% in patients 70-74 years, 75-79 years, and 80 years and older, respectively (p=0.008); and 88%, 71%, and 64% in patients with no, one, or two or more comorbid conditions, respectively (p=0.056). Cox regression analyses showed that mortality was significantly associated with age 80 years and older (relative risk 2.79 [95% CI 1.28-6.93]) and peripheral vascular disease (2.83 [1.29-6.17]), but not with diabetes, ischaemic heart disease, cerebrovascular disease, chronic obstructive airways disease, sex, or treatment method. In terms of disease burden, hospital admissions represent a low proportion of costs and was not required by a third of patients, mental quality of life in elderly dialysis patients was similar to that of elderly people in the general population, and the average annual cost per patient of 20802 (US$31200) (68% dialysis treatment, 1% transport, 19% inpatient hospital admissions, 12% medications) was within the range of other life-extending interventions. INTERPRETATION: Our results suggest that age alone should not be used as a barrier to referral and treatment and emphasise the need to consider the benefits of dialysis in elderly people. Indicators of the ability to benefit from treatment, rather than chronological age, should be used to develop policies that ensure equal access to care for all.

Aged↗
PubMed2000

Incidence and outcome of pauci-immune rapidly progressive glomerulonephritis in Wessex, UK: a 10-year retrospective study.

BACKGROUND: The Wessex Renal Unit serves a large stable population (2.5 million). Pauci-immune rapidly progressive glomerulonephritis (RPGN) is a frequent cause of acute renal failure requiring admission to our unit ( approximately 8%). At a population level, little is known of the epidemiology and outcome of RPGN. METHODS: Between 1 April 1986 and 31 March 1996, 141 cases of biopsy proven pauci-immune RPGN were seen in the Wessex region. The records of 128 patients were reviewed. Median (range) follow-up was 1.8 (0.9-9.64) years from diagnosis. RESULTS: The incidence of 4 per million was stable throughout the period. No clustering was seen. The diagnosis was made (median, 25th, 75th centile) 78.5 (45, 166) days after symptom onset. Co-morbidity (mostly hypertension) was seen in 47% of patients. Other organs affected were lungs 63%, nose/sinuses 50%, joints 42%, muscle 33%, skin 22% and nervous system 14%. Anti-neutrophil cytoplasmic antibody (ANCA) was positive in 73%; cytoplasmic ANCA 34%, peri-nuclear ANCA 26% and undifferentiated 14%. Twenty-seven per cent tested ANCA negative. The differences between the groups were small; time to diagnosis was shorter in the ANCA negative (-ve) group (P=0.02) and there were more airway symptoms in the ANCA positive (+ve) group (P:<0.05). All biopsies demonstrated a necrotizing process; crescents were seen in 96% involving (mean+/-SD) 54+/-26% of the glomeruli. Creatinine concentration (mean+/-SD) at diagnosis was 806+/-540 micromol/l. Treatment followed established immunosuppressive regimens. Initial dialysis was required by 59%, 36% needing long-term dialysis. At 1 year 68% were alive. The need for dialysis (P=0.0004) and age (P=0. 004) were poor prognostic markers. Ten per cent were transplanted, graft survival was 90% at 1 year, no recurrence was seen. CONCLUSIONS: This study, looking at a large cohort, has established the incidence and outcome of ANCA +ve and ANCA -ve RPGN in a defined stable population. It stresses the similarities between ANCA +ve and ANCA -ve cases and supports the notion that pauci-immune RPGN is part of a continuum of vasculitic illness. In this series transplantation is a safe option.

Age Distribution↗
PubMed2000

Clinical governance in primary care groups: the feasibility of deriving evidence-based performance indicators.

OBJECTIVES: To test the feasibility of deriving comparative indicators in all the practices within a primary care group. DESIGN: A retrospective audit using practice computer systems and random note review. SETTING: A primary care group in southern England. SUBJECTS: All 18 general practices in a primary care group. MAIN OUTCOME MEASURES: Twenty six evidence-based process indicators including aspirin therapy in high risk patients, detection and control of hypertension, smoking cessation advice, treatment of heart failure, raised cholesterol levels in those with established cardiovascular disease, and the treatment of atrial fibrillation. Feasibility was tested by examining whether it was possible to derive these indicators in all the practices; the problems and constraints incurred when collecting data; the variations in indicator values between practices in both their identification of diseases and in the uptake of various interventions; the possible reasons for these variations; and the cost of generating such indicators. RESULTS: It was possible to derive eight indicators in all practices and in three practices all 26 indicators. The median number of indicators derived was 12 with two practices able to generate eight. There was considerable variation in the use of computers between practices and in the ability and ease of various practice computer systems to generate indicators. Practices varied greatly in the identification of diseases and in the uptake of effective interventions. Variation in identification of ischaemic heart disease could not be explained by a higher prevalence in practices with a more deprived population. The cost of generating these indicators was 5300 Pounds. CONCLUSION: Comparative evidence-based indicators, used as part of clinical governance in primary care groups, could have the potential to turn evidence into everyday practice, to improve the quality of patient care, and to have an impact on the population's health. However, to derive such indicators and to be able to make meaningful comparisons primary care groups need greater conformity and compatibility of computer systems, improved computer skills for practice staff, and appropriate funding.

Benchmarking↗
PubMed2000

Reactions to the use of evidence-based performance indicators in primary care: a qualitative study.

OBJECTIVES: To investigate reactions to the use of evidence-based cardiovascular and stroke performance indicators within one primary care group. DESIGN: Qualitative analysis of semi-structured interviews. SETTING: Fifteen practices from a primary care group in southern England. PARTICIPANTS: Fifty two primary health care professionals including 29 general practitioners, 11 practice managers, and 12 practice nurses. MAIN OUTCOME MEASURES: Participants' perceptions towards and actions made in response to these indicators. The barriers and facilitators in using these indicators to change practice. RESULTS: Barriers to the use of the indicators were their data quality and their technical specifications, including definitions of diseases such as heart failure and the threshold for interventions such as blood pressure control. Nevertheless, the indicators were sufficiently credible to prompt most of those in primary care teams to reflect on some aspect of their performance. The most common response was to improve data quality through increased or improved accuracy of recording. There was a lack of a coordinated team approach to decision making. Primary care teams placed little importance on the potential for performance indicators to identify and address inequalities in services between practices. The most common barrier to change was a lack of time and resources to act upon indicators. CONCLUSION: For the effective implementation of national performance indicators there are many barriers to overcome at individual, practice, and primary care group levels. Additional training and resources are required for improvements in data quality and collection, further education of all members of primary care teams, and measures to foster organisational development within practices. Unless these barriers are addressed, performance indicators could initially increase apparent variation between practices.

Adult↗
PubMed1999

The impact of stroke on informal carers: a literature review.

Stroke incidence is set to rise in Western societies as population projections predict an increase in the proportion of older people. Most of these stroke survivors are supported by close kin members who play an important role in the rehabilitation and care of this group. The objective of this review was to establish the following: (a) to evaluate the impact of the stroke on the informal carers' quality of life, (b) to identify factors which help carers to cope with their caring role, (c) to evaluate health service provision for stroke carers. A systematic literature search using BIDS-EMBASE, MEDLINE and PSYCHLIT, identified 31 relevant studies. These showed that most studies concentrated on carers' psychological health and the negative impact that the stroke had. Carers ability to cope with the stroke was enhanced both by the use of positive coping strategies and more concrete measures e.g. more stroke information. Furthermore, whilst most carers were generally satisfied with health services, the few interventions directed at improving carer outcomes showed mixed results. The studies reviewed had many limitations; few gave definitions of 'informal' carer and there was a predominant use of cross-sectional studies and non-standardised outcome measures. Future studies should broaden their research question to evaluate quality of life, using standardised measures to do this and employing either a longitudinal or randomised control design to improve the robustness of results. More studies are also needed evaluating the effectiveness of health services on carers' quality of life.

Adaptation, Psychological↗
PubMed1999

Investigation of under-ascertainment in epidemiological studies based in general practice.

BACKGROUND: One of the aims of the Study of Infectious Intestinal Disease (IID) in England is to estimate the incidence of IID presenting to general practice. This sub-study aims to estimate and correct the degree of under-ascertainment in the national study. METHODS: Cases of presumed IID which presented to general practice in the national study had been ascertained by their GP. In 26 general practices, cases with computerized diagnoses suggestive of IID were identified retrospectively. Cases which fulfilled the case definition of IID and should have been ascertained to the coordinating centre but were not, represented the under-ascertainment. Logistic regression modelling was used to identify independent factors which influenced under-ascertainment. RESULTS: The records of 2021 patients were examined, 1514 were eligible and should have been ascertained but only 974 (64%) were. There was variation in ascertainment between the practices (30% to 93%). Patient-related factors independently associated with ascertainment were: i) vomiting only as opposed to diarrhoea with and without vomiting (OR 0.37) and ii) consultation in the surgery as opposed to at home (OR 2.18). Practice-related factors independently associated with ascertainment were: i) participation in the enumeration study component (OR 1.78), ii) a larger number of partners (OR 0.3 for 7-8 partners); iii) rural location (OR 2.27) and iv) previous research experience (OR 1.92). Predicted ascertainment percentages were calculated according to practice characteristics. CONCLUSION: Under-ascertainment of IID was substantial (36%) and non-random and had to be corrected. Practice characteristics influencing variation in ascertainment were identified and a multivariate model developed to identify adjustment factors which could be applied to individual practices. Researchers need to be aware of factors which influence ascertainment in acute epidemiological studies based in general practice.

Adolescent↗