Sunday, July 22, 2018

The Administration closes the National Guideline Clearinghouse: Bad for our health!

The Department of Health and Human Services (HHS) has closed the National Guideline Clearinghouse (NGC), which was housed in its Agency for Health Research and Quality (AHRQ), by pulling its funding. If one goes to the NGC website, it actually says that there is no longer funding for it. The NGC provided a major resource for consensus information, and closing it is a tremendous loss, not only for the physicians and other medical providers who depended upon its recommendations, but for the health of the American people. It is also, sadly, a loss for the patients of physicians and other medical providers who did not heed, and even opposed the existence of these guidelines. This is because  they will now have the cover that comes from the absence of the NGC when they do things that are not supported by the best evidence available.

Wait, wouldn’t my doctor want to use the best evidence available? Can’t I depend on her/him doing this? Do I have to become a medical expert?

You – we would all – hope that our doctors would use the best evidence available. This is not necessarily the newest stuff, for the obvious reason that it is new, and thus less tested. Frequently, when a test or intervention is new, it looks good, but later, when more people have been exposed to it and more data are available, negative information may emerge. (Sometimes this is because serious side effects may appear to a new drug because so many more people are using it; sometimes it is the result of straight-up fraud, as in the case of Theranos – see The Political is Personal: Corporate power, social isolation, and the health of the nation -- Part 2, April 22, 2018.) Conversely, the oldest tests and treatments are not necessarily the best either – a doctor who does not keep up after his or her training is also going to be way behind.

And guidelines are, of course, guidelines, not laws – they are meant to guide the practitioner to help make the best decisions by summarizing and presenting the evidence, for the whole population and for significant “sub”-populations. For example, older people may have a greater benefit from – or be at greater risk of harm from – a certain treatment than younger people. This could be from a different physiology (kidneys, for example, don’t function as well at cleaning out poisons in older people) or from a different risk/benefit profile (perhaps a bad outcome usually takes longer to appear than the life expectancy of a person; a 20-year lag time for something bad has a different meaning for a 50 year old than an 80 year old).

Not all guidelines have the same strength of evidence behind them. Sometimes the evidence is very strong, coming from multiple randomized controlled trials (RCTs) that are consistent with each other; at the other extreme, they can come from the opinions of a group of experts in the field who are gathered for the purpose of creating a guideline. However, in any case, the guidelines presented should be those for which the strongest evidence exists. The website for NGC still has available the inclusion criteria for the guidelines that used to exist there. The physician is always able to do something different if the recommendation is for some (good) reason not appropriate for a particular patient. But s/he should know, or be able to find – on the NGC, say – what the guidelines are for a particular course of action (test, treatment, etc.). Until just recently, they could. Not now. Which raises the question: why is it gone?

I, of course, do not know the answer, so am forced to speculate. There is some cost to maintaining the guidelines and doing the research, and many people do not like cost, but so much more is being spent on arguably less important things (if one considers the health of the people important; I do). Some people, versions of libertarians, do not like anything that even suggests government mandates, but I know few libertarians who advocate suppressing the truth. Some people are not surprised at any actions taken by the current administration and its executive departments, particularly those that seem to take on science, as has happened with climate change and the use of fossil fuels, but those seem, ultimately, to be based on money and the opportunity for profit. Thus, destroying pristine areas for fossil fuel exploration (the Arctic, the tar sands) and transport (the Keystone pipeline), as well as of the world’s climate from burning them, makes people money. Rich and powerful people.

So maybe that is where we should look for the closure of NGC. The fact is that if there are guidelines there is a rebuttable presumption that, barring differences in the individual patient that are relevant, they should be followed. If the evidence shows that a particular diagnostic test or a treatment (drug, device, etc.) is usually better, it is going to hurt the pocketbooks of the manufacturers of alternative drugs or devices or tests. And it can also hurt the pocketbooks of actual doctors if they make their money doing something that is no more effective than, or even less effective than, doing something cheaper or easier – especially if that is done by someone else. Sometimes the issue is standardization; it saves money for a hospital (and can improve quality) if only one or two types of, say, artificial joints are used. But this hurts (obviously) the manufacturers of the other brands, and perhaps is a negative for those surgeons who have learned how to use the non-preferred brands (see Atul Gawande, “Big Med”, New Yorker, August 13, 2012). It is even a bigger issue when the evidence demonstrates that the costly surgical option doesn’t work, or doesn’t work as well as, a much cheaper non-surgical option that exists. Well, then, you are threatening someone’s income – just like renewable energy threatens the income of companies that produce and sell fossil fuels.

But would doctors actually do such a thing? Resist a cheaper and more effective alternative because it would cost them money? You betcha. Not always, of course, and not all doctors, but it has happened. “In the late 1990s,” the New York Times observes in its excellent editorial on the subject,  “when it [AHRQ] endorsed nonsurgical interventions for back pain, the back surgeon lobby waged an attack that resulted in huge funding cuts and placed a permanent target on the Agency for Healthcare Research and Quality (A.H.R.Q.), the agency that houses the database.”[1] They attacked the existence of the Agency because they didn’t like (REALLY didn’t like, since it would hit them in the pocketbook!) the evidence.

Yup. It happened. I remember it. It was shocking to me (I must have been more naïve!). I lived in San Antonio at the time, and a San Antonio congressman, Henry Bonilla, was leading the charge against AHRQ, to the embarrassment of the non-back-surgeon San Antonio medical community. But they were, and are, a rich and powerful lobby. And they are still doing thousands of surgical interventions for back pain of the type that AHRQ recommended against in the ‘90s. And making a lot of money on it. Maybe you had such a procedure? Did it help? I hope so. If you are trying to decide, for this or any other complicated treatment (surgery, cancer treatment, etc.) and wanted to know what was recommended for your problem, you could have gone to the NGC website and looked it up. Not now.

One issue with the evidence, of course, is that it depends upon what research was done, and on what populations. And diagnostic and treatment plans that make money for doctors and hospitals are only of use to them if they get paid, and paid well, so they are less likely to be done to poor and uninsured or underinsured people. Maybe this is one time when not having good insurance is a health benefit!

But it shouldn’t be. We should all be covered for necessary diagnosis and treatment. And whether providers or manufacturers can make money should not be a criterion for recommending it. And now we have less access to finding out what the recommendations are.

[1]By the way, how did Fox News cover this story? I could only find one link, to Fox Vegas, which used the CNN coverage, which was quite critical of the elimination of NGC. National Fox didn’t seem to think it worth covering.

Friday, July 6, 2018

Physician frustration and "burnout": A wider breadth of practice helps!

Physician burnout is a topic that is much-discussed in the medical community. It’s not a very good term; most people have stressed, sad, or overworked days or weeks, but it is the one that we seem to be stuck with. It is true that many physicians are often not happy, feel overworked and stressed and unable to spend enough time with their families. Most important, perhaps, they feel that this leaves them unable to do as good a job caring for their patients as they would like to. The main factors are workload, both in terms of the number of people that they have to see in a day, and ever-increasing “administrative” work. A big part of this is charting on an Electronic Health Record (EHR). While this modern method of charting allows quick retrieval of much important information and makes it possible to maximize billing, it is very time consuming.

Primary care doctors, such as family physicians, have among the highest rates of “burnout”, exceeding 30% in some studies and rising to nearly half in younger physicians . A recent study by Young, Burge, and colleagues showed that family doctors spend more time entering data into EHRs than they do face-to-face with patients! Patients are justifiably upset when their doctor spends more time looking at the computer screen than they do looking at them, and it is bad for the physician-patient relationship. However, the charting still has to be done, so those doctors who are not spending time on the EHR during the encounter are staying late to do it after office hours or doing it from home on evenings and weekends, which also contributes to frustration. Studies also show that a higher percentage of female physicians report experiencing “burnout”, likely because in many or most families it is still the woman who bears the burden of household and family responsibilities, even when she has a full-time and demanding job such as a physician.

There are a variety of reasons why family and other primary care physicians are particularly vulnerable to burnout. Reimbursement per visit is lower than for most other specialties, which means there is less money to hire people or buy systems to make things more efficient. Since most physicians are employed, primarily by large hospital systems, rather than in private practice, the system drives the work, not the doctor. Of course, the logic for paying primary care physicians less is, well, non-existent, but there are many non-logical justifications, most of them based upon the tradition of “subspecialist have always made more money” and are self-serving.

One conceit is that the work of subspecialists is “harder” or “more complex” and thus justifies greater reimbursement. This is not always, or even usually, true. As I have previously discussed on this blog (e.g., Can you be "too strong" for family medicine?, March 19, 2013), the work of a family doctor is particularly complex. For each patient, the family physician takes care of, or co-manages, all of a patient’s medical – and psychological and social – issues, as opposed to just one, as subspecialists do. In terms of the day’s schedule, a family doctor sees a wide variety of patients: a person with a new acute illness can be followed by one with several chronic diseases, then a well-child, then a sports injury, then a pregnant woman, etc. I have documented this in an “AAFP One-Pager” published in the American Family Physician in December, 2014.[1]

But, because subspecialists get higher reimbursement, their employers are happier and likely to spend more money supporting them. Some (ignorant but not rare) health system administrators wonder why a family doctor cannot see more patient in a given time, like, say, orthopedic surgeons do. The orthopedist sees someone referred for a specific problem, after x-rays or more extensive (and expensive) tests like MRIs have been done, often after the patient has been seen by another professional such as a physician’s assistant, does a quick exam of the particular area and decides if surgery is needed or not, and has someone else arrange it. It is, of course, the surgery, not the clinic visit, that earns the surgeon money. The family doctor is, as noted above, addressing all of a patient’s chronic and acute medical problems, as well as the social and psychological problems, and often has to fill out forms such as disability, FMLA, etc. even when another doctor (say, that orthopedist) is doing the procedure, because those subspecialists are “too busy” (ie., earning, directly for themselves or for the health system and then indirectly for themselves, too much money per unit of time).

It is, thus, unsurprising that those specialties that are the highest-paid (e.g., orthopedic surgery) and especially those with the highest income-to-work ratios (e.g, radiology, dermatology, anesthesiology) have little difficulty recruiting new doctors, while the lower-paid specialties, like family medicine, have much more. After all, the indebtedness from medical school –typically hundreds of thousands of dollars (which usually requires annual payments of far more than the average American’s total salary) is the same whatever specialty you enter. The higher revenue generated by subspecialists allows them – or the hospital systems that employ them -- to pay for non-physicians to do a variety of tasks, both clinical (nurse specialists and physician’s assistants) and documentation (scribes, coders, etc.) The American Academy of Family Physicians (AAFP) suggests that the root cause of family physician burnout is inadequate team-based care, but the fact is that the members of those teams have to be paid, and the greater the physician reimbursement the more team members there can be.

Given all this, one could reasonably worry that family doctors will no longer be happy doing all the breadth of care that defines the potential of the specialty, such as continuing to deliver babies, or take care of their patients in the hospital, or make home visits. After all, if they are stressed out “just” seeing patients in the clinic, wouldn’t this make it even worse? Take more time? Increase burnout and stress? To me, that would be a bad thing; one of the terrific things about primary care doctors, reasonably defined as “doctors for you” (rather than for a specific condition) is that they can see you, and care for you, in all settings.

Which is why it is gratifying to read the results of a paper just published in the Annals of Family Medicine by Weidner, Phillips, Fang, and Peterson called “Burnout and Scope of Practice in New Family Physicians”. Contrary to what one might fear, it turns out that, at least among younger physicians, having a wider scope of practice – specifically caring for patients in the hospital, delivering babies, and doing home visits – is associated with a lower rate of self-perceived burnout. This is heartening – maybe being able to function at their highest level, care for people in all the settings in which they seek care, provide real continuity, do good medicine is part of the answer. Some of this may be because the breadth of care, the different kinds of problems to care for, the possibility of being there for your patient in whichever venue their care is delivered, the caring for the whole patient, is why people chose family medicine in the first place, rather than a (higher-paid) specialty where you care for only a few diagnoses or do a few procedures over and over again. 

Yes, doctors, even the lower paid specialties, make very good salaries compared to most Americans, and so it is hard for people who have lower-paying jobs, are afraid of losing their jobs, or have no jobs at all to feel too sorry. Yet it is in the interest of their health that their physicians are able to feel satisfaction with their work, most importantly to be able to do the best that they can to take care of a person’s medical needs. Medical care can be made more efficient than it is, especially in eliminating the ridiculous lack of communication between doctors, hospitals, and patients that characterizes our fragmented non-system. All workers feel more satisfaction and do a better job when they have the ability to exercise some discretion and not simply work on an endless assembly line. Medical care especially cannot be reduced to an assembly line, because you are a person, not a widget.

Our medical system needs to cover everyone, communicate within itself effectively, and be flexible enough to meet the needs of all people.

[1] Freeman J, Petterson S, Bazemore A., Accounting for complexity: aligning current payment models with the breadth of care by different specialties. Am Fam Phys 2014 Dec 1; 90(11):790. PMID 25611714

Tuesday, June 26, 2018

Bezos, Buffett, Dimon and Gawande: Better quality in health maybe; a solution, no

A big item of health news in recent weeks is the planned establishment of some sort of health delivery operation by three major corporations personified by their CEOs: Warren Buffett of Berkshire-Hathaway, Jeff Bezos of Amazon, and Jamie Dimon of JP Morgan. We have no details about what it will actually look like, but we are assured that it will be high-quality, efficient, and cost-effective, utilizing the most modern methods of achieving those goals, which our creaky, antiquated, and resistant-to-change health system does not. It will also be non-profit, important given that none of these companies are, but this is the most common model for health care in the US and in itself says very little. As the first concrete step toward its creation, and clue to what it may be, they have appointed Dr. Atul Gawande as its CEO. Presumably he will be instrumental in creating this new venture, and his views on quality and efficiency may provide guidance on what might characterize it.

Dr. Gawande, a Harvard surgeon and senior writer for the New Yorker, has provided us a prolific body of writing in that magazine and in several books, (including the best-seller about issues occurring at the end of life, “Being Mortal”), to help inform us of his views. He has a wide scope of interest in health care and a demonstrated willingness to learn from other industries. Perhaps his most famous article is “The Cost Conundrum”, which appeared in June 2009 and highlighted the wide variation on expenditures by Medicare for similar populations, focusing on the highest cost region, McAllen, TX, and comparing it to a similar population in El Paso, TX, where costs were much lower. Later, in January 2011 “The Hot Spotters” highlighted the work of Dr. Jeff Brenner in Camden, NJ, and others, to use modern geo-mapping techniques to identify the areas with the highest levels of emergency (911) utilization (unshockingly, in Camden, the two highest were a low-income senior citizens housing unit and a long-term care facility) and try to develop methods for addressing their health needs before they became emergencies. In “Big Med”, August 2012, he discusses application of some of the principles that work in restaurants such as the Cheesecake Factory to health care. The principles include enough variety to meet everyone’s needs without expensive unnecessary redundancy; he shows how this applies in orthopedic surgery and how quality is improved and costs saved when every surgeon in a hospital doesn’t use his (or, more rarely among orthopedists, her) favorite implant device and there is some standardization (commented on in this blog on August 24, 2012, Quality and price for everyone: Bigger may be better in some ways, but not all). A very good review of Gawande’s work and probable priorities has been done by the outstanding Dr. Don McCanne in his “Quote of the Day” on June 22, 2018 “Don’t wait for Atul Gawande”, and I will not repeat it here.

Of course, the employees of Berkshire-Hathaway, JP Morgan, and Amazon already have health insurance, so that this new scheme will not reduce the rate of uninsurance. It is possible that it – whatever “it” turns out to be – will allow enrollment from other employers, or possibly even individuals who are currently insured by another mechanism, whether through Medicare, the ACA-sponsored exchanges, or even Medicaid. This will depend in part on what “it” is – mostly an insurance plan, mostly a care delivery system, or a combination of both like many HMOs.

It is possible that this new operation may indeed succeed in achieving, or at least significantly moving toward, the “Triple Aim” of higher quality, greater patient satisfaction, and lower cost. Certainly the third of these is a major focus of businesses that provide health insurance to their workers, and we will grant these people the benefit of the doubt that they also wish to achieve the first two. Some HMOs have had significant success in doing so already, most notably Kaiser Permanente. Other HMOs that were once “consumer cooperatives” (eliminate the middleman and pay less for the same care or the same for more and better care) have almost all been bought by insurance companies, and it is obvious that the “save money” (or really “make more money”) leg of the #TripleAim is of far greater importance to their business model than patient satisfaction or quality. The bar, as has been demonstrated ad infinitum, including in the work of Dr. Gawande as well as other policy analysts from
academia, the foundation world, and journalism, is so low that large improvements in quality can come from things that it is we already know how to do. The major obstacle to this has always been how providers are paid, and this is where the behemoth strength of this new triumvirate may have significant impact.

Unfortunately, though, there is no suggestion that this new operation would do anything to help those currently either frozen out of the system (including poor people in states that have not expanded Medicaid, undocumented people, and those who cannot afford insurance premiums even with ACA support). The average salaries at JP Morgan and Berkshire-Hathaway are high since so many of the employees are high-level finance types, raising the mean and median. However, Amazon is a different story. Jeff Bezos may be the richest person in the world, he did not get there by paying his employees a living wage; the median income for an Amazon employee is $28,446. While they may have health insurance, it would not be surprising if many of Mr. Bezos’ employees qualify for food stamps, and have difficulty making their copays; that median salary is about the poverty level for a family of four, and if it is the median, many workers make less.

It could be argued that is unfair of me to criticize a program – especially one still in the planning stage -- for not achieving what it does not set out to achieve. However, there is nothing wrong – and indeed it is quite correct – to note that it is far from being a health care panacea. By not setting out to ensure access for everyone, it will not solve the basic problem in achieving the Triple Aim. I mean, it’s good to be focusing on quality, cost and patient satisfaction but without a plan to assure that everyone has access to care it can ring a little hollow.

As was observed by Schiff, Bindman, and Brennan more than 20 years ago, and quoted by me before (Medical errors: to err may be human, but we need systems to decrease them, August 10. 2012), denial of care – or lack of access to care for financial, geographic or other reasons -- is the “gravest of all quality defects”.

Sunday, June 10, 2018

Why don't we spend more on public health? It is harder to see the bullets we dodged -- and then there is profit.

It Saves Lives. It Can Save Money. So Why Aren’t We Spending More on Public Health?”  (New York Times, May 28, 2018). Actually, this is a terrific question. As so often, it is complicated. Let’s start with the benefits that authors Aaron E. Carroll and Austin Frakt describe. First, there are vaccines. They eliminated smallpox and virtually eliminated polio in the United States. They have dramatically reduced the rate of common childhood illnesses including measles, mumps, rubella, chicken pox, and Hemophilus influenza (H. flu) infection. They have the potential for essentially wiping out cervical cancer through immunization against HPV, and liver cancer (as well as many forms of chronic hepatitis and cirrhosis) through vaccines against Hepatitis B.

A huge public health intervention is making our environment safer. This means having good sewage and clean water, and lead-free gasoline and cleaner air. These changes have saved far more lives, and improved health much more, than all of the individual medical care interventions combined. If you have traveled abroad, especially to less developed countries, you know how important these are. Indeed, better sanitation, as well as better surveillance and treatment, have dramatically reduced other infectious diseases that were once terribly feared, notably tuberculosis. And inspection of our food supply, restaurant and otherwise, are another very important part of public health.

The other big public health measure is education. Of course, education can be and is provided to individuals by health professionals as well as populations via public service education, but it is major nationwide public health efforts that have made a big difference. These include the huge decrease in cigarette smoking, and the greater safety of automobiles and their exhausts. Cigarette smoking used to be ubiquitous (see any WW2 movie) and in what would shock young Americans today, widely practiced in restaurants and even college lecture halls. Today that is unimaginable, and smoking in most places is aberrant, with less than 15% of adults currently smoking and most of those trying to quit. Car accidents are still a major cause of death and injury, but deaths from cars are way down. Almost none of this is related to people driving more safely and almost all of it to safer design of cars (think seat belts, air bags, engines that collapse down instead of back in a collision) and roads. Lead poisoning of children is way down in most places in the US thanks to lead being banned from gasoline and paint.

There are still many challenges on the public health front. Reducing the rate of chronic diseases though education around eating huge numbers of empty calories still have a long way to go. The terrible infectious disease epidemic of recent decades, HIV, has been greatly reduced by treatment, but until there is a vaccine, high-risk sexual behaviors persist. The opioid epidemic is killing more and more people, and it is only through societal approaches that this is going to be reduced.

The epidemic of gun death is not abating; many studies and articles in the press have recently discussed the increase in the suicide rate, often prompted by recent high-profile suicides such as those of Kate Spade and Anthony Bourdain (How Suicide Quietly Morphed Into a Public Health Crisis; 5 Takeaways on America’s Increasing Suicide Rate, ). While neither Spade or Bourdain used a gun, guns are the cause of death in at least half of suicides, and suicide far exceeds homicide in terms of numbers of gun deaths. Those who believe it is not the availability of guns that causes deaths from both causes, and other methods could be used to kill oneself or others, are simply wrong. Easy availability of guns, far more effective and efficient at killing oneself or others than any other method, absolutely has been demonstrated to increase both homicide and suicide. Suicide by gun is over 90% effective; by drugs less than 5%. “Successful” suicide rates are far higher in high gun states (e.g., Montana) than in low-gun states (e.g., Massachusetts). Homicides are also more common where guns are at hand. And, in regard to school and other mass shootings, while you can kill someone with a knife or a baseball bat, but it is hard to commit mass murder with them.

So, why do we not spend more on public health? Why do we spend so much more on what is, from a societal point of view, much less effective individual health interventions, and less than 5% of that on public health? One reason, of course, is that when each of us is sick, we (usually) want treatment, as much as possible, especially if there is a chance that it could cure us, or at least ease our suffering. This is understandable, and it is tied to the fact that we have much greater awareness of treatment of something ailing us (curing our infection, relieving our pain) than of not having disease because of the presence of public health practices. As I would tell students, how often do we wake up thankful that we do not have cholera because we have a clean water supply? Indeed, when we find that the water in Flint, MI, is contaminated with lead, we are shocked because we assume our water is safe; when we find an E. coli outbreak from a restaurant, we are shocked because we assume our food is safe.

There is also, unsurprisingly, the issue of the money that to be made. The provision of public health is rarely a big profit center, and it is usually, therefore, done by government – local, state, and federal. Individual health care, however, is a huge money-maker for insurance companies, hospitals, doctors, pharmaceutical and device manufacturers, nursing home companies, and on and on. All that money – over $3.3 TRILLION by recent estimate -- spent on your and other individuals, while it may (or may not) have a salubrious impact on you, is going into someone’s pocket. On the flip side, public health interventions often reduce profit, especially when they are very effective. The struggle against tobacco, which killed more people than any other cause by far, was fought long and hard by the tobacco companies (currently now plying their wares in the less-developed world).Each of the changes to cars that led to the great increases in safety was fought by the industry. Today, we continue to see tremendous opposition to rules that make our environment (air, water) clean and safe; sadly, under the current administration, many of these rules are being rolled back, which will absolutely decrease our society’s health.

I guess I also need to address the people who believe that vaccines are unsafe. They are a major threat, and presumably haven’t seen children dying of measles, of the suffering of chicken pox and mumps, of the morbidity from H. flu infections of the middle ear (my students have never seen it!) or deaths from H. flu epiglottitis. Yes, there can be minor side effects from some vaccines, but the benefit is overwhelming.

Finally, as always finally, it is the poor and disenfranchised who suffer the worst. While sometimes we have the perverse satisfaction of outbreaks of vaccine-preventable diseases in well-to-do communities, anti-vaxxers unconscionably campaign in immigrant/refugee communities telling people to not vaccinate their children. The poor and minority city of Flint suffers a poisoned water supply. The oldest, cheapest houses are likeliest to have peeling lead paint and be located near polluting factories and dumps. Tobacco and junk food manufacturers advertise most heavily in minority neighborhoods. And, of course, the murder rate is highest in poor and minority communities.

Good medical care for individuals is valuable when it is needed, and could be less expensive. Public health measures are even more valuable and cost-effective. We need to increase the money and effort spent upon public health interventions, and certainly not scale them back.

Benjamin Franklin said an ounce of prevention is worth a pound of cure. It’s true, and is a great argument for greater investment in public health.

Saturday, June 2, 2018

The Administration's New Proposal to Address the Determinants of Health

  (a Shakespearean sonnet)

Together, many things affect our health,
Genetics and environment to start,
Where we live and whether we have wealth,
Our personal behaviors play a part.

The Trumpers say they want us to act smart,
Not to smoke, or drink too much, let’s say,
Or overeat (it might affect our heart),
Or else – they’ll take our Medicaid away.

Then we won’t have access to healthcare,
Or treatment options when we do get sick.
Clearly, this is totally unfair,
To solve the problem, it won’t do the trick.

To have a healthier society,
We need real reform, not smug piety.


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