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Eliminating Disparities in Health Care
The Agency for Healthcare Research and Quality
(AHRQ) is leading Federal research efforts to
develop knowledge and tools to help eliminate
health care disparities in the United States.
AHRQ supports and conducts research and
evaluations of health care with emphasis on
disparities related to race, ethnicity, and
socioeconomic status. The Agency focuses on
priority populations including minorities,
women, children, the elderly, low-income
individuals, and people with special health care
needs such as people with disabilities or those
who need chronic or end-of-life care.
National Healthcare Quality and Disparities Reports
The overall quality of the U.S. health care system is improving, but providers are missing
chances to help Americans avoid disease or serious complications, according to AHRQ's 2006
National Healthcare Quality Report (NHQR) and
National Healthcare Disparities Report (NHDR).
The findings from the two annual reports provide updated, congressionally mandated snapshots of the U.S. health care system. AHRQ's reports examine quality and disparities in four key areas of health care:
- Effectiveness of health care.
- Patient safety.
- Timeliness of care.
- Patient centeredness.
HQR tracks the health care system
through quality measures, such as what
proportion of heart attack patients received
recommended care when they reached the
hospital, or what percentage of children received
recommended vaccinations. The NHDR
summarizes which racial, ethnic, or income
groups are most likely to benefit from
improvements in health care.
Both reports found that the use of proven
prevention strategies lags significantly behind
other gains in health care:
- Only about 52 percent of adults reported receiving recommended colorectal cancer screenings.
- Only 68 percent of obese adults and 37 percent of overweight children were told they were overweight; blacks, Hispanics, and less educated individuals were less likely to be told.
- Only 48 percent of adults with diabetes received all three recommended screenings—blood sugar tests, foot exams, and eye exams—to prevent disease complications.
- Among people with asthma, 70 percent were
taught to recognize early signs of an attack,
49 percent were told how to change their
environment, 40 percent were given a
controller medication, and 28 percent were
given an asthma management plan.
- Only 6 percent of hospice patients did not
receive the right amount of pain medicine
and only 6 percent received care inconsistent
with their stated end-of-life wishes.
- Only 6 percent of hospitalized patients
reported communication problems with
doctors and 7 percent reported
communication problems with nurses.
However, 26 percent of hospitalized patients
reported problems with communications
about medications and 21 percent reported
problems with discharge information.
Both reports are available online at: https://archive.ahrq.gov/qual/nhqr06/nhqr06.htm and https://archive.ahrq.gov/qual/nhdr06/nhdr06.htm.
AHRQ released a new interactive Web-based tool
for States to use in measuring health care
quality. The new State Snapshot Web tool is
based on the 2005 NHQR, and it provides quick
and easy access to the many measures and tables
of the NHQR from each State's perspective.
State Snapshot tool provides valuable
- Tables that rank the 50 States and the District
of Columbia on 15 representative measures
of health care quality culled from 179
measures contained in the 2005 NHQR.
- Summary measures of the quality of types of
care (prevention, acute, and chronic), settings
of care (hospital, ambulatory, nursing home,
and home health), and clinical areas (cancer,
diabetes, heart disease, maternal and child
health, and respiratory diseases) for each
- Comparisons of each State's summary
measures to regional and national
performance, as well as comparison to the
best performing States.
- Performance meters that show at a glance a
State's performance relative to the region or
- Data tables for each State's summary
measures that show the NHQR detailed
measures and numbers behind the
Also, the State Snapshot tool features a special
focus on each State's performance in the
treatment of diabetes across three areas:
- Quality of diabetes care.
- Disparities in diabetes treatment.
- Cost savings that States might accrue by implementing disease management for diabetes for State government employees.
The State Snapshot tool is available at: http://statesnapshots.ahrq.gov.
Asthma Care Resource Guide
Asthma is a serious chronic respiratory illness
that affects a growing number of Americans and
disproportionately affects African Americans,
children, and low-income individuals. AHRQ, in
partnership with the Council of State
Governments, released Asthma Care Quality
Improvement: A Resource Guide for State Action and
its companion Workbook. The Resource Guide
and Workbook are designed to help State leaders
identify measures of asthma care quality,
assemble data on asthma care, assess areas of
care most in need of improvement, learn what
other States have done to improve asthma care,
and develop a plan for improving the quality of
care for their States.
The resource guide uses data from AHRQ's
NHQR and NHDR and Web-based State
Snapshots to help inform the Nation and States
about the quality of asthma care. The workbook
is designed for State policymakers, including
officials in State health departments, asthma
prevention and control programs, and Medicaid
offices. It includes five modules, some of which
are targeted to senior leaders responsible for
making the case for asthma care quality
improvement and taking action. Other modules
provide the information necessary for program
staff to develop and implement a quality
improvement strategy. The goal is for all groups
involved in asthma care to work together as a
team to improve the quality of asthma care.
Asthma Care Quality Improvement: A Resource
Guide for State Action and its companion
workbook can be found online at
Improving Diabetes Care in
According to the NHQR and NHDR, only 48
percent of adults with diabetes received all three
recommended screenings—blood sugar tests, foot
exams, and eye exams—to prevent disease
complications. AHRQ estimates about $2.5
billion could be saved each year by eliminating
hospitalizations related to diabetes
complications. AHRQ formed a new partnership
with three of the Nation's leading business
coalitions that is designed to help improve the
quality of diabetes care within and across
communities. The new partnership, Improving
Diabetes Care in Communities Collaborative,
brings AHRQ together with the Greater Detroit
Area Health Council, the MidAtlantic Business
Group on Health, and the Memphis Business
Group on Health.
The goal of this partnership is to support local
communities in their efforts to reduce the rate of
obesity and other risk factors that can lead to
diabetes and its complications. The partners are
working together to ensure that people with
diabetes receive appropriate health care services.
Each of the coalitions has convened
stakeholders, including businesses, providers,
health plans, insurers, consumers, and
academics, to set priorities in their efforts to
improve diabetes care and develop solutions that
fit within the community's needs and
Cross-cutting strategies for
addressing diabetes quality improvement
include a return on investment calculator for
estimating financial returns from disease
management, application of the chronic care
model, and an employer guide on managing
diabetes care with health plans. The strategies
and tools developed under the partnership and
any lessons learned will be disseminated broadly
for communities around the Nation to use in
improving the quality of diabetes care.
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Ensuring the Value in Health Care
According to the most recent data from the
Medical Expenditure Panel Survey (MEPS), 85
percent of people under age 65 and 96 percent
of the elderly had some expenditure for health
care in 2003. About one dollar for every five
dollars spent on health care (excluding health
insurance premiums), was paid out of pocket by
individuals and families. It is vitally important
to help Americans achieve access to high-quality,
safe, and effective health care, with the best
possible outcomes, and help maximize the value
realized for each dollar spent.
AHRQ is playing a key role in one of the
Department of Health and Human Services'
Secretary Michael Leavitt's priority initiatives—the Value-Driven Health Care Initiative. The goal
of the initiative is to encourage the health care
system to provide better quality and better value
for our health care dollars. Value is the
intersection of cost and quality.
In August 2006, President Bush signed an
executive order committing the Federal
government to the "four cornerstones" of value-driven
care: health information technology,
public reporting of provider quality information,
public reporting of cost information, and
incentives for value comparison. The
cornerstones are the center of the initiative, and
AHRQ is working closely with the Department
and other Agencies to promote and support them.
To accomplish the goals of a value-driven health
care system, consumers need transparent and
reliable information on the quality and cost of
health care services. The public reporting
created by the initiative will give consumer what
they need to make comparisons and choices
based on value, and providers can know how
they measure up against accepted standards of
Pay-for-Performance Decision Guide
AHRQ released a new resource to help
employers, health plans, Medicaid agencies, and
others who are considering starting a pay-for-performance
program make decisions about how to design, implement, and evaluate the activity.
The free tool, Pay for Performance: A Decision
Guide for Purchasers, poses 20 key questions that
leaders from an employer group, health plan, or
other health care purchasing group should ask
themselves as they consider a pay-for-performance
program. Included are questions
such as whether or not to partner with other
purchasers, focus on clinicians or hospitals first,
make provider participation mandatory or
voluntary, how much money to allot to the
activity, and how to address provider concerns
about risk adjustment for severity of illness. The
decision guide also includes special advice for
Medicaid agencies and Medicaid managed care
plans. Each question is followed by a discussion
that includes possible options and potential
To access Pay for
Performance: A Decision Guide for Purchasers, go to
Recent Research Findings on Health Care
Costs and Improving Performance
- More than half (52 percent) of the Nation's
health maintenance organizations (HMOs)
used pay-for-performance programs in their
contracts with doctors or hospitals in 2005.
Researchers found that nearly 90 percent of
health plans with pay-for-performance
programs included these arrangements as
part of their physician compensation and 38
percent included them in their hospital
contracts. HMOs that required enrollees to
designate a primary care physician as a
gatekeeper to specialty services were more
likely to use pay-for-performance programs
compared with those who did not require
this designation (61 vs. 25 percent).
- A new study found no ill effects of HMOs on
the health status of the near-elderly (those
aged 55 to 64). Patients with chronic health
conditions actually fared better upon
enrolling in managed care plans. Adults in
this age group who had serious and
longstanding chronic health conditions were
1.26 times as likely to report very good as
opposed to good health when they were
enrolled in HMOs. For relatively healthy
near-elders, however, being in a particular
type of plan-whether HMO, PPO, or fee-for-service—had no bearing on health status.
- Insuring adults in middle to late middle age
now could lead to improved health status
and reduce costs later in life. A prospective
study of adults aged 51 to 61 years found
that people who were uninsured at baseline
had a 35 percent higher mortality rate than
those with private insurance over a 10-year
period of time. However, when the outcomes
were analyzed over 2-year intervals,
individuals who were uninsured at the start
of each interval were 43 percent more likely
to have a major decline in their overall
health, and they were as likely to die as the
privately insured. The average annual health
care expenditure in 2001 for someone aged
51 to 61 was $12,578 for those in poor health
and $6,938 for those in fair health. In
contrast, the average annual total health care
costs for healthier adults in this same age
group were $3,922 for those in good health
and $1,791 for those in excellent health.
Medicare Drug Benefit Caps Are Associated with Lower Drug Consumption and Worse
A study, supported in part by AHRQ, examined the impact of drug benefit caps on Medicare
beneficiaries who had hypertension, hyperlipidemia, or diabetes. Researchers found that limits on drug
benefits resulted in negative consequences. Overall, Medicare beneficiaries whose benefits were capped
at $1,000 used fewer prescription drugs than those beneficiaries whose benefits were not capped.
Beneficiaries receiving long-term drug therapy whose benefits were capped had lower levels of drug
adherence (Figure 1). They also had worse physiological outcomes. Those whose benefits were capped, when compared with beneficiaries who did not have caps, had a systolic blood pressure of 140 mm Hg
or more (39.5 percent vs. 38.5 percent), LDL cholesterol greater than 130 mg/dl (21.3 percent vs. 19.6
percent), and blood sugar levels greater than 8 percent (19.7 percent vs. 17 percent).
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Developing Tools and Data for Research and Policymaking
Efforts to improve the quality and efficiency of
health care and reduce disparities in the United
States must be based on a thorough
understanding of how the Nation's health
systems work and how different organizational
and financial arrangements affect health care.
AHRQ has a broad portfolio of data on costs,
access to health care, quality, and outcomes that
can be used for research and policymaking.
Medical Expenditure Panel Survey
The Medical Expenditure Panel Survey (MEPS) is
the only national source of annual data on the
specific health services that Americans use, how frequently the services are used, the cost of the
services, and the methods of paying for those
services. MEPS is designed to help us understand
how the growth of managed care, changes in
private health insurance, and other dynamics of
today's market-driven health care delivery
system have affected, and are likely to affect, the
kinds, amounts, and costs of health car that
MEPS provides the foundation
for estimating the impact of changes on
different economic groups or special populations
such as the poor, elderly, veterans, the
uninsured, or racial/ethnic groups. For example:
- Overall outpatient prescription drug expenses
for the U.S. civilian non-institutionalized
population grew from $65.3 billion in 1996
to $177.7 billion in 2003—a 172 percent
- Outpatient prescription drugs' share of all
health care spending rose from 12 percent to
20 percent from 1996 to 2003.
- The cost of caring for U.S. adults with
diabetes rose sharply between 1996 and 2003,
a period in which the number of patients
soared from 9.9 million to 13.7 million and
the average annual inflation-adjusted
treatment costs rose from $1,299 to $1,714.
The average annual spending for prescription
medicines jumped nearly 86 percent during
the time period, from $476 to $883.
- The percentage of employees at large
companies who were eligible for health
insurance and who enrolled in plans fell
from 87 percent in 1996 to 80 percent in
2004, with the steepest decline occurring
among employees of large retail firms, from
81.5 percent to 69 percent.
- In 2004,the most expensive average cost for
family health insurance coverage—$11,742—was in the District of Columbia and the least—$7,800—was in North Dakota. The national
average cost for family coverage was $10,006.
More information on MEPS can be found online at http://www.meps.ahrq.gov.
Vermont Uses MEPS Data To Assess Options for Covering the Uninsured
State officials and legislators working on health reform measures in Vermont used reports containing
MEPS data. In May 2006, Governor Jim Douglas signed the Health Care Affordability Act into law. The
centerpiece of this legislation is a new program called Catamount Health, which establishes coverage at
group rates for uninsured individuals and offers income-related subsidies to help them purchase that
coverage. MEPS data that were used in the discussion of this legislation include data on the prevalence
of chronic illness among the uninsured; data on insurance coverage, health spending, and demographics to calculate cost impacts for a proposed buy-in to the Vermont Health Access Plan (VHAP, which offers coverage for uninsured adults who are not eligible for Medicaid); data to derive the average employer-based health insurance premium costs per worker for Vermont and other states, self-reported health status of insured and uninsured Americans, health services utilization of Americans by insured status, and estimates of the impact of various health reform initiatives in Vermont; and data on firm size and provision of health insurance.
Healthcare Cost and Utilization Project
The Healthcare Cost and Utilization Project
(HCUP) is a family of health care databases and
related software tools and products developed
through a Federal-State-Industry partnership
and sponsored by AHRQ. HCUP databases bring
together the data collection efforts of 38 State
data organizations, hospital associations, private
data organizations, and the Federal government
to create a national information resource of
patient-level health care data.
the largest collection of longitudinal hospital
care data in the United States, with all-payer, encounter-level information beginning in 1988.
These databases enable research on a broad
range of health policy issues, including cost and
quality of health services, medical practice
patterns, access to health care programs, and
outcomes of treatments at the national, State,
and local market levels.
Outpatient Data Initiatives
The largest growth in HCUP has been in
outpatient data initiatives—the acquisition of
additional State Ambulatory Surgery Databases
and State Emergency Department Databases,
partnership discussions about improving
outpatient data collection and measurement of
the quality of outpatient care, and dissemination
of outpatient data and its capacity.
In 2006, 21
States contributed ambulatory surgery data for a
combined total of 16 million discharges in over
2,900 facilities (mostly hospital-based but
including some free-standing sites). In addition,
17 States contributed outpatient emergency
department data, for a combined total of 24
million discharges in 2,400 hospitals.
HCUP Statistical Briefs
In 2006, AHRQ launched a new series of Web-based
publications, the HCUP Statistical Briefs
containing information from HCUP. These
publications provide concise, easy-to-read
information on hospital care, costs, quality,
utilization, access, and trends for all payers
(including Medicare, Medicaid, private
insurance, and the uninsured).
Each Statistical Brief covers an important health care issue. For example:
- Hospital stays of obese patients increased by
112 percent between 1996 and 2004, rising
from 797,000 to 1.7 million. Women
accounted for about 82 percent of all patients
admitted for treatment of their obesity.
Hospital costs for patients admitted for
obesity treatment were an average of $11,700
- Hospital admissions for breast cancer fell by a
third between 1997 and 2004. The
hospitalization rate for women with breast
cancer dropped from 90 per 100,000 women
to slightly fewer than 61 per 100,000 women
during the period, and the number of
hospital stays for the disease declined from
about 125,000 to 90,000. In 2004,
mastectomies accounted for 70 percent of
breast cancer surgeries in the hospital.
- Nearly 8 percent of patients age 85 and older
who are hospitalized for influenza do not
survive the disease. This death rate is more
than twice the 3 percent for hospitalized
patients aged 65 to 84. More than 21,000
people were hospitalized specifically for
influenza in 2004—a 62 percent decrease from 2003, but double the number of
hospitalizations in 2001.
- The first Federal analysis in a decade of sickle
cell disease hospitalizations shows that
admissions of adults remained stable from
1997 to 2004. In 2004, approximately 83,000
hospital stays were for adults and 30,000
were for children. Patients spent about 5 days
in the hospital, at an average cost of $6,223
per stay. Total hospital costs were nearly $500
million overall in 2004.
- Falls were the most frequent cause of injury
hospitalizations, accounting for over 38
percent of injury stays. There were 474,000
hospital stays for falls among patients age 65
and older-this age group made up about two-thirds
of hospital stays for falls. Nearly 15
percent of injury-related stays resulted from
motor vehicle traffic accidents and about 12
percent resulted from poisonings.
For more information about HCUP and to view
the Statistical Briefs, please visit http://www.ahrq.gov/research/data/hcup/index.html.
Bariatric Surgery Is Emerging as the Leading Method of Weight Loss Among Americans Who
Are Morbidly Obese
Data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project for 1998 and
2003, show that from 1998 to 2003, the total number of bariatric surgeries increased by more than 740
percent from 13,386 to 112,435. National hospital costs for bariatric surgeries increased by more than
10-fold from $173 million in 1998 to $1.74 billion in 2003, with the largest cost increase among the
privately insured. On the other hand, long-term health benefits may outweigh the costs of bariatric
surgery. One meta-analysis found that diabetes (for which care cost nearly $11,000 per person with
diabetes in 2002) was resolved in 77 percent of patients who received bariatric surgery, cholesterol
problems were improved in 70 percent, and hypertension was resolved in 62 percent of patients.
Source: National trends in the costs of bariatric surgery, by William E. Encinosa, Ph.D., Didem M. Bernard, Ph.D., and Claudia A. Steiner, M.D., M.P.H., in Bariatrics Today 3, pp. 10-12, 2005.
AHRQ Quality Indicators
AHRQ has developed an array of health care
decisionmaking and research tools that can be
used by audiences such as program managers,
purchasers, researchers, government agencies,
and others. One tool, the AHRQ Quality
Indicators (QIs), is widely used to:
- Highlight potential quality concerns.
- Identify areas that need further study and
- Track changes over time.
The AHRQ QIs are a set of indicators organized
into three modules, each of which measures
quality associated with the delivery of care
occurring in either an outpatient or an inpatient
- Prevention Quality Indictors (PQIs) are
ambulatory care-sensitive conditions that
identify adult hospital admissions that
evidence suggests could have been avoided,
at least in part, through high-quality
- Inpatient Quality Indicators (IQIs) reflect
quality of care for adults inside hospitals and
include: inpatient mortality for medical
conditions; inpatient mortality for surgical
procedures; utilization of procedures for
which there are questions of overuse,
underuse, or misuse; and volume of
procedures for which there is evidence that a
higher volume of procedures may be
associated with lower mortality.
- Patient Safety Indicators (PSIs) also reflect
quality of care for adults inside hospitals, but
focus on potentially avoidable complications
and iatrogenic events.
The AHRQ QIs are being used for national, State-level,
and hospital-level public reporting and
- AHRQ's National Healthcare Quality and
Disparities Reports and their derivative
products incorporate many PQIs and PSIs for
tracking and reporting at the national level.
Selected IQIs and composite measures are
planned for inclusion in future reports.
- The demand for information to better inform
consumers has increased, specifically demand
for standardized hospital-level comparative
data as a result of concern over quality and
patient safety in the hospital setting.
Currently, there are eight States that report
some or all of the AHRQ QIs: Texas, New
York, Wisconsin, Massachusetts, Oregon,
California, Utah, and Florida. Kentucky and
Iowa are both planning to publicly report the
AHRQ QIs in the next year or so.
The State of Connecticut Used AHRQ's PQIs To Assess its Health Care System
The Connecticut Office of Health Care Access (OHCA) used AHRQ's Prevention Quality Indicators (PQIs)
for its databook, Preventing Hospitalizations in Connecticut: Assessing Access to Community Services, FYs
2000-2004. The databook uses all 16 of AHRQ's PQIs to assess the quality of the State's health care
system outside the hospital setting. Comparing State acute care hospital discharge data to national data
provided by AHRQ, OHCA found that Connecticut had a better record of preventable hospitalizations
for 15 of the 16 PQIs. Of particular significance is the databook's conclusion that preventable
hospitalizations are increasing in the State, underscoring the need for timely intervention. Hospitals,
community health centers, and local departments of public health are using this information to design
community outreach services, particularly those for the care and management of chronic illnesses such
as diabetes and asthma. Local providers are also incorporating data into grant applications for disease
management programs, chronic illness awareness education, and increased specialist care at community
Pediatric Quality Indicators Software
In 2006, AHRQ released the Pediatric Quality
Indicators (PedQIs). The PedQIs are indicators of
children's health care that can be used with
inpatient discharge data. They are designed to
help hospitals examine both the quality of
inpatient care and the quality of outpatient care
that can be inferred from inpatient data, such as
potentially preventable hospitalizations. The
module consists of 13 provider-level indicators,
such as accidental puncture or laceration and
postoperative respiratory failure, plus 5 area-level
indicators, including admission rates for
children with asthma, gastroenteritis, perforated
appendix, and urinary tract infections as well as
diabetes short-term complication rates.
More information on the AHRQ QIs can be found on the Web site at http://www.qualityindicators.ahrq.gov.
Consumer Assessment of
Healthcare Providers and
The Consumer Assessment of Healthcare
Providers and Systems (CAHPS®) program
develops and supports the use of a
comprehensive and evolving family of
standardized surveys that ask consumers and
patients to report on and evaluate their
experiences with health care. These surveys
cover topics that are important to consumers,
such as the communication skills of providers
and the accessibility of services. CAHPS®
originally stood for the Consumer Assessment of
Health Plans Study, but as the products have
evolved beyond health plans, the name has
evolved as well to capture the full range of
survey products and tools.
CAHPS® Hospital Survey Chartbook
In 2006, CAHPS® released the CAHPS® Hospital
Survey Chartbook, which presents summary-level
results from the CAHPS® Hospital Survey,
commonly referred to as H-CAHPS. H-CAHPS
was tested by 254 hospitals across the country in
2005. A total of 84,779 people responded to the
Highlights of the survey results presented
in this report include:
- High ratings for hospital care by a majority of
survey respondents: 56 percent rated their
hospitals either "9" or "10" on a 10-point
scale where "0" is the "worst possible
hospital" and "10" is the "best possible
- Highest scores for communication with
doctors and nurses: 87 percent and 81
percent reported that doctors and nurses
(respectively) always treated them with
courtesy and respect.
- Lowest scores for communication about
medications and discharge information: 26
percent reported that hospital staff never
described possible side effects of new
medications in a way they could understand,
and 24 percent reported that hospital staff
never talked with them about whether they
would have the help they needed when they
left the hospital.
- High to moderate scores for pain
management: 77 percent reported that
hospital staff always did everything they
could to help with pain; however, only 64
percent reported that their pain was always
well controlled when they needed pain
In January 2006, the U.S. Office of Management
and Budget (OMB) officially approved the use of
the CAHPS Hospital Survey. OMB's approval
allows the Centers for Medicare & Medicaid
Services and the Hospital Quality Alliance to
begin national implementation of the
CAHPS® In-Center Hemodialysis Survey
In November 2006, the CAHPS® Consortium, in
cooperation with the Centers for Medicare &
Medicaid Services (CMS), released the CAHPS®
In-Center Hemodialysis Survey for public use.
This standardized questionnaire was designed to
help dialysis facilities and End Stage Renal
Disease (ESRD) Networks assess and improve the
experiences of their patients with in-center
CAHPS® 4.0 Version of Health Plan
CAHPS® Health Plan Survey 4.0, the newest
version of the questionnaire that first put the
CAHPS® program on the map, was released in
2006. The survey has been revised after careful
testing and solicitation of stakeholder input by
the CAHPS® Consortium and the National
Committee for Quality Assurance (NCQA). Like
all CAHPS® surveys, the Health Plan Survey 4.0
assesses those aspects of care for which the
patient is the best or only judge, and has
undergone rigorous testing and analysis by the
CAHPS® grantees in order to ensure its reliability.
These products and additional information on
CAHPS® can be found on the Web site at:
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