Health-Care Use in the Veterans Health Administration: Racial Trends and the Spirit of Inquiry
Eugene Z.Oddone, Laura A.Petersen, and Morris Weinberger
Throughout its history, the United States has provided some degree of health care to its current and post-service military personnel, particularly those injured while serving (Kizer, 1996). Prior to World War II, a relatively small-scale, loosely organized system existed to provide such care (Hollingsworth and Bondy, 1990). After World War II, the federal government recognized that the existing system was ill equipped to provide adequate care for the increasing number of veterans with severe disabilities (Hollingsworth and Bondy, 1996; Iglehart, 1996). The government established a largely inpatient-based health-care system for veterans (Iglehart, 1996), which was the genesis for the Veterans Health Administration (VHA), now the largest integrated health-care system in the United States (Kizer, 1996).
RESEARCH ON RACIAL VARIATIONS IN THE PROVISION OF CARE IN THE VETERANS HEALTH ADMINISTRATION
To understand VHA research to date regarding racial variations in health care, two issues must be emphasized. First, because virtually all studies have been limited to veterans who receive care in VHA, findings are not immediately generalizable. There is overwhelming evidence that veterans who use VHA have significantly fewer financial resources and less, if any, supplemental health insurance (Wolinsky et al., 1985; Randall et al., 1987); report meaningfully lower scores on health related quality-of-life measures (Kazis et al., 1997; Weinberger et al., 1996); and have
significantly less experience with the traditional doctor-patient relationship (Inui et al., 1984). These data clearly indicate that veterans receiving care within VHA are more medically and socioeconomically vulnerable than either nonveterans or veterans who do not use VHA.
Second, published VHA studies rely on information available in the Patient Treatment File (PTF), a national administrative database that contains a record for each admission to a VA hospital since the 1970s (Lamoreaux, 1996). PTF was developed to provide information about health-care use to VHA policy makers and managers. It does not, however, contain clinical data. Without valid clinical data, any relationship between race and health must be seen as theoretical. The nature of administrative data sets limits investigators’ ability to reach cause-and-effect conclusions about observed racial variations. On the other hand, primary data are needed for prospective studies designed to better understand whether observed racial variations can be accounted for by factors such as patients’ clinical characteristics, health/functional status, preferences for treatment options, or racism.
Given the above limitations, why should we nevertheless pursue studies examining the relationship between race and health among veterans receiving care within VHA? First, from a policy point of view, Kenneth W.Kizer, VHA Undersecretary for Health, has stated that one goal of VHA is to document that the quality of care it provides is equal to, or better than, care available in the private sector (Kizer, 1998). The Undersecretary specifically addressed actions needed to increase the accessibility of VA services. Second, VHA provides a functional safety net for a group for whom investigations about race and health may be most important—the most socioeconomically vulnerable veterans (Iglehart, 1996; Wilson and Kizer, 1997). Third, from the standpoint of research, because access to health care for eligible veterans is not limited by income, well-designed prospective studies can separate the effects of race and income. This factor is unique to studies conducted in VHA. Fourth, the veteran population contains a greater proportion of underrepresented minorities than exists in the country overall. The percentage of Blacks among all veterans is growing: they comprise 6.1 percent of World War II veterans, 8.3 percent Korean Conflict veterans, 8.6 percent of Vietnam Era veterans, and 17.1 percent of post-Vietnam veterans. The number of Hispanic veterans has also grown since World War II, from 3.4 percent to 5.7 percent (Heltman and Bonczar, 1990). Finally, research based on data from the PTF database is limited to vital statistics, as is research based on data from most administrative databases. The limitations of these data give emphasis to the critical need to supplement PTF with primary (clinical) data collection.
PLAUSIBLE PARADIGMS FOR STUDYING RACIAL VARIATIONS
At least four areas of inquiry have been advanced as plausible explanations for observed racial differences in health-care use outcomes. First, observed racial variation may result from underlying differences in clinical factors related to the disease—e.g., etiology or severity—which would affect appropriateness of procedures taken. If there are racial variations in clinical factors, observed differences may be appropriate for those cases, if all patients receive the tests and procedures needed (Chassin et al., 1987). Without an understanding of the clinical issues, one does not know whether Blacks received too few, or Whites too many, tests and procedures. The paradigm shifts from simply counting who did or did not receive a test or procedure to understanding the “appropriateness” of that procedure. Using the appropriateness paradigm regarding health-care use, both over-use by one group and under-use by another can be identified.
A second area of inquiry examines whether racial differences in health-care use are a function of patients’ ability to pay for care—i.e., an economic paradigm. Indeed, economic factors are important determinants in many health-care decisions. For example, more Whites than Blacks supplement Medicare coverage with private insurance to cover the deductible and copayment requirements of Medicare (Rice and McCall, 1985); better Medicare coverage might have given older veterans more options for care (Ashton et al., 1994). In addition, changes in eligibility or financial barriers to either Medicare or VHA care influence veterans’ decisions about where to seek care (Fleming et al., 1992).
Examining the economic factor as a paradigm for racial variation necessitates equating racial variations with socioeconomic status. Studies in this paradigm are often hampered by the need to use proxy variables, such as insurance status or zip-code-averaged income per household, because individual information is not available. Studies conducted in VHA do not have this problem because all eligible veterans (defined as those with an honorable discharge from U.S. military service) have specified and equal access to health care protected by congressional mandate. Although there are standards for complete versus partial eligibility, the vast majority of veterans cared for in VHA are eligible for unrestricted access to care with no payments required and no need for supplemental insurance. Furthermore, physicians who provide care in VHA are salaried and therefore have no financial reasons to provide or deny care for patients. This makes VHA an ideal setting for studying racial variation; here researchers can separate the effects of race and income, at least as they relate to ability to pay for care (Horner et al., 1997).
The third and emerging line of research deals with patients’ prefer-
ences regarding the health care they receive—either preferences for care within the scope of traditional health-care options or preferences for alternative strategies, such as spirituality or nonallopathic medicine. Evidence suggests that patients’ preferences reflect standards and mores of their cultures. Thus, some observed racial variations in the use or nonuse of traditional health-care procedures may reflect patients’ preferences rather than bias on the part of the health-care system or health-care providers. The patient-preference paradigm requires prospectively asking patients about their preferences. This requires time, funding, and validated measures of critical constructs, such as religiosity, trust in the health-care system or an individual provider, or patients’ preferences for a particular health-care strategy.
The fourth and last major line of inquiry is that observed differences in health-care outcomes reflect true racial bias (either conscious or unconscious) on the part of the health-care system or individual clinicians. Hypothesizing that racial bias accounts for differences in the use or receipt of certain health-care strategies mandates an understanding of racial prejudice or lack of cultural tolerance. Such biases are perhaps more difficult to measure than patient preferences or trust. It may be that true bias may never be accurately assessed. One tactic researchers have used is to try to explain observed differences in terms of some measurable construct—e.g., ability to pay, appropriateness of care, or patient preference. Then, if differences in care still remain after accounting for these other factors, it is considered that bias may be the explanation.
Paradigm 1. Disease Severity as an Explanation for Racial Differences in Care
Racial Differences in the Use of Cardiovascular Procedures
Chronic ischemic heart disease and its complications are the most prevalent disorders treated in VHA medical centers (National Center for Veterans Analysis, 1993). In addition, coronary artery disease is the leading cause of death for Blacks in the United States (Gillum and Liu, 1984). Thus, many of the studies of racial variation in health-care use have focused on cardiovascular diagnoses.
Invasive cardiovascular procedures such as percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery have been shown to delay death and relieve symptoms for selected groups of patients with coronary artery disease (Ryan et al., 1996). Despite the potential benefits of these procedures in treating coronary artery disease, Black veterans and nonveterans receive fewer of these procedures in a variety of settings. Compared to Blacks, Whites are 1.3 to
1.4 times more likely to receive cardiac catheterization, 1.5 to 2.5 times more likely to receive PTC A, and 1.9 to 2.2 times more likely to receive CABG (Whittle et al., 1993; Wenneker and Epstein, 1989). With respect to differences in the use of CABG, differences persist even after accounting for clinical appropriateness of the procedure (Hannan et al., 1998). Racial differences also occur with respect to the use of certain medications deemed to be important in preventing heart attacks (Allison et al., 1996).
Can the observed racial difference be attributable to Blacks having a lower burden of atherosclerotic blockage? Peterson et al. (1997) studied PTCA and CABG procedures in Blacks and Whites. After adjusting for disease severity and other characteristics, they reported that Blacks remained 13 percent less likely than Whites to undergo PTCA and 32 percent less likely to undergo CABG. Racial differences in rates of CABG persisted even among those with severe symptoms and among those predicted to have the greatest survival benefit—i.e., those with the most extensive blockage. Hannan et al. (1998) examined a racially diverse group of New York residents who received coronary angiography. Using detailed information to assess the clinical appropriateness of the procedure, they found that Blacks and Hispanics were approximately 40 percent less likely to receive CABG after they were deemed appropriate for the procedure. Findings suggest that differential use of these procedures persists even after accounting for disease severity. This implies that disease biology is not the underlying factor explaining differences in procedure rates, at least as it relates to cardiovascular disease.
Racial Differences in the Use of Cerebrovascular Procedures
Stroke is the third leading cause of death and a leading cause of disability among adults in the United States (American Heart Association, 1997). Blacks are at higher risk of stroke than Whites, and current reports indicate that stroke mortality among Blacks may be rising (Kaplan, 1991). Because of limitations in effectively treating disabilities caused by acute stroke, stroke prevention practices are important. Carotid endarterectomy (CE) is known to be effective in preventing stroke for a wide variety of patients. Despite their higher risk for stroke, Blacks are only one-third to one-fourth as likely to receive CE as a preventive procedure (Oddone et al., 1993; Maxwell et al., 1989).
From a clinical perspective, the most likely explanation for this is a racial difference in the degree of atherosclerotic blockage. To be effective, CE must be performed on patients with more than 70 percent blockage of a carotid artery in an operable location. Other relevant clinical factors include the patient’s symptoms, estimated operative risk, and the number and type of comorbid illnesses present. Pathophysiological studies show
that, in relation to Whites, some Black patients have lower degrees of blockage in the portion of the carotid artery that is amenable to surgery (Aronow and Schoenfeld, 1993; Prisant et al., 1993). These differences may render Blacks potentially less appropriate candidates for CE.
Based on ratings of expert clinicians (Matchar et al., 1992), CE is an appropriate procedure when the expected health benefits—e.g., increased life expectancy, pain relief, and improved functional capacity—exceed the expected health risks—e.g., procedure-related mortality and morbidity. The appropriateness of CE is adjudicated based on the degree of ipsilateral and contralateral carotid artery stenosis, the constellation of patient symptoms at presentation, and the patient’s surgical risk. To date there are no studies that document racial differences in appropriateness of care for patients eligible for, or those who have received, CE. Brook et al. (1990) found that the proportion of appropriate CE was similar for Whites and non-Whites in a sample of Medicare patients who received the procedure. In a large sample of veterans deemed eligible for CE, we found no difference in clinical appropriateness between a racially stratified sample of Whites and Blacks (Oddone et al., 1997). However, this analysis fails to account for any differences in the diagnostic evaluation process prior to receipt of carotid angiography. What has yet to be determined is whether a similar proportion of White and Black patients receive the necessary evaluation to determine appropriateness.
Paradigm 2. Economic Factors as an Explanation for Differences in Care Provided
Because race and socioeconomic status are closely associated in U.S. society, it is possible that observed patterns of usage of expensive diagnostic or therapeutic procedures reflect the ability to pay for care. Blacks represent between 2 and 4 percent of patients who receive CE (Maxwell et al., 1989; Brook et al., 1990; Oddone et al., 1993). Regardless of adjustment for income, the relative odds of Whites versus Blacks undergoing CE are approximately 3 to 1. Moreover, this degree of variation is found across hospitals with different reimbursement arrangements—in private-sector hospitals, where fee-for-service reimbursement predominates, and in VHA hospitals, where hospital budgets are capitated, physicians are salaried and have no financial incentive to perform unnecessary procedures, and patients do not have to pay for care. Thus, among hospitalized patients, “ability to pay” does not appear to explain the significant racial variation in the use of CE.
Another point is that available studies in this area only report the experiences of hospitalized patients—i.e., those who have already gained access to the system. If racial bias plays a significant role in evaluation as
well as treatment of patients, it may be a particularly important factor in the outpatient setting where presenting signs and symptoms are ostensibly more subtle and, thus, the approach to clinical management is less clear. Consequently, the experience of hospitalized patients may not be generalizable to patients prior to hospitalization. There have been no studies to address this issue for patients with cerebrovascular disease.
Paradigm 3. Patient Preference as an Explanation for Racial Differences in Care Provided
In this era of informed consent and increased recommendations for patients to advocate for themselves, patients’ own beliefs and preferences have become an increasingly important influence in the course of health-care decisions.
Patient Perceptions of Their Own Health
In self-report surveys, Blacks consistently report poorer health status than Whites (Bergner, 1993; Rogers, 1992), and self-reported health status is an important predictor of mortality regardless of race or ethnicity. But the relationship of provision of care to self-reported health status and to comorbid illness or disease severity is difficult to determine. Previous studies based on self-report of outcomes among selected patient groups provide conflicting results. Blustein et al. (1995) report that among stroke patients, Blacks reported worse physical impairment than did Whites; on the other hand, Dignan et al. (1986) found no racial differences in activities of daily living. Among dialysis patients, Tell et al. (1995) noted that Blacks reported better quality of life than did Whites. Johnson et al. (1993) found Black patients presenting with chest pain had worse health-related quality of life; but when results were adjusted for sociodemographic factors, comorbid illness, and functional status, no differences remained.
Some research has also pointed to racial differences in perceptions of symptoms. This factor may influence differential use of health-care services for cardiovascular disease as well as other illnesses (Strogatz, 1990). To the extent that Blacks perceive their symptoms to be less severe (Raczynski et al., 1994), have less access to health care (Blendon et al., 1989), or believe the health-care system to be less responsive to them once they do seek care (Weddington and Gabel, 1991), they may be less likely to consider medical intervention as either obtainable or beneficial. Ren and Amick (1996) suggest that differences they observed between Blacks and Whites, in both self-perceived health and functional status, may result from cultural factors as well as institutional racism. Differences noted in these studies are not simply a matter of self-report; they are corrobo-
rated by mortality rates, which also are associated with race (Nickens, 1995).
Most studies that attempt to explain racial variations in cardiac procedures use administrative data and, thus, have no data on patients’ preferences that might explain such variations. Whittle et al. (1997), however, surveyed a sample of VA in- and outpatients, who may or may not have had coronary artery disease, regarding their willingness to undergo heart bypass surgery, should such surgery be recommended. Black patients indicated less willingness to undergo surgery; but regardless of race, those who were less familiar with the procedure were less willing to undergo the surgery. These results suggest that race may be differentially associated with certain beliefs about cardiac procedures, but this needs to be tested in samples of patients who are actually eligible for such procedures.
Although racial variation in the delivery of cardiac procedures was first documented more than a decade ago, the etiology of this disparity remains unclear. As summarized above, data from some studies suggest that neither disease severity nor access to health care completely explains observed differences (Whittle et al., 1993; Ford and Cooper, 1995). Most prior research examining this issue has used administrative data, so detailed information about patients’ experiences of and perspectives about the cardiac treatment decision-making process was not available. Notably, one study (Maynard et al., 1986) showed that Black patients are more likely to decline recommended cardiac procedures, and White patients are more likely to request such procedures, even when only medical therapy is recommended. Preferences for information and involvement in the decision-making process regarding health care vary significantly, but female, White, younger, and better-educated patients generally desire more involvement in decision making (Ende et al., 1989). Studies have also found that patients who participate more in their treatment decisions have better subsequent health outcomes (Kaplan et al., 1989; Greenfield et al., 1985). The VA is currently funding studies incorporating patientpreference data.
It may be that the amount of information patients have about their disease and their treatment options, and their appraisal of the risks and benefits, affect the likelihood of undergoing particular treatments. Intervention studies with cancer patients have shown that although it is important to match the provision of information to the patient’s interest in receiving such information, patients who are provided information and
offered a choice about treatment options experience less anxiety and depression after cancer surgery (Morris and Royle, 1987).
Perceived Barriers to Care
The perception of having received high-quality care, and satisfaction with the process, is the “ultimate validator of the quality of health care” (Donabedian, 1966); but patients’ beliefs drive their usage of health care. Luft et al. (1990) found that patients choose a hospital based on their perceptions of the quality of that hospital. Wolinsky and Steiber (1982) found that individuals with lower socioeconomic status, but better access to medical care, focus more on the cost of a visit when choosing a new physician.
Patient satisfaction is an important element in the delivery of health care for a number of reasons. Patients who are dissatisfied with their health care change health-care providers or “doctor-shop” more frequently, disenroll from prepaid health plans more frequently, adhere less well to medical regimens prescribed by their doctors, and recall less about what their doctor has told them or advised them to do. Studies have documented that Black patients in general are less satisfied with their health care (Blendon et al., 1989). It is surprising then, that little attention has been paid to racial differences in many patient satisfaction studies. In fact, one meta-analysis of the patient satisfaction literature noted that only 58 percent of the studies even included race as an independent variable (Hall and Dornan, 1990).
Trust in the System
In the past few decades, discrimination in the health-care environment has been a subject of particular scrutiny (Gamble, 1995; Blendon et al., 1995). Since the 1972 exposure of the U.S. Public Health Service Tuskegee Syphilis Study on Untreated Syphilis in the Negro Male, during which available treatment was withheld from several hundred Black men with syphilis, it has been widely thought that Blacks remain distrustful of the medical establishment (Gamble, 1993). It has also been argued that Black distrust of the medical establishment predated the Tuskegee experiment, and that the experiment simply verified for Blacks the existence of long-standing racist attitudes in health-care provision (Gamble, 1995). Although a considerable amount has been written about the long-lasting effects of the Tuskegee study on the Black community, most of this work has been from a legal, ethical, or historical perspective. There is little empirical documentation of minorities’ trust or mistrust of their
physician(s) and health-care institutions when facing clinical decisions or undergoing diagnosis and treatment. The “Tuskegee effect” may or may not translate into distrust when the respondent is a patient. Furthermore, without specific data, it is difficult to determine whether measures of satisfaction and dissatisfaction also reflect the element of trust.
Despite VA’s long history of serving veterans, Black veterans may have concerns about racial discrimination in the VA health-care setting inasmuch as many ethnic minority servicemen and -women had difficult and alienating experiences in the military (Parson, 1985; Terry, 1984). Findings from the National Vietnam Veterans Readjustment Study indicated that Hispanics and Blacks experienced more negative effects from their military service than did their White comrades (Kulka et al., 1990). For many minority veterans, wartime experiences led to extensive and continued distrust (Allen, 1986). Indeed, earlier this century VHA itself provided a reason for possible distrust among Blacks when it attempted to segregate Black veterans in a separate hospital, in Tuskegee, Alabama, rather than serve them in the same facilities where White veterans were served (Blendon et al., 1989).
Paradigm 4. Racism as an Explanation for Differences in the Provision of Health Care
There is evidence that Blacks receive a poorer quality of care in some health-care settings than do Whites (Escarce et al., 1993; Gornick et al., 1996). Further, research has demonstrated that Blacks have less access to certain elements of health care than do Whites (Blendon et al., 1989; Escarce et al., 1993). Even when generalized access is equal, wide disparities in access to particular medical services persist. One recent analysis of Medicare data found that Black and low-income patients were less likely to have ambulatory physician’s visits, mammograms, and influenza immunizations, and that such individuals were more likely to be hospitalized or die from the lack of such services (Gornick et al., 1996). Similarly, Escarce and colleagues (1993) found that elderly Whites were more likely than elderly Blacks to receive 23 different procedures and tests, with more Whites receiving services incorporating new types of technologies.
Other research into the processes of health care has shown that ethnic minority patients receive less empathy, attention, and information from their doctors (Kaplan et al., 1995). A separate study found racial differences in the use of pain medication for patients treated in an emergency room, with Hispanic patients receiving less analgesia than Whites (Todd et al., 1993). It has been hypothesized that such experiences relate to greater distrust of the medical care system on the part of Blacks and result in decreased health-care use (Blendon et al., 1995).
In a study of patients treated for posttraumatic stress disorder in VHA, Black veterans received less treatment by several measures than Whites. When the authors examined clinician-veteran racial pairings, they concluded that variation in treatment provided was at least partially explained by the pairing of White clinicians with Black veterans (Rosenheck et al., 1995). Similarly, in another study assessing reactions to hypothetical patients, White clinicians judged Black patients to be less appropriate candidates for psychotherapy and expected more adverse reactions to treatment (Geller, 1988).
Two studies have demonstrated that Black patients are less likely to have surgery recommended to them, and that those who receive such recommendations are less likely to accept them (Maynard et al., 1986; Sedlis et al., 1997). Sedlis et al. (1997) studied postcardiac catheterization VHA patients who were all considered to be potential candidates for CABG or PTCA. They found that fewer Black than White patients were offered procedures (64.3 percent versus 72.9 percent), but of those given the option of a procedure, almost twice as many Black patients declined (Sedlis et al., 1997). These results emphasize the importance of including physician behavior and access to care as explanatory variables in studies of racial variation.
Providing detailed information about potential race-related differences in patients’ understanding of treatment options, perceptions of the quality of VHA health care, and general preferences for care is a crucial first step toward improving health care in both VHA and non-VHA health-care settings. For example, curricula for mental health providers designed to help White clinicians overcome their own negative feelings when the issue of race emerges in the clinical setting have been described (e.g., Bradshaw, 1978), but their effectiveness has not been rigorously tested. Evidence from intensive courses in the patient-physician relationship given as part of residency training programs has shown that residents’ knowledge and skills in interviewing can be improved, though the effect sizes between patient groups were too small to assess patient satisfaction and well-being.
THE VETERANS HEALTH ADMINISTRATION’S COMMITMENT TO UNDERSTANDING THE REASONS FOR RACIAL DIFFERENCES IN HEALTH CARE
VHA research has engaged in a focused program to determine the reasons for ethnic and cultural variations in the delivery of VA health services. Based on early research results, VHA acknowledged that variations were evident for a wide spectrum of invasive diagnostic and treatment procedures including cardiac catheterization and coronary artery
TABLE 15–1 Summary of Studies Funded by the Department of Veterans Affairs Health Services and Research Service That Address Important Initiatives in Understanding Racial and Ethnic Variation in Health Care Services
Delivery of mental health services to American Indians and Hispanic Americans
Joseph Westermeyer, M.D., Ph.D.; Minneapolis VAMC
1. Identify patient characteristics related to underuse of mental health
2. Develop interventions to improve use
3. Study patient outcomes associated with interventions
Cultural factors in adaptation to chronic illness
Murray Katz, M.D.; Tucson VAMC
Develop a clinically useful measure of cultural factors impacting health for patients with chronic disease
Ethnic/cultural variations in the care of veterans with osteoarthritis
Kenneth Covinsky, M.D.; Cleveland VAMC
1. Measure ethnic variation in pathways leading from joint destruction to impaired quality of life
2. Understand the relationship between cultural attitudes and treatment choices
Race, patient preferences and stroke risk reduction
Eugene Oddone, M.D.; Durham VAMC
1. Measure relationship between patient’s aversion to surgery and use of carotid endarterectomy
2. Measure interaction between provider recommendation and patient choice
bypass surgery (Whittle et al., 1993; Peterson et al., 1994) and carotid endarterectomy (Oddone et al., 1993). In all areas, these trends were mirrored in Medicare and general populations (Gornick et al., 1996).
The first level of studies sought to understand whether racial differences in rates for certain procedures were attributable to over-use in one group or under-use in the other. To answer that question, however, rigorous assessment of medical records coupled with primary (clinical) data collection that goes beyond the traditional administrative database studies was necessary.
VHA research adopted an aggressive tactic by soliciting research proposals designed to understand the underpinnings of the observed racial differences. In 1996 VHA research developed an independent committee of experts to oversee racial variation research. This group solicited grants designed to go beyond the subjective grouping of individuals into arbitrary classifications, and encouraged research that incorporates self-identity and individual perceptions of self and others that may influence the delivery of health care. They mandated that research projects go beyond prior methodology, which to date had used retrospective analyses of information from large databases—all of which lack the level of detail required to fully understand existing differences. To be funded, research projects needed to collect prospective information, identify causes of systematic variation, and use innovative measures.
Eight studies were funded (Table 15–1), committing more than 7 million dollars to this innovative research agenda. The fruits of this extensive endeavor have yet to be realized; however, the results of these studies, perhaps more so than any other focused effort in racial variation research, will allow us to truly understand some of the root causes of current racial variation in health care and, thereby, allow us to better manage patient care in all of its complexities.
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