Author: elemmon

Researcher Spotlight: Aileen Neilson

Background

Aileen joined Edinburgh University’s Usher Institute and Edinburgh Clinical Trials Unit (ECTU) as a Senior Health Economist in 2018.  Aileen’s current role includes leading and developing health economics research in The University of Edinburgh and NHS Lothian, contributing to the development of new methods and techniques in health economics through methodology research embedded within applied studies e.g. Randomised Control Trials and other study design. She has experience in conducting and managing health outcomes research and economic evaluation studies in the UK NHS setting and other European countries.

She holds a BSc in Science with Management Studies (Napier University, Edinburgh) and an MSc in Operational Research (Strathclyde University, Glasgow). Prior to joining ECTU Aileen worked as a Research Fellow with the Health Economics Research Unit, Aberdeen University (HERU) for 5 years. She has worked in various clinical areas including oncology (prevention/screening/detection/treatment), orthopaedics and trauma surgery, intensive care, stroke, rheumatic and musculoskeletal diseases and chronic pain. She has 25 years of prior research experience, in academia (e.g. Universities of Nottingham, Dundee, St Andrews, York, Aberdeen), the NHS (Lothian – Primary and Community Care Division) and in health care consultancy roles (e.g. HealthEcon AG, Basel, Switzerland, and the Norwegian Knowledge Centre for the Health Services, Oslo, Norway incorporated in the Norwegian Institute of Public Health as of 1 January 2016).

Research Interests

Aileen’s research interests are broad, spanning both developing and applying trial- and model-based economic evaluation methods of different interventions/technologies. She is particularly interested in economic evaluations of public health interventions, and research that focuses on the (improved) use of routine administrative data for cost and outcomes measurement in undertaking heath economics analyses/ economic evaluation studies.

Current Projects

SCOT-HEART-2

MSS3

Teaching

Aileen is currently the course organiser for the “Introduction to health economics and resource allocation” elective course on the Masters in Public Healtj (on-campus) which ran for the first time in 2018/19 and is currently running for 2019/20. Aileen also teaches alongside our Research Fellow, Elizabeth Lemmon, on the new undergraduate module on Health Economics which is being offered for the first time in the School of Economics. She also supervises masters’ dissertation projects. Aileen has also taught health economics courses on various masters and undergraduate programs at other academic institutions (online and on-campus).

Aileen has also been a regular presenter on a training course providing an introduction to the identification, appraisal and application of economic evaluation for policy-making in public health (run by HERU in Aberdeen and funded by the Health Economics Network for Scotland).

Aileen is also the Edinburgh representative for the new Scottish Health Economics group.

Final meeting of the Lothian Cancer Data Intelligence Project

Author: Holly Ennis


The National Cancer Research Institute Annual Meeting in Glasgow 2019 marked an important milestone for members of the ECTU health economics group involved in the Lothian Cancer Data Intelligence Project (LCDI). It marked the end of an 18 month collaborative project to explore the completeness, data quality and scope of a comprehensive linked cancer regional dataset accessed by NHS Lothian Analytical Service. The project, partially funded by the Association of the British Pharmaceutical Industry, Pfizer UK, Novartis Pharmaceuticals UK Ltd, AstraZeneca UK and NHS Lothian and funded through Joint Working with Roche Products Ltd, also sought to explore the need for real world data and how to facilitate data requests from different stakeholder groups.

In a final meeting the key deliverables of the study were presented: a data dictionary and data quality report in the form of a wiki within the public domain and a research governance framework managed by NHS Lothian ready to pilot data requests. An important part of the project was a series of worked examples, modelled around a relevant research question, which was used to test out the processes and instructions developed as part of the LCDI study. The largest of these research questions was pathway visualisation (featured below) using national datasets to look at treatment sequencing patterns in secondary breast cancer (ER +ve HER2 –ve). This was developed into an abstract and presented at the NCRI 2019 meeting by Dr Ashley Horne as part of the Silent Theatre!

Learning from the LCDI project has led to the launch of the ‘Edinburgh Real World Data Service’ which is run jointly by the Lothian Research Safe Haven Team and the Edinburgh Cancer Informatics Programme with the objective of improving the availability and use of real NHS data to inform new reimbursement models that can ultimately provide better value medicines for NHS patients.

Learn more about the Edinburgh Real World Data Service here.

INFO-BC: What We Learned From Think Aloud Pilots

Author: Alistair Bullen


Background to the project and the think aloud pilots


The INFO-BC (Supporting shared decision making in secondary breast cancer) project is continuing to make great progress towards releasing a full-scale survey to patients, health professionals and the general public. INFO-BC is a planned survey which aims to understand preferences for secondary breast cancer treatments, you can find out more here. The study recently completed the think-aloud pilot stage of the project. 10 patients and 5 health professionals piloted early versions of the questionnaire whilst being asked to talk through their decision making. The feedback we received during the pilots allowed us to make improvements to the questionnaire, we then showed the improved version of the questionnaire to the next respondents. Changes were often made to the attributes and levels in the Discrete Choice Experiment (DCE). Attributes refer to the factors of treatment which were included in the survey and levels refer to the different available options for the attribute.

The table below illustrates how the attributes and levels changed as a result of the think-aloud pilot. Diarrhoea didn’t change significantly but you can see that it is composed of three levels; None, Grade 1 and Grade 2. Grades refer to the official Common Terminology Criteria for Adverse Events (CTCAE) which are used by health professionals worldwide to classify medical problems, symptoms, and side effects. Health professionals tend to be familiar with CTCAE criteria so were told that the grades themselves, for patients they were given a description which effectively translated the grade into standard language. There were many changes which we implanted as a result of our piloting, here I will discuss three key changes which were of particular importance.


The key changes


The first key change between the first and final version of the questionnaire was the removal of the mode of administration attribute. The decision to remove the attribute was partly because several respondents told us that the attribute was not important when compared to the other attributes. Also, we were already uncertain about whether to include the attribute, several studies similar to ours which had used a mode of administration attribute in the past found it to have little effect on people’s choices, and there is already a significant body of literature on people’s preferences for mode administration.

The second key change was that progression-free survival (PFS) was swapped for overall survival (OS). We initially failed to effectively communicate to patient respondents what PFS meant. PFS is an important measure for those who study cancer. PFS is the length of time treatment can control a cancer before it begins to grow at a clinically significant rate. It does not necessarily ensure that a patient’s life expectancy or quality of life improve. We realised that it was hard to disentangle the concepts of quality of life and length of life from patients’ interpretation of PFS. This meant that patients who chose options with better PFS weren’t necessarily interested in PFS itself, they may have been interested in a better quality of life and longer survival. A recent publication by Michael J. Raphael in Canada also came to our attention which assessed to the use of PFS in studies like ours, it argued that PFS was not being effectively communicated to patients. All of these factors considered we decided that it was simpler to ask patients to consider OS rather than PFS.

The third key change was that risk of urgent hospital admission (UHA) was combined with OS. In the early versions of the questionnaire, the respondents were shown a graphic of 100 people with some coloured in to represent risk of UHA. In a separate box, patients were shown a separate graphic illustrating the survival prospects at 1 year and 5 years for 100 people. Not only did the graphics for OS prove to be difficult to interpret but we failed to communicate to patients how the two concepts were related. In the early versions of the questionnaire, we intended the risk of UHA to be life-threatening, meaning that there was risk of death. We, therefore, attempted to communicate that the OS prospects were only relevant for individuals who completed treatment and that patients who experienced a UHA were required to stop treatment either because they had died or because treatment had proved too dangerous. This relationship was both difficult to understand and an added complication. It became apparent that we needed to more clearly and simply demonstrate the relationship. The solution we enacted was to present a single graphic as shown below which demonstrated a timeline which first showed how patients experienced a UHA within their first year of treatment, then how many patients could expect to be alive at 1 year, and how many could expect to be alive at 5 years. This solution proved to be easier to understand for respondents.


Concluding remarks


The think-aloud pilots proved to be extremely useful. I spend much time thinking about the precise scenario we are asking patients to imagine and it can be difficult to see what may be confusing to someone looking at the problem with a fresh pair of eyes. I would like to thank Morag McIntyre, the research nurse for INFO-BC, for conducting the pilots. I would also like to thank all of the patients and health professionals who took time out their days to pilot the survey and contribute to this important research.

 

2019 European ISPOR

Author: Robert Nagy

2019 European International Society for Pharmacoeconomics and Outcomes (ISPOR)

As a PhD student working on a project that is on the borderline of Data Science, Medical Informatics and Health Technology Assessment, I felt it was crucial for me to attend this year’s European International Society for Pharmacoeconomics and Outcomes (ISPOR) – the leading professional international organisation for health economics and outcomes research (HEOR) – conference held in Copenhagen, in early November. This was the biggest conference of its kind to date on the continent and had the main theme of Digital Transformation of Healthcare: Changing Roles and Sharing Responsibilities’. The event attracted more than 5,500 global healthcare stakeholders and HEOR thought leaders representing more than 90 countries from all sectors of healthcare, including researchers and academics, assessors and regulators, payers and policymakers, the life sciences industry, healthcare providers, and patient engagement organisations.

Before the main conference began, I attended two hands-on pre-conference half day courses in budget impact analysis and model design held by world-leading experts. The organisers provided very detailed, useful printed course materials and software-based modelling tools that I plan to utilise during the implementation stage of my PhD.

The conference opened with the first plenary session on the 4th November, Healthcare Digitalization: Instant, On Demand, and Always Connected.” New technologies are driving change in healthcare systems; influencing the way diseases are prevented, diagnosed, and treated. This panel explored the issue of digitizing healthcare and how this is impacting healthcare and health systems globally.

The second plenary session, Shaping the Digital Healthcare System,” was held on the 5th November. Healthcare is changing rapidly with this transformation impacting every area of the healthcare system, including its structures, processes, policies, and practices. This panel examined how those working in healthcare are adapting to these unprecedented technological developments to deliver more productive, effective, and personalised care for patients.

The third and final plenary session, held on the 6th November, discussed the topic Big Healthcare Data: Endless Opportunities for Research and Learning”. Big data present a tremendous opportunity for the measurement and reporting of quality in healthcare that can enhance insight and decision making. In this session, panellists discussed a number of examples where experts are effectively using big data for research and to drive learning at the healthcare system level.

ISPOR CEO and Executive Director Nancy S. Berg stated, “ISPOR Europe 2019 featured many innovative sessions centering on healthcare transformation fuelled by digital technologies. ISPOR’s largest conference to date (with more than 5500 registrants) convened a wide variety of healthcare stakeholders to help solve many of the challenges that impact healthcare and to advance HEOR excellence to improve healthcare decisions globally.

A paradigm-shift featuring technological and system-wise transformation are therefore unavoidable. Coverage of the new, most efficient interventions and their support-mechanisms at scale pose an unsustainable financial and capacity burden on health systems worldwide.  Thus, affordability issues in health care are perceived as a ‘global crisis’ today. Consequently, patient-level real-world data should be exploited to create affordable value-added health services.

Utilisation of vast healthcare data, creating better software applications and back-end IT infrastructure to generate real-world evidence, which can be used directly by healthcare decisions-makers regarding the adoption and distribution of new innovative health technologies, are all prominent topics on policy-makers’ agendas. Overall, this can promote more efficient health care provision and ensure better patient outcomes. We are in the midst of an era in which organisations  and governmental bodies around the Globe have teamed up and really started to exploit data assets at scale by utilising the most advanced information technologies to solve a broad range of urging problems that challenges health systems’ sustainability and operations today. For me, witnessing these remarkable initiatives and actual transformations across Europe was an invaluable learning experience.

The 9th International Seminar of the European Palliative Care Research Centre

Author: Katharina Diernberger

Health Economics at the 9th International Seminar of the European Palliative Care Research Centre

At the end of October (23rd to 25th), I travelled to Krems in Austria to attend the 9th International Seminar of the European Palliative Care Research Centre (EPCRC). In this post, I will offer my thoughts on the conference and tell you a little about my work which I presented there.

This was the second time I have attended the EPCRC conference- last year it was held here in Edinburgh. Whilst I enjoyed the conference last year, my reflection was that the health economics voice was definitely lacking. So, I was really hoping for good things for the conference in Krems- especially since for me this meant travelling to my home turf! I am happy to report that I was not disappointed. This year’s presentations included a lot of health economic considerations and health economics featured as a core topic throughout. For example, a talk by Professor Nathan Cherny form Israel was mainly focussed on the Health Technology Assessment process and how it links to the Magnitude of the Clinical Benefit scale. Anna Kitta from Austria and David Blum from Switzerland presented study proposals in the area of eHealth mentioning the potential costs savings for the health care systems through to technological innovation.

I also had the great opportunity to present on the Friday morning of the conference. Having attended the conference before, I knew that the audience won’t come from a health economics background. I was therefore mindful that the mention of economics alongside end of life care might have triggered in their minds the ever present myth that Economists want to take resources away from these settings. I therefore made it my mission to ensure that I convinced the audience otherwise!  I decided to split my presentation into two parts. I started with the topic “The (in)compatibility of health economics and end of life care”.  In this first part, I introduced some of the key health economics ideas and summed up the importance and the challenges that health economics faces, particularly with respect to end of life care.  I also outlined the current situation in the UK and presented some new developments in methodological research. Hoping that I had managed to bust some health economics myths, the second part of my presentation covered the “Health economics in the EPAT study”. In this part, I showed a bit of applied health economics, presenting the economic results of a cluster randomised controlled trial testing a systematic approach in the assessment and management of cancer pain. Both presentations were well received and prompted lively discussions, so I was very happy with that.

The overall quality of the presentations at the conference, as well as the presented topics, were very well chosen and incredibly relevant to the developing field of health economics within end of life care. I got the impression that early palliative care is a major focus within the community and there is definitely a shift towards making palliative care services more flexible and patient centred. Another commonly discussed topic, which linked well with my presentation, was the potential “overtreatment” of patients in the last phase of their life.

An additional main focus of the conference was on Patient Reported Outcome Measures (PROMs) , which is of great importance for the methods development of health economics. I could take away that not just the health economists but also clinical professionals are very aware that patient questionnaires designed for a curative setting are not fit for purpose in an end of life situation.

I hope to attend next year’s conference and I am curious to see if the trend of increasing awareness and representation of health economics continues. You’ll see below some photos from the lovely Austrian dinner which the conference organisers put on for us, with traditional music and dances performed by the children group from the “Wachauer Trachten und Heimatverein Krems”.

Reflections on the first Scottish Health Economics meeting

It’s been just over one month since the official launch of Scottish Health Economics (SHE) at Discovery Point in Dundee.  Set up by the Health Economics Research Unit (HERU) in Aberdeen (find out more about SHE here), “SHE seeks to act as a vehicle for widening engagement with health economics in Scotland, bringing together users and producers of health economics who are interested in the development and application of health economics in Scotland. All activities will draw on the extensive experience and expertise Scotland offers in health economics” (SHE Terms of Reference, 2018).

Since the launch of SHE on the 3rd of October, we’ve had time to reflect and it’s safe to say we are more excited than ever about the future for health economics research in Scotland! In this post, we reflect on the event and highlight some of the take home messages.

Overview of the day

The tone for the day was set by Mandy Ryan, Director of HERU, who gave an enthusiastic welcome to all SHE participants. From this point onwards, the health economics energy in the room was palpable!

Next up, Rachel Baker, Professor of Health Economics at Glasgow Caledonian University, provided an overview of health economics research in Scotland. Of noticeable interest was the useful maps she had prepared, pin pointing where us health economists, both within academic and governmental institutions, are hiding. Although Stirling was left out of the picture (Seda Erdem and colleagues quick off the mark to rectify that!), the map surprised everyone in the room as to the sheer numbers of health economists and other bodies contributing to health economics research going on in Scotland.

 

© Prof Rachel Baker

Following Rachel’s introduction, Marjon van der Pol, Deputy Director of HERU, talked about capacity building in health economics, and strategies for attracting the next generation of health economists.

The rest of the day was packed with excellent presentations (and a delicious lunch) from academics across the SHE community on a number of interesting health economics research questions, with reflections from the policy community including the Scottish Government, Healthcare Improvement Scotland, NHS Education Scotland and NHS Health Scotland. The academic presentations included our own Research Assistant, Alistair Bullen, who gave an elevator presentation on the use of PACE Statements as source of qualitative secondary data to inform attribute selection in discrete choice experiments.

Whilst all of these presentations were extremely interesting and really showcased the wealth of health economics research going on in Scotland, perhaps the most constructive part of the day was the afternoon breakout sessions (where I think we all agreed we could have spent all day!). The sessions allowed for the opportunity to discuss what we want to get out of SHE, including activities, training, funding opportunities, and the possibility of an annual meeting.

Prof Cam Donaldson summed up the day perfectly in his closing remarks, commenting on the unmistakable enthusiasm that charged the room throughout the event.

Take home messages

As a group, we believe that the SHE network offers a starting point for collaborations with other health economics researchers in Scotland that we can build on going forward. Simply knowing and being aware of the research going on in Scotland is in itself useful to identify who holds expertise in a particular area. At the same time, SHE will allow links to form between academic researchers and the policy community, ensuring that Scottish health economics research is contributing in the issues that matter most to the people of Scotland.

Overall, we felt that the take home message from the day was really the unique position that Scotland is in and the potential that exists for collaborative work between and across academic institutions and government.

We recently completed the SHE event survey so we will wait to see the outcome of that and very much look forward to seeing how SHE develops and contributing to the networking potential that SHE offers.

EHE would like to thank all of the organisers and presenters who made the day worthwhile!

 

Researcher Spotlight: Alistair Bullen

Background

Alistair is an early career researcher who is currently the Research Assistant attached to the INFO-BC (Supporting shared decision making in secondary breast cancer) project.

He graduated from the University of York’s MSc in Health Economics in 2018 having previously completed a degree in Economics from the University of East Anglia. Alistair intends to continue to further his development towards becoming a seasoned researcher in the field of Health Economics.

Current Work

The INFO-BC project is currently the only project which Alistair is attached to. INFO-BC utilises discrete choice experiments in order to elicit patient preferences for second line treatment for secondary breast cancer. Alistair’s work involves executing systematic reviews, conducting qualitative field work and analysis, binary choice models, and utility theory.

Research Interests

Alistair is currently exploring how his current research may be able to evolve further into a topic for a PHD. He intends to progress further in either the area of cancer or the field of choice experiments, or both.

Teaching

Alistair has previously taught on the Health Economics module for the MSc in Clinical Trials.

Alistair Bullen at HESG

Author: Alistair Bullen

Health Economics Study Group and Discrete Choice Experiments

I am the primary researcher on INFO-BC. We plan to implement a discrete choice experiment (DCE). A DCE is a type of stated preference exercise where respondents make decisions hypothetical scenarios. Our team identified opportunity to use DCE’s in a secondary breast cancer setting. At the start of July I attended the Summer Health Economics Study Group (HESG) at the University of East Anglia (UEA), needless to say one of my main objectives was to discover what my peers in other parts of the UK doing in the area of preference elicitation. I found the three studies particularly interesting and have provided a summary of each of them here:

Moffatt. P, King. M, Viney. R, White. B, Butler. L, 2019. Impact and detection of straightlining response in health surveys (working paper)

The problem of straightlining is prominent in DCEs. Straightlining is when a respondent does not engage in a DCE and is instead found to be consistently choosing at random or choosing according to arbitrary factors, such as always choosing the option on the left. The authors demonstrated the problem of straightlining in an example DCE.  They also propose methods to identify straightliners and mitigate the problem. The proportion of straigliners identified was high at 45.2%, although there were concerns from the audience that the DCE used in the study was particularly complex and was therefore likely to have a higher proportion of straighliners. The methods which excluded individuals identified as straightliners appeared to provide more reliable estimates, although it remains to be seen if the same method would have the same results in the case of a more typical DCE design where there is likely to be a smaller proportion of straightliners.

McNamara. S, Tsuchiya, A. Holmes, J, 2019. Which preferences? choice architecture and normative health economics (working paper)

Stated preference exercises all have a choice architecture which affects how respondents interpret information and the decisions they make. This in turn impacts the resulting preferences. In health economics the results of stated preference can have real world effects on the decisions to provide or not provide treatments and technologies. In this study the authors illustrate how choice architecture can affect preferences using the example of a stated preference exercise eliciting public aversion to health inequalities. The authors address three key questions.

  1. If preferences are architecture sensitive, should we be using them in health-economic evaluation?
  2. If preferences are to be used in this way, what type of preference should we be using?
  3. How should we be structuring choice architectural decisions?

In summary the authors argue for the use of preferences assuming the approach is reasonable. They propose four questions to help Heath Economists structure their choice architecture. Finally they call for closer collaboration of Health Economists, behavioural scientists, philosophers, and policy makers to address the issue the sensitivity of preferences for choice architecture.

Boyers. D, Van der pol. M, Watson. V, 2019. The impact of ex-ante correction methods on hypothetical bias in Discrete Choice Experiment responses: A case study in dental care (working paper)

I acted as the discussant for this paper. The authors experimented with methods designed to mitigate hypothetical bias from their DCE. Hypothetical bias specifically refers to bias that arises when respondents fail to respond to a DCE in the same way that they would respond in an equivalent real life scenario. There was some evidence that two interventions went a small part of the way to mitigate hypothetical bias, these interventions were an honesty oath and a consequentiality script. To simplify the interventions: the honesty oath asked respondents to tick a box before the experiment and thereby promise to give honest responses; the consequentiality script informed respondents of the consequences the DCE is likely to have on policy decisions. The honesty oath was accompanied with the added complication that the completion rate was 10.3% lower than the baseline. The general verdict of the myself audience was that this is an interesting area for further research but that one would have reservations about implementing the proposed interventions unless stronger evidence was produced.

Researcher Spotlight: Katharina Diernberger

Background

Katharina is currently working as a Research Fellow for Health Economics at the Clinical Trials Unit Edinburgh and part time as a Doctoral Fellow at the Edinburgh Cancer Centre.

She is a Masters Graduate in European Health Economics and Management (EU-HEM) which included studying at the Management Center Innsbruck, University of Bologna and the University of Oslo.

She has working experience as a fully trained nurse in the Austrian health and social sector and did her BSc in Nursing.

Research Interests

Katharina’s research interests are wide spread and include Dementia and Cardio-Oncological studies as well as methodological questions such as expert elicitation for economic evaluation of diagnostic tests. Currently her main focus is in the area of end of life care. She is working with English and Scottish routine data and is involved in several Clinical Trials.

Teaching

Katharina developed and taught the Health Economics module for the MSc in Clinical Trials. Currently the module is refined and subsequently offered again in the coming academic years. She managed to involve colleagues from Edinburgh as well as health economists from Leeds and is seeking further collaboration with experts in related fields.

She is in her last few month of training for her Postgraduate Certificate in Academic Practice which she enjoyed and recommends for all (early career) researchers who strive to get involved in teaching.

Further, Katharina has supervised students from various masters programs and is having some ongoing and lined up commitments for supervision.

Current work

Currently, Katharina is doing a part time PhD on a University of Edinburgh staff scholarship. Several of the projects that Katharina is involved in feed directly into the development of her PhD.

Ongoing projects:

Cardiac Care, Allocative Efficiency in End of Life Care, ENeRgy Trial, Mabel Trial, EPAT Trial, TVT Trial

Welcome!

Hello everyone and welcome! We are the Edinburgh Health Economics (EHE) group, part of Edinburgh Clinical Trials Unit (ECTU), and this is our new blog!

In recent years, our enthusiastic team has been growing.  We now feel like it is about time that we shared with you, the research community, some of the work that we have been getting up to. For our first post, we thought that the best thing to do would be to get our Team Leader – Peter Hall – to tell you a bit about our group and our new blog.

Pete has been leading the EHE group, which bases itself within ECTU and the Usher Institute, since it was established in 2015. He is a Reader in Cancer Informatics and Health Economics, and practicing Oncologist at the Edinburgh Cancer Centre. When he isn’t treating patients, cycling to and from meetings, he is lecturing medical students, working tirelessly on one of his many research projects and keeping the EHE group on track.

Here’s what Pete had to say:

“It is an enormous privilege every day to hear the great ideas to solve problems in health economics that our group grapples with. Although Health Economists at our heart, we come from diverse backgrounds. This must be one of the reasons why we end up taking quite novel approaches to solve the established challenges of measuring value in healthcare. The environment we operate in with new data science and informatics opportunities in Scotland really gives the best opportunities to allow each of our members to shine.”

“One of our missions at the moment is to reach out to make sure that everyone knows when and how they should think about Health Economics in their research plans. The answer is ALWAYS and AS EARLY AS POSSIBLE. We hope that this blog will help you start a conversation with us. We would also love to hear from other Health Economists who share our interests.”

“As we look forward to the continuing development of EHE, the future looks bright! We hope you will join us in following this blog as we share and report on our range of activities. To find out more about our team and the projects we are working on, look out for our ‘Team Spotlight’ posts over the next few weeks!”