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Emond Y, Wolff A, Bloo G, Damen J, Westert G, Wollersheim H, Calsbeek H. Complexity and involvement as implementation challenges: results from a process analysis. BMC Health Serv Res 2021; 21:1149. [PMID: 34688287 PMCID: PMC8542304 DOI: 10.1186/s12913-021-07090-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 09/21/2021] [Indexed: 11/17/2022] Open
Abstract
Background The study objective was to analyse the implementation challenges experienced in carrying out the IMPROVE programme. This programme was designed to implement checklist-related improvement initiatives based on the national perioperative guidelines using a stepped-wedge trial design. A process analysis was carried out to investigate the involvement in the implementation activities. Methods An involvement rating measure was developed to express the extent to which the implementation programme was carried out in the hospitals. This measure reflects the number of IMPROVE-implementation activities executed and the estimated participation in these activities in all nine participating hospitals. These data were compared with prospectively collected field notes. Results Considerable variation between the hospitals was found with involvement ratings ranging from 0 to 6 (mean per measurement = 1.83 on a scale of 0–11). Major implementation challenges were respectively the study design (fixed design, time planning, long duration, repeated measurements, and data availability); the selection process of hospitals, departments and key contact person(s) (inadequately covering the entire perioperative team and stand-alone surgeons); the implementation programme (programme size and scope, tailoring, multicentre, lack of mandate, co-interventions by the Inspectorate, local intervention initiatives, intervention fatigue); and competitive events such as hospital mergers or the introduction of new IT systems, all reducing involvement. Conclusions The process analysis approach helped to explain the limited and delayed execution of the IMPROVE-implementation programme. This turned out to be very heterogeneous between hospitals, with variation in the number and content of implementation activities carried out. The identified implementation challenges reflect a high complexity with regard to the implementation programme, study design and setting. The involvement of the target professionals was put under pressure by many factors. We mostly encountered challenges, but at the same time we provide solutions for addressing them. A less complex implementation programme, a less fixed study design, a better thought-out selection of contact persons, as well as more commitment of the hospital management and surgeons would likely have contributed to better implementation results. Trial registration Dutch Trial Registry: NTR3568, retrospectively registered on 2 August 2012. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07090-z.
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Affiliation(s)
- Yvette Emond
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences (RIHS), Radboud university medical center, PO Box 9101, 114 IQ healthcare, 6500 HB, Nijmegen, The Netherlands. .,Department of Anesthesiology, Pain and Palliative Care, Radboud university medical center, Nijmegen, The Netherlands.
| | - André Wolff
- Department of Anesthesiology, Pain Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gerrit Bloo
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences (RIHS), Radboud university medical center, PO Box 9101, 114 IQ healthcare, 6500 HB, Nijmegen, The Netherlands.,Department of Anesthesiology, Pain and Palliative Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Johan Damen
- Department of Anesthesiology, Pain and Palliative Care, Radboud university medical center, Nijmegen, The Netherlands
| | - Gert Westert
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences (RIHS), Radboud university medical center, PO Box 9101, 114 IQ healthcare, 6500 HB, Nijmegen, The Netherlands
| | - Hub Wollersheim
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences (RIHS), Radboud university medical center, PO Box 9101, 114 IQ healthcare, 6500 HB, Nijmegen, The Netherlands
| | - Hiske Calsbeek
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences (RIHS), Radboud university medical center, PO Box 9101, 114 IQ healthcare, 6500 HB, Nijmegen, The Netherlands
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Amati R, Bellandi T, Kaissi AA, Hannawa AF. Testing the Integrative Quality Care Assessment Tool (INQUAT). Int J Health Care Qual Assur 2019; 33:120-144. [PMID: 31940150 DOI: 10.1108/ijhcqa-03-2018-0065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE Identifying the factors that contribute or hinder the provision of good quality care within healthcare institutions, from the managers' perspective, is important for the success of quality improvement initiatives. The purpose of this paper is to test the Integrative Quality Care Assessment Tool (INQUAT) that was previously developed with a sample of healthcare managers in the USA. DESIGN/METHODOLOGY/APPROACH Written narratives of 69 good and poor quality care episodes were collected from 37 managers in Italy. A quantitative content analysis was conducted using the INQUAT coding scheme, to compare the results of the US-based study to the new Italian sample. FINDINGS The core frame of the INQUAT was replicated and the meta-categories showed similar distributions compared to the US data. Structure (i.e. organizational, staff and facility resources) covered 8 percent of all the coded units related to quality aspects; context (i.e. clinical factors and patient factors) 10 percent; process (i.e. communication, professional diligence, timeliness, errors and continuity of care) 49 percent; and outcome (i.e. process- and short-term outcomes) 32 percent. However, compared to the US results, Italian managers attributed more importance to different categories' subcomponents, possibly due to the specificity of each sample. For example, professional diligence, errors and continuity of care acquired more weight, to the detriment of communication. Furthermore, the data showed that process subcomponents were associated to perceived quality more than outcomes. RESEARCH LIMITATIONS/IMPLICATIONS The major limitation of this investigation was the small sample size. Further studies are needed to test the reliability and validity of the INQUAT. ORIGINALITY/VALUE The INQUAT is proposed as a tool to systematically conduct in depth analyses of successful and unsuccessful healthcare events, allowing to better understand the factors that contribute to good quality and to identify specific areas that may need to be targeted in quality improvement initiatives.
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Affiliation(s)
- Rebecca Amati
- Faculty of Communication Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Tommaso Bellandi
- Center for Clinical Risk Management and Patient Safety, Florence, Italy
| | - Amer A Kaissi
- Department of Health Care Administration, Trinity University, San Antonio, Texas, USA
| | - Annegret F Hannawa
- Faculty of Communication Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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Warner G, Drainoni ML, Parker V, Agins BD, Eldred L. Factors Associated with the Successful Implementation of a Quality Improvement Project in Human Immunodeficiency Virus Ambulatory Care Clinics. Am J Med Qual 2016; 19:75-82. [PMID: 15115278 DOI: 10.1177/106286060401900205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We examined a quality improvement (QI) program, offered to ambulatory care clinics (N = 82) serving human immunodeficiency virus-positive clients, to determine what factors predicted the clinic independently implementing QI processes without their program consultant's help. Initial analyses examined clinics at 4 levels of involvement: withdrew from the project, initial QI proficiency, advanced QI proficiency, and consultant independent. The initial and advanced stages were collapsed into 1 group (consultant dependent) and compared with consultant-independent clinics for multivariate logistic regression. In the multivariate models, 3 factors significantly predicted the clinic being consultant independent: staffing level (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.2-2.2), the number of participating months (OR = 1.4, 95% CI = 1.0-2.0), and baseline QI readiness (OR = 1.1, 95% CI = 1.0-1.3). Receiver operator curves were calculated for significant predictors; the strongest predictor was staffing (c statistic = .79). Clinics that are organizationally prepared for QI, allow adequate time to adopt QI methods into their organization, and provide adequate QI staffing are more likely to independently apply QI methods.
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Affiliation(s)
- Grace Warner
- Center for Health Quality, Outcomes, and Economic Research, VAMC, Bedford, Mass, USA.
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Donahue KE, Halladay JR, Wise A, Reiter K, Lee SYD, Ward K, Mitchell M, Qaqish B. Facilitators of transforming primary care: a look under the hood at practice leadership. Ann Fam Med 2013; 11 Suppl 1:S27-33. [PMID: 23690383 PMCID: PMC3707244 DOI: 10.1370/afm.1492] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE This study examined how characteristics of practice leadership affect the change process in a statewide initiative to improve the quality of diabetes and asthma care. METHODS We used a mixed methods approach, involving analyses of existing quality improvement data on 76 practices with at least 1 year of participation and focus groups with clinicians and staff in a 12-practice subsample. Existing data included monthly diabetes or asthma measures (clinical measures) and monthly practice implementation, leadership, and practice engagement scores rated by an external practice coach. RESULTS Of the 76 practices, 51 focused on diabetes and 25 on asthma. In aggregate, 50% to 78% made improvements within in each clinical measure in the first year. The odds of making practice changes were greater for practices with higher leadership scores (odds ratios = 2.41-4.20). Among practices focused on diabetes, those with higher leadership scores had higher odds of performing nephropathy screening (odds ratio = 1.37, 95% CI, 1.08-1.74); no significant associations were seen for the intermediate outcome measures of hemoglobin A1c, blood pressure, and cholesterol. Focus groups revealed the importance of a leader, typically a physician, who believed in the transformation work (ie, a visionary leader) and promoted practice engagement through education and cross-training. Practices with greater change implementation also mentioned the importance of a midlevel operational leader who helped to create and sustain practice changes. This person communicated and interacted well with, and was respected by both clinicians and staff. CONCLUSIONS In the presence of a vision for transformation, operational leaders within practices can facilitate practice changes that are associated with clinical improvement.
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Affiliation(s)
- Katrina E Donahue
- University of North Carolina, Department of Family Medicine, Chapel Hill, North Carolina 27599, USA.
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Vedel I, Ghadi V, De Stampa M, Routelous C, Bergman H, Ankri J, Lapointe L. Diffusion of a collaborative care model in primary care: a longitudinal qualitative study. BMC FAMILY PRACTICE 2013; 14:3. [PMID: 23289966 PMCID: PMC3558442 DOI: 10.1186/1471-2296-14-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Accepted: 12/21/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although collaborative team models (CTM) improve care processes and health outcomes, their diffusion poses challenges related to difficulties in securing their adoption by primary care clinicians (PCPs). The objectives of this study are to understand: (1) how the perceived characteristics of a CTM influenced clinicians' decision to adopt -or not- the model; and (2) the model's diffusion process. METHODS We conducted a longitudinal case study based on the Diffusion of Innovations Theory. First, diffusion curves were developed for all 175 PCPs and 59 nurses practicing in one borough of Paris. Second, semi-structured interviews were conducted with a representative sample of 40 PCPs and 15 nurses to better understand the implementation dynamics. RESULTS Diffusion curves showed that 3.5 years after the start of the implementation, 100% of nurses and over 80% of PCPs had adopted the CTM. The dynamics of the CTM's diffusion were different between the PCPs and the nurses. The slopes of the two curves are also distinctly different. Among the nurses, the critical mass of adopters was attained faster, since they adopted the CTM earlier and more quickly than the PCPs. Results of the semi-structured interviews showed that these differences in diffusion dynamics were mostly founded in differences between the PCPs' and the nurses' perceptions of the CTM's compatibility with norms, values and practices and its relative advantage (impact on patient management and work practices). Opinion leaders played a key role in the diffusion of the CTM among PCPs. CONCLUSION CTM diffusion is a social phenomenon that requires a major commitment by clinicians and a willingness to take risks; the role of opinion leaders is key. Paying attention to the notion of a critical mass of adopters is essential to developing implementation strategies that will accelerate the adoption process by clinicians.
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Affiliation(s)
- Isabelle Vedel
- Solidage, McGill University - Université de Montréal Research Group on Frailty and Aging - Lady Davis Institute, Jewish General Hospital, H466, 3755, Ch. Côte Ste Catherine, Montreal, Québec H3T 1E2, Canada
| | - Veronique Ghadi
- Santé Vieillissement research group, Versailles St Quentin University, 49 rue Mirabeau, Paris, 75016, France
| | - Matthieu De Stampa
- Santé Vieillissement research group, Versailles St Quentin University, 49 rue Mirabeau, Paris, 75016, France
| | - Christelle Routelous
- Management Institute, Ecole des Hautes Etudes en Santé Publique, Avenue du Professeur Léon-Bernard - CS 74312, Rennes cedex, 35043, France
| | - Howard Bergman
- Department of Family Medicine, McGill University, 515-517 av. des Pins Ouest, Montreal, Quebec, H2W 1S4, Canada
| | - Joel Ankri
- Santé Vieillissement research group, Versailles St Quentin University, 49 rue Mirabeau, Paris, 75016, France
| | - Liette Lapointe
- Desautels Faculty of Management, McGill University, 1001 Sherbrooke St. West, Montreal, Quebec, H3A 1G5, Canada
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Birken SA, Lee SYD, Weiner BJ. Uncovering middle managers' role in healthcare innovation implementation. Implement Sci 2012; 7:28. [PMID: 22472001 PMCID: PMC3372435 DOI: 10.1186/1748-5908-7-28] [Citation(s) in RCA: 152] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 04/03/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Middle managers have received little attention in extant health services research, yet they may have a key role in healthcare innovation implementation. The gap between evidence of effective care and practice may be attributed in part to poor healthcare innovation implementation. Investigating middle managers' role in healthcare innovation implementation may reveal an opportunity for improvement. In this paper, we present a theory of middle managers' role in healthcare innovation implementation to fill the gap in the literature and to stimulate research that empirically examines middle managers' influence on innovation implementation in healthcare organizations. DISCUSSION Extant healthcare innovation implementation research has primarily focused on the roles of physicians and top managers. Largely overlooked is the role of middle managers. We suggest that middle managers influence healthcare innovation implementation by diffusing information, synthesizing information, mediating between strategy and day-to-day activities, and selling innovation implementation. SUMMARY Teamwork designs have become popular in healthcare organizations. Because middle managers oversee these team initiatives, their potential to influence innovation implementation has grown. Future research should investigate middle managers' role in healthcare innovation implementation. Findings may aid top managers in leveraging middle managers' influence to improve the effectiveness of healthcare innovation implementation.
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Affiliation(s)
- Sarah A Birken
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill 1107-A McGavran-Greenberg Campus Box 7411 Chapel Hill, NC 27599-7411, USA
| | - Shoou-Yih Daniel Lee
- Department of Health Management and Policy, University of Michigan School of Public Health, 1420 Washington Heights, Ann Arbor, Michigan 48109-2029, USA
| | - Bryan J Weiner
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, McGavran-Greenberg Hall, Campus Box 7411, Chapel Hill 27599-7411, USA
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Clinician- and organization-level factors in the adoption of evidence-based care for depression in primary care. Health Care Manage Rev 2008; 33:289-99. [PMID: 18815494 DOI: 10.1097/01.hcm.0000318766.29277.49] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE Although more individuals are receiving care for depression than those in the past, they often do not receive high-quality care. Strategies to improve quality have focused on changing clinician behavior and more recently on reducing practice barriers. Both strategies hold promise but have had widely varying success either because practices have not successfully removed barriers or because removing barriers alone is not sufficient for improving care. It is unknown under which circumstances clinicians with a high propensity toward recognizing depression and providing depression care can overcome barriers. We explore organizational and clinician factors affecting patient receipt of guideline-concordant services. METHODOLOGY/APPROACH We use data from adult patients with major depression receiving care in a geographically diverse group of primary care practices participating in the Quality Improvement for Depression study. We estimate the effects of barriers and clinician propensity on six aspects of depression care and adequate treatment. FINDINGS Barriers and propensity interact in affecting depression services. In comparison with similar clinicians in practices with few barriers, high-propensity clinicians working in practices with more barriers are less likely to provide depression education and are likely to provide fewer follow-up calls and fewer follow-up visits. High-propensity clinicians are more likely to offer antidepressants in practices with more barriers. PRACTICE IMPLICATIONS To improve the quality of care, efforts should both eliminate practice barriers and increase clinician propensity to provide care. Future research on factors associated with quality improvement can benefit from an approach which specifies how organizational and clinician factors interact to enact change.
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Solberg LI. Improving medical practice: a conceptual framework. Ann Fam Med 2007; 5:251-6. [PMID: 17548853 PMCID: PMC1886486 DOI: 10.1370/afm.666] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2006] [Revised: 09/28/2006] [Accepted: 10/03/2006] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The purpose of this article is to produce a relatively simple conceptual framework for guiding and studying practice improvement. METHODS I summarize the lessons from my experience with a variety of quality improvement research studies during the last 30 years, supplemented with relevant literature from both medicine and other industries about the issues associated with successful quality improvement. RESULTS My experience suggests that organizational leadership with an urgent vision for change, ability to manage the change process, and selection of systematic changes capable of fulfilling the vision are each critical for successful quality improvement. Published literature from other industries emphasizes the importance of a goal-directed change process managed by leaders who recognize the need to engage their employees and other leaders in a disciplined but flexible way that accommodates external and internal factors and uses teams and group learning. It also suggests the importance of organizational context and the level of external and internal barriers and facilitators for change. The resulting model proposes that priority, change process, and care process content are necessary for measurable improvements in quality of care and patient outcomes, although internal and external barriers must also be attended to and addressed. CONCLUSION This framework may provide a guide to those in the front lines of care who would like to make the care transformations that are needed to greatly improve care. It may also be helpful to those who are developing or testing interventions and recruiting medical practices for such change efforts.
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Affiliation(s)
- Leif I Solberg
- HealthPartners Research Foundation, Minneapolis, Minn 55440, USA.
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Leventhal H, Friedman MA. Does establishing fidelity of treatment help in understanding treatment efficacy? Comment on Bellg et al. (2004). Health Psychol 2005; 23:452-6. [PMID: 15367064 DOI: 10.1037/0278-6133.23.5.452] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Comments on the article by Bellg et al (see record 2004-18051-001). To test the effects of a behavioral change on specific health outcomes, the Behavior Change Consortium insists on strict adherence to fidelity at 5 steps in behavioral trials: study design, provider training, treatment delivery, treatment receipt, and enactment of treatment skills. The authors argue that the demand for fidelity at every step ignores 2 critical sets of factors: (a) there are few theoretically grounded empirical studies of the processes involved in successful transitions in this sequence and (b) trials with perfect fidelity absent a theoretical model of transitions will produce evidence for interventions that lack a conceptual basis for adaptation to differences among diseases, treatments, patients, practitioners, medical institutions, and cultures and that therefore cannot be implemented in clinical practice.
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Affiliation(s)
- Howard Leventhal
- Institute for Health, Health Care Policy and Aging Research and Department of Psychology, Rutgers, The State University of New Jersey, New Brunswick, NJ 08901-1293, USA.
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Grol R. Changing physicians' competence and performance: finding the balance between the individual and the organization. THE JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS 2002; 22:244-251. [PMID: 12613060 DOI: 10.1002/chp.1340220409] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
There are serious problems associated with the underuse, overuse, and misuse of health care. Part of the solution involves changing practicing physicians' competence and performance, but this proves to be a difficult task. People differ widely in their views of how the behavior of physicians can be effectively changed. Some approaches focus on improving the knowledge, skills, or attitudes of professionals, whereas others believe in changing the social interaction and collaboration within teams or changing the organizational or political context. Some believe in self-motivation and regulation by those who need to change, whereas others emphasize external stimuli, pressure, or control. However, systematic reviews show that no current approach is superior for all purposes and target groups and that we may need them all, well integrated, to achieve effective improvements in patient care. Educational activities for professionals are not sufficient and should be combined with activities and measures at other levels. Those wishing to improve the competence and performance of physicians must be aware of the limitations of educational approaches and know how to integrate these with approaches that focus on teams, organizations, or the political or economic context. Teachers of physicians need to develop their knowledge and skills in these areas to be successful.
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Affiliation(s)
- Richard Grol
- Center for Quality of Care Research, Nijmegen University Medical Centre, Netherlands
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