Association of a Lean Surgical Plan of the Day With Reduced Operating Room Time for Head and Neck Free Flap Reconstruction | Facial Plastic Surgery | JAMA Otolaryngology–Head & Neck Surgery | JAMA Network
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Figure.  Sample Free Flap Plan of the Day
Sample Free Flap Plan of the Day
Table 1.  Primary Sources of Time Waste Identified by Lean Methodology8
Primary Sources of Time Waste Identified by Lean Methodology
Table 2.  Surgical Times Measured Before and After Implementation of the Free Flap Plan of the Day
Surgical Times Measured Before and After Implementation of the Free Flap Plan of the Day
1.
Singh  B, Cordeiro  PG, Santamaria  E, Shaha  AR, Pfister  DG, Shah  JP.  Factors associated with complications in microvascular reconstruction of head and neck defects.  Plast Reconstr Surg. 1999;103(2):403-411. doi:10.1097/00006534-199902000-00007PubMedGoogle ScholarCrossref
2.
Brady  JS, Desai  SV, Crippen  MM,  et al.  Association of anesthesia duration with complications after microvascular reconstruction of the head and neck.  JAMA Facial Plast Surg. 2018;20(3):188-195. doi:10.1001/jamafacial.2017.1607PubMedGoogle ScholarCrossref
3.
Offodile  AC  II, Aherrera  A, Wenger  J, Rajab  TK, Guo  L.  Impact of increasing operative time on the incidence of early failure and complications following free tissue transfer? a risk factor analysis of 2,008 patients from the ACS-NSQIP database.  Microsurgery. 2017;37(1):12-20. doi:10.1002/micr.22387PubMedGoogle ScholarCrossref
4.
White  LJ, Zhang  H, Strickland  KF,  et al.  Factors associated with hospital length of stay following fibular free-tissue reconstruction of head and neck defects: assessment using the American College of Surgeons national surgical quality improvement program (ACS NSQIP) criteria.  JAMA Otolaryngol Head Neck Surg. 2015;141(12):1052-1058. doi:10.1001/jamaoto.2015.0756PubMedGoogle ScholarCrossref
5.
Sweeny  L, Rosenthal  EL, Light  T,  et al.  Effect of overlapping operations on outcomes in microvascular reconstructions of the head and neck.  Otolaryngol Head Neck Surg. 2017;156(4):627-635. doi:10.1177/0194599817691746PubMedGoogle ScholarCrossref
6.
Toussaint  JS, Berry  LL.  The promise of Lean in health care.  Mayo Clin Proc. 2013;88(1):74-82. doi:10.1016/j.mayocp.2012.07.025PubMedGoogle ScholarCrossref
7.
Cohen  J.  Statistical Power Analysis for the Behavioral Sciences. 2nd ed. London, England: Routledge; 1988.
8.
Skhmot  N. The 8 wastes of Lean. The Lean Way. https://theleanway.net/The-8-Wastes-of-Lean. Published August 5, 2017. Accessed July 12, 2019.
9.
Kakarala  K, Emerick  KS, Lin  DT, Rocco  JW, Deschler  DG.  Free flap reconstruction in 1999 and 2009: changing case characteristics and outcomes.  Laryngoscope. 2012;122(10):2160-2163. doi:10.1002/lary.23457PubMedGoogle ScholarCrossref
10.
Nundy  S, Mukherjee  A, Sexton  JB,  et al.  Impact of preoperative briefings on operating room delays: a preliminary report.  Arch Surg. 2008;143(11):1068-1072. doi:10.1001/archsurg.143.11.1068PubMedGoogle ScholarCrossref
11.
Holt  NF, Silverman  DG, Prasad  R, Dziura  J, Ruskin  KJ.  Preanesthesia clinics, information management, and operating room delays: results of a survey of practicing anesthesiologists.  Anesth Analg. 2007;104(3):615-618. doi:10.1213/01.ane.0000255253.62668.3aPubMedGoogle ScholarCrossref
12.
Overdyk  FJ, Harvey  SC, Fishman  RL, Shippey  F.  Successful strategies for improving operating room efficiency at academic institutions.  Anesth Analg. 1998;86(4):896-906. doi:10.1213/00000539-199804000-00039PubMedGoogle ScholarCrossref
13.
Shippert  RD.  A study of time-dependent operating room fees and how to save $100 000 by using time-saving products.  Am J Cosmet Surg. 2005;22(1):25-34. doi:10.1177/074880680502200104Google ScholarCrossref
14.
Christian  CK, Gustafson  ML, Roth  EM,  et al.  A prospective study of patient safety in the operating room.  Surgery. 2006;139(2):159-173. doi:10.1016/j.surg.2005.07.037PubMedGoogle ScholarCrossref
15.
Lingard  L, Espin  S, Whyte  S,  et al.  Communication failures in the operating room: an observational classification of recurrent types and effects.  Qual Saf Health Care. 2004;13(5):330-334. doi:10.1136/qshc.2003.008425PubMedGoogle ScholarCrossref
16.
Lingard  L, Reznick  R, Espin  S, Regehr  G, DeVito  I.  Team communications in the operating room: talk patterns, sites of tension, and implications for novices.  Acad Med. 2002;77(3):232-237. doi:10.1097/00001888-200203000-00013PubMedGoogle ScholarCrossref
17.
Contag  SP, Golub  JS, Teknos  TN,  et al.  Professional burnout among microvascular and reconstructive free-flap head and neck surgeons in the United States.  Arch Otolaryngol Head Neck Surg. 2010;136(10):950-956. doi:10.1001/archoto.2010.154PubMedGoogle ScholarCrossref
Original Investigation
August 15, 2019

Association of a Lean Surgical Plan of the Day With Reduced Operating Room Time for Head and Neck Free Flap Reconstruction

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, Kansas City
  • 2University of Kansas Hospital, Kansas City
JAMA Otolaryngol Head Neck Surg. 2019;145(10):926-930. doi:10.1001/jamaoto.2019.2250
Key Points

Question  Can using Lean methodology improve operative efficiency for head and neck free flap reconstruction?

Findings  In this cohort study of 210 patients, a single intervention, the free flap plan of the day, was created using Lean methodology. Use of the plan of the day was associated with a clinically meaningful decrease in operating room times.

Meaning  The free flap plan of the day may improve operating room efficiency for head and neck free flap reconstruction.

Abstract

Importance  Inefficiency in the operating room (OR) is detrimental to the patient, the hospital, and the surgeon. Head and neck procedures requiring microvascular reconstruction are complex, lengthy operations in which prolonged operative time is associated with higher complication rates and increased costs.

Objective  To use Lean methodology to identify potential OR efficiency improvement opportunities for head and neck surgical cases involving free tissue transfer, to implement an intervention, the free flap plan of the day, and to evaluate OR times after implementation.

Design, Setting, and Participants  Phase 1: In 2015, with the assistance of the Lean Promotion Office at our institution, a tertiary academic medical center, we identified efficiency-improvement opportunities for 10 patients undergoing free flap reconstruction. Phase 2: A single intervention, the free flap plan of the day, was implemented on February 1, 2016. A retrospective medical record review of head and neck free flap reconstructions beginning 2 years before the implementation of the intervention and ending 2 years after the intervention was performed from February 1, 2014 until February 1, 2018 to analyze OR times, cost, and complications. Mean OR times were compared using the t test.

Main Outcomes and Measures  In-room-to-incision time and total OR time.

Results  Phase 1: The surgical procedures of 10 patients undergoing free flap reconstruction were observed by Lean specialists, and a time study with a process map was completed. Using this framework, major opportunities for decreasing intraoperative time waste were identified. Multiple communication breakdowns were seen to drive intraoperative time waste; therefore, a free flap plan of the day was created to improve communication between team members. Phase 2: 200 patients were included in the study and were categorized into 2 groups, no plan group (n = 104) and plan group (n = 96), based on whether the plan of the day was used or not. The age and sex distributions of the study participants were not collected. Mean in-room-to-incision time was 54.3 minutes for the no plan group and 47.2 minutes for the plan group (difference, 7.1 minutes; 95% CI, 3.8-10.4 minutes). Mean total OR time was 524.1 minutes for the no plan group and 467.4 minutes for the plan group (difference, 56.7 minutes; 95% CI, 23.6-89.6 minutes).

Conclusions and Relevance  Lean methodology was used to identify efficiency-improvement opportunities for head and neck free flap reconstruction procedures and to design a focused intervention. A free flap plan of the day was used in this study to improve communication between the OR team and was found to improve efficiency and be associated with reduced OR times.

Introduction

Free tissue transfer has become the gold standard for reconstructing many complex head and neck defects. Overall success rates and functional outcomes have improved greatly over time as surgeons’ experience with the technique has increased. Nevertheless, complication rates for head and neck free flap reconstruction remain high, resulting in patient morbidity, delays in adjuvant treatments, and increasing cost to the health system.1-5

Increasing operating room (OR) time has been correlated with increasing rates of flap failure and postoperative complications.2,3 Unlike other factors such as prior history of radiation therapy or medical comorbidities, which are intrinsic to the patient, OR time may be modifiable by the surgical team.

Lean management techniques6 are increasingly being applied to health care to improve quality by minimizing waste in processes and procedures. The goal of Lean is to create a culture of continuous quality improvement in which all members of the team are responsible and empowered to identify and eliminate waste. Extensive training is disseminated throughout the institution to bring the necessary skills to the ground level, where the work is actually being done. Tools such as process mapping can be used to break down a complex procedure into its constituent parts to understand sources of waste and opportunities for improvement. In this study, we used Lean methodology to identify opportunities for time waste reduction in the operating room during head and neck free flap reconstruction. We devised a single intervention, the free flap plan of the day, and retrospectively studied the differences in OR times between 2 cohorts before and after the implementation.

Methods

This quality improvement project was conducted at the University of Kansas Medical Center and was approved by the University of Kansas institutional review board, which waived the need for written informed consent because of the use of retrospective medical record data.

Phase 1

In July 2015, a team was assembled consisting of surgeons, anesthesia clinicians, nurses, scrub technicians, and consultants from the Lean Promotion Office at our institution; the goal was to identify opportunities for process improvement in head and neck free flap reconstruction. A process map was created to understand the nature and sequence of events that occurred in the OR during free flap reconstruction and the roles and responsibilities of all members of the team (surgeon, anesthetist, nurse, scrub technician). Ten procedures of patients undergoing free flap reconstruction were observed by Lean consultants not on the OR team. Stopwatches were used to record times for individual tasks identified in the process map. Using these data, various sources of time waste and opportunities for improvement were identified.

Phase 2

A single intervention, the free flap plan of the day, was implemented on February 1, 2016, for all cases involving head and neck free flap reconstruction. This intervention involved the head and neck surgery fellow filling out a 1-page spreadsheet (Figure) that contained critical information about the proposed donor site(s), airway management, antibiotics, special equipment, and other characteristics. This document was sent electronically to the preoperative area, OR nurses, and anesthesia team before surgery. A paper copy of the plan of the day was placed into the patient’s record and also posted in the OR where it was accessible to all team members. Key points from the document were open to discussion in the preoperative area or in the OR and emphasized during the surgical time-out. A retrospective medical record review of head and neck free flap reconstruction procedures performed from February 1, 2014, to February 1, 2018, at the University of Kansas Hospital was performed to analyze OR times before and after the implementation of the free flap plan of the day. Measured times included the in-room-to-incision time and the total OR time for each patient. Included patients were categorized into 2 groups according to the date of the surgery, either before the intervention (no plan group) or after intervention (plan group). The magnitude of the intervention was assessed with the absolute difference and Cohen d in times between the 2 groups. Cohen d values were interpreted as d = 0.2 for small effect size; d = 0.5 for medium effect size; and d = 0.8 for large effect size.7

Results
Phase 1

Numerous sources of waste were identified through the Lean process map and time study (Table 1). These were categorized into the 8 wastes commonly identified in Lean: defects, overproduction, waiting, transportation, inventory, motion, extra-processing, and unused talent.8 A common thread connecting many instances of time waste was poor communication between team members. For example, the nursing and anesthesia teams often were not aware of the proposed donor site, and therefore an intravenous line or arterial line might be placed into the donor site and then would be moved to another extremity resulting in time waste to replace the line as well as morbidity to the patient. Equipment needs were also often not clearly communicated, resulting in critical equipment such as plating hardware not being at the right place at the right time; this resulted in time waste due to waiting and wasted motion to retrieve the needed equipment.

The free flap plan of the day was developed through an iterative, collaborative process that involved formal and informal meetings between nursing, anesthesia, surgeons, and scrub technicians to identify the critical information required by all team members (Figure). Using the information gathered through the process mapping and time study, as well as the through the collective experience of the group, the pieces of information judged to be most relevant were included in the plan of the day document. The information captured in this document was designed to improve perioperative communication to increase efficiency and quality of care during head and neck free flap reconstruction cases.

Phase 2

The free flap plan of the day was implemented on February 1, 2016. Two hundred patients who met the inclusion and exclusion criteria during the 2 years before and 2 years after this date were included in the study. There were 104 patients in the no plan group and 96 patients in the plan group. All patients in the intervention period were treated using the plan of the day as intended.

Mean in-room-to-incision time was 54.3 minutes for the no plan group and 47.2 minutes for the plan group, yielding an average time savings of 7.1 minutes (95% CI, 3.8-10.4 minutes, Cohen d = 0.6). Mean total OR time was 524.1 minutes for the no plan group and 467.4 minutes for the plan group, yielding an average time savings of 56.7 minutes (95% CI, 23.6-89.6 minutes; Cohen d = 0.5) (Table 2). These Cohen d values were interpreted as medium effect sizes.7

Discussion

Inefficiency in the OR is detrimental to the patient, the hospital, and the surgeon. Head and neck free flap reconstruction is a complex procedure with many moving parts and with great potential for inefficiencies. Increased operative time has been associated with increased risk of postoperative complications in multiple studies.1-4 In a recent large series of head and neck free flap cases from 2 high surgical volume institutions, a mean OR time of 7.1 hours was reported.5 While 7 hours is a vast improvement over the early days of head and neck free flap reconstruction, when cases lasted 2 to 3 times longer or more, there is still room for efficiency improvement. Previous studies have described strategies that have proven valuable at the institutional level to improve efficiency and outcomes for these cases.9

Lean methodology has been increasingly used in the health care field to combat waste.6 Although establishing a Lean program requires significant training and investment, the rewards to the institution in terms of waste reduction and quality improvement are worthwhile. The shift in culture nurtured by Lean institutions empowers employees at all levels to actively participate in these endeavors. In this study, we utilized Lean methodology to first understand the complex processes that occur during a procedure involving head and neck free flap reconstruction. The roles of the various players on the OR team were mapped in detail, and opportunities for waste reduction were thus readily identified. Breakdown in communication between team members was identified as a common denominator among multiple waste reduction opportunities. Therefore, we devised the free flap plan of the day to improve perioperative communication among team members regarding critical portions of the procedure.

Previous studies have focused on reducing OR delays and improving communication using interventions such as a preoperative briefing or routine consultation in a preanesthesia clinic.10,11 Overdyk et al12 conducted a similar study in 2 phases: in the first phase they investigated causes of OR time waste and educated OR staff regarding sources of time waste; in the second phase they found significant reductions in time waste. In contrast, we chose to study a single, reproducible intervention, the free flap plan of the day. Rather than simply append our plan of the day to the existing surgical time-out, we chose to implement it as a truly perioperative communication tool. We realized that to address some of the sources of waste identified by the Lean methodology, we would have to intervene during the preoperative period (eg, to prevent lines being placed into the flap site, to ensure everyone was on the same page regarding airway management, and to ensure that the correct equipment was available). It is also important to note that the plan of the day can and should be a living document that changes with the needs of the team. Lean interventions are meant to incorporate ongoing cycles of quality improvement. Information can be added or subtracted from the template as needed as experience with the plan grows.

Reducing OR time is not only beneficial to patients by reducing complications, but it also helps decrease health system costs. Cost in health care is notoriously difficult to accurately describe, but 1 study estimated that OR costs average $66 per minute.13 In the present study, we found a time savings of 56.6 minutes per case on average over 96 cases; if we use the cost estimate of $66 per minute, this yields a potential cost savings of $358 617.

There are many other potential benefits of the free flap plan of the day that were not formally assessed in this study. Keeping everybody involved in the procedure on the same page and avoiding communication errors can improve patient safety and enhance team performance.14,15 Better communication between the OR team also results in reduced tension in the OR and provides a better teaching environment.16 Finally, burnout among microvascular surgeons is a well-described phenomenon that is multifactorial.17 Undoubtedly, long days and nights in the OR and frequent complications play a large role. If the free flap plan of the day helps to lessen these burdens, it may also provide a personal benefit to the microvascular surgeon. A possible criticism of this intervention is that it adds yet another administrative burden to the already overburdened surgeon. We chose to have our head and neck surgical oncology fellow be responsible for filling out and disseminating the plan of the day partly for this reason. However, we have also found that the plan of the day has increased communication between the fellow and attending surgeons regarding the surgical plan, facilitating exchange of ideas preoperatively and benefiting fellow education.

While this project specifically focused on head and neck free flap reconstruction, a plan of the day might be useful for any complex procedure. A few examples of otolaryngology procedures that might benefit from a plan of the day would be anterior and lateral skull base tumor resection and reconstruction, airway reconstruction, and complex facial trauma. Procedures with multiple surgeons or services involved and complex equipment needs are particularly prone to the types of waste identified in the present study and could benefit from a plan of the day. The methods used in this project could be used to identify the key points to include in the plan for a particular procedure.

Limitations

A key weakness of this study is the retrospective design, which allows for substantial sources of bias. Because blinding the participants was impossible given the nature of the intervention, the Hawthorne effect, in which participants alter behavior owing to observation, may have played a role in the decreased times noted in this study. That is, the team might have been motivated to improve efficiency in the context of being measured for the study intervention. Institutional and surgeon expertise could also have improved during the study period, and these improvements could explain the reduction in OR time independent of the free flap plan of the day intervention. However, the head and neck free flap program at our institution was well established for many years prior to the start of this project, making this source of bias less likely. It is, however, likely that factors other than the free flap plan of the day also contributed to reductions in OR time during the study period. A prospective randomized clinical trial would certainly help to control for other variables that might contribute to improvements in efficiency.

Conclusions

Lean methodology was used to identify efficiency improvement opportunities for head and neck free flap reconstruction cases and design a focused intervention. A free flap plan of the day was used to improve communication between the OR team members and was associated with clinically meaningful reductions in OR times. This intervention may have benefits to patients and health systems in terms of improving quality of care and reducing costs for these complex procedures.

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Article Information

Accepted for Publication: April 20, 2019.

Corresponding Author: Kiran Kakarala, MD, Department of Otolaryngology–Head and Neck Surgery, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160 (kkakarala@kumc.edu).

Published Online: August 15, 2019. doi:10.1001/jamaoto.2019.2250

Author Contributions: Dr Ibrahim had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Ibrahim, Shnayder, Westbrook, Kakarala.

Acquisition, analysis, or interpretation of data: Ibrahim, Ndeti, Bur, Tsue, Westbrook, Kakarala.

Drafting of the manuscript: Ibrahim, Kakarala.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Kakarala.

Obtained funding: None.

Administrative, technical, or material support: Ibrahim, Ndeti, Westbrook, Kakarala.

Study supervision: Ibrahim, Bur, Shnayder, Tsue, Kakarala.

Conflict of Interest Disclosures: None reported.

Meeting Presentation: This paper was presented at the American Head and Neck Society Annual Meeting; May 1, 2019; Austin, Texas.

References
1.
Singh  B, Cordeiro  PG, Santamaria  E, Shaha  AR, Pfister  DG, Shah  JP.  Factors associated with complications in microvascular reconstruction of head and neck defects.  Plast Reconstr Surg. 1999;103(2):403-411. doi:10.1097/00006534-199902000-00007PubMedGoogle ScholarCrossref
2.
Brady  JS, Desai  SV, Crippen  MM,  et al.  Association of anesthesia duration with complications after microvascular reconstruction of the head and neck.  JAMA Facial Plast Surg. 2018;20(3):188-195. doi:10.1001/jamafacial.2017.1607PubMedGoogle ScholarCrossref
3.
Offodile  AC  II, Aherrera  A, Wenger  J, Rajab  TK, Guo  L.  Impact of increasing operative time on the incidence of early failure and complications following free tissue transfer? a risk factor analysis of 2,008 patients from the ACS-NSQIP database.  Microsurgery. 2017;37(1):12-20. doi:10.1002/micr.22387PubMedGoogle ScholarCrossref
4.
White  LJ, Zhang  H, Strickland  KF,  et al.  Factors associated with hospital length of stay following fibular free-tissue reconstruction of head and neck defects: assessment using the American College of Surgeons national surgical quality improvement program (ACS NSQIP) criteria.  JAMA Otolaryngol Head Neck Surg. 2015;141(12):1052-1058. doi:10.1001/jamaoto.2015.0756PubMedGoogle ScholarCrossref
5.
Sweeny  L, Rosenthal  EL, Light  T,  et al.  Effect of overlapping operations on outcomes in microvascular reconstructions of the head and neck.  Otolaryngol Head Neck Surg. 2017;156(4):627-635. doi:10.1177/0194599817691746PubMedGoogle ScholarCrossref
6.
Toussaint  JS, Berry  LL.  The promise of Lean in health care.  Mayo Clin Proc. 2013;88(1):74-82. doi:10.1016/j.mayocp.2012.07.025PubMedGoogle ScholarCrossref
7.
Cohen  J.  Statistical Power Analysis for the Behavioral Sciences. 2nd ed. London, England: Routledge; 1988.
8.
Skhmot  N. The 8 wastes of Lean. The Lean Way. https://theleanway.net/The-8-Wastes-of-Lean. Published August 5, 2017. Accessed July 12, 2019.
9.
Kakarala  K, Emerick  KS, Lin  DT, Rocco  JW, Deschler  DG.  Free flap reconstruction in 1999 and 2009: changing case characteristics and outcomes.  Laryngoscope. 2012;122(10):2160-2163. doi:10.1002/lary.23457PubMedGoogle ScholarCrossref
10.
Nundy  S, Mukherjee  A, Sexton  JB,  et al.  Impact of preoperative briefings on operating room delays: a preliminary report.  Arch Surg. 2008;143(11):1068-1072. doi:10.1001/archsurg.143.11.1068PubMedGoogle ScholarCrossref
11.
Holt  NF, Silverman  DG, Prasad  R, Dziura  J, Ruskin  KJ.  Preanesthesia clinics, information management, and operating room delays: results of a survey of practicing anesthesiologists.  Anesth Analg. 2007;104(3):615-618. doi:10.1213/01.ane.0000255253.62668.3aPubMedGoogle ScholarCrossref
12.
Overdyk  FJ, Harvey  SC, Fishman  RL, Shippey  F.  Successful strategies for improving operating room efficiency at academic institutions.  Anesth Analg. 1998;86(4):896-906. doi:10.1213/00000539-199804000-00039PubMedGoogle ScholarCrossref
13.
Shippert  RD.  A study of time-dependent operating room fees and how to save $100 000 by using time-saving products.  Am J Cosmet Surg. 2005;22(1):25-34. doi:10.1177/074880680502200104Google ScholarCrossref
14.
Christian  CK, Gustafson  ML, Roth  EM,  et al.  A prospective study of patient safety in the operating room.  Surgery. 2006;139(2):159-173. doi:10.1016/j.surg.2005.07.037PubMedGoogle ScholarCrossref
15.
Lingard  L, Espin  S, Whyte  S,  et al.  Communication failures in the operating room: an observational classification of recurrent types and effects.  Qual Saf Health Care. 2004;13(5):330-334. doi:10.1136/qshc.2003.008425PubMedGoogle ScholarCrossref
16.
Lingard  L, Reznick  R, Espin  S, Regehr  G, DeVito  I.  Team communications in the operating room: talk patterns, sites of tension, and implications for novices.  Acad Med. 2002;77(3):232-237. doi:10.1097/00001888-200203000-00013PubMedGoogle ScholarCrossref
17.
Contag  SP, Golub  JS, Teknos  TN,  et al.  Professional burnout among microvascular and reconstructive free-flap head and neck surgeons in the United States.  Arch Otolaryngol Head Neck Surg. 2010;136(10):950-956. doi:10.1001/archoto.2010.154PubMedGoogle ScholarCrossref
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