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6 months ago

The Impact of Personalised Healthcare on Traditional MedTechs

HealthPad
Directory:
Medical Technology
Tags:
commentary
DNA sequencing
MedTech
personalised medicine
personalised treatment strategy
targeted therapies
  • Healthcare is shifting from uniform treatments to personalised care, driven by genetics, lifestyle, and technology
  • Patients benefit from targeted therapies that deliver early disease detection, enhanced therapies and proactive prevention
  • Traditional MedTechs, accustomed to one-size-fits-all devices, face challenges but also can find opportunities from individualised care for growth and innovation
  • To capitalise on these opportunities, conventional corporations must recalibrate their strategies and collaborate with start-ups and healthcare institutions
 
The Impact of Personalised Healthcare on Traditional MedTechs

Personalised medicine, also known as precision medicine, marks a departure from traditional medical practices by acknowledging the interplay of genetics, lifestyle, and environment in shaping an individual's health. Rather than adhering to one-size-fits-all treatments, individualised care prioritises early detection and proactive prevention, tailoring interventions based on each patient's unique genetic makeup. Digitalisation, together with advances in medical technology, enables the combination and analysis of genomic information with other diagnostic data to identify patterns that help to determine an individual’s risk of developing a disease, detect illness earlier, and determine the most effective interventions. For example, in cancer treatment, personalised therapies target specific proteins driving cancer growth, offering more effective alternatives to conventional methods like customary chemotherapy. Findings of a 2012 study published in Trends in Molecular Medicine found that the response rate to a targeted therapy for acute myeloid leukaemia to be at 90% compared with 35% for standard chemotherapy. Another notable development in customised care is the DNA medication pass, which enables clinicians to identify the most suitable drugs for individual patients, reducing adverse reactions and hospital admissions due to drug-related complications. Such personalised approaches empower patients with treatments aligned to their genetic predispositions and foster greater autonomy and engagement in healthcare decisions.

In today's data-driven environment, the emphasis on precision care is growing, and creating a shift in healthcare delivery. A recent research paper published in the Journal of Translational Medicine suggests that personalised medicine will lead to the next generation of healthcare by 2030. While many traditional medical technology companies are content with supplying standardised medical devices to hospitals, an increasing number wish to pivot and capitalise on the rapidly growing targeted healthcare segment. However, they face the challenge of adapting their established frameworks, which are not designed to create bespoke solutions and services. This emphasises the significance of adaptability across diverse healthcare settings. Forward-thinking corporations, however, recognise the need to evolve. By investing in novel R&D initiatives and fostering collaboration throughout the healthcare spectrum, they position themselves favourably. Conversely, companies resistant to change risk stagnation and eventual obsolescence in an era where personalised care is rapidly gaining traction.
 
In this Commentary

This Commentary delves into the impact of personalised healthcare on traditional MedTech companies, highlighting the imperative for alignment with customised care to remain competitive. It explores how targeted medicine, driven by advancements in genetics, digitalisation, and medical technology, is reshaping healthcare delivery by prioritising individualised treatments tailored to patients' unique genetic makeup. The Commentary emphasises the need to adapt conventional strategies amidst industry trends, addressing challenges such as regulatory complexities and technology adoption barriers. Through initiatives like partnerships, novel R&D, diversification, and strategic M&A, traditional MedTechs can position themselves to lead in the era of precision care. The Commentary offers examples of start-ups and established firms addressing this segment, insights into the opportunities and challenges traditional companies face in adapting to the growing emphasis on personalised healthcare, and emphasises the importance of innovation, collaboration, and proactive responses to industry shifts.
 
Brief History

The roots of personalised healthcare can be traced back to ancient civilisations where healers recognised individual differences in response to treatments. However, formalised concepts began to emerge in the late 19th and early 20th centuries with the advent of modern medicine. The discovery of the structure of DNA by James Watson and Francis Crick in 1953 laid the foundation for understanding the role of genetics in health and disease. Advances in DNA sequencing technologies in the late 20th century, particularly the completion of the Human Genome Project in 2003, enabled scientists to decipher the entire human genetic code, ushering in the genomic era.
 
In the late 20th century, researchers began to explore how genetic variations influence an individual's response to drugs. Pharmacogenomics emerged as a field focused on tailoring drug treatments to a person's genetic makeup, aiming to maximise efficacy and minimise adverse effects. Rapid advancements in technology, such as next-generation sequencing and high-throughput screening, have made it more feasible and cost-effective to analyse large amounts of genetic data. This has accelerated research in tailored therapies and expanded their application beyond pharmacogenomics to include risk assessment, disease diagnosis, and treatment selection.
As we suggested, one of the earliest and most successful applications of customised healthcare has been in oncology. Precision oncology uses genomic profiling to identify genetic mutations driving cancer growth and matches patients with targeted therapies designed to address their specific mutations. The success stories in treating certain cancers, such as leukaemia and melanoma have fuelled further interest and investment in personalised approaches.
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The rise of big data analytics and artificial intelligence (AI) has been instrumental in advancing targeted care. By integrating genetic, clinical, lifestyle, and environmental data, AI algorithms can identify patterns, predict disease risks, and recommend precise interventions targeted to an individual’s unique profile. Governments have recognised the potential of these approaches to improve patient outcomes and reduce healthcare costs. Endeavours such as the Precision Medicine Initiative in the US, the NHS Long Term Plan in the UK, and similar efforts in other countries aim to accelerate the adoption of customised medicine. As technology continues to evolve and our understanding of genetics and biology deepens, personalised healthcare is poised to become increasingly integral to mainstream medical practice, ultimately leading to better health outcomes.
 
Challenges and Barriers to Personalised Care

Customised medicine, while promising, faces challenges. One hurdle lies in the complexity and sheer volume of data required to tailor treatments to individual patients. Integrating diverse datasets from genomics, medical history, lifestyle factors, and environmental influences demands sophisticated analytics and robust privacy safeguards. Additionally, interoperability issues between different healthcare systems impede data exchange and collaboration among healthcare providers. Economic constraints further obstruct widespread adoption, as customised therapies often come with hefty price tags, limiting access for many patients. Regulatory frameworks must also evolve to accommodate the dynamic nature of tailored medicine, ensuring rigorous oversight without stifling innovation. Moreover, educating healthcare professionals and patients about the benefits and limitations of personalised approaches is essential for fostering trust and acceptance. Overcoming these challenges demands interdisciplinary collaboration, technological advancements, and a commitment to equitable access to focussed healthcare.
 
The Changing Landscape of Traditional MedTechs

Despite these challenges, the growing emphasis on personalised care represents a shift in traditional MedTech markets. Although the precise timeline for tailored therapies to substantially influence conventional corporations remains uncertain, the trend signals a clear direction for the industry. The International Consortium for Personalised Medicine (ICPerMed) envisions a healthcare landscape firmly rooted in customised medicine principles by 2030. This vision entails an ecosystem where individual characteristics inform diagnostics, treatments, and preventive measures, resulting in heightened effectiveness and economic value, all while ensuring equitable access for all individuals.
 
Historically, MedTech markets have exhibited a degree of reluctance in adopting new technologies, offering some comfort to conventional leaders in the field. However, the insights provided by the ICPerMed research should serve as a catalyst for traditional enterprises to re-evaluate their strategies and product offerings if they intend to capitalise on the growing trend of customised care. Notably, investments in innovative technologies that facilitate precision diagnostics, targeted therapies, and patient-centric interventions have already proven effective and are on the rise.
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Furthermore, the integration of data analytics and remote monitoring capabilities is reshaping the dynamics among medical devices, patients, and healthcare providers. This integration fosters enhanced connectivity and delivers real-time insights, thereby helping to transform the healthcare ecosystem. As tailored care gains momentum, traditional corporations must embrace agility, collaboration, and an understanding of patient preferences to thrive. This necessitates a proactive re-evaluation of their strategies.
Healthcare Firms Leading the Shift Towards Personalised Care

Many early-stage MedTech companies and established healthcare firms are leveraging evolving technologies and data to meet the growing demand for personalised healthcare. Omada Health, for instance, offers a platform combining connected devices and data analytics to help manage chronic conditions through tailored lifestyle interventions. iRhythm Technologies' Zio patch, a wearable cardiac monitor, uses advanced algorithms to detect heart conditions more accurately. Butterfly Network's Butterfly iQ is the first smartphone-connected whole-body ultrasound system, enhancing imaging quality and diagnostic capabilities through AI. Mature enterprises like AliveCor and Fitbit, now part of Google, have also pivoted to tailored healthcare. AliveCor’s  KardiaMobile provides at-home ECGs and shares data for customised treatment plans, while Fitbit offers devices with advanced health monitoring features and personalised wellness programmes. Dexcom's G6 CGM System provides real-time glucose tracking integrated with health data platforms. Roche has shifted towards customised healthcare with digital health solutions like the Roche Diabetes Care platform and the NAVIFY Tumor Board for personalised cancer treatments. 23andMe, initially known for genetic testing, now partners with pharmaceutical companies for drug discovery and develops tailored treatment plans based on genetic data.
 
Transforming MedTech in the Era of Personalised Care

The healthcare industry is undergoing a transformation marked by a shift towards patient-centric care and the adoption of value-based healthcare models. This shift is driving increased collaboration among traditional MedTech firms, healthcare providers, and emerging players, all united in their goal to innovate and tackle the complex challenges facing healthcare today. Regulatory changes and technological advancements also are playing roles in reshaping the competitive landscape, guiding the industry towards more patient-centred, value-driven, and collaborative approaches. In response to these evolving dynamics, MedTech companies are transforming their product development strategies by embracing agile and interdisciplinary approaches. Leveraging digital technologies, they are adapting to changing demands through virtual testing, data-driven design optimisation, and rapid prototyping.
 
The move towards personalised care is not only transforming product development strategies but also reshaping business models within the MedTech industry. There is a growing emphasis on outcome-based pricing and service-oriented solutions, reflecting the industry's focus on delivering measurable results and comprehensive care experiences. Digital health platforms and software-as-a-service (SaaS) offerings are emerging as key drivers of revenue, highlighting the importance of innovation and customer engagement in staying competitive and relevant.
 
Amid these transformations, regulatory and compliance considerations are crucial. Regulatory frameworks are becoming more stringent, emphasising product safety, efficacy, and data privacy. Compliance with varying standards across geographies is essential for market access, requiring companies to navigate these landscapes skilfully to sustain growth. Regulatory bodies are also evolving to tackle emerging challenges like cybersecurity and interoperability, highlighting the need for effective regulatory management in today's MedTech ecosystem. Addressing these challenges demands collaboration among stakeholders to build trust, promote standards, and ease the adoption of innovative technologies. Only through concerted efforts can the industry overcome these obstacles and fully realise the potential of customised care in transforming healthcare delivery.
 
Adaptation Strategies for Traditional MedTech Companies

To strengthen their alignment with personalised healthcare, traditional MedTechs can adopt several strategies. One effective approach, which, in a previous Commentary, we referred to as the Third Way, involves forming partnerships and collaborations with start-ups, research institutions, or other industry players. Through these partnerships, corporations can gain access to novel technologies, broaden their market reach, and expedite the pace of innovation. Additionally, diversification emerges as another adaptation strategy, enabling companies to venture into adjacent markets or therapeutic areas. This not only helps in mitigating risks but also enables them to capitalise on emerging opportunities within the healthcare landscape. Furthermore, many traditional corporations opt for M&A to bolster their market position, acquire specialised capabilities, or tap into new customer segments. Collectively, these strategies empower traditional corporations to navigate industry transitions towards customised care, foster sustained growth, and uphold their competitive edge.
 
Takeaways
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This Commentary highlights the need for companies to re-evaluate their strategies in response to the industry's shift toward personalised care, a force shaping the future of healthcare delivery. It suggests traditional enterprises should proactively address challenges such as regulatory compliance, data security, and technological adoption barriers. Yet, within these challenges lie significant opportunities for growth and innovation. By pursuing strategic partnerships, investing in R&D, diversifying, and engaging in M&A, corporations can lead in the era of customised care, influencing healthcare's trajectory. Despite obstacles, the outlook for traditional enterprises is promising, driven by technological advancements and global healthcare demands. Success, however, depends on their agility, resilience, and proactive adaptation to the evolving landscape. By leveraging innovation and fostering collaboration, traditional MedTechs can navigate complexity and continue to drive positive transformation within the industry.
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7 years ago

Why Blockchain technology will not disrupt healthcare

HealthPad
Directory:
Health Policy
Tags:
big data
bitcoin
commentary
diagnostic strategies
electronic health records
electronic patients records
interoperability
patients data
personalised treatment strategy
  • Everyone connected with healthcare supports interoperability saying it improves care, reduces medical errors and lowers costs
  • But interoperability is a long way from reality and electronic patient records are only part of an answer
  • Could Blockchain a technology disrupting financial systems resolve interoperability in healthcare?
  • Blockchain is an open-source decentralized “accounting” platform that underpins crypto currencies
  • Blockchain does not require any central data hubs, which in healthcare have been shown to be easily breached
  • Blockchain technology creates a virtual digital ledger that could automatically record every interaction with patient data in a cryptographically verifiable manner
  • Some experts believe that Blockchain could improve diagnosis, enhance personalised therapies, and prevent highly prevalent devastating and costly diseases
  • Why aren’t healthcare leaders pursuing Blockchain with vigour?
 
Why Blockchain technology will not disrupt healthcare

Blockchain technology is disrupting financial systems by enhancing the reconciliation of global transactions and creating an immutable audit trail, which significantly enhances the ability to track information at lower costs, while protecting confidentiality. Could Blockchain do something similar for healthcare and resolve the challenges of interoperability by providing an inexpensive and enhanced means to immutably track, store, and protect a variety of patient data from multiple sources, while giving different levels of access to health professionals and the public?
 
Blockchain and crypto currencies

You might not have heard of Blockchain, but probably you have heard of bitcoin; an intangible or crypto currency, which was created in 2008 when a programmer called Satoshi Nakamoto (a pseudonym) described bitcoin’s design in a paper posted to a cryptography e-mail list. Then in early 2009 Nakamoto released Blockchain: an open source, global decentralized accounting ledger, which underpins bitcoin by executing and immutably recording transactions without the need of a middleman. Instead of a centrally managed database, copies of the cryptographic balance book are spread across a network and automatically updated as transactions take place. Bitcoin gave rise to other crypto-currencies. Crypto currencies only exist as transactions and balances recorded on a public ledger in the cloud, and verified by a distributed group of computers.
 
Broad support for interoperability
 
Just about everyone connected with healthcare - clinicians, providers, payers, patients and policy makers - support interoperability, suggesting data must flow rapidly, easily and flawlessly through healthcare ecosystems to reduce medical errors, improve diagnosis, enhance patient care, and lower costs. Despite such overwhelming support, interoperability is a long way from a reality. As a result, health providers spend too much time calling other providers about patient information, emailing images and records, and attempting to coordinate care efforts across disjointed and disconnected healthcare systems. This is a significant drain on valuable human resources, which could be more effectively spent with patients or used to remotely monitor patients’ conditions. Blockchain may provide a solution to challenges of interoperability in healthcare.
 
Electronic patient records do not resolve interoperability

A common misconception is that electronic patient records (EPR) resolve interoperability. They do not. EPRs were created to coordinate patient care inside healthcare settings by replacing paper records and filing cabinets. EPRs were not designed as open systems, which can easily collect, amalgamate and monitor a range of medical, genetic and personal information from multiple sources. To realize the full potential and promise of interoperability EPRs need to be easily accessible digitally, and in addition, have the capability to collect and manage remotely generated patient healthcare data as well as pharmacy and prescription information; family-health histories; genomic information and clinical-study data. To make this a reality existing data management conventions need to be significantly enhanced, and this is where Blockchain could help.

 

Blockchain will become a standard technology
 
Think of a bitcoin, or any other crypto currency, as a block capable of storing data. Each block can be subdivided countless times to create subsections. Thus, it is easy to see that a block may serve as a directory for a healthcare provider. Data recorded on a block can be public, but are encrypted and stored across a network. All data are immutable except for additions. Because of these and other capabilities, it seems reasonable to assume that Blockchain may become a standard technology over the next decade.
 
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Blockchain and healthcare

Because crypto currencies are unregulated and sometimes used for money laundering, they are perceived as “shadowy”. However, this should not be a reason for not considering Blockchain technology. 30 corporations, including J.P. Morgan and Microsoft, are uniting to develop decentralized computing networks based on Blockchain technology. Further crypto currencies are approaching the mainstream,  and within the financial sector, there is significant and growing interests in Blockchain technology to improve interoperability. Financial services and healthcare have similar interoperability challenges, but health providers appear reluctant to contemplate fundamental re-design of EPRs; despite the fact that there is a critical need for innovation as genomic data and personalized targeted therapies rise in significance and require advanced data management capabilities. Here are 2 brief examples, which describe how Blockchain is being used in financial services.
 
Blockchain’s use in financial services
 
In October 2017, the State Bank of India (SBI) announced its intention to implement Blockchain technology to improve the efficiency, transparency, security and confidentiality of its transactions while reducing costs. In November 2017, the SBI’s Blockchain partner, Primechain Technologies suggested that the key benefits of Blockchain for banks include, “Greatly improved security, reduced infrastructure cost, greater transparency, auditability and real-time automated settlements.”
 
Dubai, a global city in the United Arab Emirates, is preparing to introduce emCash as a crypto currency, and could become the world’s first Blockchain government by 2020. The changes Dubai is implementing eventually will lead to the end of traditional banking. Driving the transformation is Nasser Saidi, chief economists of the Dubai International Financial Centre, a former vice-governor of the Bank of Lebanon and a former economics and industry minister of that country. Saidi perceives the benefits of Blockchain to include the phasing out of costly traditional infrastructure services such as accounting and auditing.
 
Significant data challenges

Returning to healthcare, there are specific challenges facing interoperability, which include: (i) how to ensure patient records remain secure and are not lost or corrupted given that so many people are involved in the healthcare process for a single patient, and communication gaps and data-sharing issues are pervasive, and (ii) how can health providers effectively amalgamate and monitor genetic, clinical and personal data from a variety of sources, which are required to improve diagnosis, enhance treatments and reduce the burden of devastating and costly diseases. 
 
Vulnerability of patient data

Not only do EPRs fail to resolve these two basic challenges of interoperability they are vulnerable to cybercriminals. Recently there has been an epidemic of computer hackers stealing EPRs. In June 2016 a hacker claimed to have obtained more than 10m health records, and was alleged to be selling them on the dark web. Also in 2016 in the US there were hundreds of breaches involving millions of EPRs, which were reported to the Department of Health and Human Services. The hacking of 2 American health insurers alone, Anthem and Premera Blue Cross, affected some 90m EPRs.
 
In the UK, patient data and NHS England’s computers are no less secure. On 12 May 2017, a relatively unsophisticated ransomware called WannaCry, infected NHS computers and affected the health service’s ability to provide care to patients. In October 2017, the National Audit Office (NAO) published a report on the impact of WannaCry, which found that 19,500 medical appointments were cancelled, computers at 600 primary care offices were locked and five hospitals had to divert ambulances elsewhere. Amyas Morse, head of the NAO suggests that, “The NHS needs to get their act together to ensure the NHS is better protected against future attacks.”
 
Healthcare legacy systems
 
Despite the potential benefits of Blockchain to healthcare, providers have not worked out fully how to move on from their legacy systems and employ innovative digital technologies with sufficient vigour to effectively enhance the overall quality of care while reducing costs. Instead they tinker at the edges of technologies, and fail to learn from best practices in adjacent industries.  
 
“Doctors and the medical community are the biggest deterrent for change”
 
Devi Shetty, heart surgeon, founder, and Chairperson of Narayana Health articulates this failure: “Doctors and the medical community are the biggest deterrent for the penetration of innovative IT systems in healthcare to improve patient care . . . IT has penetrated every industry in the world with the exception of healthcare. The only IT in patient care is software built into medical devices, which doctors can’t stop. Elsewhere there is a dearth of innovative IT systems to enhance care,” see video. Notwithstanding, Shetty believes that, “The future of healthcare is not going to be an extension of the past. The next big thing in healthcare is not going to be a new drug, a new medical device or a new operation. It is going to be IT.”
 
 
Google, Blockchain and healthcare
 
Previous HealthPad Commentaries have suggested that the failure of healthcare providers to fully embrace innovative technologies, especially those associated with patient data, has created an opportunity for giant technology companies to enter the healthcare sector, which shall dis-intermediate healthcare professionals.

In May 2017, Google announced that its AI-powered subsidiary, DeepMind Health, intends to develop the “Verifiable Data Audit”, which uses Blockchain technology to create a digital ledger, which automatically records every interaction with patient data in a cryptographically verifiable manner. This is expected to significantly reduce medical errors since any change or access to the patient data is visible, and both healthcare providers and patients would be able to securely track personal health records in real-time.
 
Takeaways

Blockchain is a new innovative and powerful technology that could play a significant role in overcoming the challenges of interoperability in healthcare, which would significantly help to enhance the quality of care, improve diagnosis, reduce costs and prevent devastating diseases. However, even if Blockchain were the perfect technological solution, which enabled interoperability, change would not happen in the short term. As Max Planck said, “A new scientific innovation does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.” While we wait for those who control our healthcare systems to die, billions of people will continue to suffer from preventable lifetime diseases, healthcare costs will escalate, healthcare systems will go bankrupt, and productivity in the general economy will fall.
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7 years, 1 month ago

Why are combined rheumatology- dermatology clinics important for people with psoriasis and PsA?

Bruce Kirkham
Directory:
Rheumatology
Tags:
doctor-patient relationship
medical treatement
patients' outcomes
personalised treatment strategy
PsA
psoriasis
psoriatic arthritis
skin disease
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7 years, 1 month ago

When are steroid injections used in the management of PsA?

Ellie Korendowych
Directory:
Rheumatology
Tags:
joint damage
joint inflammation
personalised treatment strategy
PsA
psoriatic arthritis
steroid injections
steroid medications
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7 years, 1 month ago

How do you measure treatment response for PsA?

Ellie Korendowych
Directory:
Rheumatology
Tags:
doctor-patient relationship
individual response
patients' outcomes
personalised treatment strategy
PsA
psoriatic arthritis
treatment response
treat to target treatment
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7 years, 1 month ago

Patient surveys suggest that a large proportion of patients are dissatisfied with their psoriasis and PsA medications. Why is this?

Laura Coates
Directory:
Rheumatology
Tags:
arthritis
injectable medications
oral medications
patients' voices
personalised treatment strategy
PsA
psoriatic arthritis
risk/benefit drug assessment
side effects
topical medications
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7 years, 1 month ago

What are the challenges of developing personalised therapies for people with PsA?

Laura Coates
Directory:
Rheumatology
Tags:
arthritis
clinical studies
lack of data
personalised treatment strategy
PsA
psoriasis
psoriatic arthritis
targeted therapy
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8 years, 2 months ago

Principal diseases that implantable drug-eluting devices are used for

Thomas Chen
Directory:
Medical Technology
Tags:
biosensor technology
breast cancer
cancer treatment
central nervous system
central nervous system diseases
drug-eluting device
pancreatic cancer
personalised treatment strategy
sensing technology
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joined 10 years, 7 months ago

EUTROC

European Translational Research network in Ovarian Cancer
Directory:
Cancer
Expertise:
cancer network
cancer research
clinical trials
diagnostic strategies
education and conferences
ovarian cancer
personalised treatment strategy
standardised protocols
Translational research
translational studies

EUTROC (European Translational Research network in Ovarian Cancer) is a European cancer network addressing the fragmentation currently hindering translational research for cutting edge therapies in ovarian cancer.

It will strengthen European excellence in the diagnosis and treatment of OC.

The need to bring promising drug candidates and treatments into clinical settings is currently delayed by the lack of standardised protocols for preclinical animal studies, lack of suitable ovarian cancer models, lack of validated predictive biomarker diagnostics, and integrated appropriate management of translational research partners (including pharma and biotech companies).

Developing effective diagnostic and treatment strategies require structured joint efforts of experts on tumor immunology, epigenetics, pathology, bioinformatics, drug development and delivery, trial development, clinical oncology and gynecological oncology.

Leading European researchers and clinicians together with the pharmaceutical industry and biotech companies will focus on preclinical and clinical studies in ovarian cancer. Therefore new targets will be identified, validated and translated to new drugs and brought to clinical practice. Standardisation and harmonisation of laboratory practices and good clinical practice procedures will BE performed within the consortium.

The consortium combines expertise in clinical as well as preclinical research. Involved researchers are coordinating a number of investigator-initiated Phase I, II trials.The Network will build a platform for research and strong educational programs for the next generation of experts aimed at developing individualised patients benefit.


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11 years ago

How should the palliative care team personalise a treatment strategy?

Whitfield Growdon
Directory:
Palliative Care
Tags:
palliative care doctors
personalised treatment strategy
quality of life
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