The Health Diary Telemonitoring and Hospital-Based Home Care Improve Quality of Life Among Elderly Multimorbid COPD and Chronic Heart Failure Subjects

Figures & data

Table 1 Subject Characteristics

	All (n = 94)	CHF (n = 58)	COPD (n = 36)	P-value CHF vs COPD
Age	80 ± 8 (65–100)	83 ± 7 (65–100)	75 ± 6 (65–86)	<0.001
Women, n (%)	51 (54)	29 (50)	22 (61)	n.s.
Current smokers, n (%)	12 (13)	2 (3)	10 (29)	<0.001
Ex-smokers, n (%)	56 (60)	31 (54)	25 (71)
Never smokers, n (%)	25 (27)	25 (43)	0 (0)
Pack-year	19 ± 21 (0–100)	8 ± 13 (0–59)	38 ± 19 (1–100)	<0.001
BMI	26 ± 6 (12–43)	27 ± 5 (16–43)	24 ± 6 (12–41)	<0.01
SAT (%)	93 ± 5 (70–99)	95 ± 3 (82–99)	90 ± 6 (70–98)	<0.001
Subjects on LTOT, n (%)	7 (7)	0 (0)	7 (19)
CCI, mean (SD)	4.3 (2.3)	4.9 (2.3)	3.4 (2.0)	<0.001
CCI, n (%)
0–1	9 (10)	4 (7)	5 (14)	<0.001
2	13 (14)	4 (7)	9 (25)
3	19 (20)	7 (12)	12 (33)
≥4	53 (56)	43 (74)	10 (28)
Subjects with COPD, n (%)	53 (56)	17 (29)	36 (100)
FEV1 (% predicted), COPD subjects only	46 ± 19 (13–96)	58 ± 18 (23–96)	39 ± 15 (13–79)	<0.001
GOLD stage, n (%)
I-II	16 (30)	13 (76)	3 (8)	<0.001
III	10 (19)	3 (18)	7 (20)
IV	27 (51)	1 (6)	26 (72)
GOLD grade, n (%)
A-B	7 (13)	6 (35)	1 (3)	<0.001
C	0 (0)	0 (0)	0 (0)
D	46 (87)	11 (65)	35 (97)
Subjects with CHF, n (%)	80 (85)	58 (100)	22 (61)
NYHA-class, n (%)
3	66 (82)	46 (79)	20 (91)	n.s.
4	14 (18)	12 (21)	2 (9)

Notes: Results are presented as means ± 1 S.D. (range) for continuous variables and percentage for categorical variables. P-values are from Chi-square test and Student’s t-test (unpaired).

Abbreviations: BMI, body mass index; CCI, Charlson Comorbidity Index; CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; FEV₁, forced expiratory volume in one second; GOLD, Global Initiative for Chronic Obstructive Lung Disease; LTOT, long-term oxygen therapy; NYHA, New York Heart Association Functional Class; SAT, blood oxygen saturation; yrs, years; N.s., not significant (p-value ≥ 0.05).

Table 2 General HRQoL Assessed with EQ-5D and RAND-36 at Inclusion (Baseline)

	All (n = 89–92)	CHF (n = 56–58)	COPD (n = 33–34)	P-value CHF vs COPD
EQ-5D index	0.53 ± 0.30 (−0.24–1.00)	0.54 ± 0.30 (−0.18–1.00)	0.52 ± 0.31 (−0.24–1.00)	n.s.
EQ-5D VAS	50.3 ± 16.4 (0–90)	50.9 ± 16.5 (0–90)	49.4 ± 16.5 (10–80)	n.s.
EQ-5D1, mobility, n (%)
No problems	25 (27.2)	16 (27.6)	9 (26.5)	n.s.
Some problems	67 (72.8)	42 (72.4)	25 (73.5)	n.s.
Extreme problems	0 (0)	0 (0)	0 (0)	n.s.
EQ-5D2, self-care, n (%)
No problems	55 (59.8)	36 (62.1)	19 (55.9)	n.s.
Some problems	34 (37.0)	20 (34.5)	14 (41.2)	n.s.
Extreme problems	3 (3.3)	2 (3.4)	1 (2.9)	n.s.
EQ-5D3, usual activity, n (%)
No problems	34 (37.0)	24 (41.4)	10 (29.4)	n.s.
Some problems	43 (46.7)	24 (41.4)	19 (55.9)	n.s.
Extreme problems	15 (16.3)	10 (17.2)	5 (14.7)	n.s.
EQ-5D4, pain/discomfort, n (%)
No problems	19 (20.7)	12 (20.7)	7 (20.6)	n.s.
Some problems	61 (66.3)	38 (65.5)	23 (67.6)	n.s.
Extreme problems	12 (13.0)	8 (13.8)	4 (11.8)	n.s.
EQ-5D5, anxiety/depression, n (%)
No problems	37 (40.2)	27 (46.6)	10 (29.4)	n.s.
Some problems	50 (54.3)	29 (50.0)	21 (61.8)	n.s.
Extreme problems	5 (5.4)	2 (3.4)	3 (8.8)	n.s.
RAND-36
PF	20.7 ± 18.4 (0–95)	22.0 ± 19.5 (0–95)	18.4 ± 16.4 (0–50)	n.s.
RP	10.8 ± 24.3 (0–100)	13.6 ± 27.2 (0–100)	6.1 ± 17.7 (0–75)	n.s.
BP	55.4 ± 28.5 (10–100)	55.0 ± 29.9 (10–100)	56.1 ± 26.5 (10–100)	n.s.
GH	38.2 ± 21.2 (0–85)	46.4 ± 19.3 (10–85)	24.2 ± 16.6 (0–65)	<0.001
VT	41.4 ± 18.1 (0–90)	42.5 ± 18.8 (0–90)	39.4 ± 16.9 (0–70)	n.s.
SF	51.6 ± 28.3 (0–100)	54.1 ± 28.5 (0–100)	47.4 ± 27.8 (0–100)	n.s.
RE	40.4 ± 41.6 (0–100)	43.5 ± 43.1 (0–100)	35.4 ± 39.0 (0–100)	n.s.
MH	60.4 ± 18.9 (20–96)	62.6 ± 18.0 (20–96)	56.8 ± 20.0 (20–96)	n.s.

Notes: Results are presented as means ± 1 S.D. (range) for continuous variables and percentage for categorical variables. P-values are from Fisher’s exact test and Student’s t-test (unpaired).

Abbreviations: BP, bodily pain; CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; GH, general health; HRQoL, health-related quality of life; MH, mental health; PF, physical functioning; RE, role-emotional; RP, role-physical; SF, social functioning; VT, vitality; N.s. = not significant (p-value ≥ 0.05).

Table 3 General and Disease-Specific HRQoL – Changes Over Time

	All				CHF				COPD
	Baseline	+1 month	+6 months	+12 months	Baseline	+1 month	+6 months	+12 months	Baseline	+1 month	+ 6 months	+12 months
EQ-5D index	0.53	0.57	0.53	0.46
EQ-5D VAS	50.4	54.1*	50.7	53.0
RAND-36
PF	20.7	20.8	20.4	18.6
RP	10.8	20.0*	22.4***	18.7
BP	55.4	62.2*	55.8	56.0
GH	38.2	42.6*	43.5*	42.0
VT	41.4	43.2	46.6*	42.6
SF	51.6	61.0***	60.3***	62.0***
RE	40.5	55.8*	57.4***	55.5*
MH	60.4	67.5***	69.4***	66.5*
MLHFQ Score					42.6	36.2*	39.3	40.3
MLHFQ Physical					20.4	19.4	21.9	21.2
MLHFQ Emotional					9.0	7.5*	8.2	8.7
SGRQ Symptom									57.2	50.9*	52.9	57.5
SGRQ Activity									78.4	80.8	82.5	84.8***
SGRQ Impact									46.6	49.2	47.4	50.9*
SGRQ Total									59.4	58.9	58.9	62.7

Notes: Results are presented as means. P-values are from GEE regression analysis. P-value vs baseline is indicated; *p < 0.05; ***p < 0.001.

Abbreviations: BP, bodily pain; CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; GEE, Generalized Estimating Equations; GH, general health; HRQoL, health-related quality of life; MLHFQ, Minnesota Living with Heart Failure Questionnaire; MH, mental health; PF, physical functioning; RE, role-emotional; RP, role-physical; SF, social functioning; SGRQ, St. Georges Respiratory Questionnaire; VT, vitality.

Table 4 Measures of Healthcare Dependency

	All Subjects (n = 94)	CHF (n = 58)	COPD (n = 36)	P-value CHF vs COPD
Hospitalizations (all causes) during the yr prior inclusion per subject (n)	3.2 ± 1.7 (2–10)	3.1±1.5 (2–10)	3.4±1.8 (2–9)	n.s.
Hospitalizations (all causes) during the study period per subject (n)	0.9 ± 1.4 (0–7)	0.8 ± 1.3 (0–7)	1.2 ± 1.5 (0–6)	n.s.
HBHC; use of P.R.N. medication per subject (n)	128.4 ± 235.3 (0–1329)	97.2 ± 178.6 (0–910)	178.6 ± 301.5 (0–1329)	n.s.
HBHC; changed prescriptions per subject (n)	8.5 ± 7.0 (0–39)	6.9 ± 4.3 (0–17)	10.9 ± 9.6 (0–39)	<0.01
HBHC; home care visits per subject (n)
By physician per subject	9.2 ± 6.2 (1–32)	8.0 ± 4.5 (1–18)	11.2 ± 7.9 (1–32)	<0.01
By nurse per subject	33.7 ± 34.7 (2–251)	28.8 ± 18.8 (2–87)	41.6 ± 49.4 (2–251)	n.s.
By physiotherapist per subject	2.5 ± 2.6 (0–12)	2.3 ± 2.2 (0–9)	2.7 ± 3.2 (0–12)	n.s.
By dietician per subject	0.3 ± 0.7 (0–4)	0.2 ± 0.7 (0–4)	0.5 ± 0.8 (0–3)	n.s.
By curator per subject	0.4 ± 1.4 (0–9)	0.0 ± 0.1 (0–1)	0.9 ± 2.1 (0–9)	n.s.
HBHC; total home care contacts (home visits & phone calls) per subject (n)	77.7 ± 61.9 (3–334)	67.4 ± 38.0 (5–187)	94.4 ± 84.4 (3–334)	<0.05
Other healthcare contacts per subject (n)
Emergency care	0.9 ± 1.4 (0–7)	0.8 ± 0.9 (0–4)	1.2 ± 1.9 (0–7)	n.s.
Primary care	10.4 ± 14.6 (0–85)	13.0 ± 15.6 (0–85)	6.4 ± 11.9 (0–46)	<0.05
Other outpatient care	4.7 ± 5.2 (0–22)	4.1 ± 4.6 (0–21)	5.6 ± 6.0 (0–22)	n.s.
HBHC; number of serious SMS alarms per subject (n)
Alarms; patient-reported values were outside predetermined limits	18.0 ± 29.1 (0–198)	10.7 ± 16.1 (0–80)	29.8 ± 40.0 (0–198)	<0.01
Alarms; all SMS	35.4 ± 38.2 (0–242)	27.7 ± 25.1 (0–98)	47.7 ± 50.9 (0–242)	<0.05
Healthcare costs per subject (€)
HBHC	15,534 ± 13,200 (246–76,994)	13,122 ± 8034 (993–36,774)	19,420 ± 18,240 (246–76,994)	<0.05
Hospitalizations	7003 ± 14,217 (0–76,376)	4823 ± 9802 (0–41,068)	10,516 ± 18,974 (0–76,376)	n.s.
Emergency care	488 ± 753 (0–3944)	410 ± 495 (0–1949)	615 ± 1039 (0–3944)	n.s.
Primary care	1315 ± 1892 (0–9971)	1707 ± 2188 (0–9971)	683 ± 1024 (0–4636)	<0.05
Other outpatient care	1903 ± 2494 (0–12,181)	1453 ± 1977 (0–8914)	2627 ± 3049 (0–12,181)	<0.05
Total costs	26,244 ± 22,459 (246–123,482)	21,515 ± 14,753 (1848–58,566)	33,862 ± 29,818 (246–123,482)	<0.01

Notes: Results are presented as means ± 1 S.D. (range) and p-values are from Student’s t-test.

Abbreviations: CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease, HBHC, specialized hospital-based home care; P.R.N., as-needed; N.s., not significant (p-value ≥ 0.05).

Table 5 Significant Correlations of Measures of Healthcare Dependency and HRQoL Variables

	EQ-5D		RAND-36								MLHFQ			SGRQ
	Index	VAS	PF	RP	BP	GH	VT	SF	RE	MH	Score	Phys.	Emot.	Symp.	Act.	Imp.	Total
Exacerbations	−0.12	−0.17	−0.10	−0.03	−0.05	−0.35**	−0.06	−0.12	−0.06	−0.08	−0.03	−0.01	−0.10	0.31	0.12	0.22	0.25
Alarms; patient-reported values were outside predetermined limits	−0.15	−0.21*	−0.18	−0.22*	−0.17	−0.31**	−0.10	−0.23*	−0.22*	−0.16	0.23	0.25	0.17	0.16	0.13	0.25	0.23
Alarms; all SMS	−0.12	−0.15	−0.14	−0.18	−0.18	−0.27**	−0.11	−0.19	−0.22*	−0.17	0.19	0.20	0.12	0.17	0.04	0.18	0.16
Hospitalizations (previous year)	−0.10	0.03	−0.20	0.07	−0.07	−0.01	−0.09	0.03	−0.14	−0.11	0.15	0.07	0.01	−0.09	−0.12	0.04	0.01
Hospitalizations (study year)	−0.19	−0.05	−0.17	−0.17	−0.16	−0.03	−0.10	−0.08	0.02	0.01	0.01	0.04	−0.04	0.01	0.17	0.27	0.26
Emergency care	−0.13	0.01	−0.13	−0.14	−0.05	−0.04	−0.12	−0.06	−0.07	0.04	−0.15	−0.18	−0.21	0.05	0.14	0.28	0.26
Primary care	0.10	−0.07	0.15	0.05	−0.07	0.05	0.03	0.05	0.05	0.11	0.11	0.07	−0.01	−0.35*	−0.30	−0.27	−0.33
Other outpatient care	0.03	−0.08	−0.08	−0.13	−0.13	−0.13	0.01	−0.06	−0.21*	0.02	0.07	0.03	−0.07	−0.25	−0.09	0.04	−0.06
Healthcare by HBHC;
P.R.N. medications	−0.24*	−0.17	−0.16	−0.15	−0.23*	−0.21*	−0.09	−0.21*	−0.14	−0.03	0.26	0.26*	0.18	0.28	0.18	0.27	0.29
Changed prescriptions	−0.13	−0.18	−0.10	−0.11	−0.10	−0.29**	−0.15	−0.12	−0.07	−0.10	0.28*	0.34**	0.09	0.32	0.04	0.24	0.23
HBHC phone calls by nurse	−0.25*	−0.17	−0.21*	−0.27**	−0.26*	−0.29**	−0.24*	−0.25*	−0.27*	−0.25*	0.38**	0.39**	0.26*	0.24	0.08	0.27	0.25
HBHC phone calls by physician	−0.10	−0.22*	−0.05	−0.17	−0.22*	−0.32**	−0.16	−0.22*	−0.24*	−0.16	0.34*	0.29*	0.27*	0.16	0.07	0.22	0.19
HBHC phone calls by physiotherapist	−0.01	0.04	0.02	−0.08	0.08	−0.05	−0.08	−0.05	−0.13	−0.08	0.12	0.09	0.11	0.13	0.08	0.25	0.22
HBHC phone calls by dietician	−0.25*	−0.29**	−0.12	−0.13	−0.19	−0.29**	−0.13	−0.16	−0.07	−0.07	0.12	0.11	0.05	0.22	0.29	0.27	0.30
HBHC phone calls by curator	−0.15	−0.22*	−0.07	−0.03	−0.19	−0.23*	−0.10	−0.23*	−0.27**	−0.28**	0.21	0.18	0.12	−0.02	−0.03	0.14	0.08
Total HBHC phone calls	−0.27*	−0.21*	−0.19	−0.23*	−0.25*	−0.27*	−0.22*	−0.25*	−0.27*	−0.22*	0.40**	0.40**	0.33*	0.31	0.10	0.36*	0.32
HBHC home visit by nurse	−0.16	−0.13	−0.13	−0.13	−0.10	−0.21*	−0.10	−0.10	−0.05	−0.05	0.26	0.32*	0.11	0.16	0.08	0.06	0.09
HBHC home visit by physician	−0.28**	−0.27**	−0.23*	−0.18	−0.20	−0.36**	−0.27**	−0.20	−0.17	−0.18	0.35**	0.38**	0.15	0.33	0.12	0.37*	0.34
HBHC home visit by physiotherapist	−0.21*	−0.19	−0.17	−0.31**	−0.21*	−0.26*	−0.27**	−0.22*	−0.20	−0.14	0.28*	0.30*	0.21	0.25	0.15	0.37*	0.35*
HBHC home visit by curator	−0.24*	−0.23*	−0.15	−0.09	−0.22*	−0.28**	−0.15	−0.28**	−0.28**	−0.33**	0.20	0.16	0.10	0.03	0.17	0.26	0.22
HBHC home visit by dietician	−0.01	−0.01	−0.09	−0.04	−0.11	−0.21*	−0.19	−0.08	0.05	−0.01	0.11	0.12	0.11	−0.03	−0.01	0.13	0.08
Total HBHC home visits	−0.19	−0.17	−0.16	−0.16	−0.14	−0.26*	−0.15	−0.13	−0.09	−0.09	0.30*	0.36**	0.14	0.20	0.10	0.13	0.15
Healthcare costs;
Hospitalizations (study year)	−0.09	−0.01	−0.13	−0.18	−0.13	−0.05	−0.13	−0.05	0.02	0.02	0.05	0.06	−0.03	−0.12	0.08	−0.02	0.03
Emergency care	−0.18	−0.04	−0.15	−0.15	−0.08	−0.07	−0.17	−0.04	−0.06	−0.01	−0.08	−0.13	−0.19	0.08	0.08	0.27	0.25
Primary care	0.02	−0.04	0.02	−0.01	0.01	0.11	0.04	0.06	−0.04	0.09	0.04	0.01	−0.03	−0.35*	−0.32	−0.26	−0.32
Other outpatient care	0.13	−0.01	−0.01	−0.10	−0.07	−0.14	0.07	−0.04	−0.08	0.15	0.07	0.02	−0.07	−0.40*	0.01	−0.10	−0.15
HBHC	−0.21*	−0.22*	−0.19	−0.17	−0.15	−0.30**	−0.18	−0.16	−0.11	−0.11	0.34*	0.39**	0.15	0.21	0.13	0.19	0.20
Total cost	−0.17	−0.14	−0.20	−0.23*	−0.18	−0.21*	−0.18	−0.13	−0.07	−0.02	0.23	0.25	0.05	−0.01	0.12	0.09	0.12

Notes: Pearson’s correlation coefficient (r) was calculated for normally distributed continuous variables; *p < 0.05; **p < 0.01.

Abbreviations: BP, bodily pain; CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; GH, general health; HBHC, specialized hospital-based home care; HRQoL, health-related quality of life; MLHFQ, Minnesota Living with Heart Failure Questionnaire; MH, mental health; PF, physical functioning; P.R.N., as-needed; RE, role-emotional; RP, role-physical; SF, social functioning; SGRQ, St. Georges Respiratory Questionnaire; VT, vitality.

Table 6 Results of a Multivariable Linear Regression Analysis (Backward Elimination)

	EQ-5D		RAND-36								MLHFQ			SGRQ
	Index	VAS	PF	RP	BP	GH	VT	SF	RE	MH	Score	Phys.	Emot.	Symp.	Act.	Imp.	Total
Intercept	0.59***	53***	75***	23***	66***	−2.8	49***	62***	130***	−19	27***	14***	6.7***	24*	80***	42***	58***
Group (ref=CHF)	-	-	-	-	-	−12**	-	-	−25**	-	-	-	-	-	-	-	-
Age	-	-	−0.47*	-	-	0.56*	-	-	-	0.82***	-	-	-	-	-	-	-
Sex (ref=men)	-	-	−7.5*	-	-	-	-	-	-	-	-	-	-	-	-	-	-
BMI	-	-	-	-	-	0.8*	-	-	-	0.76*	-	-	-	-	-	-	-
CCI points	-	-	-	-	-	-	-	-	−5.4**	-	-	-	-	3.5*	-	-	-
NYHA (Ref=3)	-	-	-	-	-	-	-	-	-	-	14*	6.1*	-	-	-	-	-
GOLD stage (Ref=I-III)	-	-	-	-	-	-	-	-	-	-	-	-	-	20**	-	-	-
Exacerbations	-	-	-	-	-	-	-	-	-	2.0*	-	-	-	-	-	-	-
Hospitalizations (previous year)	-	-	−3.0*	-	-	-	-	-	−4.9*	-	-	-	-	-	-	-	-
Hospitalizations (study year)	-	-	-	-	-	-	-	-	6.4*	-	-	-	-	-	-	9.2*	-
Other outpatient care	-	-	-	-	-	-	-	-	-	0.79*	-	-	-	-	-	-	-
Healthcare by HBHC;
P.R.N. medications	−0.00031*	-	-	-	-	-	-	-	-	-	-	-	-	0.02*	-	-	-
Changed prescriptions	0.02**	-	-	-	-	-	-	-	1.5*	-	-	-	-	-	-	-	-
HBHC phone calls by nurse	-	-	-	-	−0.61*	−0.41*	−0.41*	-	−1.9***	−0.71***	0.80**	0.41**	-	0.78**	-	-	-
HBHC phone calls by physician	-	-	-	-	-	-	-	-	-	-	-	-	0.31*	-	-	1.1*	-
HBHC phone calls by dietician	-	−3.1**	-	-	-	-	-	-	-	4.0*	-	-	-	-	-	-	-
HBHC phone calls by curator	-	-	-	-	-	-	-	-	-	-	-	-	-	−3.7*	-	-	-
HBHC home visit by nurse	-	-	0.77**	-	-	-	-	0.88*	-	-	-	-	-	-	-	-	-
HBHC home visit by physician	−0.02*	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-
HBHC home visit by physiotherapist	-	-	-	−2.8**	-	-	-	-	-	-	-	-	-	-	-	-	1.9*
HBHC home visit by curator	-	-	-	-	-	-	-	-	-	−3.9**	-	-	-	-	-	-	-
Total HBHC home visits	−0.0023*	-	−0.66**	-	-	-	-	−0.78*	-	-	-	-	-	-	-	-	-
Healthcare costs;
Primary care	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	−0.0057*
Other outpatient care	0.000028*	-	-	-	-	-	-	-	-	-	-	-	-	−0.0032***	-	-	-
Total cost	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	−0.00042*	-
R^Citation2	0.22	0.09	0.21	0.10	0.07	0.35	0.06	0.08	0.28	0.32	0.22	0.22	0.07	0.56	-	0.24	0.27
Adjusted R^2	0.17	0.08	0.16	0.09	0.06	0.32	0.05	0.06	0.23	0.26	0.19	0.19	0.06	0.46	-	0.16	0.22

Notes: *p < 0.05; **p < 0.01; ***p < 0.001.

Abbreviations: BMI, body mass index; BP, bodily pain; CCI, Charlson Comorbidity Index; CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; GH, general health; GOLD, Global Initiative for Chronic Obstructive Lung Disease; HBHC, hospital-based homecare; HRQoL, health-related quality of life; MLHFQ, Minnesota Living with Heart Failure Questionnaire; MH, mental health; NYHA, New York Heart Association Functional Class; PF, physical functioning; RE, role-emotional; RP, role-physical; SF, social functioning; SGRQ, St. Georges Respiratory Questionnaire; VT, vitality.

PonikowskiP, VoorsAA, AnkerSD, et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur J Heart Fail. 2016;2016(18):891–975. doi:10.1002/ejhf.592

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