How Much Does It Cost to Raise a Baby With Down Syndrome

J Pediatr. Author manuscript; available in PMC 2013 Dec 11.

Published in final edited form as:

PMCID: PMC3858577

NIHMSID: NIHMS315104

Direct health care costs of children and adolescents with Downwards syndrome

Elizabeth A Geelhoed

Schoolhouse of Population Health M431, The University of Western Australia, 35 Stirling Hwy, Crawley WA 6009, Ph: + 61 viii 6488 7129, Fax: + 61 8 6488 1188, ua.ude.awu@deohleeG.htebazilE

Ami Bebbington

Telethon Establish of Kid Wellness Research, Centre for Kid Wellness Research, University of Western Commonwealth of australia, PO Box 855 Westward Perth WA 6872 Australia

Carol Bower

Telethon Institute of Kid Health Enquiry, Center for Child Wellness Research, University of Western Australia, PO Box 855 Due west Perth WA 6872 Commonwealth of australia

Aditya Deshpande

Telethon Institute of Kid Health Research, Heart for Child Health Inquiry, University of Western Australia, PO Box 855 Westward Perth WA 6872 Australia

Helen Leonard

Telethon Institute of Kid Wellness Research, Centre for Kid Wellness Research, University of Western Australia, PO Box 855 W Perth WA 6872 Commonwealth of australia

Abstract

Objective

To assess the direct almanac health intendance costs for children and adolescents with Downwards syndrome in Western Australia and to explore the variation in wellness care utilisation including respite, co-ordinate to historic period and disease profile.

Report design

Population-based data were derived from a cross sectional questionnaire which was distributed to all families who had a child with Down syndrome up to 25 years of age in Western Australia.

Results

70-iii percentage of families (363/500) responded to the survey. Mean annual cost was $four,209 AUD ($iv,287 USD) for straight health intendance including hospital, medical, pharmaceutical, respite and therapy with a median cost of $1,701. Overall, costs decreased with age. The turn down in costs was a consequence of decreasing utilisation of hospital, medical and therapy costs with historic period. Conversely, respite increased with historic period and also with dependency. Health care costs were greater in all age groups with increasing dependency and for a previous or current diagnosis of congenital centre disease. Annual wellness care costs did non vary by parental income, including cost of respite.

Conclusions

Straight health intendance costs for children with Down syndrome decrease with age to approximate population costs, although costs of respite show an increasing trend.

Keywords: Down syndrome, direct health intendance costs, wellness intendance utilisation

Although cognitive impairment in children and adults with intellectual inability affects every mean solar day functioning, for many individuals health profiles are unremarkable. In contrast, the effects of Down syndrome involve a range of medical weather including intellectual disability which may be identified at birth or develop over the life span.^ane,two There take been considerable improvements in medical and surgical management, especially of the early on identified co-morbidities, leading to increased infant, child^three and adult survival⁴ overall although ethnic disparities still persist.^3,five Changes in clinical practice along with changes in attitudes to the management of children with disabilities also appears to lead to benefits for ongoing health with likely amend quality of life for those affected and their families. All the same the medical burden associated with Down syndrome is non trivial and the employ at least of hospital services has been shown to be greater than for the equivalent general population.^1,half-dozen

Down syndrome is the commonest known cause of intellectual inability with a live birth prevalence approaching i per 1000 births^vii in Western Australia (WA) which is consistent with data from other developed countries.⁸ Although the birth prevalence in WA has remained fairly stable over fourth dimension, changes in epidemiology accept occurred with an increase in Downward syndrome conceptions associated with overall increase in maternal age balanced past an increment in prenatal screening, diagnosis and terminations of affected pregnancies. Worldwide in that location continues to be variation in the birth prevalence of Downward syndrome associated with availability of prenatal screening in add-on to legislation, socio-cultural and religious attitudes to termination.ⁱ

Despite recognized demands on the health care system, few studies have reported the health costs for children with this condition. One study from the U.S. reported the health care costs for children with Downwards syndrome was up to 13 times higher than for children without Down syndrome^nine. Still costs were reported just for children who were members of a health insurance organisation, which may represent a more highly serviced group. A study of adolescents in Kingdom of denmark demonstrated that wellness costs for Down syndrome individuals were just under twice that of controls.¹⁰

The aim of this study was to explore the wellness costs for Down syndrome throughout childhood and adolescence by comparison data from a cross-exclusive survey of health resource utilisation for individuals with Down's syndrome with historic period specific population data. Costs are presented every bit mean costs per twelvemonth to provide information on total resource needs for this group and hence to empathise the total resource needs in relation to age. Costs are also presented every bit median costs to better reverberate the typical wellness resource needs for a child with Down syndrome. Costs are of interest in relation to age-adjusted mean population costs and previously reported costs, and provide important data for the evaluation of cost-effectiveness of treatments for this grouping. This information is also useful for policy makers to result change and to make adequate provision for individuals with Downward syndrome.

Methods

Children with Down syndrome anile less than 25 years in 2004 were identified from the IDEA (Intellectual Disability Exploring Answers) database, a population-based register of children with intellectual disability in WA.¹¹ With the approval of the Ethics Commission of the Women and Children Health Services in WA and the bankroll of the parent back up group 'Down's syndrome WA', families of all 500 children/young adults with Down's syndrome registered with the Inability Services Commission and able to be contacted were invited to participate in a cross-sectional survey. Preliminary airplane pilot testing ensured that the questionnaire was relevant and captured of import resource, health, functional and family characteristics while being sensitive to the complexity of ongoing care-giving demands. Information was sought to describe the demographics, associated wellness atmospheric condition and straight health care costs attributable to families with a child with Down syndrome. Health resource needs included hospital, medical, pharmaceutical, community and respite care throughout the previous twelvemonth. Hours or days of respite were based on the care provided to families as reported by them to the study. Information included the number of hours, the frequency and the providing agency and was separated according to overnight or day care. Data collection was completed during 2005. Iii quarters of families completed the questionnaire on paper, 12.6% online, and 12.4% by telephone interview. None of the children among the respondent families were living in an institution.

Measurement of contained performance in this group has been published previously¹² using a modified version of the WeeFIM.¹³ The WeeFIM consists of questions concerning 18 tasks in half dozen domains of operation - self-care (feeding, grooming, dressing and bathing), sphincter control (maintaining continency), transfers, locomotion, advice and social cognition. For each task, parents were asked to tick one box and one sub-box adjacent to the statements that best matched their child's level of competency at the job. Answers were scored (with the highest possible score on each question being seven) for a maximum total score of 126.

Costs

Resources items were calculated according to survey results reported by the family, computed to units per year and costed according to the unit cost in Australian dollars in 2009. Costs were adjusted where necessary using Australian health alphabetize deflators.¹⁴ Australian dollars are roughly at parity with U.s.a. dollars. ($1AUD equals $i.02 USD). Medical and dental costs were derived from the Medical Benefit Schedule. Therapy services and paid Domicile and Community Intendance services were based on data from the Disability Services Commission (DSC) and included brusk and long term respite care. Hospital admission costs were based on a hateful bed twenty-four hour period cost in 2008.^fifteen Costs for medications were derived from the Schedule of Pharmaceutical Benefits. Complementary medicines, non-durable health-related products and therapeutic devices were based on expenditure provided by the parents. Costs were calculated from the health system perspective and therefore practice non generally reverberate out of pocket costs to the families.

Statistical Methods

Costs were presented as both hateful cost per person – to correspond the total cost burden, and as median cost – to represent the probable expected cost for an individual. The full costs for different groups of individuals with Down syndrome were compared using non-parametric methods to account for the highly not-normal distribution of costs within groups. Linear regression was used to predict differences resulting from single-indicate increases in continuous measures such as the WeeFIM.

Results

Of the 500 families invited to participate, 363 (73%) families completed the survey. The historic period of the affected individuals ranged from 0 to 24 years with a mean age of 12.3 years and a median historic period of 13 years (Table I). Xl-iv pct were females and 56% males which is representative of the sex ratio for Down syndrome overall.^sixteen Iii quarters of the families resided in the metropolitan surface area. Two individuals were excluded from the toll assay due to lack of data (n=361).

Table 1

Total annual health care costs for individuals with Downward syndrome, by age and area of expenditure

Age group	Subjects		Total mean wellness intendance cost (median)	Full mean cost of hospital care (median)	Total mean cost of medical care (GP and Specialist) (median)	Total mean cost of pharmaceutical intendance (median)	Total 'other costs' (median)
	Thou	F
0-four due north = 58	29	29	$8491 ($6199)	$3450 ($1282)	$695 ($621)	$126 ($36)	$4219 ($126)
5- 9 n = 75	40	35	$4207 ($2468)	$762 ($36)	$660 ($553)	$189 ($46)	$2595 ($189)
10 - fourteen due north = 86	51	35	$3048 ($1262)	$1040 ($0)	$504 ($348)	$88 ($13)	$1416 ($88)
fifteen-19 n = 81	45	36	$2687 ($798)	$450 ($17)	$426 ($323)	$87 ($10)	$1724 ($87)
20-24 n = 61	39	22	$3798 ($569)	$2001 ($0)	$393 ($267)	$113 ($twenty)	$1290 ($113)
Full n = 361	204	157	$4209 ($1701)	$1400 ($35)	$531 ($416)	$119 ($24)	$2159 ($119)

A description of the medical conditions has recently been reported.^two 40 5 percent were reported to take always had a middle condition. Other ordinarily reported conditions, were middle (most common), ear, and respiratory problems, although some of these, particularly heart weather condition, were no longer ongoing.

The total mean annual health care costs beyond all historic period groups was $4,209, with a median of $1,701 and a standard divergence $half dozen,705 (Table I). This skewed distribution occurs with most disease costs - most half the full costs (46%) were accounted for past 10% individuals. Total cost by quartiles was $428, $one,701, $iv,760. Mean costs declined with increasing age, except for the twenty-24 historic period group, which contained a unmarried high-cost outlier. Median costs are shown in the Figure, which demonstrates that for the typical individual with Down syndrome, nigh costs were borne inside the beginning two years of life and rapidly decreased thereafter.

Median annual health intendance price per person with Down syndrome by age

Breakdown of the total health cost indicated that hospital cost is a significant correspondent, only this is exceeded in about historic period groups by 'other' costs which primarily comprised therapy and respite intendance (87%). Although therapy (most unremarkably simply not limited to physiotherapy, occupational therapy, hydrotherapy and speech therapy) dominated this cost category in the younger age groups, respite was the major toll in the older age groups. Therapy represented 85% 'other costs' in the 0-4 year historic period grouping, but declined to 35% for ages over 20 years. Conversely, respite increased from 4% to sixty% of 'other' costs beyond the same age groups.

The near commonly utilised therapy was speech therapy for 84 individuals at a mean cost of $1,878 per year, followed by occupational therapy (52 cases, mean toll $1505 per yr) and hydrotherapy/swimming classes (46 cases, hateful cost $1,442 per year).

Respite care was accessed for simply xiv% individuals, although utilize increased with age and dependency. Although rare among the 0-4 year historic period group (a single instance), some respite care was accessed for approximately 1 third of the individuals aged over 15 years.

The cost of medical visits decreased with increasing age. The mean number of visits to a general practitioner (GP) declined from 6 per year in the under 5 year age group, to 3 per year for age groups over 10 years, which attained mean population GP omnipresence rates in Commonwealth of australia.¹⁷

The tendency in use of medication likewise showed some decrease with age, although the difference was not statistically significant and the proportion using regular medication remained high in all age groups. (80 3 percent in historic period groups under 10 years compared with 70% in older age groups).

No big differences in mean or median full or sub-total wellness costs were axiomatic betwixt those living in rural WA (mean total price $3,424, 95% CI $ii,482 - $iv,366, median total cost $1,804, interquartile range (IQR) $392 - $4,774) and those living in the metropolitan area (mean full cost $4,466, 95% CI $three,536 - $5,396, median total toll $1437, IQR $555 - $4,230, p value=0.95 for rank sum examination).

Comparison with mean population costs

Mean almanac health costs were compared with population age-adjusted mean costs, and the results are shown in Table II. Wellness costs were higher for individuals with Down syndrome at all ages, but the differential decreased from 4 times the mean toll in young children, to 1.7 times the mean cost in adolescents and young adults. The cost for a typical individual with Down syndrome (as indicated by the median) approached the population mean during boyhood. (Hateful population costs were lowest in the five-fourteen yr age group and increased in the xv-24 year age group.)

Table 2

Full mean annual health costs for individuals with Down's syndrome, compared with population data, 2009

Historic period group	Total mean annual health costs
	Down syndrome	Australian mean	Ratio
0-4	$eight,491	$2,023	iv.two
v-14	$3,588	$935	iii.8
xv-24	$iii,164	$1,844	1.seven

Costs by presence of congenital centre disease

Total wellness costs were compared co-ordinate to whether or not there had been a diagnosis of congenital centre disease (CHD) (current or previous). 3 hundred and sixty families provided information most CHD, of whom 45% reported that their kid had ever been diagnosed. Equally shown in Tabular array Three, the difference in total health cost was significant between the two groups (p=0.02). Private age groups did not show statistically significant differences, although the deviation in the 0-ane twelvemonth age group approached significance (p=0.07). The sharp decline in total toll with increasing age was reflected in both groups, and the differential betwixt the ii groups also decreased with increasing age.

Table 3

Total annual health intendance toll co-ordinate to 'ever' diagnosis of congenital heart disease (CHD)

Age group	No CHD		CHD (ever diagnosis)
	Total annual health intendance cost		Total annual health intendance cost
	Mean	Median	Mean	Median
0 - 1 yrs	$9,612	$half dozen,072	$12,978	$12,016
due north=26
2 - 5 yrs	$5,730	$5,514	$5,845	$4,945
n = 32
5 - 9 yrs	$3,765	$two,594	$4,725	$3,695
n = 75
ten - fourteen yrs	$2,536	$i,280	$3,693	$1,326
n = 86
xv-19 yrs	$2,149	$639	$3,469	$1,030
northward = 81
20-24 yrs	$4,059	$535	$3,221	$821
north = 61
Total n=361	$3,537	$i,523	$5,035	$ii,487

Toll by level of functional ability

A single point increase in functional independence in the WeeFIM scale was associated with a large decrease ($87) in full cost, a adequately big decrease in hospital costs and other costs, and small-scale decreases in medical and chemist's shop costs (adjusted for age). When WeeFIM scores were grouped past categories according to complete independence (requiring no help), partially independent (requiring supervision) and dependent (requiring aid) these relationships were again demonstrated, with the near dependent having the highest full costs, in particular, higher hospital, medical and other costs, fifty-fifty subsequently adjusting for age. For those in the to the lowest degree able group, total toll was $3520.84 (CI $2420- $5123), in the next most able group, costs were $1492.48 (CI $1173 - $1899), and for those in the nearly able group costs were $590.44 with (CI 458 - $759).

Cost past income

The total toll of health intendance was compared with annual parental income to assess whether boosted services were accessed more by those able to afford them. The highest and lowest income groups reported very similar health intendance costs throughout the twelvemonth of reporting, although eye income groups reported spending less. Differences were not statistically meaning. The comparing of utilize of respite intendance across income groups besides demonstrated no significant differences.

Give-and-take

Nosotros report health care cost information throughout childhood and boyhood for Down's syndrome. The total mean annual toll of medical intendance was $4,209 across age groups with a median price of $1,701. The distribution was skewed in terms of age, where well-nigh costs occurred during the starting time year of life, and in terms of a minor number contributing disproportionately to overall toll. The major costs were hospitalisation and 'other health costs', comprising costs for therapy and respite intendance. Highest costs overall were most likely to be associated with young children requiring hospitalisation for center surgery.

Total health care cost was more than 4 times the population mean in young children but decreased to only i.7 times the population hateful by the stop of adolescence. Diagnosis of built heart disease and level of independence influenced full healthcare price, independently of historic period.

Full hateful health care costs were similar to those reported for blazon-one diabetes ($3,640 AUD in 2009 for all ages),¹⁸ although Down's syndrome costs were much higher in the get-go years of life, direct health care costs for type-1 diabetes increase throughout life. Costs for individuals aged xv-24 years were similar in both groups ($2,267 for type-ane diabetes compared with $2,407 for Down syndrome).

Our costs are considerably less than those estimated by Boulet et al,^ix who institute that costs in 0-4 year erstwhile children with Down syndrome were 12-13 times higher for members of a health insurance organisation than for the hateful child of this age in the United States. Dissimilar the U.s.a., Australia provides universal health care and hence our report is more likely to be representative of the general population. Also in comparing, our study demonstrated a lower proportion of costs owing to inpatient care in 0-4 yr olds (41% in our study compared with 60% in theirs). Our hospital costs did non include respite care only, as shown above, this component was minimal for the 0-4 age group. Both studies demonstrated sharp declines in toll after the first yr of life, and our study likewise established that this typically continues throughout childhood admitting more gradually. The differential betwixt CHD and not CHD was also much higher in the U.Southward. study compared with ours, however both studies demonstrated a failing disparity co-ordinate to age, and our study showed longer term continuation of this trend. Our results were consequent with the study by Goldstein¹⁰ which demonstrated that the cost of health services for adolescents with Down syndrome was i.12 times the cost for controls compared with 1.7 in this written report.

The one component that demonstrated an opposing trend was the cost of respite which increased with historic period. Further enquiry is required to explore trends in older age groups. Interestingly, the demand for respite did not vary according to parental income, which may advise needs are beingness met, or alternatively that needs are being met by unpaid (and unquantified) assistance.

There was wide variation in costs every bit demonstrated by the standard difference, which is non unexpected given the multifariousness of atmospheric condition and severities evident among individuals with Downward syndrome. Considering of the potential for a small number of outliers to influence the mean, the typical cost, as demonstrated by the median is an important indicator of expected resource needs for an individual with Down syndrome. Median costs demonstrated clearly identified trends with age.

Although we had a 73% response, we do not accept information on the severity of Down syndrome in the individuals who were non represented. All the same the proportions of associated atmospheric condition were establish to be consistent with reported frequencies, for example well-nigh half our cohort reported a diagnosis of a heart condition.^xvi Similarly our rural – metropolitan distribution of individual cases was consistent with the population distribution in WA.

This written report describes only direct wellness care costs attributable to children and young adults with Down syndrome and does not address overall costs to families affected by Down's syndrome, such as special education, individual transport needs, housing modifications and related costs to family members, for example in relation to employment opportunities.

We conclude that health care costs for children and young adults with Down syndrome are highest in the first years of life, and cost predictors include diagnosis of heart illness and level of independent performance. An important finding is that the demands on wellness services decline significantly with age to approach population levels during adolescence, indicating the full general level of adept wellness within this group. The exception is in the component of respite which increases with age.

Acknowledgments

The authors gratefully acknowledge the participation and ongoing contributions of families in the Down Syndrome Now Study. Nosotros would also like to give thanks Downward Syndrome WA and staff at the Disability Services Commission for their ongoing assistance in the study.

Funded past the National Institutes of Health (5R01HD043100-05) and NHMRC (fellowship #634341). H.L. was previously funded by NHMRC program grant 353514, and is currently funded by NHMRC Senior Inquiry Fellowship #572568. A.B. is funded by NHMRC program grant 572742.

Footnotes

The authors declare no conflicts of involvement.

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Contributor Data

Elizabeth A Geelhoed, School of Population Health M431, The University of Western Australia, 35 Stirling Hwy, Crawley WA 6009, Ph: + 61 8 6488 7129, Fax: + 61 8 6488 1188, ua.ude.awu@deohleeG.htebazilE.

Ami Bebbington, Telethon Institute of Kid Health Research, Eye for Child Health Research, Academy of Western Commonwealth of australia, PO Box 855 West Perth WA 6872 Australia.

Ballad Bower, Telethon Institute of Child Health Research, Centre for Child Health Research, University of Western Commonwealth of australia, PO Box 855 W Perth WA 6872 Australia.

Aditya Deshpande, Telethon Constitute of Kid Health Inquiry, Centre for Child Health Inquiry, Academy of Western Australia, PO Box 855 West Perth WA 6872 Australia.

Helen Leonard, Telethon Institute of Child Health Enquiry, Centre for Child Health Research, Academy of Western Commonwealth of australia, PO Box 855 West Perth WA 6872 Australia.

References

one. Thomas Yard, Bourke J, Girdler S, Bebbington A, Jacoby P, Leonard H. Variation over time in medical conditions and health service utilisation of children with Downwardly syndrome. J Pediatr. doi: ten.1016/j.jpeds2010.08.045. In press. [PubMed] [CrossRef] [Google Scholar]

2. Leonard S, Bower C, Petterson B, Leonard H. Medical aspects of school-anile children with Down syndrome. Dev Med Child Neurol. 1999;41:683–688. [PubMed] [Google Scholar]

3. Leonard Southward, Bower C, Petterson B, Leonard H. Survival of infants built-in with Down syndrome: 1980-96. Paediatr Perinat Epidemiol. 2000;14:163–171. [PubMed] [Google Scholar]

iv. Bittles AH, Glasson EJ. Clinical, social, and ethical implications of changing life expectancy in Down syndrome. Dev Med Kid Neurol. 2004;46:282–half dozen. [PubMed] [Google Scholar]

5. Rasmussen SA, Wong LY, Correa A, Gambrell D, Friedman JM. Survival in infants with Downwardly syndrome, Metropolitan Atlanta, 1979-1998. J Pediatr. 2006;148:806–812. [PubMed] [Google Scholar]

half-dozen. Dye DE, Maxwell KS, Goldblatt J, Bower C, Leonard H, Bourke J, et al. The impact of single cistron and chromosomal disorders on infirmary admissions of children and adolescents: a population based study. Public Health Genomics. 2010 December ane; doi: x.1159/000321767. Published online. [PubMed] [CrossRef] [Google Scholar]

7. Bower C, Rudy E, Callaghan A, Quick J, Cosgrove P, Nassar N. Report of the Birth Defects Registry of Western Commonwealth of australia 1980-2008. Perth: King Edward Infirmary, Women and Newborn Wellness Service; 2009. Number 16. [Google Scholar]

8. Thomas K, Girdler S, Bourke J, Deshpande A, Bathgate K, Fehr South, et al. Overview of Health Issues in School-aged Children with Down syndrome. In: Urbano RC, editor. International Review of Enquiry in Mental Retardation. Academic Press; 2010. pp. 67–106. [Google Scholar]

9. Boulet SL, Molinari NA, Grosse SD, Honein MA, Correa-Villaseñor A. Health care expenditures for infants and young children with Down syndrome in a privately insured population. J Pediatr. 2008;153:241–6. [PubMed] [Google Scholar]

10. Goldstein H. One year of health and social services for adolescents with Down's syndrome. A calculation of costs in a representative expanse of Denmark. Soc Psychiatry Psychiatr Epidemiol. 1989;24:30–4. [PubMed] [Google Scholar]

eleven. Petterson B, Leonard H, Bourke J, Sanders R, Chalmers R, Jacoby P, et al. Idea (Intellectual Disability Exploring Answers): A population-based database for intellectual disability in Western Australia. Ann Hum Biol. 2005;32:237–243. [PubMed] [Google Scholar]

12. Bourke J, Ricciardo B, Bebbington A, Aiberti K, Jacoby P, Dyke P, et al. Physical and mental health in mothers of children with Downwards syndrome. J Paediatr. 2008;153:320–6. [PMC costless article] [PubMed] [Google Scholar]

13. Leonard S, Msall M, Bower C, Tremont Yard, Leonard H. Functional status of school-aged children with Down's syndrome. J Paediatr Child Health. 2001;38:160–165. [PubMed] [Google Scholar]

fifteen. Australian Establish of Health and Welfare. Health services series no 33 Cat no HSE 71. Canberra: AIHW; 2009b. Australian hospital statistics 2007–08. [Google Scholar]

xvi. Staples AJ, Sutherland GR, Haan EA, Clisby S. Epidemiology of Down Syndrome in S Australia, 1960-89. Am J Hum Genet. 1991;49:1014–24. [PMC complimentary article] [PubMed] [Google Scholar]

17. Britt H, Miller GC, Charles J, Henderson J, Bayram C, Valenti L, et al. General do series no 28 Cat no GEP 28. Canberra: AIHW; 2010. General practise activity in Commonwealth of australia 2000–01 to 2009–10: 10 year datatables. [Google Scholar]

18. Colagiuri Stephen Academy of Sydney. Boden Institure of Obesity, Nutrition and Exercise (BIONE) & University of Sydney. Menzies Centre for Wellness Policy. Diabetes Unit of measurement & Diabetes Australia. Eli Lilly Australia. & Juvenile Diabetes Research Foundation. DiabCo$t Commonwealth of australia: Blazon 1: assessing the burden of type 1 diabetes in Australia / Stephen Colagiuri [et al] Diabetes Australia; A.C.T: 2009. [Google Scholar]

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