Efficiency

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In a restrictive sense defined either as minimizing the opportunity cost of attaining a given output or as maximizing the output for a given opportunity

Efficiency 111

cost. The general term used by economists is known as Pareto-efficiency. This is an allocation of resources such that it is not possible to reallocate them without imposing uncompensated losses of utility on some individual. A variant is potential Pareto-efficiency, where it is not possible to reallocate resources without imposing uncompensatable losses on someone (that is, the losses may not actually be compensated). It is common to see the notion of efficiency expressed at three different levels: technical efficiency, where more inputs are not used than are technically necessary to attain a given output; cost-efficiency or cost-effectiveness, where a given output is produced using the least-cost technically efficient combination of inputs (or, conversely, output is maximized for a given level of cost); Pareto-efficiency, where output is not only technically efficient and cost-efficient but is also set at an efficient rate such that any diminution or increase would impose uncompensated losses on some individual. Pareto-efficiency is also termed 'allocative efficiency' (a somewhat unhelpful term since all three ideas of efficiency are about resource allocation). The first two ideas concern the allocation of inputs to outputs; the third concerns the allocation of outputs to consumers, clients or users.

A variant idea of efficiency is known as extra-welfarism. With this (rather than general utility or welfare) as the framework, the maximand may be whatever the analyst or policy maker selects as appropriate. In health policy, health or health gain are common objectives. In such cases, health may be set as the maximand and efficiency implies either achieving a given overall level of health in the population at the least opportunity cost or, for a given set of resources, maximizing their impact on overall health. The idea of 'overall' health implies, of course, some means of 'adding up' the health of individual people, which will entail some distributional value judgments concerning the weight each is to have. In extra-welfarism, it is common not to extend the idea of efficiency to achieve an efficient distribution of outputs to clients, leaving this as a matter of equity, to be determined in other ways and by other criteria. Needless to say, equity objectives can themselves also be achieved with varying degrees of efficiency.

It should be plain that 'efficiency' is an inherently normative term. It tends to commend itself to economists, who do not always stop to think that whether it is good to be efficient may depend on what it is one is being efficient at doing. An efficiently run torture chamber scarcely commends itself, indeed it were better for such places to be inefficient than efficient. See also Interpersonal Comparisons of Utility, Kaldor-Hicks Criterion, Utility, X-inefficiency.

112 Elasticity

Elasticity

The responsiveness of a dependent variable (for example, output or demand) to changes in one of the variables determining it (for example, an input, price or income), ceteris paribus. It may be positive or negative. Numerically it is given by

. . % change in dependent variable elasticity =-.

% change in determining variable

Commonly encountered elasticities are income elasticity (the responsiveness of consumption to changes in income); demand elasticity or own-price elasticity (the responsiveness of the consumption of a good or service to a change in its price), cross (price) elasticity (the responsiveness of the consumption of a good or service to a change in the price of another good or service) and elasticity of substitution (the responsiveness of the ratio of two inputs to a change in the marginal rate of substitution).

Elasticity of Substitution

A measure of the curvature of an isoquant. See Elasticity. Ellsberg Paradox

An awkwardness for expected utility theory. In experiments, subjects have displayed an aversion to ambiguity contrary to the assumptions of expected utility theory. See Ambiguity.

Empirical

Of experience, evidence, observation or experiment as distinct from a priori or being based on reason only.

Employee Benefit Plan

A US plan created or maintained by an employer or employee organization that provides benefits for employees. The term may cover retirement pension plans, other plans for life insurance, health and dental insurance and disabil-

Endowment 113

ity income insurance. A plan's cost may be completely paid for by the employer or be shared with employees. A plan may also cover such benefits as sick leave, disability, profit sharing or stock purchasing.

Emporiatics

The medical specialty concerned with diseases and treatments of travellers. End of Scale Bias

A form of bias found in some instruments for measuring health status. It involves a reluctance on the part of experimental subjects to use the extremes of the scale they are offered.

Endemic

Disease prevalences in a particular location that do not vary much over time. Endocrinology

The medical specialty concerned with the structure and physiology of endocrine glands (glands that secrete directly into the bloodstream).

Endogenous

Usually descriptive of a characteristic of a variable in an economic model. A variable is endogenous if it is a function of parameters or variables in the model. Cf. Exogenous.

Endowment

In economics this usually refers to the bundle of goods and money that each individual is assumed to hold at the beginning of an analysis.

114 End-point End-point

Defines the ultimate outcome in a clinical trial. Common end-points are severe toxicity, disease progression or death. These end-points (other than death) are rarely end-points of the sort to satisfy economists because they are not easily interpretable in welfare terms and/or because they mark an endpoint in time beyond which further measurement and observation is not done (which may require modelling if there are significant post-end-point events for cost-effectiveness purposes). From such a perspective, such end-points plainly are not 'ultimate'.

Acronym for ear, nose and throat, the surgical specialty of otorhinolaryngol-

ogy.

Entitlement Theory

This is a libertarian theory that holds that a distribution of goods, or income and wealth, is just if it arises in a non-coercive way (for example via voluntary trading between individuals). Cf. Fairness, Utilitarianism.

Epidemic

A rapid increase in the prevalence of a disease. Levels of an infection. Cf.

Endemic, Pandemic.

Epidemiology

The study of the relationship between risk factors and disease in human populations, including factors that can change the relationship, and the application of such analysis to the design and management of health care systems. Clinical epidemiology is studied in clinical settings, usually by clinician epidemiologists, and usually with patients as subjects. Experimental epidemiology involves controlled experiments as in laboratory experiments or randomized controlled trials (RCTs). An epidemiological experiment seems to be a synonym for an RCT. Epidemiology may be descriptive (which merely records the facts as they appear to be) or analytic

Equilibrium 115

(usually involving the development and/or the testing of hypotheses). See

Clinical Epidemiology.

Episode of Care

The course of treatment from a patient's first encounter with a health care provider through to the completion of the last encounter.

EQ-5D

EQ-5D is a standardized instrument for use in developing a measure of health outcome. It is particularly associated with the QALY (quality-adjusted life-year). It is designed for self-completion by respondents and is suited for use in postal surveys, clinics and face-to-face interviews. It is cognitively simple, taking only a few minutes to complete. Instructions to respondents are included in the questionnaire. The current 3-level, 5-dimensional format of the EQ-5D has the following dimensions: Mobility, Self-care, Usual activity, Pain/discomfort and Anxiety/depression, each scored on a three-point scale (1- no problem, 2 - some problem, 3 - extreme problem). This generates 245 separate states of health (35 + 'perfect health' and 'dead'). See Assessment Quality of Life, Disability-adjusted Life-year, EuroQol, Health Gain, Health Status, Health Utilities Index, Healthy Year Equivalents, Quality-adjusted Life-year, SF-6D, SF-8, SF-12, SF-36.

Equilibrium

In economics, equilibrium is the term used usually to describe the (not necessarily unique) solution to a set of simultaneous equations that represent the key relationships in an economy. Thus the equilibrium price and quantity in a simple three-equation model of the economy are those at which demand equals supply, there being an equation for demand, for supply and the equilibrium condition that the price at which transactions take place is the same for demanders and suppliers and that the quantity supplied be equal to that demanded. Unless something changes (that is, the ceteris paribus qualifier is violated), these equilibrium values will, granted some side conditions, be stable, so the system as a whole is in a kind of balance which no one has any particular reason to want to change. See General Equilibrium, Nash Equilibrium, Partial Equilibrium.

116 Equity

Equity

This has two quite distinct meanings in economics. One is from accounting. (See Balance Sheet.) The other is from political philosophy. While efficiency is one ethical imperative in the design and operation of health services and other determinants of health, equity is the second major consideration. It is not necessarily to be identified with equality, but relates in general to ethical judgments about the fairness of income and wealth distributions, cost and benefit distributions, accessibility of health services, exposure to health-threatening hazards and so on. Although not the same as 'equality', equity nearly always involves the equality of something (such as opportunity, health, accessibility). Horizontal equity refers to the fairness in the treatment of apparent equals (such as persons with the same income). Vertical equity refers to fairness in the treatment of apparent unequals (such as persons with different incomes). A distribution of something (such as health, income or health insurance costs) is said to be horizontally equitable when people are treated the same in some relevant respect. Thus, if the relevant respect (a value judgment) is 'need', then an equitable distribution is one that treats people with the same need in the same way. A distribution is said to be vertically equitable when people who are different in some relevant way are treated appropriately differently. Thus, if the relevant respect is again 'need', an equitable distribution will accord more (of some relevant entity) to those in greater need. How much more will normally entail further value judgments.

Equivalence of Numbers

A preference measurement technique in which subjects are asked how many patients in a designated state of health should have their lives extended by one year for that to be equivalent to extending the lives of 100 healthy people by one year. See Person Trade-off Method.

Equivalence Scale

A scale used in equivalizing incomes or expenditures in order to make fair comparisons between households of different sizes and composition. See

Equivalization.

Ergonomics 117

Equivalence Study

A type of clinical trial where the aim is to establish whether one treatment is as effective (or equivalent to) another. It is most commonly used when the new treatment is expected to be as effective as an existing one but also to have fewer side-effects, a faster recovery rate, lower cost, or other relevant difference. Same as equivalence trial.

Equivalence Trial

Same as equivalence study.

Equivalent Annual Cost

The constant annual sum of money having the same present value as a stream of actual annual costs. Also known as annuitized value.

Equivalent Variation

The equivalent variation in income is the minimum (maximum) amount of money which would have to be given to (taken away from) an individual to make them as well off as they would have been after a price fall (rise). Cf. Compensating Variation. See Kaldor-Hicks Criterion, Willingness to Accept, Willingness to Pay.

Equivalization

An adjustment made to incomes or expenditures to enable fair comparisons to be made between households of different sizes and composition.

Ergonomics

The study of the interaction between people, their workplace and working environment, including assessing the physiological effects on workers of the design of tools, equipment and working methods.

118 Error Components Model

Error Components Model

A regression model for panel data. See Multiple (Linear) Regression. Error Term

Consider the following simple regression model:

Y = a + bXj + e,, where the subscript i refers to the ith observation. The random error term e, (epsilon) captures all the variation in the dependent variable Yi that is not explained by the X, (independent) variables.

Ethics Committee

Ethics committees are agencies (some statutory) that are designed to protect people who are directly or indirectly the subjects of, or might be affected by, research. Their approval is normally required for research involving patients, relatives or carers of patients; access to data, organs or other bodily material of past and present patients; foetal material and IVF involving patients; the recently dead in hospitals; the use of, or potential access to, health care premises or facilities; health care staff, recruited as research participants by virtue of their professional role.

Ethnography

The qualitative study of human races and cultures. Etiology

The study of the causes of disease. Also 'aetiology'.

EuroQol

Same as EQ-5D.

Excess 119

EuroQol Group

An international group of economists and decision theorists (mainly but not exclusively European) who developed the EQ-5D measure of health-related quality of life (quality-adjusted life-year). Their website is at www.euroqol. org/.

Event Rate

The proportion of patients in a group in whom the event is observed. Thus, if the event is observed in 33 out of 100 patients, the event rate is 0.33.

Evidence-based Medicine

The practice of medicine informed by the best available evidence of effectiveness and other empirically amenable aspects of the clinical management of a patient. There is a lot of argument as to what constitutes 'evidence' and the weight to put upon different kinds of evidence (for example, evidence got from randomized control trials or from observational studies). There is remarkably little evidence that evidence-based medicine (often abbreviated to EBM) leads to better health outcomes for patients, though it must be said that this is absence of (good) evidence rather than (good) evidence of absence.

Ex Ante

A Latin tag meaning a variable as it was before a decision or event, sometimes used to mean the planned value of a choice variable as in 'ex ante saving'. Cf. Ex Post.

Excess

A term used in insurance to mean the sum payable by the insured person, or deducted from the insurer's compensation, in the event of a claim. See

Coinsurance, Copayment.

120 Excess Burden Excess Burden

A loss of consumer's and/or producer's surplus. See Burden of Taxation, Deadweight Loss, Moral Hazard.

Excess Demand

A condition that exists when the demand for a good exceeds its supply at the prevailing price.

Excess Supply

A condition that exists when the supply for a good exceeds its demand at the prevailing price.

Exchangeability

Sometimes used in a similar way to generalizability. In statistics it has a technical meaning. The random vectors {xb xn} are exchangeable if their joint distribution is invariant under permutations.

Exchequer Cost

A cost that falls ultimately on taxpayers. Exchequer Revenue

Revenue that ultimately acts to reduce claims on taxpayers. Exclusion Bias

A form of bias in a clinical trial arising from non-random withdrawals from the trial.

Expected Utility Theory 121

Existence Value

The value placed upon the continued existence of an asset. In the context of benefits accruing to future generations, it is sometimes termed bequest value.

Exogenous

Usually descriptive of a characteristic of a variable in an economic model. A variable is exogenous if it is not a function of parameters or variables in the model. Cf. Endogenous.

Expansion Path

A locus in a two-input diagram which is the set of tangencies between isoquants and isocost lines as output expands.

Expected Utility

A utility number weighted by the probability of its occurrence. See Expected Utility Theory.

Expected Utility Theory

Expected utility theory postulates that a decision maker chooses (sometimes, ought to choose) between risky or uncertain prospects by comparing their expected utility values. Essentially the approach entails assuming that people maximize a weighted sum of utilities under uncertainty, where the weights are probabilities and choices are between gambles or lotteries containing goods and services of various kinds. The theory was developed in eighteenth-century Switzerland and became popular after it was axiomatized in the mid-twentieth century. There are many alternative axiomatizations but all share the key features of transitivity and continuity (common to all utility theories), completeness and von NeumannMorgenstern (VNM) independence. Completeness implies that, if lottery x is preferred to lottery y and lottery y is preferred to lottery z, then there is some combination of x and z that will be preferred to y. The VNM axiom means, roughly speaking, that adding a third lottery to two lotteries, whose ranking has already been determined, will not affect that ranking. The

122 Expected Value

VNM tag honours those who axiomatized the theory in the last century, John von Neumann (1903-1957) and Oscar Morgenstern (1902-1976), whose book Theory of Games and Economic Behaviour (Princeton: Princeton University Press, 1944) laid many of the foundations of expected utility theory (though not, oddly, that of the axiom bearing their names). This was also the beginning of game theory since expected utility theory's axioms were offered (and accepted by many influential scientists) as a justification for the use of expectations in game theory. Cf. Prospect Theory, Regret Theory. See Utility.

Expected Value

The weighted average of all possible values of a variable, where the weights are probabilities.

Expected-value-of-information

The use of Bayesian and frequentist probabilistic approaches to uncertainty in decision-analytic situations like cost-effectiveness analysis usually builds on data that are at best only partially relevant. One therefore needs to adjust empirical distributions, use explicit judgmental distributions, or collect new data. In determining whether or not to collect additional data, the expected-value-of-information (EVPI) approach, as its name implies, invites the analyst to consider the expected value (in the form of a reduction in opportunity loss) of additional (perfect) information (and the costs of getting it). EVPI comes in two forms: global, in which the reduction in opportunity loss from making a decision is estimated across all uncertain parameters; and partial, in which the reduction in loss relates to getting perfect information about a specific parameter.

Expenditures on Health Care

The total expenditures (public and private) on health care services in a country (or on/by a client group) over a period of time. There have been innumerable international comparisons of health care expenditures, often motivated by the false idea that there is a magic benchmark somewhere 'out there' that other decision makers (can they be politicians?) have got right and that you can use to buttress your case for more (less) spending in your own neck of the woods. The variation in per capita spending (public or private or both combined) and

Expenditures on Health Care 123

in fractions of GDP taken up by health care is substantial, as may be seen in the table.

Health expenditures as a percentage of GDP

1960

1970

1980

1990

1995

1996

2001

Australia

4.9

5.7

7.3

8.3

8.6

8.5

8.9

Austria

4.3

5.3

7.7

7.2

8.0

8.0

7.7

Belgium

3.4

4.1

6.5

7.5

7.9

7.8

9.0

Canada

5.5

7.1

7.2

9.1

9.6

9.5

9.7

Czech Republic

5.4

7.5

7.2

7.3

Denmark

3.6

6.1

6.8

6.5

6.4

6.3

8.6

Finland

3.9

5.7

6.5

8.0

7.6

7.4

7.0

France

4.2

5.8

7.6

8.9

9.9

9.7

9.5

Germany

4.8

6.3

8.8

8.7

10.4

10.5

10.7

Greece

2.9

4.0

4.3

5.2

7.2

4.7

9.4

Hungary

6.1

7.1

6.7

6.8

Iceland

3.3

5.0

6.2

7.9

8.2

8.2

9.2

Ireland

3.8

5.3

8.7

6.7

7.0

5.9

6.5

Italy

3.6

5.2

7.0

8.1

7.8

7.7

8.4

Japan

4.4

6.4

6.0

7.2

7.2

7.6

Korea

2.1

2.9

3.9

3.9

4.0

5.9

Luxembourg

3.7

6.2

6.6

7.0

7.3

5.6

Mexico

4.9

4.6

6.6

Netherlands

3.8

5.9

7.9

8.3

8.7

8.5

8.9

New Zealand

4.3

5.2

6.0

7.0

7.1

7.1

8.2

Norway

2.9

4.5

7.0

7.8

8.0

7.9

8.3

Poland

4.4

5.0

6.3

Portugal

2.8

5.8

6.5

8.2

8.3

9.2

Spain

1.5

3.7

5.6

6.9

7.3

7.4

7.5

Sweden

4.7

7.1

9.4

8.8

7.2

7.3

8.7

Switzerland

3.1

4.9

6.9

8.3

9.6

9.7

10.9

Turkey

2.4

3.3

2.9

United Kingdom

3.9

4.5

5.6

6.0

6.9

6.9

7.6

United States

5.2

7.3

9.1

12.6

14.1

14.0

1. Notwithstanding considerable efforts at homogeneity, part of the inter-country differences is caused by statistical artefacts.

2. 1996 ratios are preliminary estimates.

3. Some 2002 data are for 2001.

Notes:

1. Notwithstanding considerable efforts at homogeneity, part of the inter-country differences is caused by statistical artefacts.

2. 1996 ratios are preliminary estimates.

3. Some 2002 data are for 2001.

Source: Adapted from Table 10: Total Expenditure on Health, % GDP; 'OECD Health Data 2004', © OECD 2004.

124 Experience Rating

The most clearly consistent and robust outcome of econometric studies is that per capita GDP is a major determinant and that the aggregate income elasticity of demand for health care is around +1.0 after allowing for confounders.

Experience Rating

The setting of insurance premia where the probabilities used are based on the historical risk, for example as revealed by past claims experience. Cf. Community Rating.

Experimental Arm

The group of people in a clinical trial receiving (or not receiving) a health care technology of interest whose experience will be compared with a control group. See Clinical Trial.

Experimental Event Rate

The proportion of patients in an experimental treatment group who are observed to experience the outcome of interest.

Explanatory Trial

A species of controlled clinical trial. Explanatory trials test whether an intervention has efficacy; that is, whether it can have a beneficial effect in an ideal situation. They yield understanding of the processes and pathways through which the procedure being tested has its effects. The explanatory trial seeks to maximize internal validity by assuring rigorous control for confounding variables. Cf. Pragmatic Trial.

Explanatory Variable

Same as independent variable.

External Effects 125

Ex Post

A Latin tag indicating the value of a variable after a decision or event. Sometimes used to denote the outcome value of a variable as in 'ex post saving'. See Ex Ante.

Extended Dominance

An option that is dominated by another having the form of a linear combination of two other options. Dominance means that the combination option both is more effective and costs less than the simple option.

External Effects

These relate to the consequences of an action by one individual or group as they fall on others. There may be external costs and external benefits. Some are pecuniary, affecting only the value of other resources (as when an innovation makes a previously valuable resource obsolete); some are technological, affecting physically other people (communicable disease is a classic example of this type of - negative - externality; network externality is another, where it refers to any change in the benefit that an agent derives from a good when the number of other agents consuming the same kind of good changes; antimicrobial resistance is another: herd immunity from vaccination is a positive example); some are utility effects that impinge on the subjective values of others (as when, for example, one person feels sympathy and distress at the sickness of another, or pleasure at their recovery). This latter is sometimes known as a caring externality. When there are beneficial externalities of this kind, the standard maximizing behaviour assumed for individuals may not result in a Pareto optimum, notably if the marginal benefit received by the caring person is larger than the net marginal cost of the good or service to the consumer (that is, the marginal cost less the marginal value to the consumer). In the figure, a consumer has a demand curve (marginal valuation curve) shown by MVJ and would, assuming that the price is equal to marginal social cost (here assumed constant for convenience), select output rate Q. However, at that rate of consumption, some other caring individual or individuals also derive utility from this individual's consumption, as shown by the height of the curve labelled EMV (external marginal valuation) at this point. The optimal output rate is Q, beyond which the marginal cost to society exceeds the marginal value to society, as shown by the vertical sum of the two curves, Dj and EMV. This is a Pareto-optimal

126 External Validity

126 External Validity

Output rate

equilibrium, which might be obtained through subsidizing Q consumption, regulating it, or through direct exchange (as in charitable giving) between individuals (note here that, in the optimum, the marginal value placed by carers (Qa) is just equal to the difference between the marginal cost and the consumer's valuation (cb). Note also that the mere existence of an externality is not a ground either for predicting inefficiency or for subsidizing health care. If the EMV fell to zero at a rate of consumption lower than Q there is still an externality but it is not 'Pareto-relevant', being entirely inframarginal. The analysis of external costs proceeds in a similar fashion, but summing internal and external costs vertically rather than the internal and external 'demands'.

External Validity

The extent to which the results of a study can be generalized beyond the setting in which they were derived without misleading. Cf. Internal Validity.

Externality

Same as external effects.

Extra Billing

Same as balance billing.

Extra-welfarism 127

Extraneous Variable

Same as confounder.

Extra-welfarism

Extra-welfarism is an alternative way of doing normative economics to conventional welfare economics. Conventionally it is assumed that utility is the maximand, that sources of utility are goods and services, and that social welfare is derivable from (and only from) individual utilities. Thus health care constitutes the goods and services that may (amongst other things) enhance health. Health, in turn, is a source of utility, both directly and through the effects good health has on one's capacity to enjoy other goods and services.

Extra-welfarism has regard to a wider range of attributes than people's consumption of goods and services and might, for example, include changes in consumption or work patterns as direct sources of utility or disutility; or other states and changes in them (for example being divorced or getting divorced), participating in decisions, sharing sorrows, overcoming difficulties, feeling that one 'belongs', being 'private'. Extra-welfarism is 'extra' in enabling not only the consideration of other things that contribute to human flourishing beyond goods and services and the utility to be had from them, but also the effects on people of the processes and transitions of life.

In health, extra-welfarism commonly postulates health itself as the maximand of the health care sector, rather than the individual utility to which it may give rise. One specific advantage of the approach is that objectives cast in terms of 'health gain' are commonly set by policy makers, and this approach fits well with the social decision-making approach in cost-benefit analysis. Another is that it makes no heroic assumptions about the ability of sick people to make rational utility-maximizing decisions on their own behalf, though it certainly assumes that collective decision making is improved by the use of 'rational' processes like cost-effectiveness analysis. Yet another is that indicators of value such as willingness to pay may be judged to be too contaminated by abilities to pay and imperfections in the agency relationship to be relied upon in the construction of health care priorities and the allocation of health care resources. A final advantage is that the method has proved valuable in laying bare the kind of value judgments that necessarily inhere in any concept of 'health'.

There is no scientifically 'correct' choice to be made between welfarism and extra-welfarism (though the ways in which costs and benefits are considered might vary radically between them). One's choice between them depends

128 Extra-welfarism principally on either a direct value judgment or on a judgment about what is the most helpful way of setting up a problem in a particular circumstance. For example, if the agency on whose behalf some research is being undertaken wishes to discover the cost-effectiveness of a new diagnostic procedure, and that agency has clearly espoused 'health' as its maximand, it may be most appropriate to adopt an extra-welfarist approach, taking health gain as the maximand and considering pragmatically other factors deemed significant by the research clients (such as 'ease of implementation', short-term 'impact on waiting times', 'political acceptability' and the costs of achieving 'political acceptability').

The quality-adjusted life-year (QALY) is the most common entity chosen as maximand under extra-welfarism. In this context, however, it is probably best not to view the QALY as an index of (in some sense, average) preferences for health but as a representation of a collectively determined outcome measure explicitly posited by an authoritative agency; that is, an agency deemed to be a sufficient authority for the value judgments that are embodied in a QALY. These value judgments may, of course, accord a high place to respecting people's preferences. See Welfare Economics.

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Health And Fitness 101

Health And Fitness 101

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