- Hospital Casemix Protocol;
- Private Hospital Data Bureau;
- National Admitted Patient Collection;
- Private Health Establishments Collection;
- National Hospital Cost Data Collection;
- National Perinatal Statistics Collection; and
- National Cancer Registry.
- to determine demographic and diagnostic characteristics of patients undergoing joint replacement surgery throughout Australia;
- to provide accurate information on the use of different types of prostheses in both primary and revision joint replacements;
- to evaluate the effectiveness of different types of joint replacement prostheses and surgical techniques at a national level;
- to compare the Australian joint replacement experience to that of other countries;
- to provide confidential data to individual surgeons and hospitals to audit their joint replacement surgery; and
- to educate Australian orthopaedic surgeons in the most effective prostheses and surgical techniques to achieve successful outcomes.
This section summarises and describes the national collections of private hospital data that were identified and considered for inclusion as part of the streamlining component of this Review.
The following collections were identified as within scope for this Review:
These collections are described in more detail in the sections below.
The collections that have been excluded and the reasons for their exclusion are summarised in section 2.1.8.
2.1.1 Hospital Casemix Protocol
The HCP is mandated through Federal legislation. The Private Health Insurance Act 2007 and its associated rules require private hospitals to provide HCP data to health insurers4. Health insurers in turn are required to provide the HCP data, supplemented with additional data fields specific to their role as insurers, to the Department5.
4 Private Health Insurance (Health Insurance Business) Rules 2010.
5 Private Health Insurance (Data Provision) Rules 2010.
Private hospitals are required to submit data in accordance with data specifications published by the Department6. Data are submitted electronically, in a fixed file format using the American Standard Code for Information Interchange (ASCII) standard. The data required include both admitted patient data and data related to non admitted patient treatment.
6 Hospital Casemix Protocol, Australian Department of Health and Ageing.
For the admitted data, data are submitted monthly and a separate record is required for each admitted patient episode that ends in a given month. For non-admitted data, data are submitted on a quarterly basis, with a separate record for each non-admitted patient service.
If the hospital provides an insured patient with rehabilitation in an admitted setting, additional data relating to that rehabilitation episode need to be submitted in a different format, with an episode linkage identifier to allow the rehabilitation record to be linked to the corresponding admitted episode record.
In effect, a private hospital is required to prepare a separate file of episode level data for each insurer whose patients were treated in the given month and transmit each file separately to the relevant insurer. Where rehabilitation patients have been treated, a further file needs to be submitted to the relevant insurer(s).
Some streamlining is already achieved through the agency of the Australian Health Services Alliance (AHSA), which provides a bureau service for its members7. This allows a private hospital to send the HCP files for those member funds to a single location – the AHSA.Top of page
7 At the time of this Review, AHSA represented 27 insurance funds.
The range of data provided to insurers by private hospitals includes the name and other patient details, clinical details of the episode (including principal diagnosis, procedure and details of types of care provided), hospital charges and administrative details related to the episode. The insurer removes the patient name and adds data related to the benefits before forwarding the data to the Department.
The Private Health Insurance Act 2007 requires HCP data be submitted for any and all admitted patient episodes where an insurance claim is lodged with an insurer. This requirement is imposed on all declared hospitals8. Under this Act both private and public hospitals may be declared. This means that both public and private hospitals are required to submit HCP data for insured patients to insurers, and that insurers are required to pass this on to the Department for both public and private hospital episodes.
8 Section 121-5 of the Private Hospital Act 2007 states “A hospital is a facility for which a declaration under subsection (6) is in force.” and Section 121-6 states “The Minister may…declare that a facility is a hospital”. As such, a “declared hospital” is one that has been declared by the Minister under this Act.
However, the HCP admitted and rehabilitation data requirements are usually less onerous for public hospitals than for private hospitals. Historically, public hospitals usually do not have service contracts with insurance funds and so are able to claim only the default benefits for insured patients. As a result, public hospitals have only provided that subset of HCP data required to allow payment of default benefits, meaning that much of the detail of the patient episode is not provided. When the Private Health Insurance Act 2007 was drafted, States and Territories were not prepared to provide full HCP data for their public hospitals. Consequently, public hospitals continue to provide a less complete HCP data set to insurance funds, although the long-term aim is for public hospitals to move to full HCP provision9.
9 Reporting Requirements for Hospital Casemix Protocol (HCP, HCP1 & HCP2), GT-Dental And Private Hospitals Data Bureau (PHDB). Australian Department of Health and Ageing.
In spite of the legislative requirement to submit HCP data, occasionally a hospital fails to provide the HCP data set to an insurer. In this situation the insurer is required to follow-up the hospital themselves. If this initial follow-up is unsuccessful, the insurer is required to advise the Department and is the Department's responsibility to further follow-up the hospital concerned. At present the Department is not actively following up these non-compliance situations.
The data are able to be used by insurers to analyse the range of conditions for which their members receive hospital services, the profile of services provided to their members by private hospitals, and the variation in charges and fees applied by different private hospitals.
The Department use the HCP data it receives to inform policy and planning in both the private hospital and private health insurance areas. It is also used as needed to brief the Minister or to respond to parliamentary questions.
In the past the Department prepared a CD of analysed HCP data that was distributed to hospitals, allowing hospitals to compare themselves with industry averages or benchmarks. This product has been discontinued as the Department no longer has the resources available to produce this on a regular basis.Top of page
2.1.2 Private Hospital Data Bureau
The PHDB is mandated through Federal legislation. The Private Health Insurance Act 2007 and its associated rules require private hospitals to provide PHDB data directly to the Department10.
10 Private Health Insurance (Health Insurance Business) Rules 2010
Private hospitals are required to submit data in accordance with data specifications published by the Department11. Data are submitted electronically, in a fixed, ASCII file format. The data required comprise episode data for all admitted patients.
11Hospital Casemix Protocol, Australian Department of Health and Ageing.
Data are submitted monthly and a separate record is required for each admitted patient episode that ends in a given month. The range of data provided to the Department by private hospitals includes non identifying patient details, clinical details of the episode (including principal diagnosis, procedure and details of types of care provided), and administrative details related to the episode.
The Private Health Insurance Act 2007 requires PHDB data to be submitted for any and all admitted patient episodes within a declared private hospital. Consequently, PHDB data are not provided by public hospitals and are only provided by those private hospitals that are declared under the Act.
The Department maintains a list of PHDB eligible hospitals. This list essentially is an amalgamation of the Department's list of declared hospitals under the Private Health Insurance Act 2007 and the Australian Institute of Health and Welfare's (AIHW) list of hospitals that contribute to the national admitted patient collection (APC).
In spite of the legislative requirement to submit PHDB data, occasionally a hospital fails to provide the PHDB data set to the Department. It is the Department's responsibility to follow-up the hospital concerned. At present, approximately 570 private hospitals submit data regularly to the PHDB. The PHDB is viewed as approximately 85% complete in its coverage. This is based on a comparison with data held in the APC maintained by the AIHW. However, this comparison is subject to uncertainty as some States and Territories do not separately identify which private hospitals submit data to the APC.
The Department has developed a web browser based portal for submission of PHDB data. It actively encourages hospitals to use this portal for the submission of data as it is a secure process and makes it easier for hospitals to complete the data submission process.Top of page
The Department uses the PHDB data for a wide range of purposes. These include analyses to inform policy and program development and evaluation. An annual report is produced which gets wide use within the industry as well as by researchers and others with an interest in the private hospital sector12. The PHDB data is also used as needed to brief the Minister or to respond to parliamentary questions.
12 PHDB Annual Report 2009-10. Australian Department of Health and Ageing.
On occasion the Department also responds to requests from individual hospitals to analyse their own data for example, day surgeries have occasionally requested a comparison of their average theatre time with the national average for the peer day surgeries. However, these specific requests are often dealt with using the APC data given its greater coverage.
The data have been used recently for the development of private hospital profiles within the Department. This work is analogous to other work within the Department to develop public hospital profiles although the detail for the private hospital profiles is different to that for the public.
2.1.3 National Admitted Patient Collection
The APC is a national collection of morbidity data comprising episode level data for all hospitals in Australia – public and private. This collection is managed and maintained by the AIHW and is also referred to as the National Hospital Morbidity Database.
The AIHW receives data annually from States and Territories. Each State or Territory supplies episode level data for the preceding financial year for all or most public and private hospitals within its jurisdiction. For the 2009-10 APC data submission process, data were not provided for 2 public hospitals nor for private day hospital facilities in the NT or ACT nor for 2 other private hospitals13. In 2009-10, the extent of under counting of private hospital episodes in the APC was of the order of 3.3%. This estimate was derived from a comparison between the numbers of private hospital episodes in the APC and those reported to the Australian Bureau of Statistics, through PHEC.
13 Australian Hospital Statistics, 2009-10. AIHW, April 2011.Top of page
Data are supplied according to the National Minimum Data Set (NMDS) specification for admitted patient care. Each episode record contains non identifying patient demographics, administrative data and clinical data specific to the episode.
The arrangement for provision of APC data to the AIHW is based on the National Health Information Agreement, under which the States And Territories agreed to provide the data14. This agreement also covers the data standards and associated developmental work under which the APC operates.
14 METeOR, National Health Information Agreement.
However, the original submission of admitted episode level data by private hospitals to the various States and Territories takes place under different arrangements within each jurisdiction. In some jurisdictions, there is a legislative requirement for each private hospital to provide admitted episode data, sometimes as a condition of the licence. However, in other jurisdictions there is no such requirement and the arrangement under which private hospitals provide the data is essentially voluntary. Table 3 summarises the basis on which private hospitals provide admitted patient data for each of the states and territories.
Table 3 Basis on which private hospitals provide admitted patient data, by State and Territory.
|New South Wales||Required under legislation.|
|Victoria||Required under legislation.|
|Queensland||Required under legislation.|
|South Australia||Provided voluntarily.|
|Western Australia||Required under legislation.|
|Northern Territory||Provided voluntarily.|
|Australian Capital Territory||Provided voluntarily.|
The APC data are used for a range of purposes. They are fundamental to a number of AIHW publications, such as the Australian Hospital Statistics series. A copy of the APC is also provided to the Department which uses it for a range of research, policy analysis, planning and policy development.
The APC is also a valuable resource for a range of other purposes and is fundamental to the development of consistent and comparable national performance measures. For example, it is used to populate various indicators of activity currently reported on the myHospitals website15. In the future it will be used to generate performance measures under the National Health Care Agreement and the COAG health care reform process. It is also used extensively by researchers, commentators and policymakers across the Australian health sector.
15 MyHospitals.Top of page
2.1.4 Private Health Establishments Collection
The PHEC is operated and maintained by the ABS. The collection has operated annually since 1991-92, with the exception of 2007-08 when budget measures caused it to be suspended during a period of review16. Following detailed review, involving consultation with a range of users and the industry, the PHEC was reinstituted as an annual collection in 2008-09.
16 Private Hospitals, Australia, 2009-10. ABS, 17 June 2011. Catalogue number 4390.0
PHEC operates under the authority of the Census and Statistics Act 1905. That Act empowers the Commonwealth Statistician to direct private hospitals to contribute their data to the PHEC.
The scope of PHEC includes all private hospitals licensed by States and Territories and all free standing day hospitals approved by the Commonwealth. It includes data from each such facility relating to its ownership, basis for operation, accreditation, activities, staffing and finances17,18.
17 Private Hospitals Establishment Survey 2008-09 Establishment Survey. ABS, 2009.
18 Private Hospitals, Australia, 2009-10. ABS, 17 June 2011. Catalogue number 4390.0.
The ABS has negotiated arrangements with States and Territories to streamline collection of part of the data required for PHEC. Subject to consent from the private hospital concerned, the ABS receives data on admitted patient activity for that private hospital directly from the relevant State or Territory. This arrangement means that the hospital does not need to extract and collate the necessary data from its own systems. This arrangement works for those private hospitals that provide admitted patient data to their State or Territory and who choose to complete the authorisation for the release of health data. Feedback from industry representatives and from States and Territories suggests that around 90% to 95% of all private hospitals provide their admitted data to PHEC in this way. Nonetheless, the remaining data sought by PHEC are still required to be provided by the hospital itself.
The PHEC data are reported in summary form each year in the Private Hospitals, Australia series of annual publications. These publications are seen as extremely useful at an industry level, rather than at the individual hospital level. They are seen as providing a very good, possibly the most accurate, high level summary of treatment activity across the whole private hospital sector. They also provide the only publicly available summary data on the characteristics, financing and workforce of private hospitals.
The Census and Statistics Act 1905 prevents the ABS from releasing PHEC data that might lead to the identification of individual private hospitals. Consequently, smaller jurisdictions' data are aggregated in publications derived from PHEC. For example, in the Private Hospitals, Australia publication Tasmania, Northern Territory and Australian Capital Territory results are combined.
This constraint limits the utility of the PHEC data somewhat. However, it is possible to obtain more detailed analyses than those published through ad hoc requests to the ABS, provided the resulting tables do not lead to the identification of individual hospitals. This approach was adopted by the Productivity Commission in its research study into public and private hospitals in Australia19.
19 Public and Private Hospitals, Productivity Commission Research Report. Productivity Commission. December, 2009.Top of page
2.1.5 National Hospital Cost Data Collection
The National Hospital Cost Data Collection (NHCDC) is managed by the Department. It is an annual collection of activity and cost data from public and private hospitals across Australia, which has been operating since 1996. The most recently completed round of data collection was for the 2008-09 financial year. The report for that round was published in December 200920.
20 National Hospital Cost Data Collection, Cost Report Round 13 (2008–2009). Commonwealth of Australia. Canberra, December 2009.
NHCDC is essentially a voluntary collection, involving collaboration among the Department, States and Territories, and private hospitals. Public hospitals’ data are provided through the active co-ordination of each State and Territory health authority, while private hospitals’ data are provided directly by the hospitals themselves.
For the 2008-09 round, 169 private hospitals participated, comprising 59 free standing day hospitals and 110 other private hospitals. In terms of admitted episodes in private hospitals, the 2008-09 NHCDC accounted for 41% of episodes in free standing day hospitals and 71% of episodes in other private hospitals.
The NHCDC aims to capture all private hospitals with 200 or more episodes in the year concerned21. It relies on the data captured through the PHDB to determine which hospitals are in scope for each year’s round of data collection, before approaching the hospitals themselves.
21 The same activity threshold is also used for the public hospitals’ component of the NHCDC.
The NHCDC aims to collect cost and activity information for admitted episodes, non admitted services and emergency department services. The private hospitals’ component only covers admitted episodes. Data quality for the private hospitals’ component is variable, with significant caveats due to issues with inconsistent handling and reporting of costs, small AR-DRG volumes affecting estimates for free standing day hospitals and incomplete or inaccurate data affecting allocation of costs. In addition, private hospitals mostly lack the patient level feeder systems to capture consumption costs, thereby requiring estimation of hospitals’ costs through cost modelling, for the majority of private hospitals and free standing day hospitals.
Data can be submitted via a web based portal and the Department provides tools to carry out quality review of the data prior to its submission. For the 2008-09 round, a national co-ordinator also was appointed to facilitate the collection and review of the private hospitals’ data.
The admitted episodes’ component of the NHCDC produces reports on relative costs per episode by AR-DRG22 and by cost categories23, as well as relative cost weights. These outputs are reported separately for public and private hospitals, and are produced for different subgroups of these hospitals. Time series comparisons are also produced, allowing some examination of variations in costs over time.
22 Australian Refined Diagnosis Related Group classification (AR-DRG) is used for reporting.
23 These cost categories are referred to as “cost buckets”.
These outputs are used to inform casemix based funding models in various States and Territories, as well as in the development and implementation of Commonwealth policy. There is some use of the private sector results by hospitals to compare their cost structures with national averages. The Productivity Commission also made use of the NHCDC data in its research study into public and private hospitals24. The Commission found it difficult to apply the data due to significant differences in data quality and approaches to costs’ classification and allocation between public and private hospitals.
24 Public and Private Hospitals, Productivity Commission Research Report. Productivity Commission. December, 2009. Available at: .
A review of the NHCDC and its processes was carried out in 2008 and the findings and recommendations from that review have guided and continue to guide the further development of the collection over time.
2.1.6 National Perinatal Statistics Collection
The National Perinatal Statistics Collection (NPSC) is operated by the National Perinatal Statistics Unit (NPSU). This is a collaborating unit with the AIHW based at the University of New South Wales25.Top of page
25 National Perinatal Statistics Collection (NPSC), University of New South Wales.
The NPSC collates data on pregnancy and childbirth, with State and Territory based units providing the data annually. The collected data conform to an NMDS for perinatal data. Individual States and Territories may collect a larger set of data than this NMDS, depending upon their local needs. Each State and Territory mandates reporting of birth related data to their respective maternal perinatal data collections, with the exception of the ACT. In most cases, the responsibility for providing the data lies with the attending midwife. Where there is no attending midwife and delivery takes place in a private hospital, the responsibility usually lies with the hospital.
The processes for collection and reporting of the perinatal data are well-established. In most jurisdictions they have been operating for more than 20 years. Some streamlining at a local level is already evident. For example, the ACT uses its admitted patient collection to obtain some birth related data is used in its perinatal collections.
The NPSC is used to report on a range of maternal and perinatal statistics. The annual Mothers and Babies report has been produced since 1991. It is also used for research purposes.
2.1.7 Australian Cancer Database
The Australian Cancer Database (ACD) is managed and maintained by the Cancer and Screening Unit within the AIHW. That unit operates the ACD in collaboration with the Australasian Association of Cancer Registries (AACR), as part of the functions of the National Cancer Statistics Clearing House (NCSCH)26.
The ACD collects data on incidence of new cases of cancer and on deaths due to cancers. NCSCH receives the data from State and Territory based cancer registries, on an annual basis, in accordance with a specified protocol27. That protocol lists the data items that are collected nationally, although States and Territory cancer registries usually collect a superset of this national data set.
Data are collected, collated and reported in terms of cases of cancer, rather than health care activities such as admission to hospital, non admitted treatment at a hospital or visits to community based health practitioners. As such, the State and Territory level processes involve collection and reconciliation of data from multiple sources – hospitals, medical specialists, pathologists, deaths’ data et cetera – to build individual cancer case records. It is these case records whose details that are summarised and submitted to the ACD. Each State and Territory has a legislative basis requiring health care providers to submit information to that jurisdiction’s registry, when a patient is diagnosed or treated for cancer.
The processes for collection and reporting of the cancer data are well-established. In most jurisdictions they have been operating for more than 30 years.
The data collected by the ACD is used for a range of reporting and research purposes, including the ongoing series of Australian Cancer Incidence and Mortality books28. The data are also available to researchers, subject to ethical and confidentiality requirements.Top of page
2.1.8 Existing collections excluded from consideration for streamlining.
In undertaking stakeholder interviews for this Review and in carrying out associated research, a number of additional national collections that involved private hospitals submission of data that were identified. These additional collections were considered but for the reasons outlined below, they were deemed to be outside the scope of this Review.
The primary reasons for excluding collections centred on whether the private hospitals' participation in the collections was imposed or otherwise mandatory and whether the Commonwealth, usually through the agency of the Department, was in a position to directly influence the operation of the collections.
National Joint Replacement Register
The National Joint Replacement Register was established in 1999 by the Australian Orthopaedic Association and continues to be operated by that Association today. The Register collects data from all hospitals undertake joint replacement procedures throughout Australia29.
The Register commenced operations in 1999 as a collection only from selected South Australian hospitals. Its scope was expanded gradually to include all Australian hospitals by 2003. The Association states the aims of the Register to be:
Data collected by the Register include limited patient demographics, diagnostic information and detailed data on the replacement procedure(s) performed and specific prostheses used. The Register produces annual reports and a number of supplementary reports on specific issues or with a specific research focus. The Association also undertake systematic review of the performance of prostheses based on the data held in the Register. The results of these reviews can be used by the Department to advise the Therapeutic Goods Administration on the listing of specific prostheses.
The National Joint Replacement Register, while funded by the Department through a levy on prostheses’ manufacturers and distributors30, the Australian Orthopaedic Association operates the Register independently of the Commonwealth Government. The process of data collection also tends to operate through the agency of surgeons and nursing staff within hospitals. For these reasons, the National Joint Replacement Register was seen to be outside the scope of this Review.
30 Private Health Insurance (National Joint Replacement Register Levy) Act 2009.Top of page
Private Mental Health Alliance Centralised Data Management Service
The Private Mental Health Alliance (PMHA) is a peak industry body for private-sector mental health services in Australia31. The Centralised Data Management Service (CDMS) is operated by the PMHA and collect data from participating private psychiatric hospitals on the clinical status of patients before and after treatment. Hospitals' participation in the CDMS is voluntary and currently around 40 hospitals participate32.
31 The Private Mental Health Alliance.
32 Centralised Data Management Service, Private Mental Health Alliance.
The principle purpose of the CDMS is to improve the quality and effectiveness of the services provided by private psychiatric hospitals. An annual statistical summary is produced from the data collected and hospitals are also provided with direct feedback on their performance relative to their peers.
The Service is jointly funded by the Australian Government, private health insurers and the participating hospitals themselves. It has operated since 2001 and stakeholders interviewed for this Review saw it as an exemplary model for successfully engaging the private hospital sector in providing data for performance monitoring and reporting purposes.
Nonetheless, given the voluntary nature of this collection and the fact that it is beyond the influence of the Department, the CDMS was seen as being outside the scope of this Review.
Australasian Rehabilitation Outcomes Centre
The Australasian Rehabilitation Outcomes Collaboration (AROC) was developed and is operated by the Centre for Health Services Development at the University of Wollongong. AROC collects and reports on data from the specialist medical rehabilitation sector33. The data are collected for a range of purposes, including national benchmarking, assessing efficacy of interventions, providing clinical and management information reports for stakeholders in the rehabilitation sector and annual reporting.
33 AROC. What is AROC?
AROC obtains and holds data from both public and private hospitals. The collection is voluntary, with private hospitals subscribing to the AROC process on a voluntary basis. In return, they receive value added analytical outputs that allow them to assess their outcomes and performance against industry benchmarks.
Given the voluntary nature of AROC and the fact that the Commonwealth does not have direct influence over its operation, it was seen as outside the scope of this Review.Top of page
Palliative Care Outcomes Collaboration
The Palliative Care Outcomes Centre (PCOC) was developed and is operated by the Centre for Health Services Development at the University of Wollongong. PCOC collects and reports on data from palliative care service providers34. The data are collected to support national benchmarking and improvement of palliative care quality and outcomes. Data collection began from 2008 and for the period from July to December 2009, PCOC estimated that it captured data on 75 per cent or more of admitted, overnight stay palliative care episodes for most jurisdictions.
34 PCOC. What is PCOC?
PCOC obtains and holds data from both public and private hospitals. The collection is voluntary, with private hospitals subscribing to the AROC process on a voluntary basis. In return, they receive value added analytical outputs that allow them to assess their outcomes and performance against industry benchmarks.
Given the voluntary nature of PCOC and the fact that the Commonwealth does not have direct influence over its operation, it was seen as outside the scope of this Review.
ANZICS Centre for Outcome and Resource Evaluation
The Australian and New Zealand Intensive Care Society (ANZICS) maintains several data collections through its Centre for Outcome and Resource Evaluation (CORE). The three data collections maintained by CORE are the Adult Patient Database (APD), the Australian and New Zealand Paediatric Intensive Care Registry (ANZPIC), and the Critical Care Resources collection (CCR)35.
The principal aims of these collections are to provide a peer review mechanism for Australian and New Zealand intensive care units who participate, as well as a database for epidemiological and related research purposes and catalogue of intensive care resources. While participation in the CORE collections is open to all intensive care units in Australia and New Zealand, participation is voluntary.
Given the voluntary nature of the ANZICS CORE collections and the fact that the Commonwealth does not have direct influence over their operations, they were seen as outside the scope of this Review.Top of page
The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) operates under the auspices of Kidney Health Australia and the Australia and New Zealand Society of Nephrology. It captures data on the incidence, prevalence and outcome of treatment for patients with end stage renal failure.
The Register captures data on patients treated at all dialysis and kidney transplant units throughout Australia and New Zealand36. As such, private hospitals and day centres providing dialysis services submit data to ANZDATA.
36 ANZDATA Registry Report 2010. Australia and New Zealand Dialysis and Transplant Registry Adelaide, South Australia.
Contributing units submit data monthly for key events such as new patients, transplants and deaths. In addition, units submit an annual survey capturing a detailed cross-section of patient and treatment data for each patient actively receiving treatment.
ANZDATA produces an annual report based on the data collected. It also makes the data available for research and planning purposes and undertakes its own research.
Although participation in ANZDATA includes all dialysis and transplant units in Australia and New Zealand, participation is voluntary. Given this voluntary nature of participation and the fact that the Commonwealth does not have direct influence over ANZDATA and its operations, it was seen as outside the scope of this Review.