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What Works and Why? Lessons Learned from 6 AHRQ Grantees* Implementing Comparative Effectiveness Research November 17, 2014 *AHRQ's Accelerating Implementation.

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Presentation on theme: "What Works and Why? Lessons Learned from 6 AHRQ Grantees* Implementing Comparative Effectiveness Research November 17, 2014 *AHRQ's Accelerating Implementation."— Presentation transcript:

1 What Works and Why? Lessons Learned from 6 AHRQ Grantees* Implementing Comparative Effectiveness Research November 17, 2014 *AHRQ's Accelerating Implementation of Comparative Effectiveness Findings on Clinical and Delivery System Interventions by Leveraging AHRQ Networks program 1

2 Welcome AHRQ Grantee Teams 2010: 6 teams funded under Accelerating Implementation of Comparative Effectiveness Findings on Clinical and Delivery System Interventions by Leveraging AHRQ Networks 2014: 8 teams funded under Disseminating Patient Centered Outcomes Research to Improve Healthcare Delivery 2

3 Overview of Today’s Webinar I. High Level Overview of 6 Grants to Implement CER (Moderator: Peggy McNamara, AHRQ) 1. Pittsburgh Regional Health Initiative 2. Dartmouth CO-OP Project/CECH PBRNs 3. Rutgers University 4. Carolinas Healthcare System 5. Westat, working with University of Oklahoma Health Sciences Center 6. Johns Hopkins University II. Grantee Lessons Learned (Moderator: James Dearing, Michigan State University) III. Grantee Tools & Wrap-Up (Peggy McNamara and Jan De La Mare, AHRQ) Your questions and perspectives solicited throughout the Webinar 3

4 Mental Health Interventions 4 Pittsburgh Regional Health Initiative Dartmouth CO-OP Project/CECH PBRNs Rutgers University

5 Partners in Integrated Care (PIC): Support Screening for Depression and Alcohol and Drug Misuse Funded Organization: Pittsburgh Regional Health Initiative (PRHI) Affiliated Network: AHRQ Chartered Value Exchange (CVE) Learning Network, and Network for Regional Healthcare Improvement (NRHI) Geographic Focus: Pennsylvania, Wisconsin, Minnesota, and Massachusetts 5

6 PIC: Support Screening for Depression and Alcohol and Drug Misuse Intervention at a Glance Evidence Being Disseminated ► IMPACT model for USPSTF recommendation of adult depression screening when staff-assisted depression care supports are in place ► SBIRT model for USPSTF recommendation of adult alcohol misuse screening and brief intervention ► Adult screening and brief interventions for other drug misuse based on emerging and promising evidence at the time Primary Aim ► To rapidly disseminate and test an integrated IMPACT-SBIRT team-based model in 90 primary care office practices in 4 states, comparing response and remission rates to evidence base Intervention Description ► Planning: Collaborative creation of “PIC Toolkit”, training modules, data tracking tools, software, and marketing materials ► Implementation: Practice recruitment, staff hiring, and protocol-based multi-state roll-out ► Refinement: Live (site-visits, regional meetings) and online (webinars, Tomorrow’s HealthCare) Lead Implementers ► “Integration Specialists”- LCSW, MSW, LPC, MA, or RN, trained in PIC protocol and motivational interviewing ► Primary care physicians ► Consulting psychiatrists External Supports ► Regional pay-for-performance ► PCMH ► ACO incentives ► CEU credits 6

7 PIC: Support Screening for Depression and Alcohol and Drug Misuse Achievements ► Implementation in 57 primary care offices ► Over 60,000 screens for depression and unhealthy substance use ► Among eligible patients, 3,186 received depression services and 429 received substance misuse services ► Response and remission outcomes comparable across sites (Kaplan-Meier survival curves) ► Defined role of office-based “Integration Specialist” Sustainability ► PRHI Website: All PIC materials available free of charge (PIC Toolkit, literature review, marketing videos) ► New grants: COMPASS (CMS Innovation Center); applications from WIPHL and PRHI/NRHI ► State-based public health: Massachusetts (MA-SBIRT), Minnesota Department of Public Safety (SBIRT), University of Wisconsin (PIC) ► Managed care organizations: Medicaid payers (Pennsylvania) ► Employer outreaches: Wisconsin 7

8 Teen Mental Health (TMH) Project Funded Organization: Dartmouth Primary Care Cooperative (Dartmouth CO-OP) Information Project Affiliated Network: Clinicians Enhancing Child Health (CECH) Practice-Based Research Network (PBRN) Geographic Focus: Vermont, New Hampshire 8

9 Teen Mental Health (TMH) Project Intervention at a Glance Evidence Being Disseminated ► USPSTF recommendation: “Screen adolescents (12–18 years of age) for major depressive disorder when systems are in place to ensure 1) accurate diagnosis, 2) psychotherapy, and 3) follow-up” Primary Aim ► To develop, pilot test, implement, and evaluate a “TMH office system” in 15 rural pediatric and family medicine practices Intervention Description ► TMH office system to support identification and appropriate treatment of adolescent depression ► In person and web-based training in TMH and customization support Lead Implementers ► Physicians and care managers in the practices External Supports ► 7 of 12 practices used TMH for American Board of Pediatrics’ Maintenance of Certification ► Option of using TMH to fulfill ACO and PCMH requirements ► Marginal revenue from billing for screening did not cover billing costs for some practices ► Disseminators engaged payers in discussions, but a financing model was not found to cover the full cost of the intervention 9

10 Teen Mental Health (TMH) Project Achievements ► TMH office system was developed and implemented in 12 practices ► Total of 9,894 teens were screened Sustainability ► 7 of 12 practices continued to screen and use the TMH registry 9 months after active intervention ended ► The remaining 5 practices report continuing some components, but did stop use of the registry 10

11 Accelerating Utilization of CE Findings in Medicaid Mental Health: MEDNET Funded Organization: Rutgers University, Center for Health Services Research on Pharmacotherapy, Chronic Disease Management, and Outcomes Affiliated Network: Multistate MEDNET/SMINET consortium of states, evolving from CERTs collaborative project with Medicaid Medical Directors Learning Network Geographic Focus: ► 6 states: MO, TX, CA (Orange County), ME, OK, and WA ► 2 additional “affiliate” states: OH and WI 11

12 Medicaid Mental Health: MEDNET Intervention at a Glance Evidence Being Disseminated ► 10 specific clinical target areas included: 1) mental health drug polypharmacy; 2) management of metabolic risks of antipsychotics (AP); 3) AP utilization for children under age 6; 4) higher than recommended doses of APs; 5) utilization of appropriate mental health services as a complement or alternative to psychotropic treatments; 6) consistency between diagnoses and treatments; 7) improvement of treatment adherence for adults with severe mental illness; 8) identification and prediction of high risk/high utilization beneficiaries and targeting of services to these subpopulations; 9) safe and effective psychotropic and mental health services use by foster care youth; and 10) safe and effective psychotropic and mental health services use by nursing home residents ► Quality improvement (QI) science was also disseminated Primary Aim ► Safe and judicious prescribing of AP medications across life span and among multiple high risk Medicaid populations Intervention Description ► Multi-state public/academic consortium charged with sharing evidence-based practices and quality data at the provider level to improve AP prescribing practices ► Standardized, consensus driven AP Quality Metrics were developed and used to: track improvements; identify individuals at risk, and benchmark trends among participating states ► Leveraging local policy environments, customized state-specific CQI interventions were developed and implemented to improve prescribing patterns Lead Implementers ► State Medicaid, mental health and child welfare agency leadership ► Experts from the Rutgers-Columbia mental health CERTs ► Broad state level Stakeholder Collaborative workgroups External Supports ► Ongoing clinical, administrative, policy, and QI science TA was available throughout the project 12

13 Medicaid Mental Health: MEDNET Achievements ► 3 MEDNET Quality Metrics adapted and adopted by NCQA for inclusion in HEDIS 2015 ► Reviewed and improved Texas Foster Care Prescribing Parameters ► State-specific prescribing oversight improvements: o Community Mental Health Center feedback reports and CQI collaborative in WA o Managed Care Organization/county guideline development and metabolic management initiative on Orange County o Integration of quality metrics into MO and ME health home programs o New prescribing guidelines and oversight/second opinion triggers in TX o Integration of metrics into Medicaid Drug Utilization Review and care integration initiative in OK o Prescribing changes included 45% in reduction in AP polypharmacy in targeted WA clinics o 52% polypharmacy reduction in TX, and 41% in OK o Substantial reductions in AP treatment in youngest children in TX ► Successful, continuation “EBP spread funding” from AHRQ – SMINET ► Incorporation of measurement driven QI processes and metrics into ongoing state administrative processes, including managed care oversight Sustainability ► 6 of 6 participant states integrated the MEDNET quality metrics, often in multiple projects, to track quality improvements o ACA Health Homes, External Quality Review Organization performance contracts, Drug Utilization Review programs, Prior Authorization algorithms, and CMS Dual Demonstration projects 13

14 Physical Health Interventions 14 Carolinas Health Care SystemWestat, on behalf of University of Oklahoma Health Sciences Center Johns Hopkins University

15 Asthma Comparative Effectiveness (ACE): Using Shared Decision Making (SDM) to Improve Outcomes for Patients with Asthma within an Integrated Healthcare System Funded Organization: Carolinas Healthcare System Affiliated Network: Mecklenburg Area Primary Care Research Network (MAPPR) Practice-Based Research Network (PBRN) Geographic Focus: North and South Carolina 15

16 Asthma Comparative Effectiveness (ACE): Using SDM Intervention at a Glance Evidence Being Disseminated ► NHLBI guidelines for the diagnosis and treatment of Asthma and Shared Treatment Decision Making Improves Adherence and Outcomes in Poorly Controlled Asthma. Am J Respir Crit Care Med. March 15, 2010 Primary Aim ► To adapt, implement, and evaluate a “Shared Decision Making Toolkit” in 6 primary care hospital-based practices serving a vulnerable Medicare population Intervention Description ► A facilitator-led approach was used to partner with providers, staff and train health coaches to adopt and implement the shared decision making toolkit; and assisted health coaches to convene clinics for patients Lead Implementers ► Facilitators train practice implementation team during a participatory “rollout” process adapted to culture at each practice. Typical implementers are physician champions and practice managers. External Supports ► Physicians and practices used asthma SDM clinic for American Board of Family Medicine Maintenance of Certification ► SDM was used to help 1 practice get PCMH level III certification ► Hospital based practices can bill for support staff such as pharmacist acting as health coach for patients 16

17 Asthma Comparative Effectiveness (ACE): Using SDM Achievements ► 258 English & Spanish, Adult, and Pediatric patients participated in 358 SDM Half-Day Clinic Visits ► At 6 months post SDM, asthma exacerbations dropped by 42% in the ED, 50% for hospitalizations, and a 46% drop in oral prednisone use ► 86% of patients reported the asthma treatment decision was shared between the patient and provider Sustainability ► 4 of 6 original practices still hold regular SDM half day clinics and all 6 practices still use SDM toolkit components during asthma treatment planning ► Results from this project were used to successfully obtain PCORI funding for state-wide dissemination of SDM across 30 sites ► Partnership with Medicaid has enabled the toolkit to be incorporated in materials distributed to 278 practices across NC 17

18 Leveraging Practice Based Research Networks (PBRNs) to Accelerate Implementation and Diffusion of Chronic Kidney Disease (CKD) Guidelines in Primary Care Practice Funded Organization: University of Oklahoma Health Sciences Center (OUHSC), Oklahoma City, OK Affiliated Networks/Geographic Focus: ► Oklahoma Physicians Resource/Research Network ► Los Angeles Practice-Based Research Network ► Minnesota Academy of Family Physicians Research Network ► Wisconsin Research and Education Network 18

19 Chronic Kidney Disease (CKD) Project Intervention at a Glance Evidence Being Disseminated ► 8 processes of care from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Guidelines: 1) making and documenting the diagnosis, 2) ordering appropriate tests based upon severity of disease, 3) discontinuing potentially harmful medications, 4) starting potentially beneficial medications, 5) managing diabetes and cardiovascular disease risk factors, 6) educating patients about vein preservation, 7) giving appropriate immunizations, and 8) referring patients with advanced disease Primary Aim ► To determine whether networks could increase dissemination, implementation, and diffusion of evidence-based treatment guidelines for chronic kidney disease (CKD) by leveraging early adopter practices Intervention Description ► Wave I: Practices from 4 PBRNs received baseline and periodic performance feedback, academic detailing, and weekly practice facilitation for 6 months ► Wave II: Wave I practices + 2 additional practices received similar performance feedback and academic detailing, monthly practice facilitation, and participated in 6 monthly “local” learning collaboratives (LLCs) led by Wave I clinicians Lead Implementers ► Physicians in the practices and Practice Facilitators provided by the PBRNs External Supports ► Maintenance Of Certification Part IV credit provided by the American Boards of Family Medicine and Internal Medicine ► CME credit available through the American Academy of Family Physicians 19

20 Chronic Kidney Disease (CKD) Project Achievements ► Wave I: 711 patients, 31 of 32 practices o Increased use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs/ARBs), discontinuation of nonsteroidal anti- inflammatory drugs (NSAIDs), testing for anemia, and testing and/or treatment for vitamin D deficiency ► Wave II: 1179 patients, 58 of 62 practices enrolled o Also increased use of ACEIs/ARBs and testing and/or treatment of vitamin D deficiency Sustainability ► Newly implemented processes were typically accompanied by the creation of templates, order sets, and other modifications to the electronic health records ► Increased awareness of the importance of eGFR (an estimated value derived from a measured serum creatinine and population means for age and gender) created by the project o Automatic calculation of eGFR by labs used by participating practices prior to or as a result of the project 20

21 Cardiovascular Surgical Translational Study Funded Organization: Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality Affiliated Network: None Geographic Focus: 11 hospitals in 9 states (OH, FL, MA, MD, MO, NC, NY, SC, TX) 21

22 Cardiovascular Surgical Translational Study Intervention at a Glance Evidence Being Disseminated ► Prevention methods for 3 common infections Primary Aim ► Prevention methods for 3 common infections ► To implement and evaluate the impact of a patient safety program in 11 of cardiac surgery operating rooms (OR), 8 intensive care units (ICU), 9 inpatient units, and 3 universal bed units on: o Healthcare-associated infection (HAI) rates o Patient safety culture, cross-unit teamwork, and transitions of care o Comparison to passive audit and feedback Intervention Description ► Evidenced-based prevention toolkits for surgical site infections (SSI), central line- associated bloodstream infections (CLABSI) and ventilator-associated pneumonia or events (VAP/VAE) plus the Comprehensive Unit-based Safety Program (CUSP) ► Standardizing technical components of the work (evidence summaries and measures), while encouraging local innovation in the adaptive components (implementation and culture change) Lead Implementers ► Unit-based multidisciplinary teams in 11 hospitals External Supports ► None 22

23 Cardiovascular Surgical Translational Study Achievements ► Development and implementation of SSI; CLABSI; and VAP/VAE prevention bundles and CUSP in 11 hospitals ► Preliminary data (March 2014) show median CLABSI rates decreased to 0.00 per 1,000 line-days (baseline: 1.52, 1.23); median VAP rates sustained at 0.00 per 1,000 vent-days (baseline: 0.00); downward trend observed in median SSI rates but some variation exists ► Culture regarding leadership improved; scores on open communication and feedback about errors were lower (1 yr. post- implementation vs. baseline) Sustainability (Note: this project ended in July 2014; sustainability data not yet available) ► Embed: Make policies and procedures, train new people, walk the process ► Expand: Pass it on to other units, identify and address the next challenge 23

24 Grantee Discussion: Lessons Learned What did you do that worked well? What did you try that didn’t work? What are your funding, research and policy recommendations for AHRQ and other funders re: dissemination and implementation? Facilitator: James Dearing, PhD Michigan State University 24

25 Grantee Tools Tools developed by grantee teams that may be useful for other dissemination and implementation teams to adapt 25

26 PIC: Support Screening for Depression and Alcohol and Drug Misuse Dissemination and Implementation Resources Name of ToolPurpose of ToolLink to Download Tool 1. PIC Toolkit Marketing and Communication Train the Trainer Primary Care Training Practice Support & Care Delivery IT & Measurement Entire suite of materials to conduct recruitment, implementation, and refinement -toolkit 2. Marketing Videos Overview The Pennsylvania Experience The Minnesota Experience The Business Case for PIC Quick orientation to project, recruitment, and stakeholder engagement Pittsburgh Regional Health Initiative 26

27 Teen Mental Health (TMH) Project Dissemination and Implementation Resources Name of ToolPurpose of ToolLink to Download Tool 1. Clinician Guide: Depression Screening and Management To provide the necessary information and materials to allow practices to implement the project on their own enMental/Clinician%20Guide%2023_2.2.11.pdf 2. There is Treatment for Depression - (Customized Brochure) To allow participating practices to create a customizable brochure about depression treatment enMental/Treatment_for_Depression.pdf 3. Medication Management To provide guidelines about the most commonly recommended SSRIs for adolescents enMental/Medication%20Management.f or.web.pdf 4. “Caring for Myself” – My Self Care Plan A tool to help set self-care goals enMental/Caring%20for%20Myself.5.2. 11.pdf 5. Primary Care Referral and Communication Form A tool to facilitate communication and treatment between referring clinician and the mental health professional enMental/PCP%20Referral%20and%20 Communication.pdf 6. Understanding Teen Depression For the Teen enMental/teen_depression_TN.html Dartmouth CO-OP Project/CECH PBRNs 27

28 Teen Mental Health (TMH) Project Dissemination and Implementation Resources Name of ToolPurpose of ToolLink to Download Tool 7. Healthy SleepingFor the Teen Mental/healthy_sleeping_TN.html 8. Eating HealthFor the Teen Mental/eating_healthy_TN.html 9. Using RelaxationInformation Sheet with Things to do and Different Relaxation Techniques – for the Teen Mental/using_relaxation_TN.html 10. Problem-SolvingInformation Sheet with steps to help solve problems – for the Teen Mental/problem_solving_TN.html 11. Cognitive Behavioral Therapy Information Sheet describing cognitive behavioral therapy – for the Parent Mental/Cognitive_Behavioral_PT.html 12. AntidepressantsInformation sheet about antidepressants – for the Parent Mental/Antidepressants_PT.html 13. Teen Mental Health Web Site Full access to comprehensive range of parent and teen psycho-education and self-care handouts Mental/ Dartmouth CO-OP Project/CECH PBRNs 28

29 Medicaid Mental Health: MEDNET Dissemination and Implementation Resources Name of ToolPurpose of ToolLink to Download Tool 1. Implementing a State- Level Quality Improvement Collaborative: A Resource Guide from the Medicaid Network for Evidence-based Treatment (MEDNET). This guide can help policymakers work with other stakeholders to improve health outcomes in their State. It describes steps to follow to implement state level quality improvement collaborative. MMD/MEDNETResourceGuide 0314.pdf 2. NCQA added 3 measures that assess the safe and judicious use of antipsychotic (AP) medications in children and adolescents Use of Multiple Concurrent APs in Children and Adolescents Metabolic Monitoring for Children and Adolescents on APs Use of First-Line Psychosocial Care for Children and Adolescents on APs /NewsArchive/2014NewsArchiv e/NewsReleaseJuly12014.aspx 3. Psychotropic Medication Utilization Parameters for Children and Youth in Foster Care Developed by the Texas DFPS, the parameters have been used nationally as a best practice guide to psychotropic medication prescribing. ments/Child_Protection/pdf/TxF osterCareParameters- September2013.pdf Rutgers University 29

30 Medicaid Mental Health: MEDNET Dissemination and Implementation Resources Name of ToolPurpose of ToolLink to Download Tool 4. The Rutgers CERT Helps Establish Updated Parameters for Psychotropic Medication Use in Texas Foster Children, by Audrey Humphries (April 2014) AHRQ/Mental Health CERTs supported the development of an article that provides a summary of best practices associated with psychotropic use and identifies many related resources. -tools/foster-children-psychotropic- use/ 5. Mental Health Problems in Foster Care Children Handout developed for foster parents to prepare for doctor visits when a foster child has mental health problems. tools/mental-health-problems- foster-children/ 6. Finnerty et al. (2014), MEDNET: A Multi-state Policymaker/ Researcher Collaboration in Improve Prescribing Practices, Psychiatric Services Describes the development, infrastructure, challenges, and early evidence of success of this public-academic partnership. f/10.1176/ 30 Rutgers University

31 Medicaid Mental Health: MEDNET Dissemination and Implementation Resources Name of ToolPurpose of ToolLink to Download Tool 7. Data Speaks: Integrated Data Systems to Facilitate Cross- System Collaboration Data is critical to public policy decision making yet the availability of data a great challenge. This panel presented the types of data which will advance the work of states in overseeing psychotropic use. wide/mentalhealth/effectiveness/psy chotropic.cfm 8. Maine Health and Wellness Toolkit, Maine DHHS, SAMHSA, September 2013. This toolkit helps mental health agencies integrate whole health into their service settings. It addresses health and wellness into agency culture; screening to assess health status; involve and empower consumers; and link with community resources. mentalhealth/wellness/toolkit/index. shtml 9. CalOptima: A Guide for AP Use CalOptima makes clinical practice guidelines available to providers. Guidelines have been reviewed and approved by CalOptima’s Clinical Quality Improvement Committee. ers/ManualsPoliciesAndResources/ ~/media/Files/CalOptimaOrg/Provid ers/ManualsPoliciesResources/Clini calPracticeGuidelines/CalOptimaAt ypicalAntipsychoticGuidelines.ashx 31 Rutgers University

32 Asthma Comparative Effectiveness (ACE): Using SDM Dissemination and Implementation Resources Name of ToolPurpose of ToolLink to Download Tool 1. Asthma Shared Decision Making Toolkit Shared Decision Making toolkit in English and Spanish SDM engagement testimony from patients, health coaches and physicians. Implementation Resources 2. Asthma Action Plan incorporating medication decision support based on NHBLI guidelines Asthma Action Plan generatorhttps://asthma.carolinashealthcare. org/Form 3. The Amazings asthma App game App to engage children in game that educates around asthma Carolinas Healthcare System 32

33 Chronic Kidney Disease (CKD) Project Dissemination and Implementation Resources Name of ToolPurpose of ToolLink to Download Tool 1. Chronic Kidney Disease Clinical Practice Guidelines Implementation Toolkit CKD Guideline Recommendations for Primary Care (one-pager) Screening and diagnosis guidelines Patient education tasks and approaches CKD: A patient’s guide (English/Spanish) Medication discontinuation and cautions Lab tests Reducing rate of CKD progression Managing CKD complications Immunizations Cardiovascular risk factor management Nephrology referral Under development (Estimated date of completion: Spring 2015; contact: Zsolt Nagykaldi at 2. Practice Facilitator Certificate Program Designed and developed by national experts who drew upon the training modules in the AHRQ Practice Facilitation Handbook. Web based with live video seminars scheduled weekly and local internships at certified sites. http://www.millardfillmorecolleg Westat, working with University of Oklahoma Health Sciences Center 33

34 Cardiovascular Surgical Translational Study Dissemination and Implementation Resources Name of ToolPurpose of ToolLink to Download Tool 1. Surgical Site Infection (SSI) Prevention Toolkit To provide evidence and strategies for how to use resources for SSI Prevention https://armstrongresearch.hopkinsm 2. Central Line-Associated Bloodstream Infection (CLABSI) Prevention Toolkit To provide evidence and strategies for how to use resources for CLABSI Prevention https://armstrongresearch.hopkinsm 3. Ventilator-Associated Pneumonia (VAP) Infection Prevention Toolkit To provide evidence and strategies for how to use resources for VAP/VAE Prevention https://armstrongresearch.hopkinsm 4. Comprehensive Unit- based Safety Program (CUSP) To provide guidance for implementing CUSP to improve safety culture https://armstrongresearch.hopkinsm Johns Hopkins University 34

35 Cardiovascular Surgical Translational Study Dissemination and Implementation Resources Name of ToolPurpose of ToolLink to Download Tool 5. Cross Unit Exercise: Teamwork across Units To facilitate discussion and improve teamwork, communication, and coordination across multiple hospital units sts/Handoffs/Appendix_A_20120305_ Teamwork_across_units.pdf 6. Assessment of Care Transitions Tool To help an organization evaluate the transition of care of a patient from one unit to another and the verbal handoff associated with it CSTS/Calls_Presentations/Content_C alls/20130822_ACT_v9.docx Johns Hopkins University 35

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