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Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Nearly 3 out of 4 Americans don’t take their medications as directed, resulting in serious health consequences. As a health care professional, you are in a critical position to help patients understand the vital role medication plays in managing a chronic condition such as diabetes, asthma, COPD, hypertension and high cholesterol. Although great care has been used to put together the content of this website, the National Consumers League (NCL) does not accept any responsibilities or liabilities for the consequences of Medicine Alerts not being complete or incorrect, nor for any non-receiving of NCL Medicine Alerts. NCL and its parents, affiliates, officers, directors, employees, suppliers and subcontractors are not responsible for (A) Any missed reminders, events, medications; or (B) repercussions or consequences, medical, health-related or otherwise, of missed reminders, events or medications relating to your use of the reminder service, including, without limitation, any message delivery or failed message delivery for any reason.
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The teens in one arm of the study receive only mailings to their home communicating simple messages related to their diabetes, like the timing of their next appointments.
The televisits use a HIPAA-compliant, web-based videoconferencing technology provided by Boston Children’s Telehealth Program. The visits encourage patients to create their own diabetes and self-care goals and to think about how to progress toward these goals. The trial is just beginning, but Rhodes is hopeful that in the near future she’ll see patients better managing their conditions and getting healthier. Patients who were enrolled in a medication synchronization program from their local pharmacy averaged more than 100 additional days of therapy annually and 30% more likely to take their medication as prescribed than those patients not part of a synchronized program, according to NCPA. The study was conducted at 10 independent community pharmacies throughout the nation from April 1, 2013 through September 30,2013. All comments must follow the ModernMedicine Network community rules and terms of use, and will be moderated. Quality Matters reported on emerging models and trends in health care delivery reform and interviews with leaders in the field.
Summary: A Findlay, Ohio–based collaborative made up of local employers, physicians, and a hospital system pooled data from employee health claims to find variation in the quality and cost of treatment of their employees. Issue Efforts to standardize care for specific conditions by encouraging providers to follow evidence-based guidelines are designed to reduce overuse of medical services and avoidable hospitalizations, as well as unwarranted emergency department use, which together contribute to rising health care costs and drain resources that might be better spent increasing access to care. To employers, such standardization is seen as a means of improving the value of services their employees receive and lowering costs—thus enabling employers to remain competitive with other businesses in countries with lower health care spending.
Data that would provide a comprehensive view of such variation are dispersed among many sources, including large insurers, employers, disease management programs, pharmacy benefit programs, and government payers, all of which capture health claims data for discrete populations of patients.
Organization and Setting The Employer Data Project was formed in 2005 by a handful of employers operating around Findlay, Ohio, the local hospital system, and representatives of more than 300 local primary and specialty care physicians.
The hospital system, Blanchard Valley Health System (BVHS), consists of two hospitals with a total of 175 beds. While the hospital system serves as the organizing body of EDOC, employers and physicians play an equal role in setting agendas for the group's thrice-annual meetings. The participating primary care and specialty care physicians tend to work in small practices of two to seven doctors, but many are represented by the Hancock Medical Group, a physician association.
Objective EDOC creates a forum in which employers and providers can discuss the quality and cost of care in the community. Process of Change EDOC relies heavily on the analysis of health care claims supplied by the employers, which use different third-party vendors to process the claims of their employees. For EDOC, the task of creating a reliable profile of physician performance proved to be complicated because it required properly attributing care to physicians who changed roles, depending on the venue in which they worked (for example, some switched from emergency department doctors one day to primary care physicians the next.) The data from the third-party administrator of the health claims were sometimes problematic because they included claims for the Medicare population that were based only on secondary insurance, and thus excluded claims that involved Medicare, making costs look lower than they truly were. Another problem was that the employers and the pharmacy benefit managers with whom the employers contracted also used different approaches to processing claims, and these had to be resolved before analysis could proceed.
To address this issue, EDOC spent six months educating physicians about the importance of proper coding, beginning with hypertension and gastro-esophageal reflux disease (GERD). To encourage adherence to evidence-based guidelines, physicians from EDOC also provided other local physicians with information about appropriate management and therapies.
The focus on hypertension led to a 25.5 percent reduction in the combined costs of physician visits and hospital care from 2004 to 2007.
The group also examined emergency department visits, which were of great concern to employers. The physicians also noted that a large number of their colleagues in private practice were referring parents to the emergency department after hours to obtain treatment for their children's ear infections, rather than using an after-hours service to triage such calls. EDOC explained to the physicians the importance of not referring such parents to the emergency department.
EDOC also worked to standardize treatment for diabetic patients who were hospitalized to ensure that the treating physicians used the most current methods for controlling blood sugar, which has an impact on patients' ability to recover from the condition or surgery for which they were hospitalized. The EDOC physicians also urged employers to change their benefit plans to ensure diabetic patients received proper nutritional counseling and diabetes education and to provide incentives, such as low copayments for pharmacy benefits and physician office visits, for patients to increase medication adherence and patient engagement. As a result of its collaboration with providers and other employers, Marathon Oil also forged relationships with the local nursing and pharmacy schools to use their students at workplace clinics.
One employer, Whirlpool Corp., went beyond these efforts to create a patient-centered medical home program in 2010. The hospital system quickly followed suit, creating a similar program for its employees that began in 2011. Early results suggest that medical homes, coupled with value-based plan design, are an effective means of increasing delivery of preventive care.
Whirlpool has also found that patients with a medical home are more likely to use their benefits for diabetes care than employees whose care is not provided through a medical home. Next Steps EDOC has also worked to standardize care for GERD in an effort to reduce GERD-related emergency department visits. Going forward, the physicians in EDOC would like to focus on heart failure, lipid management, and chronic renal disease.
Lessons In offering advice to other communities, leaders of the EDOC program stress the importance of taking an open-minded, non-adversarial approach to meetings involving employers and providers, especially at the outset. Providers that do work closely with employers can learn valuable lessons about business process improvement, Malaney says.
Selecting physicians with the temperament and willingness to analyze a large amount of data was also critical, Schroeder says. Implications While the EDOC is making significant strides in reducing variation and improving quality, the program may be difficult to replicate in some large metropolitan environments, especially those with numerous hospitals in competition with one another.
There are indications, however, that stakeholders with divergent interests can collaborate to achieve the goals of such programs. Securing the participation of private insurers and government payers is also critical to creating a complete picture of provider performance and the impact of benefit design on outcomes. Schroeder also expressed concern that some employers seem reluctant to change employee benefits, especially benefits that are popular with patients such as the use of chiropractic care for low back pain.
The physicians and the hospital also face resistance from providers and as a result Malaney says some of the programs have hit a plateau, which EDOC members find frustrating. This study was based on publicly available information and self-reported data provided by the case study institution(s).
The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. Sign up to receive newsletters and alerts about research, events, and more in the topic areas you care about most. The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. Richmond, Virginia -As part of its mission to improve patient adherence and outcomes through packaging, the Healthcare Compliance Packaging Council (HCPC) is excited to announce the winners of its annual Compliance Package of the Year competition.HCPC's Compliance Package of the Year competition has been an annual event since 1995 and recognizes the most innovative pharmaceutical packagesdesigned to improve patient adherence for the preceding market year. One of the judges reviewing the entries made these remarks concerning the Orkambi compliance-prompting prescription package, "Vertex Pharmaceuticals' Orkambi pack for treatment of cystic fibrosis is quite simply one of the best pharmaceutical package designs I've ever seen. Januvia is a once daily prescription diabetes pill that, along with diet and exercise, helps lower blood sugar in adults with type 2 diabetes.

A calendared blister, clearly labeled by day on each individual pill cavity, highlighting the 4 week dosing regimen. Prescription Afrezza® is a rapid acting inhaled insulin breathed through your lungs and is used to control high blood sugar in adults with type 1 and type 2 diabetes. Also provided to the patient are two prewrapped inhalers in a prepackaged carton, protecting the inhaler from dust, particulate, etc. The individual pouches and inhaler carton are combined with regulatory literature in the dispensing carton.
Several of the judges noted that inhalation therapy can be a complicated process for patients but approved of the well-developed Afrezza package. TB disease was once a leading cause of death in the United States, but since 1993 the rates of TB in the country have declined in all groups.
In 2011, TB disease was reported in 1533 non-Hispanic blacks in the United States, accounting for 23% of all people reported with TB nationally. Socioeconomic factors impact health outcomes and are associated with poverty, including limited access to quality health care, unemployment, housing, and transportation.
Language and cultural barriers, including health knowledge, stigma associated with the disease, values, and beliefs may also place certain populations at higher risk. TB remains a serious threat, especially for people who are infected with human immunodeficiency virus (HIV). Blacks accounted for an estimated 44% of all new HIV infections among adults and adolescents (aged 13 years or older) in 2010, despite representing only 12% to 14% of the U.S. Without treatment, as with other opportunistic infections, HIV and TB can work together to shorten the life of the person infected. In addition to HIV, other underlying medical conditions may increase the risk that latent TB infection will progress to TB disease.
Delayed detection and diagnosis of TB disease, as well as delayed reporting of TB disease remains a challenge in TB prevention and treatment. To achieve TB elimination, ongoing efforts are needed to address the persistent disparities that exist among racial and ethnic minorities in the United States.
CDC is working on projects designed to educate and raise awareness about TB in black communities. Other CDC activities include a study to identify the socio-cultural, racial, and health system barriers specifically for blacks with or at risk for TB. MedActionPlan allows providers to customize, document and print patient-friendly medication schedules and discharge instructions based on standard health literacy principles.
MedActionPlan makes the discharge process more efficient, and provides continuity of care between inpatient and outpatient services. MedActionPlan is an excellent patient education tool, a proven resource for teaching patients about their medication therapy. Our Mission: To provide the healthcare industry with innovative resources that utilize cutting-edge technology and proven health literacy principles to empower patients to become active partners in their healthcare. There are many factors that contribute to non-adherence, but the effect is always the same – patients are putting their health and their future at risk. We will not collect any personal or private medical or health information for this service. This means that you, not us, are entirely responsible for setting up the messages you send using the Reminder Service. You are responsible for maintaining the confidentiality of your registration for the Reminder Service and security of your telephone, wireless device, or computer. However, you agree that we have the right to monitor the messages from time to time and to disclose any information as necessary to satisfy any law, regulation or other governmental request, to operate the Reminder Service properly, or to protect ourselves or our users.
For greater certainty, we do not guarantee that the reminder service will be available, run error-free or uninterrupted, that we will correct all errors or deficiencies related thereto or that all messages sent by you will arrive at their intended destination on time. TO THE EXTENT YOUR JURISDICTION DOES NOT ALLOW THE EXCLUSION OF CERTAIN WARRANTIES OR LIMITATIONS OF OR EXCLUSIONS OF LIABILITY FOR INCIDENTAL AND CONSEQUENTIAL DAMAGES, THE ABOVE LIMITATIONS MAY NOT APPLY TO YOU. That excitement conspicuously slips away when they’re faced with managing something less glamorous—like diabetes. All have a hemoglobin A1c greater than 8 percent at the time of enrollment (levels of 6.5 percent or higher indicate diabetes). A six-month curriculum has been developed for teens in the second arm of the study, which includes downloading blood glucose data remotely from home and participating in monthly televisits with two professionals—a diabetes nurse educator to discuss the diabetes management plan and to set goals, and a social worker to provide support to implement the goals. At the end of each televisit, parents are invited to join in and understand how they can help their children at home. If all goes according to plan, this kind of intervention could be helpful for patients with other chronic conditions as well. Pharmacy dispensing data was collected for six months before the study and then six months during the study to determine medication adherence rates. Nearly 90% of patients who received synchronized refills were considered adherent as measured by the proportion of days covered compared to 56% of patients not receiving synchronized refills,” NCPA stated.
The enrolled patients were taking on average 5.9 medications and the 10 pharmacies dispensed 20 more prescriptions per year on average for these patients.
ModernMedicine reserves the right to use the comments we receive, in whole or in part,in any medium. To reduce the identified variation, the collaborative encouraged physicians to follow standardized treatment protocols, especially for chronic conditions such as hypertension and diabetes.
Researchers have suggested as much as 30 percent of all health care spending is lost to overuse of medical services and other forms of waste. Aggregating those data is a challenge because providers and payers may use different methodologies to assess performance and disagree about the validity of the data. Findlay is a largely rural community approximately 50 miles south of Toledo that has a population of 36,672, according to a 2009 estimate based on census figures. The majority of the employers are manufacturers with a stable base of employees, meaning they often pay employees' claims for decades rather than years and thus have an incentive to lower costs and improve care.
The health system also operates a level 3 trauma center, two retirement homes, a hospice, and a durable medical equipment company.
The physicians, who are all volunteers who consider quality improvement an important goal, represent different specialties. In particular, local employers were concerned that the costs of care did not correspond to the value of services their employees were receiving. To aggregate the data from multiple sources and harmonize the approach to analysis, the participating employers hired The Delta Group, a South Carolina–based company that specializes in measuring the clinical and financial performance of health care organizations. But once complete, the aggregated and de-identified data enabled employers to benchmark their cost and quality data against the larger group as well as national figures. While the data suggested wide variation in fees, these results had been distorted by inappropriate coding by physicians.
For example, one physician coded the rehabilitation of a patient who had a catastrophic motorcycle accident solely as a knee replacement, which again led to a misstatement of costs.
In addition to providing training, EDOC sent a nurse employed by the Hancock Medical Group to audit medical charts in physician offices, which heightened physicians' awareness of the need for close blood pressure control. Physicians received reports showing their individual results, group practice results, and EDOC-wide results after each hypertension audit. Pharmacy costs fell more modestly; when pharmacy costs were added to physician and hospital care, the overall reduction fell to 11 percent. They discovered that physicians in the emergency department were arguably practicing defensive medicine, such as ordering magnetic resonance imaging when a regular X-ray and a physical exam would have sufficed.
Making matters worse, the emergency staff were referring these patients back to primary care practices the next day to assess the effectiveness of the treatment, a practice that increased costs but provided little value as antibiotics for ear infections do not take effect for days, if not weeks. Emergency department physicians were asked to tell parents to call but not visit the doctor's office the next day.
Effecting this change required significant collaboration between hospital departments, such as nursing and dietary services, to ensure the proper timing of medication and meal services, as well as training for physicians. Marathon Oil was an early adopter of the physicians' recommendations; it began covering nutritional counseling and providing additional coverage for physician visits, among other benefits.
They also learned of potential wellness strategies, such as the use of employer-sponsored cooking classes.
To do so, it offered a modest (and undisclosed) payment to participating physicians to maintain a more comprehensive registry of care provided to patients with chronic diseases.
Between both employers, there is a total of 3,725 participants (including employees and their dependents) in the medical home program, the goal of which is to provide a comprehensive view of care and to use that information to help employees seek more preventive care.
The number of physicals for adults and children who had medical homes more than doubled from 564 in 2009 to 1,200 in 2010. Forty-seven percent of patients with a medical home make use of their medical benefits for diabetes care, compared with 35 percent of non–medical home patients, while 60 percent of medical home patients take advantage of pharmacy benefits. That program has reduced such visits by 35 percent from 36 in 2005 to 22 in 2007, the most recent year for which results are available. They also would like to see greater use of value-based benefit design to support patient engagement. Other employers may follow the lead of Whirlpool and BVHS if the results demonstrate cost savings and quality improvements.
The employers "have a lot of data and it is by no means all good," says the hospital system's CEO, Scott Malaney. His discussions with employers helped him recognize what manufacturers have long known: the importance of removing variation at the beginning of the process rather than the end.
Physicians participating in this program volunteered their time and did so because they had a strong commitment to quality improvement.
Other employers have hesitated about paying for expensive hypertension drugs that may be needed or switching to over-the-counter medication for GERD.
The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund’s case studies series is not an endorsement by the Fund for receipt of health care from the institution. The studies are intended to enable other institutions to draw lessons from the studied institutions’ experience that will be helpful in their own efforts to become high performers. Carton artwork provides detailed dosing instructions, a color coded dosing chart based on the number of units needed per dose, as well as a calendar to guide the patient in timely replacement of the disposable inhaler unit.
In 2011, a total of 10,528 TB cases were reported in the United States; however, blacks continue to have a disproportionate share of TB.

Dwindling resources and loss of public health capacity, including access to care and maintaining clinical and public health expertise add to the challenge. This relates to a greater proportion of people in these groups who have other risk factors for TB. These factors can directly or indirectly increase the risk for TB disease and present barriers to treatment of this disease. People infected with HIV are more likely than uninfected people to get sick with other infections and diseases, including TB. Compared with other races and ethnicities, Blacks account for a higher proportion of HIV infections at all stages of diseasea€”from new infections to deaths.
For example, the risk is higher in people with diabetes, substance abuse (including injection of illegal drugs), silicosis, or those undergoing medical treatments with corticosteroids.
Because the number of TB cases in the United States is declining, there is decreased awareness of TB signs and symptoms among health care providers and at-risk populations. In one project, representatives from ten sites where disproportionate cases of TB disease are reported in blacks received training to enhance skills for engaging communities, develop strategies, and sustain partnerships for reducing TB rates. The studya€™s goals include the development and testing of interventions to eliminate racial and ethnic disparities in TB rates in blacks; and to make improvements in health-seeking behavior, contact investigations, culturally sensitive case management, and completion of treatment among black TB patients.
The findings will be used to propose performance goals and indicators for TB programs in an effort to encourage faster diagnosis and treatment in this population. It improves the medication reconciliation process, as patients leave with a current home medication list. In partnership with over 130 public and private stakeholder organizations, the campaign offers adherence resources to help patients and the health care professionals who care for them.
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The thought is that more frequent and convenient visits might help foster realistic routines. Each patient was called monthly to discuss their medication and dosing regimens and determine if any doctor visits or hospitalizations changed their medication therapy. The hospital system also redesigned its care practices for diabetic patients with a goal of improving outcomes and reducing lengths of stay. Collaborations among employers and providers to analyze such data and reach consensus about problems in care can expedite efforts to reduce variation by demonstrating to providers the importance of standardization and by demonstrating to employers and other payers the need for changes to benefit design. For the purposes of the Employer Data Project, which the group refers to as EDOC, the hospital system serves as both the organizing entity and a participating employer.
Physician representatives say the multidisciplinary approach is essential to understanding and improving care coordination among specialists and primary care physicians. One local employer estimated that prior to the creation of EDOC, charges for some procedures were significantly higher than other communities in which it operated, a gap it attributed in part to the increased cost of attracting physicians to a rural community.
To create a basis for comparison, the company uses a nationally recognized severity adjustment system and episode-of-care measures for discrete procedures and conditions, such as hypertension, diabetes, and knee replacement surgery.
Some had coded complex cases with co-morbidities as cases without co-morbidities, making the cost of care appear more expensive than expected. These efforts resulted in a reclassification of hypertension cases with and without co-morbidities. The focus on hypertension enabled the physicians to point out a secondary problem: patients were not following up with their doctors on self-measured blood pressure results, which are essential to assess the effectiveness of prescribed medications. EDOC estimates that the employers as a group saved $528,000 over a two-year period in 2006 and 2007, or $121 per patient.
EDOC physicians rather than an employer's third-party administrator identified the problem and communicated it to the emergency physicians by educating them about the impact of extra costs on employers. To educate parents about the changes in practice, a physician wrote an article for the local newspaper and employers included similar messages in their employee newsletters. To improve adherence to evidence-based guidelines, EDOC provided training and implemented a registry system that enabled physicians, many of whom did not have electronic health record systems, to record the tests they administered and procedures performed through a Web-based system. The program increased the percentage of diabetic patients with basal insulin orders, a proactive approach to controlling blood sugar as recommended by the American Diabetes Association, from 47 percent in January 2006 to 69 percent in April 2010 (Exhibit 2). Other employers followed by providing full coverage for laboratory tests and office visits, as well as low copayments on diabetes medications.
The company also decreased copayments for patients seeking preventive care, including cancer screenings.
The number of mammograms for women age 40 or older increased by 64 percent over the same period, while the number of colonoscopies for patients age 50 and above tripled from 51 to 149. Persuading other physicians to adopt their recommendations was made easier by pointing out that such programs will help the physicians prepare for the rewards and penalties associated with forthcoming pay-for-performance programs from government and other payers.
However, Malaney, the system's CEO, thinks insurers may be reluctant to share proprietary claims data.
We are far from hitting the goals of all those parameters, but we are a heck of a lot better off compared to the baseline data set," Orr says.
It is important to note, however, that even the best-performing organizations may fall short in some areas; doing well in one dimension of quality does not necessarily mean that the same level of quality will be achieved in other dimensions. ORKAMBI® is provided in convenient daily blister units, with graphics clearly highlighting the AM and PM dosing requirements. The carton opens from the top whereby the inner flap provides easy-to-read dosage instructions. But, beyond successfully introducing a method of accomplishing this, the Afreeza package successfully provides clear instructions and an inhalation device that provides a high degree of user friendliness: the color coding for different dosages, and the simplicity of the inhalation device. The bacteria usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney, spine, and brain. The percentage of TB cases in blacks is higher than expected based on the percentage of blacks in the U.S. It is critical to reach those at highest risk for TB, and to identify and implement innovative strategies to improve testing and treatment. Like other communities, blacks face a number of challenges that contribute to higher rates of TB. For people with TB disease, inadequate treatment can lead to treatment failure, relapse, ongoing transmission, and development of drug resistance. Patients may be less likely to seek medical care and health care providers may be less likely to consider TB as the cause.
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The collaboration has provided a venue for physicians to suggest changes to employer benefit programs that encourage patients to seek more preventive care and increase medication adherence.
Despite these potential benefits, leaders of such collaborations say they are few and far between. The goal of EDOC was to explore other causes behind these costs and to reach a consensus on the most appropriate way to address them. Such episode-of-care measures, which are severity adjusted, include total inpatient, outpatient, and pharmacy benefits and have been used by other employer groups to identify variation in the cost and quality of treating these conditions and procedures. Some of the employers responded by increasing workplace blood pressure checks and asking their occupational nurses to record the results and encourage patients to communicate them to their physicians.
EDOC also provided physicians with individual, group, and EDOC-wide results on adherence to evidence-based guidelines for diabetes care. During this time period, the number of patients with one or more emergency department visits fell by 14 percent, to 210. Whirlpool says it is too early to tell whether the medical home program has reduced costs, but it is monitoring this.
The employers felt it was important not to do so: "The biggest thing was for the doctors to be able to put themselves in our shoes and for us to be able to put ourselves in their shoes," says Robin Love, Marathon's benefits administration manager. Inside the box are four separate and identical folding cartons that all open just like the larger outer carton.
For people with latent TB infection, medication for a condition with no symptoms of illness is often not a priority.
In the cardiovascular disease patients, the medications were heart failure drugs, antianginal agents, antiarrhythmic drugs, and antiplatelet agents. One employer in the collaborative went on to create a patient-centered medical home that has more than doubled cancer screenings while reducing emergency department use.
McDaniel believes physicians also strengthened their arguments for value-based insurance design by stressing the financial benefit of proposed changes.
Thus, it is critical to adopt systematic approaches for improving quality and preventing harm to patients and staff.
All packaging components are color coded, with each of the four cartons representing a seven day supply of medications, four tablets per day.
Anindication of each cartridge strength is also molded in the plastic of the individual cartridge. If looking at only people born in the United States, the proportion of TB in blacks is even greater. Although rates of TB in blacks have declined substantially over the past decade, the disparity remains. Addressing the TB disparity among blacks is an important priority; prevention and control efforts should be targeted to this population. Skinner, "Geography and the Debate Over Medicare Reform," Health Affairs Web Exclusive (February 13, 2002) and E. Fisher, "More Care Is Not Better Care," Expert Voices, Issue 7 (National Institute for Health Care Management, January 2005).
This estimate is based on a study of geographic variation in health care, which found greater spending for health care services does not yield better outcomes.

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