Out-of-hours primary care: a population-based study of the diagnostic scope of telephone contacts

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1 Fmily Prctice, 2016, Vol. 33, No. 5, doi: /fmpr/cmw048 Advnce Access publiction 21 June 2016 Helth Service Reserch Out-of-hours primry cre: popultion-bsed study of the dignostic scope of telephone contcts Grete Moth*, Lind Huibers, Morten Bondo Christensen nd Peter Vedsted The Reserch Unit for Generl Prctice, Arhus University, Arhus, Denmrk. *Correspondence to Grete Moth, The Reserch Unit for Generl Prctice, Arhus University, 2 Brtholins Alle, Arhus C 8000, Denmrk; E-mil: moth@ph.u.dk Abstrct Bckground. GPs nswer ll ptient clls to the out-of-hours primry cre (OOH-PC) services in Denmrk. Knowledge is scrce on how the trige-gps ct on the specific resons for encounter (RFE). Objective. This study ims to describe the RFEs, the pplied dignoses nd the severity of helth problems presented in clls to the OOH-PC. Methods. This ws 1-yer cross-sectionl study bsed on IT-integrted pop-up questionnires ddressing ptients helth problems. We included only telephone contcts tht were ctegorized ccording to their trige outcome s telephone consulttions, direct dmissions to hospitl or referrls for fce-to-fce contct. The GP-ssessed severity ws clculted for ge groups nd types of outcome. We identified the 20 most frequent primry RFEs nd dignoses for ech type of contct termintion. Results. We included 7810 telephone clls. Clls considered non-severe mde up two-thirds of the clls terminted s telephone consulttions, wheres clls considered potentilly severe mde up the min prt of referrls (52.3%). Overll, the 20 most frequent RFEs ccounted for 45.2% of ll RFEs, fever being the most frequent (10.0%). Some RFEs were terminted mostly s telephone consulttions [e.g. insect bite/sting (75.9%)], wheres others were most often referred for fce-tofce contct [i.e. dyspnoe (79.1%)] or directly to hospitl [i.e. chest pin (29.4%)]. Conclusion. The distribution of the RFEs on trige outcomes, dominted by more severe dignoses in referrls indictes suitble referrl level. However, future reserch on fctors relted to the demnding tsk of telephone trige is highly relevnt for postdoctorl trining of GPs. Key words: After hours, Denmrk, dignosis, primry helth cre, reson for encounter, severity, trige. Introduction Out-of-hours primry cre (OOH-PC) services hve ttrcted ttention in mny countries due to growing need to estblish sfe nd efficient orgniztion for hndling people s cute helth-relted demnds (1 3). In Denmrk, like in mny Europen countries, GP form the first line of helth cre during the dytime by providing free medicl cre to ll listed ptients nd cting s gtekeepers to specilized helth cre (4). In four of the five Dnish helth cre dministrtive regions, the GPs re lso responsible for providing OOH cre in lrge region-bsed coopertives from 4 p.m. to 8.m. on weekdys nd throughout weekends nd public holidys (4,5). Besides the OOH-PC, citizens cn in cse of cute nd life-thretening helth problems cll the emergency service centres, in which clls re nswered by nurses (6). Wheres nurses re responsible for nswering the telephone in the OOH-PC of mny countries, in Denmrk, GPs nswer nd trige ll ptient clls mde to the OOH-PC services. In more thn hlf of ll clls (59%), the GP offers telephone consulttion, either to The Author Published by Oxford University Press. All rights reserved. For permissions, plese e-mil: journls.permissions@oup.com. 504

2 Out-of-hours primry cre 505 provide dvice nd tretment or to fcilitte direct dmission to hospitl (7). For the remining clls, the GP refers the ptient to clinic consulttion or home visit. Previous studies show tht mny OOH-PC clls re due to minor ilments (2,7 11). This suggests tht some of these cses could hve been treted by self-cre or hve been ttended to during office hours by the ptient s own GP (7,12). However, only few studies hve focused on the specific resons for encounter (RFE) in OOH-PC clls (2,7,13) nd on how trige-gps ct on RFEs, i.e. by mking specific dignosis in telephone consulttion, by referring the ptient for fce-to-fce contct t the OOH-PC services or by dmitting the ptient directly to hospitl. In Denmrk, the present ptient record system does not involve systemtic registrtion of codes for the RFE nor dignoses. Knowledge bout how helth problems re dignosed nd triged by doctors during telephone contcts is importnt for the plnning of the OOH-PC services nd in the eduction of helth cre professionls. This study ims to describe the RFEs, pplied dignoses, new episodes/excerbtions of chronic disese, nd the GP-ssessed severity of helth problems ddressed in telephone contcts to the OOH-PC tht triggered telephone consulttion, direct dmission to the hospitl or referrl to fce-to-fce contct t the OOH-PC service. Methods Setting This cross-sectionl study ws performed in the OOH-PC service of the Centrl Denmrk Region, which provides cre for 1.25 million inhbitnts nd registers totl of nnul OOH-PC clls. Clls re terminted s telephone consulttions (dvice with or without prescription or with direct dmission to the hospitl) or s telephone referrls (referrl to subsequent fce-to-fce contct with GP t the OOH-PC service). Design The present study is bsed on comprehensive 1-yer cross-sectionl survey on RFE nd disese ptterns in the Dnish OOH-PC service (LV-KOS) performed from 1 June 2010 to 31 My 2011 (7). GPs were invited to prticipte in the study when logging on to the electronic ptient dministrtion system t the beginning of shift in the OOH-PC services. Only one GP could prticipte per type of shift (telephone trige, clinic consulttions or home visits) in ech 8-hour shift. A pop-up questionnire ppered rndomly fter every 10th telephone cll from ptient. Bckground dt on contct, time, dte nd prescribed mediction s well s informtion on the GPs were obtined from the opertionl computer system. The GPs received bsic remunertion for their prticiption (20 euro) nd for ech registered contct (4 euro). A representtive smple of 385 out of 700 GPs in the region prticipted in the LV-KOS t lest once (55.0%) nd of ll telephone shifts during the 1-yer study period, 95.5% ws covered by prticipting GPs. They registered in totl contcts (4620 telephone consulttions, 3190 telephone referrls, 6973 clinic consulttions nd 6674 home visits). The registered ptient contcts were highly representtive of ll contcts in the study period with regrd to ge nd gender, s the distribution on these prmeters for the included contcts compred with ll contcts in the study period vried <3% (14). Further informtion regrding the LV-KOS study is described in detil elsewhere (7,14). (ii) the GP-ssessed severity ( Severe nd potentilly life thretening, Mybe severe nd needs to be seen, Not severe, but the ptient is ill, The ptient is not ill nd Don t know ); (iii) the probble dignosis (stted in text); nd (iv) whether the ptient ws dmitted directly to hospitl or not. In ddition to this, we extrcted informtion from the electronic ptient record system on (i) the type of contct (i.e. telephone consulttion including direct dmission to the hospitl nd referrl for fce-to-fce contct); (ii) the RFE from the GP s sttement in the ptient record (stted in text); nd (iii) gender nd ge of the ptient. These dt were trnsferred electroniclly to the reserchers securing tht no dt were lost. Dt mngement The present study included only telephone contcts becuse they represent the entrnce for ll ptient contcts to the OOH-PC services nd therefore reflect ll RFEs nd the GPs evlutions t the point of ccess to the OOH-PC. Ptient ge ws ctegorized into eight ge groups (0 4, 5 13, 14 30, 31 40, 41 50, 51 60, nd >75 yers). RFEs nd dignoses stted in text were coded mnully using the Interntionl Clssifiction of Primry Cre 2nd Edition (ICPC-2) (15). The coding of dignoses ws performed by trined medicl student who ws supervised by resercher. In cse of mbiguous or uncler text, ny dditionl informtion in the ptient record (e.g. mediction prescribed nd the stted probble dignosis) ws used to estblish the RFE. Outcome We defined the outcome ccording the termintion of clls, telephone consulttions, telephone referrls to fce-to-fce contcts nd telephone contcts with direct dmission to hospitl (without preceding fce-to-fce contct). Anlysis Descriptive nlyses were performed. For comprison, the percentge of clls to the OOH-PC in the region in the study period ws clculted for ech gender nd ge group. The distribution of GP-ssessed severity ws clculted for ech ge group, strtified by the outcome of the telephone contct. In the presenttion, contcts ending with direct dmission to hospitl were included in the ctegory telephone consulttions becuse they were mnged s such nd were ll considered severe. The 20 most frequent primry RFEs were identified, nd we clculted the distribution of RFEs on the outcome of the telephone contcts. Finlly, the 20 most frequently pplied dignoses were identified nd clculted by the outcome of the telephone contcts. Anlyses were performed in STATA (Version 13.0, SttCorp LP). Results Telephone contcts to the OOH-PC services A totl of 7810 telephone contcts were included (Tble 1). Among these, 59.1% were terminted on the telephone either s telephone consulttions (56.5%) or s direct dmissions to hospitl (2.6%). Presenting with 1454 children below 5 yers of ge this group formed the reltively lrgest group of ll ptients (18.6%). New episodes ccounted for 81.4% of the contcts, while excerbtion of chronic disese comprised 13.3%. Dt The questionnire included the following four questions: (i) whether the contct ws new episode or n excerbtion of chronic disese; GP-ssessed severity Two-thirds (67.0%) of ll contcts were considered non-severe by the GP. Tble 2 shows tht clls considered Not severe, but

3 506 Fmily Prctice, 2016, Vol. 33, No. 5 the ptient ws ill mde up the min shre of telephone consulttions, vrying from 48.6% to 73.3% cross the ge groups. Contcts considered Mybe severe nd needs to be seen mde up the min shre of referrls for fce-to-fce contct, vrying from 42.7% to 63.1% cross the ge groups. Furthermore, the proportion of contcts considered Severe nd potentilly life thretening rose with incresing ge for both trige outcomes (Tble 2). Tble 1. Bseline chrcteristics of the study smple of 7810 telephone contcts in Dnish out-of-hours primry cre service in 12-month study period from June 2010 Reson for encounter In totl, 392 different RFEs were stted. Overll, the 20 most frequent RFEs ccounted for 45.2% of ll RFEs (Tble 3), fever being the most frequent RFE (10.0%), followed by stomch pin nd cough (3.6% ech). There ws lrge vrition in mode of termintion depending on the nture of the RFEs. For some RFEs, the mjority of cses were terminted s telephone consulttions [e.g. drug prescription (98.1%), teeth/gum complint (89.0%) nd insect bite/sting (75.9%)]. In contrst hereto, some RFEs were mostly referred for fce-to-fce contct [i.e. dyspnoe (79.1%), chest pin (40.2%) nd loclized bdominl pin (61.1%)] or directly to hospitl [i.e. chest pin (29.4%) nd dyspnoe (4.5%)]. Chrcteristics Number of contcts (%) Sex Femle 4133 (52.9) Mle 3677 (47.1) Age group (18.6) (8.8) (22.4) (12.9) (9.8) (7.8) (10.1) > (9.7) New episode or excerbtion of chronic disese New 6361 (81.5) Excerbtion 1032 (13.2) Missing informtion 417 (5.3) Outcome of the telephone contct Telephone consulttion 4414 (56.5) Telephone referrl 3190 (40.9) Direct referrl/dmission to hospitl 206 (2.6) Telephone contcts ended with telephone consulttion, fce-to-fce contct t the OOH-PC or direct referrl/dmission to the hospitl. Probble dignoses Tble 4 shows tht the 20 most frequently pplied dignoses in telephone consulttions mde up 37.3% of ll dignoses. The most frequent such dignoses were cystitis (3.3%), gstroenteritis (3.3%), cute upper respirtory infection (3.1%) nd infectious conjunctivitis (3.1%). In referrls to fce-to-fce contct, the most frequently stted pplied dignoses were pneumoni (7.2%), cute tonsillitis (5.3%) nd cute otitis medi (4.1%). The direct hospitl dmissions were dominted by pplied dignoses of cute myocrdil infrction (17.0%) nd stroke/cerebrovsculr ccident (7.8%). Discussion Key results The study included rndom clls to the OOH-PC service of which 56.5% were terminted s telephone consulttions, 40.9% were referred for fce-to-fce contct t OOH-PC nd 2.6% were directly dmitted to hospitl. One-fifth of ll clls concerned young children younger thn 5 yers. Eight out of 10 clls concerned new episodes of illness. Severe or potentilly severe helth problems mde up <30% of ll clls to the OOH-PC, but this shre incresed with ge. A lrge vriety of RFEs nd pplied dignoses chrcterized the clls; thus, lmost 400 different RFEs were Tble 2. The GP-ssessed severity of the 7810 out-of-hours primry cre telephone contcts strtified by ge groups nd types of contct Age group GP-ssessed severity in telephone consulttions, N (%) Severe nd potentilly life thretening Mybe severe nd needs to be seen Not severe, but the ptient is ill Not ill Do not know All (1.5) 49 (5.7) 636 (73.3) 145 (16.7) 25 (2.9) 868 (100) (1.5) 24 (5.9) 294 (71.9) 71 (17.4) 14 (3.4) 409 (100) (2.5) 79 (7.2) 714 (64.7) 232 (21.0) 51 (4.6) (100) (2.9) 40 (6.5) 387 (63.1) 131 (21.4) 37 (6.0) 613 (100) (3.3) 30 (6.6) 306 (67.3) 75 (16.3) 29 (6.4) 455 (100) (8.4) 33 (9.2) 224 (62.8) 51 (14.3) 19 (5.3) 357 (100) (9.0) 49 (11.3) 254 (58.5) 59 (15.9) 23 (5.3) 434 (100) >75 58 (15.2) 52 (13.7) 185 (48.6) 46 (12.1) 40 (10.5) 381 (100) GP-ssessed severity in telephone referrls (2.2) 250 (42.7) 290 (49.5) 18 (3.1) 15 (2.6) 586 (100) (1.8) 130 (47.1) 128 (46.4) 6 (2.2) 7 (2.5) 276 (100) (2.5) 283 (44.0) 290 (45.1) 28 (4.4) 26 (4.0) 643 (100) (3.3) 187 (47.0) 170 (42.7) 13 (3.3) 15 (3.8) 398 (100) (2.0) 135 (44.0) 146 (47.6) 11 (3.6) 9 (2.9) 307 (100) (2.8) 133 (53.4) 99 (39.8) 5 (2.0) 5 (2.0) 249 (100) (5.7) 222 (63.1) 90 (25.6) 14 (4.0) 6 (1.7) 352 (100) >75 33 (8.7) 216 (57.0) 96 (25.3) 6 (25.3) 28 (7.4) 379 (100) Including direct referrl/dmission to hospitl.

4 Out-of-hours primry cre 507 Tble 3. The 20 most frequent reson for encounters strtified by type of outcome (telephone consulttions, referrl to fce-to-fce contct, direct referrl/dmission to hospitl) All telephone contcts Outcome of telephone contct Most frequent RFEs N (% of ll) Telephone consulttion (%) Referrl to fce-to-fce contct (%) Direct referrl/dmission to hospitl (%) Fever 780 (10.0) Generl stomch pin 306 (3.6) Cough 284 (3.6) Er pin 218 (2.8) Throt symptom 205 (2.6) Lcertion/cut 169 (2.2) Vomiting 160 (2.1) Hedche 144 (1.8) Dyspnoe 134 (1.7) No specified RFE 133 (1.7) Loclized bdominl pin 126 (1.6) Insect bite/sting 113 (1.5) Drug prescription 106 (1.4) Chest pin NOS 102 (1.3) Bck symptom 99 (1.3) Loclized rsh 99 (1.3) Teeth/gum complint 91 (1.2) Sneezing/nsl congestion 91 (1.2) Foot/toe complint 87 (1.1) Dirrhoe 86 (1.1) Other RFEs 4277 (54.8) NOS, not otherwise specified. Tble 4. The 20 most frequent probble dignoses ssigned in the clls strtified by outcome (telephone consulttions, referrl to fce-tofce contct, direct referrl/dmission to hospitl) Telephone consulttions (%) Referrls to fce-to-fce contct (%) Direct referrl/dmission to hospitl Cystitis (3.5) Pneumoni (7.2) Acute myocrdil infrction (17.0) Gstroenteritis (3.4) Tonsillitis cute (5.3) Stroke/cerebrovsculr ccident (7.8) Upper respirtory infection cute (3.3) Acute otitis medi (4.1) Poisoning by medicl gent (3.9) Conjunctivitis infectious (3.2) Generl stomch pin (3.0) Peptic ulcer, other (2.9) Acute otitis medi (2.9) Fever (2.8) Frcture, other (2.4) Virl disese other/nos (2.1) Cystitis (2.6) Atril fibrilltion/flutter (2.4) Influenz (2.1) Lcertion/cut (2.6) Frcture, femur (2.4) Drug prescription (2.0) Upper respirtory infection cute (2.3) Lcertion/cut (1.9) Lcertion/cut (1.8) Skin infection post-trumtic (2.1) Chronic obstructive pulmonry disese (1.9) Fever (1.7) Gstroenteritis (1.9) Concussion (1.9) Insect bit/sting (1.7) Acute bronchitis/bronchiolitis (1.7) Brething problem, other (1.5) Generl stomch pin (1.5) Chronic obstructive pulmonry disese (1.7) Epilepsy (1.5) Urticri (1.4) Foreign body in eye (1.4) Nose bleed/epistxis (1.5) Constiption (1.4) Skin infection other (1.3) Allergy/llergic rection NOS (1.5) Other RFE NES (1.3) Asthm (1.3) Convulsion/seizure (1.5) Teeth/gum complint (1.2) Infectious disese other/nos (1.3) Abdominl pin/crmps generl (1.5) Sinusitis (1.2) Appendicitis (1.2) Deth (1.5) Adverse effect of medicl gent (1.2) Urinry retention (1.2) Toxic effect non-medicinl substnce (1.5) Worms/other prsites (1.2) Urinry clculus (1.1) Bruise/contusion (1.1) Generl disese NOS (1.1) Other dignoses (61.1) Other dignoses (52.8) Other dignoses (22.3) NES, not elsewhere specified; NOS, not otherwise specified. For 22 dignoses, the proportion ws 1.0%. observed. Fever ws the most frequent RFE followed by stomch pin nd cough. Strengths nd limittions The results of the present study were bsed on lrge representtive smple of contcts to the OOH-PC service (the LV-KOS study), which gives high sttisticl precision (7). We voided missing dt through electronic registrtion of dt nd obtined lrge vriety of bseline dt on the contcts from the electronic ptient records. The GP feedbck on the fesibility of registrtion nd the cceptbility of prticiption indictes tht the GPs registrtions re vlid, which is underpinned by prticiption coverge reching 95.5% of ll GP telephone duty periods.

5 508 Fmily Prctice, 2016, Vol. 33, No. 5 Yet, GPs were ble to decline completion of pop-up questionnire, which my be the cse in periods of very hevy work lod. The prticiption coverge ws high nd the demnds for registrtion were widely ccepted, so we expect the missed registrtions to be limited. Also, missed registrtions re likely to be rndom nd not systemticlly relted to ny of the included vribles in the present study, thus minimizing the risk of selection bis. We extrcted the RFE from the GP ptient record notes to sve time for the GPs. These notes were often short nd not lwys unmbiguous nd imply interprettion of ptient informtion by the GP. This my hve introduced some informtion bis. However, the dditionl informtion in the ptient record, especilly informtion on prescribed mediction nd the dignosis mde, enbled us to identify the RFE in most of the uncertin cses. The GPs were sked to stte the probble dignosis bsed on the telephone contct. Thus, the dignoses were not vlidted in ctul exmintions of the ptients, which might hve ltered some of the dignoses. However, for the purpose of the present study, the vrition in ICPC codes for RFEs nd dignoses proved interesting. Comprison with existing literture Overll, telephone consulttion rte of 56.5% is high compred with the rtes reported from other countries (7). This is probbly relted to the fct tht GPs serve s front line stff, performing the telephone trige of ptient clls s trige requires high level of medicl knowledge, primry cre perspective, nd experience in triging clls in the OOH-PC service (3,16). The lrge vriety of RFEs observed in ptient contcts in the present study underlines the dvntge of hving generlists hndle trige. Fever ws the most common RFE, which is in line with other findings, including findings from other countries nd other types of OOH orgniztions. Dt show tht OOH services re often contcted for symptoms relted to infectious diseses (8,10,13). In line with other studies, we found tht young children constituted lrge prt of the clls mde to the OOH-PC service (2,8,16), which my contribute to the high frequency of fever s RFE. Furthermore, we found tht reltively lrge shre of contcts concerned ptients ged yers. In contrst to the young children, who lso represented lrge prt of clls, one could ssume tht people from this ge group re of good helth compred with older people. Yet, they my hve other resons for contcting the OOH-PC, such s difficulties ccessing GP clinic within office hours or need for ressurnce nd informtion (17 19). It is noticeble tht of ll contcts, only ~1 in 10 ws due to excerbtion of chronic disese. A pper bsed on the LV-KOS dt showed tht only bout one-fourth of clls from ptients with chronic diseses were due to their chronic condition (20). This finding indictes tht chronic cre is lrgely being mnged within office hours. A Dutch study of OOH-PC reported tht 10.4% of non-frequent ttenders contcts were due to chronic disese (10), which is in line with our finding. It seems to indicte optiml helth cre for chronic ptients in contrst to potentil extensive use of emergency nd out-of-hours helth cre services for these ptients. The dignoses tht were ssigned to contcts tht were referred for fce-to-fce consulttion were more severe or clled for further investigtion nd tretment (e.g. lcertion/cut) more so thn the dignoses mde in telephone consulttions. It is, however, interesting tht the second nd third most frequent dignoses in clls referred for fce-to-fce contct were cute tonsillitis nd otitis medi, s these helth problems often do not need ntibiotic tretment ccording to guidelines nd thus could often wit doctor s opinion until office hours. This observtion begs the question whether this pttern cn be chnged s ptients my hve become ccustomed to receiving throt swp or ntibiotic tretment. Generlizbility nd implictions for reserch nd prctice The findings of the present study re likely to be representtive for countries with similr orgniztion of the OOH primry cre service, s it is indicted in previous ppers (2,3). The GPs in Denmrk plced in the frontline nswering direct clls from ptients mkes difference between Denmrk nd most other countries nd is relevnt subject for further reserch. Such reserch will llow us to chieve more knowledge on centrl issues in this field nd it my inform postgrdute trining of GP-trinees, who will be triging OOH-PC clls in the future. A reltively lrge proportion of telephone contcts were ssessed s non-severe nd terminted on the phone. Ptient eduction concerning the use of OOH-PC could be n option, provided some use of the OOH-PC cn be redirected to dytime generl prctice. A prt of the clls ws referred directly for hospitl tretment, which seems n importnt spect of GP-triged OOH-PC. It is relevnt to investigte why young ptients re frequently ttending OOH-PC nd whether these contcts re medicl relevnt, to see how possibly more optiml helth-seeking behviour cn be chieved. The study provides documenttion for nd knowledge on the helth problems cusing clls to the OOH-PC services nd my thus be useful for discussions of the indictions for referring ptients to fce-to-fce consulttions. Moreover, knowledge on citizens resons for clling the OOH primry cre services my prove useful in plnning the orgniztion nd how to mke the most optiml use of the resources vilble. Conclusion More thn hlf of the clls to the OOH-PC were terminted s telephone consulttions, nd the mjority of the clls concerned non-severe helth problems. About hlf of the clls referred for fceto-fce contct were considered severe or potentilly severe by the GPs, nd this shre ws ccounted for minly by the older ge groups. Symptoms of infection were by fr the most frequent RFEs, but lrge vriety of RFEs ws seen. The distribution of the most frequent dignoses by trige outcomes reveled tht telephone referrls for subsequent OOH-PC fce-to-fce contct concerned more severe dignoses thn dignoses terminted s telephone consulttions. This knowledge my contribute to the plnning of the OOH-PC service. Authors contributions GM contributed substntilly to the design, to the cquisition, nlysis nd interprettion of dt. GM mde the first drft nd the subsequent revisions of the mnuscript, nd she hs pproved the version published. LH contributed substntilly to the interprettion of dt nd prticipted ctively in writing nd revising the mnuscript criticlly. Furthermore, LH hs given her finl pprovl for the published version of the mnuscript. MBC contributed substntilly to the design of the study nd prticipted in the writing nd revision of the mnuscript nd hs lso given his pprovl for the published version of the mnuscript. PV contributed substntilly to the design of the study, to the interprettion of dt nd prticipted ctively in writing nd revising the mnuscript criticlly, nd he hs given his pprovl of the published version of the mnuscript. Acknowledgements The uthors thnk ll the GPs who prticipted in this study, nd they lso extend their grtitude to PhD student Lone Flrup who mnged the logistics of the study.

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