Orthopedics

Review Article 

Physician Rating Scales Do Not Accurately Rate Physicians

Matthew B. Burn, MD; David M. Lintner, MD; Pedro E. Cosculluela, MD; Kevin E. Varner, MD; Shari R. Liberman, MD; Patrick C. McCulloch, MD; Joshua D. Harris, MD

Abstract

The purpose of this study was to determine the proportion of questions used by online physician rating scales to directly rate physicians themselves. A systematic review was performed of online, patient-reported physician rating scales. Fourteen websites were identified containing patient-reported physician rating scales, with the most common questions pertaining to office staff courtesy, wait time, overall rating (entered, not calculated), trust/confidence in physician, and time spent with patient. Overall, 28% directly rated the physician, 48% rated both the physician and the office, and 24% rated the office alone. There is great variation in the questions used, and most fail to directly rate physicians themselves. [Orthopedics. 2018; 41(4):e445–e456.]

Abstract

The purpose of this study was to determine the proportion of questions used by online physician rating scales to directly rate physicians themselves. A systematic review was performed of online, patient-reported physician rating scales. Fourteen websites were identified containing patient-reported physician rating scales, with the most common questions pertaining to office staff courtesy, wait time, overall rating (entered, not calculated), trust/confidence in physician, and time spent with patient. Overall, 28% directly rated the physician, 48% rated both the physician and the office, and 24% rated the office alone. There is great variation in the questions used, and most fail to directly rate physicians themselves. [Orthopedics. 2018; 41(4):e445–e456.]

In the current health care environment with an emphasis on the “value of care,” there has been a transition from a pay-for-performance model (rewarding quantity of care) to a value-based model (rewarding quality of care). Although cost (direct and indirect) can be easily calculated, measurement of the quality of care is complicated and multifactorial. Quality of care is determined by (1) the reviewer (ie, patient, provider, hospital, or payers) and (2) the method of measurement (ie, subjective patient-reported scales, objective outcome measures, readmission rates, complications or mortality, and so forth). Subjective patient-reported physician rating scales are being increasingly used for this purpose; however, most have been administered using physician documents, and the results have only been available to the hospital and providers (ie, Clinician and Group Consumer Assessment of Healthcare Providers and Systems developed by the Agency for Healthcare Research and Quality and administered by Press Ganey Associates).1,2 Release of these scales (ie, physician rating websites) to the public will theoretically empower patients to make better decisions about their health care when selecting a provider.

Initially, physician rating scales were incorporated into review websites for all other commercial products. In 2004, RateMDs was developed specifically for patients to rate physicians; it was quickly followed by other physician rating websites, including Healthgrades and Vitals. However, in medicine, unlike in the food and travel industries, patients' best interests often do not align with their personal opinions or expectations. If satisfaction ratings are used to measure clinical success and determine reimbursement, this can lead to patients' either receiving unnecessary interventions or tests or not receiving necessary but undesirable testing or care.3 Two common examples involve treating viral upper respiratory illnesses (ie, the common cold) with antibiotics and prescribing narcotic pain medications, with both leading to greater patient satisfaction but also increased antibiotic resistance and narcotic addiction, respectively.4–8 Studies have shown that although the most satisfied patients frequently spend the most on health care and prescription drugs, they also have higher hospitalization and mortality rates.3–5

In addition to these ethical dilemmas, the currently available “physician” rating scales (both conventional and online) have broad questions aimed at evaluating the entire patient “experience,” including elements outside of the direct control of the physician (ie, wait times, office décor, staff friendliness), rather than just interactions of the physician, leading to confusion among consumers. Although prior studies have reported the components evaluated by physician rating scales, they have not comprehensively evaluated the proportion of these scales specifically rating the physician directly. The authors performed a systematic review to determine (1) the components of care evaluated by currently available physician rating scales and (2) which of these factors are under the direct control of or directly grade the physician. The authors hypothesized that less than 50% of the factors used to rate physicians are under their direct control or directly grade them.

Websites

Identification

This systematic review was registered with the International Prospective Register of Systematic Reviews. It was conducted and reported using all applicable components of the protocol described by Preferred Reporting Items for Systematic Reviews and Meta-Analyses.9 The search was performed by 2 of the authors (M.B.B., J.D.H.) using the Google search engine for the period between October 12, 2015, and November 12, 2015. Three sets of search terms were used: (1) “Doctor grade” OR “Doctor score” OR “Doctor rating” OR “Doctor review”; (2) “Provider survey questions” OR “Patient experience scorecard public”; and (3) “Physician” OR “Doctor” AND “Grade” OR “Rate.” Each search term, including the quotations (ie, “Doctor”) and modifiers (ie, AND and OR), was entered into the Google search engine exactly as listed above. Similar to previously published studies, the first 100 websites found using each of these 3 search terms were reviewed (a total of 300 websites) (Figure).10

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart illustrating application of exclusion criteria.

Figure:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart illustrating application of exclusion criteria.

Selection Criteria

The 2 authors who performed the search reviewed all 300 websites. During the primary analysis, websites were excluded if they did not contain a physician rating scale that was completed by patients (Figure). Websites with (1) online news articles or blogs not discussing health care–related topics, (2) online news articles or blogs discussing health care–related topics, (3) commercial sales, (4) discussion of television doctor shows, (5) journal articles not discussing health care–related topics, and (6) journal articles discussing health care–related topics but not including physician rating scales were excluded. During the secondary analysis, the remaining websites were reviewed in-depth. Websites were excluded from final analysis if they (1) were a duplicate (ie, found using more than 1 of the 3 sets of search terms), (2) only contained links to other already included rating websites, (3) only graded hospitals (not individual physicians), and (4) only reported Medicare readmission codes rather than subjective patient grading. Two “physical document” grading scales (National Health Service survey and Clinician and Group Consumer Assessment of Healthcare Providers and Systems) were found during the initial search and, although they do not have publicly accessible online scores, were included because they contained patient-reported physician rating scales.

Data Extraction

Each website selected for final review was independently assessed by the same 2 authors without blinding for website identifiers, such as website name, company, and affiliations. Data collected fell into 3 categories: (1) website demographics and characteristics, (2) available physician demographics, and (3) components of the physician rating scale. Website demographics and features for each physician rating website were reviewed (Table 1). Online publicly available physician demographics were reviewed for each of the included physician rating websites (Table 2). The components of each rating scale were reviewed to count and categorize the questions patients were asked about their physician and their physician's office. The authors categorized these questions into 3 groups: (1) those that rated the physician directly, (2) those that rated both the physician and the office, and (3) those that rated the office directly (office staff, parking, location, cost, equipment, and so forth) (Table 3). Descriptive statistics were calculated for each physician rating scale.

Access, Characteristics and Demographics, and Searchability of the 14 WebsitesaAccess, Characteristics and Demographics, and Searchability of the 14 Websitesa

Table 1:

Access, Characteristics and Demographics, and Searchability of the 14 Websites

Physician Information Available on the 14 Websitesa

Table 2:

Physician Information Available on the 14 Websites

Summary of the Components (Questions/Comments) Used by the Online Patient-Reported Physician Rating ScalesaSummary of the Components (Questions/Comments) Used by the Online Patient-Reported Physician Rating Scalesa

Table 3:

Summary of the Components (Questions/Comments) Used by the Online Patient-Reported Physician Rating Scales

Results

With the use of these 3 sets of search terms and the Google search engine, 300 websites were identified. A total of 263 of these websites were excluded because they did not contain a patient-reported physician rating scale (Figure). An additional 23 websites were excluded because they were duplicates (n=6), linked to another already included website (n=5), contained rating scales of hospitals rather than individual physicians (n=10), or contained ratings based on Medicare data rather than patient-reported scales (n=2). Thus, 14 websites were available for final analysis11–24 (Table 4), containing a mean of 9 (SD, 8; range, 1–33) checkbox questions and 1 (SD, 1; range, 0–2) comment box. Demographic information for each of the 14 physician rating websites, including (1) whether the website was free to access, (2) where patient reviews could be linked to social media, (3) the methods used by the website to verify patients, (4) the parameters patients can use to search for physicians, and (5) the demographics collected about the patients themselves, is listed in Table 1. Most of the websites did not require verification that an appointment with the physician had occurred (71%). Publicly available demographic information for physicians is presented in Table 2. Most of the websites included each physician's office address (100%) and phone number (75%) and contained a link to practice websites (67%). Years of experience (33%), procedures performed (33%), and conditions treated (33%) received less emphasis. Two websites (Table 3) were online versions of conventional physical document rating scales: (1) the National Health Service patient survey,19 which had a total of 62 questions, with 33 questions being about the physician or office (24% grading the physician directly, and 36% grading both the physician and the office); and (2) the Clinician and Group Consumer Assessment of Healthcare Providers and Systems,12 which had a total of 31 questions, with 18 questions being about the physician or office (46% grading the physician directly, and 31% grading both the physician and the office). Twelve websites (Table 3) represented free online patient-reported physician rating scales. These ranged in length from 1 question15,23 (patient-reported, rather than calculated, “overall rating”) to 11 questions. The 3 websites with the greatest number of questions were Real-Self21 (11 questions); Angie's List11 (11 questions); and Healthgrades17 (9 questions). The 3 websites with the highest percentage of questions directly grading the physician were IWantGreatCare18 (67%); RateMDs20 (50%); and Healthgrades17 (44%). The top 3 websites with questions that grade the physician alone and the physician and the office together (excluding DrScore and Yelp, which had only 1 patient-reported, rather than calculated, overall rating question) were (1) IWantGreatCare18 (100%); (2) Zocdoc24 (100%); and (3) Vitals22 (88%).

Websites That Contained Patient-Entered Physician Rating Scales

Table 4:

Websites That Contained Patient-Entered Physician Rating Scales

The most common questions used by these scales were versions of (1) courtesy of office staff (71%); (2) wait time, promptness, or punctuality (64%); (3) overall rating (entered, not calculated) (57%); (4) trust/confidence in physician/knowledge (50%); (5) time spent with patient (43%); and (6) recommend to family/friend (43%). Although 2 questionnaires (14%) included a patient-reported “treatment success” question, none (0%) included patient-reported “surgeon skill” questions or reported outcome scores to measure success. All (100%) of the online-only rating scales included an open-ended comment section for patients to complete.

Discussion

The authors reviewed online physician rating scales to (1) determine the components (ie, questions) used by these rating scales and (2) calculate the proportion of these under the direct control of, and therefore actually rating, the physician. Although there is much variation in the questions used by physician rating websites, they tend to follow several themes: office staff friendliness/courtesy (found in 71% of rating scales); wait times (64%); trust/confidence in the physician (50%); communication skills (bedside manner, 36%; listens/answers questions, 36%; and communication, 29%); and whether the patient would recommend the physician (43%). These findings were similar to those of prior studies.10,25–27 Reimann and Strech,10 who reviewed English and German physician rating websites, found that the most common questions were related to wait times (100% of rating scales), trust/confidence in the physician (86%), and office staff friendliness/courtesy (81%). The study by de Groot et al28 found that patients deemed wait time and physician expertise to be the most important factors in selecting a physician or surgeon. Although these studies analyzed the components found on physician rating websites, no prior studies have discussed the proportion that directly rate the physician in question. In fact, this study found that most of the questions are out of the physician's direct control. This had been mentioned but not measured in prior studies, which stated that reviews focused more on office décor than on whether the physician delivered good health care.29–32 Of the 14 rating scales reviewed, only 4 had a greater number of questions focused directly on the physician than on the office/physician or office alone. Overall, an average of 28% of questions directly rated the physician (confirming the authors' hypothesis of less than 50%), whereas 48% and 24% rated both the physician and the office and the office alone, respectively.

Despite the explosion of physician rating websites, little has been published regarding the quality and applicability of these scales. RateMDs, one of the first physician rating websites, had 500,000 available physician ratings in its first 4 years online (2004 to 2008).33 In 2008, Healthgrades and Vitals entered the market and rapidly grew in popularity. By 2010, 24% to 47% of American adults reported reading physician reviews online prior to choosing a physician. In 2016, as a sign of the increased acceptance of physician rating websites, UnitedHealthcare, one of the largest health insurance providers,34 linked Healthgrades ratings to physician profiles on its website to “reinforce quality of care.”35 Although studies have shown that online rating scales correlate well with conventional paper rating scales, correlations between patient satisfaction and objective outcome scores have varied.36 Some studies have shown that patient satisfaction correlates with higher medical costs, more hospital admissions, and a higher mortality rate without evidence that there is a correlation with a measurable improvement in objective outcomes,37–43 whereas other studies have shown a correlation with improved outcomes.44 Most physicians agree that patient satisfaction should be part of the way physicians are evaluated, but it should not be confused as being synonymous with overall physician performance or overall quality of care.10,25 Outside of patient satisfaction alone not being a good measure of overall clinical care, the methodology used by most physician rating websites is lacking. In fact, most patient satisfaction surveys do not even include more than half of the components required to measure patient satisfaction.10,25 Orthopedic surgery is one of the most frequently searched specialties, but it is reported to have the lowest overall online patient satisfaction ratings.45,46 Bakhsh and Mesfin,26 specifically examining online ratings of orthopedic surgeons, found that “surgeon knowledge” and “bedside manner” were most correlated with the physicians' overall rating, which correlates with prior studies showing poor communication and bedside manner to be the most common reasons why patients seek a second opinion after seeing an orthopedic surgeon.47

To be broad and generalizable, physician rating websites are full of information of questionable value, which could be improved by specialty-specific rating scales. Although the focus, goals, and day-to-day work (including the level of patient interaction) of hospitalists, family practice physicians, emergency medicine physicians, dermatologists, radiologists, and surgeons vary considerably, physician rating websites attempt to evaluate all of these with a single all-inclusive rating scale. In a family practice, clinical success and outcomes may be measured by vital signs and laboratory values (ie, body mass index, blood pressure, glucose, hemoglobin A1c), and patient education can be the main driver in the achievement of these goals (ie, weight loss). In contrast, surgeons use patient education to foster informed decision-making, with clinical success and outcomes being primarily determined by patient selection and technical or surgical skills that are not measured by patient satisfaction scores. Currently, there are no freely or easily accessible databases containing reports of individual physicians' technical expertise or objective outcome measurements (eg, imaging [radiography], functional measures [strength, range of motion, dexterity], and time to return to sports, work, or even activities of daily living).10 Public reporting of physician performance (including both patient satisfaction and objective outcome scores) should improve the quality of health care by allowing patients to make educated choices regarding physician and allowing physicians to monitor their own practices for areas of improvement.48 However, if flawed or inconsistent methodology is used, the inaccurate ratings could mislead or confuse both patients and physicians.48 Recently, websites have emerged (eg, ProPublica Surgeon Scorecard) that claim to be a publicly available surgeon “objective outcome measure.” Instead of a clinical outcome measure, they represent administrative data relying on an “adjusted complication rate” calculated from Medicare readmission codes that have a latency of 1 to 2 years and include a limited number of procedures (currently 8), only the first 30 days postoperatively, and many complications unrelated to the index surgical procedure. They fail to include the immediate postoperative period (during the index admission), during which 67% of postoperative complications occur, or any complications more than 30 days after surgery.48–52 Penalizing surgeons for complications unrelated to the surgery itself (usually due to medical comorbidities) may encourage “cherry picking” of healthier patients for elective procedures.49

Most physician rating websites, including all but 1 reviewed, are “open chain,” meaning that, in the interest of patient privacy, anyone with Internet access (including individual physicians, their office staff, or reputation-based businesses) can post 1 or more reviews without verification of actual consultation with the physician, thus permitting unscrupulous physicians to manipulate their own scores.10,30,53 Additionally, some physician rating websites offer physicians upgraded membership, allowing them to choose to remove negative ratings.22 Both the National Health Service survey and the Clinician and Group Consumer Assessment of Healthcare Providers and Systems survey are truly “closed chain” by being physical documents mailed to a patient after a confirmed visit with a physician. Zocdoc is the most closed chain of all, allowing reviews to be posted only by patients who make an appointment through their website only with physicians who pay to be listed. However, after making an appointment, patients can leave a physician rating after the appointment date regardless of whether they actually attended the appointment. Often information listed on physician rating websites is “inaccurate or outdated” because it is derived directly from other databases (ie, other physician rating websites, medical board websites).53 Studies have shown that only 3% to 28% of physicians listed on physician rating websites have 1 or more ratings available, which leads to skewing and volatility of rating scales that may not be representative of the actual patient experience.25,27,29,30,31,47,48,53–56 Physicians fear that there is a tendency for reviews to be posted only by outliers with terrible experiences; however, prior studies have shown that most (>85%) reviews posted on physician rating websites are positive.4,10,25,29–31,54,57 Given all of these factors, it is not surprising that the public is skeptical regarding the accuracy of reviews. A poll conducted by C.S. Mott Children's Hospital indicated that although 30% of parents review online physician ratings, two-thirds (69%) believe that some of the reviews are fake, 64% believe there are not enough reviews to make a good decision, and only 11% have ever rated a physician online.48,58 Most patients report that they rely heavily on recommendations from other physicians and from family and friends.38 Trehan and Daluiski45 suggested that some of these inconsistencies could be improved via frequent internal monitoring by physician rating websites to eliminate outlying reviews (either positive or negative) and to make a physician's ratings public only when a specific number of reviews have been received.

This study had limitations. First, the search results are dynamic. Searches done today may have different findings. Second, selection bias was introduced by reviewing only the first 100 search results. However, the authors' method of searching was a reproduction of the process used by patients when evaluating potential physicians. The first 100 results were chosen based on a prior study, and the authors agree that it is unlikely that most patients would review results beyond this.10 Third, the search results were limited to English websites, which adds a selection bias. However, Reimann and Strech10 found similar questions on English and German physician rating websites.

Conclusion

Current physician rating websites have the benefit of being freely and widely available, but they often contain unreliable data that dilute physician ratings with those of the office facility and staff. Although patient satisfaction has a role in evaluating the quality of care, it is but 1 piece of the picture and should be viewed along with objective outcome measures. More work is needed to adequately delineate which questions would optimally measure patient satisfaction with direct physician care and to incorporate measures of diagnostic and/or technical expertise and objective outcomes.

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  58. C.S. Mott Children's Hospital. National poll on children's health: many parents wary of online ratings for doctors. http://mottnpch.org/sites/default/files/documents/032116_doctorratings_1.pdf. Accessed April 1, 2016.

Access, Characteristics and Demographics, and Searchability of the 14 Websitesa

CharacteristicHealth gradesVitalsRate MDsCG-CAHPSNHS SurveyDoctor ScorecardDrScoreYelpEyeDoctor ReviewReal SelfDoctor BaseIWant GreatCareZocdocAngie's ListEach Categoryb
Free to accessYesYesYesNANAYesYesYesYesYesYesYesYes92%
Social network connectionsYesYesNANAYesYesYesYes50%
Patient verification
  Asked if recent appointment with physicianYesYesYesYesYesYesYesYesYesYes71%
  Requires verification of recent appointment with physicianYesYesYesYes29%
  Survey mailed to patient after attending appointmentYesYes14%
  Name requiredNANAYesYesYesYesYes42%
  Email requiredYesNANAYesYesYesYesYes50%
  Able to substitute text message for emailYesNANA8%
Search by
  Disease/conditionYesYesNANAYesYesYes42%
  Surgical procedureYesNANAYesYes25%
  SpecialtyYesYesYesNANAYesYesYesYesYesYesYesYesYes100%
  Practice or groupYesYesNANAYesYesYesYes50%
  Region (city/state/country)YesYesYesNANAYesYesYesYesYesYesYesYesYes100%
  Insurance acceptedYesNANAYesYes25%
  Provider nameYesYesYesNANAYesYesYesYesYesYesYesYesYes100%
  Provider sexYesNANAYes17%
  Languages spokenNANAYes8%
Patient demographics
  Report timing or number of office visits with physicianYesYesYesYesYesYesYes50%
  SexYesYesYesYesYes36%
  Age groupYesYesYesYesYes36%
  RaceYesYesYes21%
  EducationYesYes14%

Physician Information Available on the 14 Websitesa

CharacteristicHealth gradesVitalsRate MDsCG-CAHPSNHS SurveyDoctor ScorecardDrScoreYelpEyeDoctor ReviewReal SelfDoctor BaseIWant GreatCareZocdocAngie's ListEach Categoryb
AgeLNANAE17%
Years of experience (stated, not implied)LNANALLE33%
SexEENANALE33%
SpecialtyEEENANAEEEEEEEEE100%
Board certificationsEENANALEEE50%
Sanctions/malpractice/board actionsLNANAL17%
Education & trainingEEENANALEEE58%
Research & publicationsENANAE17%
Awards & recognitionsLLLNANALLL50%
Procedures done by physicianEENANAEE33%
Conditions treated by physicianEEENANAE33%
Languages spokenEEENANAEE42%
Office addressEEENANAEEEEEEEEE100%
Office phone numberEEENANAEEEEEE75%
Insurances acceptedELENANAEE42%
Directs you to physician's websiteLENANAEEEEEE67%
Directions/mapsLLLNANALLLLLLL83%

Summary of the Components (Questions/Comments) Used by the Online Patient-Reported Physician Rating Scalesa

CharacteristicHealth gradesVitalsRate MDsCG-CAHPSNHS SurveyDoctor ScorecardDrScoreYelpEye Doctor ReviewReal SelfDoctor BaseIWant GreatCareZocdocAngie's ListEach Categoryb
Total number of questions984316271151666410
Number of questions on quality of visit/provider984183371151163311
Subjective commentsYesYesYesNoNoYesYesYesYesYesYesYesYesYes
Physician
  Time spent with patient11111143%
  Bedside manner/helpfulness1111136%
  Listens to & answers questions1111136%
  Treats patient with care/respect1114%
  Communication/explains care in layman's term111129%
  Involved you in your own care17%
  Trust/confidence in physician/knowledge111121150%
  Explains post-visit instructions1114%
  Total “physician alone” questions44%38%50%46%24%0%0%0%40%27%0%67%33%20%
Both physician & office
  Overall rating (entered, not calculated)1111111157%
  Recommend to family/friend11111143%
  Ease of scheduling routine appointments1181136%
  Ease of scheduling urgent appointment1114%
  Wait time, promptness, or punctuality12121111164%
  After visit follow-up with patient (results)11121%
   “Treatment success” (patient judged)1114%
  Total “physician & office” questions33%50%25%31%36%43%100%100%40%36%33%33%67%40%
Office
  Ease of contact during regular hours111129%
  Ease of phone contact after hours57%
  Office environment/cleanliness/comfort111129%
  Courtesy of office staff111272113171%
  Cost of visit/procedures12121%
  Total “office” questions22%13%25%23%39%57%0%0%20%36%67%0%0%40%

Websites That Contained Patient-Entered Physician Rating Scales

WebsiteaURL
Healthgradeshttp://www.healthgrades.com
Vitalshttp://www.vitals.com
RateMDshttps://www.ratemds.com
CG-CAHPSbhttps://cahps.ahrq.gov/surveys-guidance/cg/instructions/downloadsurvey3.0.html
NHS Surveyhttp://gp-survey-production.s3.amazonaws.com/archive/2015/July/qandletter/14-008280-01_GPPS_England_Y9W2_January2015_FINAL.pdf
DoctorScorecardhttp://www.doctorscorecard.com
DrScorehttp://www.drscore.com
Yelphttp://www.yelp.com
EyeDoctorReviewhttp://www.eyedoctorreview.com
RealSelfhttps://www.realself.com
DoctorBasehttps://doctorbase.com/patient-reviews
IWantGreatCarehttps://www.iwantgreatcare.org
Zocdochttps://www.zocdoc.com
Angie's Listhttp://www.angieslist.com/articles/angies-list-top-doctors-dentists.htm
Authors

The authors are from the Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, Houston, Texas.

Drs Burn, Lintner, Cosculluela, Liberman, and McCulloch have no relevant financial relationships to disclose. Dr Varner is a paid consultant for In2Bone and Solana, receives royalties from In2Bone and Solana, and holds stock in In2Bone and Wright Medical Technology, Inc. Dr Harris is a paid consultant for NIA Magellan, has received research support from DePuy and Smith & Nephew, and is on the speaker's bureau of Smith & Nephew.

Correspondence should be addressed to: Joshua D. Harris, MD, Department of Orthopedics & Sports Medicine, Houston Methodist Hospital, 6550 Fannin St, Smith Tower, Ste 2500, Houston, TX 77030 ( joshuaharrismd@gmail.com).

Received: February 23, 2017
Accepted: July 31, 2017
Posted Online: April 16, 2018

10.3928/01477447-20180409-06

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