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1.  Evaluation of an eHealth Intervention in Chronic Care for Frail Older People: Why Adherence is the First Target 
Background
Older people suffering from frailty often receive fragmented chronic care from multiple professionals. According to the literature, there is an urgent need for coordination of care.
Objective
The objective of this study was to investigate the effectiveness of an online health community (OHC) intervention for older people with frailty aimed at facilitating multidisciplinary communication.
Methods
The design was a controlled before-after study with 12 months follow-up in 11 family practices in the eastern part of the Netherlands. Participants consisted of frail older people living in the community requiring multidisciplinary (long-term) care. The intervention used was the health and welfare portal (ZWIP): an OHC for frail elderly patients, their informal caregivers and professionals. ZWIP contains a secure messaging system supplemented by a shared electronic health record. Primary outcomes were scores on the Instrumental Activities of Daily Living scale (IADL), mental health, and social activity limitations.
Results
There were 290 patients in the intervention group and 392 in the control group. Of these, 76/290 (26.2%) in the intervention group actively used ZWIP. After 12 months follow-up, we observed no significant improvement on primary patient outcomes. ADL improved in the intervention group with a standardized score of 0.21 (P=.27); IADL improved with 0.50 points, P=.64.
Conclusions
Only a small percentage of frail elderly people in the study intensively used ZWIP, our newly developed and innovative eHealth tool. The use of this OHC did not significantly improve patient outcomes. This was most likely due to the limited use of the OHC, and a relatively short follow-up time. Increasing actual use of eHealth intervention seems a precondition for large-scale evaluation, and earlier adoption before frailty develops may improve later use and effectiveness of ZWIP.
doi:10.2196/jmir.3057
PMCID: PMC4090371  PMID: 24966146
eHealth; frail elderly; care coordination; chronic care
2.  Filling the Gaps in a Fragmented Health Care System: Development of the Health and Welfare Information Portal (ZWIP) 
JMIR Research Protocols  2012;1(2):e10.
Background
Current health care systems are not optimally designed to meet the needs of our aging populations. First, the fragmentation of care often results in discontinuity of care that can undermine the quality of care provided. Second, patient involvement in care decisions is not sufficiently facilitated.
Objective
To describe the development and the content of a program aimed at: (1) facilitating self-management and shared decision making by frail older people and informal caregivers, and (2) reducing fragmentation of care by improving collaboration among professionals involved in the care of frail older people through a combined multidisciplinary electronic health record (EHR) and personal health record (PHR).
Methods
We used intervention mapping to systematically develop our program in six consecutive steps. Throughout this development, the target populations (ie, professionals, frail older people, and informal caregivers) were involved extensively through their participation in semi-structured interviews and working groups.
Results
We developed the Health and Welfare Information Portal (ZWIP), a personal, Internet-based conference table for multidisciplinary communication and information exchange for frail older people, their informal caregivers, and professionals. Further, we selected and developed methods for implementation of the program, which included an interdisciplinary educational course for professionals involved in the care of frail older people, and planned the evaluation of the program.
Conclusions
This paper describes the successful development and the content of the ZWIP as well as the strategies developed for its implementation. Throughout the development, representatives of future users were involved extensively. Future studies will establish the effects of the ZWIP on self-management and shared decision making by frail older people as well as on collaboration among the professionals involved.
doi:10.2196/resprot.1945
PMCID: PMC3626145  PMID: 23611877
Self-care; cooperative behavior; interdisciplinary communication; electronic health records; frail elderly
3.  Development of an instrument for the identification of frail older people as a target population for integrated care 
The British Journal of General Practice  2013;63(608):e225-e231.
Background
Primary care is increasingly interested in the identification of frailty, as it selects the target population for integrated care. However, instruments for the identification of frailty specifically validated for use in primary care are scarce. This study developed the Easycare Two-step Older persons Screening (Easycare-TOS), which provides a valid, efficient, and pragmatic screening procedure to identify frail older people.
Aim
This paper aims to describe the development of the Easycare-TOS and the data from the pilot studies.
Design and setting
Observational pilot study in seven academic GP practices in and around Nijmegen, The Netherlands.
Method
The Easycare-TOS was developed in a cyclic process with the input of stakeholders. In every cycle, the requirements were first defined, then translated into a prototype that was tested in a pilot study. The Easycare-TOS makes optimal use of prior knowledge of the GP, and the professionals’ appraisal is decisive in the frailty decision, instead of a cut-off score. Further, it considers aspects of frailty, as well as aspects of the care context of the patient.
Results
The pilot data have shown that after step 1, two-thirds of the patients do not need further assessment, because they are judged as not frail, based on prior knowledge of the GP. The overall prevalence of frailty in this pilot study is 24%. Most professionals who participated in the pilot studies considered the time investment acceptable and the method to be of added value.
Conclusion
The Easycare-TOS instrument meets the predefined efficiency, flexibility, and acceptability requirements for use as an identification instrument for frailty in primary care.
doi:10.3399/bjgp13X664289
PMCID: PMC3582982  PMID: 23561790
delivery of health care, integrated; efficiency; feasibility studies; frail elderly; primary health care
4.  Patient reported barriers and facilitators to using a self-management booklet for hip and knee osteoarthritis in primary care: results of a qualitative interview study 
BMC Family Practice  2013;14:181.
Background
To enhance guideline-based non-surgical management of hip or knee osteoarthritis (OA), a multidisciplinary, stepped-care strategy has been implemented in primary care in a region of the Netherlands. To facilitate this implementation, the self-management booklet “Care for Osteoarthritis” was developed and introduced. The aim of the booklet was to educate patients about OA, to enhance the patient’s active role in the treatment course, and to improve the communication with health care providers. To successfully introduce the booklet on a large scale we assessed barriers and facilitators for patients to using this booklet.
Methods
Seventeen primary care patients with hip or knee OA who received the self-management booklet participated in this qualitative study using semi-structured interviews. Purposive sampling was used to ensure diversity of the patients’ view about the booklet. The interviews were transcribed verbatim and analysed using a thematic analysis approach.
Results
Three core themes with patient perceived barriers and facilitators to use the booklet emerged from the interviews: 1) the role of health care providers, 2) the patient’s perceptions about OA and its manageability, and 3) the patient’s perceptions about the usefulness of the booklet and patient’s information needs. Regarding the first theme, a barrier was the lack of encouragement from health care providers to use the booklet in the treatment course of OA. Moreover, patients had doubts concerning the health care providers’ endorsement of non-surgical treatment for OA. Barriers from the second theme were: thinking that OA is not treatable or that being pro-active during the treatment course is not important. In contrast, being convinced about the importance of an active participation in the treatment course was a facilitator. Third, patients’ perceptions about the usefulness of the booklet and patients’ information needs were both identified as barriers as well as facilitators for booklet use.
Conclusions
This study contributes to the understanding of patient perceived barriers and facilitators to use a self-management booklet in the treatment course of OA. The results offer practical starting points to tailor the implementation activities of the booklet nationwide and to introduce comparable educational tools in OA primary care or in other chronic diseases.
doi:10.1186/1471-2296-14-181
PMCID: PMC4219393  PMID: 24289303
5.  Home visits for frail older people: a qualitative study on the needs and preferences of frail older people and their informal caregivers 
The British Journal of General Practice  2012;62(601):e554-e560.
Background
A number of studies have examined the effects of home visits and showed inconsistent results on physical functioning, institutionalisation, and mortality. Despite continuing interest from professionals in home visits for older people, reports on older people’s needs and preferences for such visits are scarce.
Aim
This qualitative study aims to explore the views and needs of community-dwelling frail older people concerning home visits.
Design and setting
A qualitative study including interviews with frail older persons and their informal caregivers living in the area of Nijmegen, the Netherlands.
Method
Semi-structured interviews were conducted with frail older people and informal caregivers. A grounded theory approach was used for data-analysis.
Results
Eleven frail older people and 11 informal caregivers were included. Most participants emphasised the importance of home visits for frail older people. They felt that it would give older people the personal attention they used to receive from GPs but miss nowadays. Most stated that this would give them more trust in GPs. Participants stated that trust is one of the most important factors in a good patient–professional relationship. Further, participants preferred home visits to focus on the psychosocial context of the patient. They stated that more knowledge of the psychosocial context and a good patient–professional relationship would enable the professional to provide better and more patient-centred care.
Conclusion
Patients’ expectations of home visits are quite different from the actual purpose of home visiting programmes; that is, care and wellbeing versus cure and prevention. This difference may partly explain why the effectiveness of home visits remains controversial. Future studies on home visits should involve patients in the development of home visiting programmes.
doi:10.3399/bjgp12X653606
PMCID: PMC3404333  PMID: 22867679
frail elderly; house calls; patient preference; primary health care
6.  Measuring continuity of care: psychometric properties of the Nijmegen Continuity Questionnaire 
The British Journal of General Practice  2012;62(600):e949-e957.
Background
Recently, the Nijmegen Continuity Questionnaire (NCQ) was developed. It aims to measure continuity of care from the patient perspective across primary and secondary care settings. Initial pilot testing proved promising.
Aim
To further examine the validity, discriminative ability, and reliability of the NCQ.
Design
A prospective psychometric instrument validation study in primary and secondary care in the Netherlands.
Method
The NCQ was administered to patients with a chronic disease recruited from general practice (n = 145) and hospital outpatient departments (n = 123) (response rate 76%). A principal component analysis was performed to confirm three subscales that had been found previously. Construct validity was tested by correlating the NCQ score to scores of other scales measuring quality of care, continuity, trust, and satisfaction. Discriminative ability was tested by investigating differences in continuity subscores of different subgroups. Test–retest reliability was analysed in 172 patients.
Results
Principal factor analysis confirmed the previously found three continuity subscales — personal continuity, care provider knows me; personal continuity, care provider shows commitment; and team/cross-boundary continuity. Construct validity was demonstrated through expected correlations with other variables and discriminative ability through expected differences in continuity subscores of different subgroups. Test–retest reliability was high (the intraclass correlation coefficient varied between 0.71 and 0.82).
Conclusion
This study provides evidence for the validity, discriminative ability, and reliability of the NCQ. The NCQ can be of value to identify problems in continuity of care.
doi:10.3399/bjgp12X652364
PMCID: PMC3381279  PMID: 22782001
continuity of patient care; factor analysis, statistical; healthcare surveys; questionnaires; reproducibility of results
7.  Continuity in different care modes and its relationship to quality of life: a randomised controlled trial in patients with COPD 
The British Journal of General Practice  2012;62(599):e422-e428.
Background
New care modes in primary care may affect patients’ experienced continuity of care.
Aim
To analyse whether experienced continuity for patients with chronic obstructive pulmonary disease (COPD) changes after different care modes are introduced, and to analyse the relationship between continuity of care and patients’ quality of life.
Design and setting
Randomised controlled trial with 2-year follow-up in general practice in the Netherlands.
Method
A total of 180 patients with COPD were randomly assigned to three different care modes: self-management, regular monitoring by a practice nurse, and care provided by the GP at the patient's own initiative (usual care). Experienced continuity of care as personal continuity (proportion of visits with patient's own GP) and team continuity (continuity by the primary healthcare team) was measured using a self-administered patient questionnaire. Quality of life was measured using the Chronic Respiratory Questionnaire.
Results
Of the final sample (n = 148), those patients receiving usual care experienced the highest personal continuity, although the chance of not contacting any care provider was also highest in this group (29% versus 2% receiving self-management, and 5% receiving regular monitoring). There were no differences in experienced team continuity in the three care modes. No relationship was found between continuity and changes in quality of life.
Conclusion
Although personal continuity decreases when new care modes are introduced, no evidence that this affects patients’ experienced team continuity or patients’ quality of life was found. Patients still experienced smooth, ongoing care, and considered care to be connected. Overall, no evidence was found indicating that the introduction of new care modes in primary care for patients with COPD should be discouraged.
doi:10.3399/bjgp12X649115
PMCID: PMC3361122  PMID: 22687235
continuity of patient care; general practice; pulmonary disease, chronic obstructive; quality of life
8.  Agreement of general practitioners with the guideline-based stepped-care strategy for patients with osteoarthritis of the hip or knee: a cross-sectional study 
BMC Family Practice  2013;14:33.
Background
To improve the management of hip or knee osteoarthritis (OA), a multidisciplinary guideline-based stepped-care strategy (SCS) with recommendations regarding the appropriate non-surgical treatment modalities and optimal sequence for care has been developed. Implementation of this SCS in the general practice may be hampered by the negative attitude of general practitioners (GPs) towards the strategy. In order to develop a tailored implementation plan, we assessed the GPs’ views regarding specific recommendations in the SCS and their working procedures with regard to OA.
Methods
A survey was conducted among a random sample of Dutch GPs. Questions included the GP’s demographical characteristics and the practice setting as well as how the management of OA was organized and whether the GPs supported the SCS recommendations. In particular, we assessed GP’s views regarding the effectiveness of 14 recommended and non-recommended treatment modalities. Furthermore, we calculated their agreement with 7 statements based on the SCS recommendations regarding the sequence for care. With a linear regression model, we identified factors that seemed to influence the GPs’ agreement with the SCS recommendations.
Results
Four hundred fifty-six GPs (37%) aged 30–65 years, of whom 278 males (61%), responded. Seven of the 11 recommended modalities (i.e. oral Non-Steroidal Anti-Inflammatory Drugs, physical therapy, glucocorticoid intra-articular injections, education, lifestyle advice, acetaminophen, and tramadol) were considered effective by the majority of the GPs (varying between 95-60%). The mean agreement score, based on a 5-point scale, with the recommendations regarding the sequence for care was 2.8 (SD = 0.5). Ten percent of the variance in GPs’ agreement could be explained by the GPs’ attitudes regarding the effectiveness of the recommended and non-recommended non-surgical treatment modalities and the type of practice.
Conclusion
In general, GPs support the recommendations in the SCS. Therefore, we expect that their attitudes will not impede a successful implementation in general practice. Our results provide several starting points on which to focus implementation activities for specific SCS recommendations; those related to the prescription of pain medication and the use of X-rays. We could not identify factors that contribute substantially to GPs’ attitudes regarding the SCS recommendations regarding the sequence for care.
doi:10.1186/1471-2296-14-33
PMCID: PMC3602050  PMID: 23497253
9.  The CareWell-primary care program: design of a cluster controlled trial and process evaluation of a complex intervention targeting community-dwelling frail elderly 
BMC Family Practice  2012;13:115.
Background
With increasing age and longevity, the rising number of frail elders with complex and numerous health-related needs demands a coordinated health care delivery system integrating cure, care and welfare. Studies on the effectiveness of such comprehensive chronic care models targeting frail elders show inconclusive results. The CareWell-primary care program is a complex intervention targeting community-dwelling frail elderly people, that aims to prevent functional decline, improve quality of life, and reduce or postpone hospital and nursing home admissions of community dwelling frail elderly.
Methods/design
The CareWell-primary care study includes a (cost-) effectiveness study and a comprehensive process evaluation. In a one-year pragmatic, cluster controlled trial, six general practices are non-randomly recruited to adopt the CareWell-primary care program and six control practices will deliver ‘care as usual’. Each practice includes a random sample of fifty frail elders aged 70 years or above in the cost-effectiveness study. A sample of patients and informal caregivers and all health care professionals participating in the CareWell-primary care program are included in the process evaluation. In the cost-effectiveness study, the primary outcome is the level of functional abilities as measured with the Katz-15 index. Hierarchical mixed-effects regression models / multilevel modeling approach will be used, since the study participants are nested within the general practices. Furthermore, incremental cost-effectiveness ratios will be calculated as costs per QALY gained and as costs weighed against functional abilities. In the process evaluation, mixed methods will be used to provide insight in the implementation degree of the program, patients’ and professionals’ approval of the program, and the barriers and facilitators to implementation.
Discussion
The CareWell-primary care study will provide new insights into the (cost-) effectiveness, feasibility, and barriers and facilitators for implementation of this complex intervention in primary care.
Trial registration
The CareWell-primary care study is registered in the ClinicalTrials.gov Protocol Registration System: NCT01499797
doi:10.1186/1471-2296-13-115
PMCID: PMC3527269  PMID: 23216685
Frail elderly; Complex intervention; Integrated care; Functional status; Cost-effectiveness; Implementation; Process evaluation; Primary care
10.  Heart failure patients’ experiences with continuity of care and its relation to medication adherence: a cross-sectional study 
BMC Family Practice  2012;13:86.
Background
A growing number of health care providers are nowadays involved in heart failure care. This could lead to discontinuity and fragmentation of care, thus reducing trust and hence poorer medication adherence. This study aims to explore heart failure patients’ experiences with continuity of care, and its relation to medication adherence.
Methods
We collected data from 327 primary care patients with chronic heart failure. Experienced continuity of care was measured using a patient questionnaire and by reviewing patients’ medical records. Continuity of care was defined as a multidimensional concept including personal continuity (seeing the same doctor every time), team continuity (collaboration between care providers in general practice) and cross-boundary continuity (collaboration between general practice and hospital). Medication adherence was measured using a validated patient questionnaire. The relation between continuity of care and medication adherence was analysed by using chi-square tests.
Results
In total, 53% of patients stated not seeing any care provider in general practice in the last year concerning their heart failure. Of the patients who did contact a care provider in general practice, 46% contacted two or more care providers. Respectively 38% and 51% of patients experienced the highest levels of team and cross-boundary continuity. In total, 14% experienced low levels of team continuity and 11% experienced low levels of cross-boundary continuity. Higher scores on personal continuity were significantly related to better medication adherence (p < 0.01). No clear relation was found between team- or cross-boundary continuity and medication adherence.
Conclusions
A small majority of patients that contacted a care provider in general practice for their heart failure, contacted only one care provider. Most heart failure patients experienced high levels of collaboration between care providers in general practice and between GP and cardiologist. However, in a considerable number of patients, continuity of care could still be improved. Efforts to improve personal continuity may lead to better medication adherence.
doi:10.1186/1471-2296-13-86
PMCID: PMC3515359  PMID: 22905797
Continuity of care; Personal continuity; Team continuity; Cross-boundary continuity; Heart failure; Medication adherence
11.  Implementation of an innovative web-based conference table for community-dwelling frail older people, their informal caregivers and professionals: a process evaluation 
Background
Due to fragmentation of care, continuity of care is often limited in the care provided to frail older people. Further, frail older people are not always enabled to become involved in their own care. Therefore, we developed the Health and Welfare Information Portal (ZWIP), a shared Electronic Health Record combined with a communication tool for community-dwelling frail older people and primary care professionals. This article describes the process evaluation of its implementation, and aims to establish (1) the outcomes of the implementation process, (2) which implementation strategies and barriers and facilitators contributed to these outcomes, and (3) how its future implementation could be improved.
Methods
Mixed methods study, consisting of (1) a survey among professionals (n = 118) and monitoring the use of the ZWIP by frail older people and professionals, followed by (2) semi-structured interviews with purposively selected professionals (n = 12).
Results
290 frail older people and 169 professionals participated in the ZWIP. At the end of the implementation period, 55% of frail older people and informal caregivers, and 84% of professionals had logged on to their ZWIP at least once. For professionals, the exposure to the implementation strategies was generally as planned, they considered the interprofessional educational program and the helpdesk very important strategies. However, frail older people’s exposure to the implementation strategies was less than intended. Facilitators for the ZWIP were the perceived need to enhance interprofessional collaboration and the ZWIP application being user-friendly. Barriers included the low computer-literacy of frail older people, a preference for personal communication and limited use of the ZWIP by other professionals and frail older people. Interviewees recommended using the ZWIP for other target populations as well and adding further strategies that may help frail older people to feel more comfortable with computers and the ZWIP.
Conclusions
This study describes the implementation process of an innovative e-health intervention for community-dwelling frail older people, informal caregivers and primary care professionals. As e-health is an important medium for overcoming fragmentation of healthcare and facilitating patient involvement, but its adoption in everyday practice remains a challenge, the positive results of this implementation are promising.
doi:10.1186/1472-6963-12-251
PMCID: PMC3470954  PMID: 22894654
E-health; Implementation; Process evaluation; Frail older people; Primary care
12.  Measurement Properties of Questionnaires Measuring Continuity of Care: A Systematic Review 
PLoS ONE  2012;7(7):e42256.
Background
Continuity of care is widely acknowledged as a core value in family medicine. In this systematic review, we aimed to identify the instruments measuring continuity of care and to assess the quality of their measurement properties.
Methods
We did a systematic review using the PubMed, Embase and PsycINFO databases, with an extensive search strategy including ‘continuity of care’, ‘coordination of care’, ‘integration of care’, ‘patient centered care’, ‘case management’ and its linguistic variations. We searched from 1995 to October 2011 and included articles describing the development and/or evaluation of the measurement properties of instruments measuring one or more dimensions of continuity of care (1) care from the same provider who knows and follows the patient (personal continuity), (2) communication and cooperation between care providers in one care setting (team continuity), and (3) communication and cooperation between care providers in different care settings (cross-boundary continuity). We assessed the methodological quality of the measurement properties of each instrument using the COSMIN checklist.
Results
We included 24 articles describing the development and/or evaluation of 21 instruments. Ten instruments measured all three dimensions of continuity of care. Instruments were developed for different groups of patients or providers. For most instruments, three or four of the six measurement properties were assessed (mostly internal consistency, content validity, structural validity and construct validity). Six instruments scored positive on the quality of at least three of six measurement properties.
Conclusions
Most included instruments have problems with either the number or quality of its assessed measurement properties or the ability to measure all three dimensions of continuity of care. Based on the results of this review, we recommend the use of one of the four most promising instruments, depending on the target population Diabetes Continuity of Care Questionnaire, Alberta Continuity of Services Scale-Mental Health, Heart Continuity of Care Questionnaire, and Nijmegen Continuity Questionnaire.
doi:10.1371/journal.pone.0042256
PMCID: PMC3409169  PMID: 22860100
13.  Study protocol: optimization of complex palliative care at home via telemedicine. A cluster randomized controlled trial 
BMC Palliative Care  2011;10:13.
Background
Due to the growing number of elderly with advanced chronic conditions, healthcare services will come under increasing pressure. Teleconsultation is an innovative approach to deliver quality of care for palliative patients at home. Quantitative studies assessing the effect of teleconsultation on clinical outcomes are scarce. The aim of this present study is to investigate the effectiveness of teleconsultation in complex palliative homecare.
Methods/Design
During a 2-year recruitment period, GPs are invited to participate in this cluster randomized controlled trial. When a GP refers an eligible patient for the study, the GP is randomized to the intervention group or the control group. Patients in the intervention group have a weekly teleconsultation with a nurse practitioner and/or a physician of the palliative consultation team. The nurse practitioner, in cooperation with the palliative care specialist of the palliative consultation team, advises the GP on treatment policy of the patient. The primary outcome of patient symptom burden is assessed at baseline and weekly using the Edmonton Symptom Assessment Scale (ESAS) and at baseline and every four weeks using the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes are self-perceived burden from informal care (EDIZ), patient experienced continuity of medical care (NCQ), patient and caregiver satisfaction with the teleconsultation (PSQ), the experienced problems and needs in palliative care (PNPC-sv) and the number of hospital admissions.
Discussion
This is one of the first randomized controlled trials in palliative telecare. Our data will verify whether telemedicine positively affects palliative homecare.
Trial registration
The Netherlands National Trial Register NTR2817
doi:10.1186/1472-684X-10-13
PMCID: PMC3176474  PMID: 21827696
14.  Recently enlisted patients in general practice use more health care resources 
BMC Family Practice  2007;8:64.
Background
The continuity of care is one of the cornerstones of general practice. General practitioners find personal relationships with their patients important as they enable them to provide a higher quality of care. A long-lasting relationship with patients is assumed to be a prior condition for attaining this high quality. We studied the differences in use of care between recently enlisted patients and those patients who have been enlisted for a longer period.
Methods
104 general practices in the Netherlands participated the study. We performed a retrospective cohort study in which patients who have been enlisted for less than 1 year (n = 10,102) were matched for age, sex and health insurance with patients who have been enlisted for longer in the same general practice. The two cohorts were compared with regard to the number of contacts with the general practice, diagnoses, rate of prescribing, and the referral rate in a year. These variables were chosen as indicators of differences in the use of care.
Results
In the year following their enlistment, a higher percentage of recently enlisted patients had at least one contact with the practice, received a prescription or was referred. They also had a higher probability of receiving a prescription for an antibiotic. Furthermore, they had a higher mean number of contacts and referrals, but not a higher mean number of prescriptions.
Conclusion
Recently enlisted patients used more health care resources in the first year after their enlistment compared to patients enlisted longer. This could not be explained by differences in health.
doi:10.1186/1471-2296-8-64
PMCID: PMC2235863  PMID: 18047642

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