Poison-related visits in a pediatric emergency department: A retrospective analysis of patients who bypass poison control centers

a b s t r a c t

Introduction: Poison control centers (PCC) are an effective means to prevent unnecessary emergency department (ED) visits associated with poisoning exposures. However, not all patients with poison exposures utilize the PCC. The purpose of this study was to identify unintentional pediatric poisoning exposures presenting to a large US children’s hospital that could have been managed onsite (i.e., at home) if consultation with a PCC had occurred prior to the ED visit.

Methods: Using ED encounters from a tertiary children’s hospital, unintentional pharmaceutical, chemical, or fume exposures occurring between October 1, 2014 and September 30, 2015 were identified from ICD-9-CM bill- ing codes. Two specialists in poison information reviewed the medical records of the identified patients who had no contact with the PCC and determined whether these encounters were preventable through PCC triage. De- scriptive statistics examined the differences between the encounters. Data were analyzed in R v3.2.4 (Vienna, Austria) and SAS v9.4 (SAS Institute, Cary, NC).

Results: In the total study population (n = 231), 98 (42.4%) were PCC triaged and 133 (57.6%) were caregiver self- referred to the ED. For those who self-referred, 62 (46.6%) patients would have been recommended to be man- aged onsite instead of presenting at the ED for medical care. Analgesics and household cleaning products were the most common pharmaceutical and chemical exposures, respectively.

Conclusions: Nearly half of ED visits for pediatric patients with unintentional poisoning exposures could have been avoided by contacting a PCC. Educational and self-efficacy-based interventions are needed to expand the public’s use of PCC services.

(C) 2019


Poison control centers (PCCs) are consulted on the management of exposures to wide array of agents such as pharmaceuticals, chemicals, fumes, venoms, and foods, among others. In 2016, over 2 million poison exposure cases from the general public and healthcare professionals were managed at US PCCs [1].

* Corresponding author at: Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, One University Heights, Karpen Hall 143, Asheville, NC 28804, United States of America.

E-mail addresses: [email protected] (A.R. Johnson), [email protected] (C.R. Tak), [email protected] (K. Anderson), [email protected]

(B. Dahl), [email protected] (C. Smith), [email protected] (B.I. Crouch).

1 Co-first authorship.

Poison control centers are an effective means of triaging poisoning exposures and preventing unnecessary hospital utilization [2]. Nearly 50% of consults to PCCs involve children younger than 6 years old [1]. The majority of consults can be managed onsite with telephone follow-up, thus potentially avoiding unnecessary ED visits [1]. However, not all pediatric caregivers utilize PCC services. A previous investigation found that a significant percentage of referrals to the ED for pediatric pa- tients with poisoning exposures were “medically inappropriate” [3]. However, it is currently unknown what portion of pediatric patients, who bypass PCC services and possibly medical care altogether, and are caregiver or self-referred to the ED, could have been safely managed onsite by the PCC.

The purpose of this study was to identify unintentional pediatric poi- soning exposures presenting to a large US children’s hospital that could have been managed onsite (i.e., at home) if consultation with a PCC had occurred prior to the ED visit. We also described the patient

0735-6757/(C) 2019

demographic and clinical characteristics associated with visits that could have been avoided by contacting a PCC.

Patients and methods

Data source and study population

Primary Children’s Hospital (PCH) is a tertiary children’s hospital that serves a large area in the Intermountain West region, including Utah, Idaho, Nevada, Wyoming, and Montana. Among the wide array of pediatric medical specialties provided, specialized emergency care is available.

The Utah Poison Control Center is an accredited poison cen- ter that provides services to the state of Utah. Each year, the UPCC re- sponds to N40,000 human poisoning exposure inquiries by caregivers, patients and healthcare professionals. The PCC emergency hotline is managed by skilled specialists in poison information (SPIs) who have extensive toxicology training and medical backgrounds (primarily nurses and pharmacists). Specialists in poison information are required to obtain national certification after they have managed at least 2000 human exposures calls and worked N1200 h on the emergency hotline.

The electronic data warehouse at PCH was queried from 10/1/2014 to 9/30/2015 to identify unintentional poisoning-related ED visits and subsequent inpatient admissions. Visits were identified by ICD-9-CM di- agnosis codes related to unintentional exposures to pharmaceuticals (ICD-9-CM: 960-979.9) and non-pharmaceutical chemicals and fumes (ICD-9-CM: 506.0-506.9; 980.0-989.9). Patients 18 years and under were included in the analysis.

Visits were matched to poisoning exposures in the UPCC electronic medical record via patient identifiers. This matching determined the type of contact with the UPCC: “PCC referred”- care giver or patient contacted the UPCC and was referred to the ED; Healthcare facility (HCF) contact – healthcare facility contacted the PCC after the caregiver or patient self-referred; and “no contact” with the PCC by caregiver, pa- tient, or healthcare facility. Healthcare facility contact and no contact were grouped into “caregiver self-referred.”


Electronic chart review was performed by one investigator on each visit identified through the PCH electronic data warehouse. Information that would be obtained during a PCC telephone call was abstracted from the ED note onto a data collection form and included the following: age, sex, ED history of present illness, time of ED presentation, time post ex- posure, substance – including exact product, strength, and amount; route of exposure, past medical history, presence or absence of clinical effects, and treatments provided prior to ED presentation (excluding emergency medical services treatment). ED encounter date, weight, race, ethnicity, means of transport to the hospital, insurance status, facil- ity costs, and admission status were obtained for the analysis through the PCH data warehouse.

Two certified specialists in poison information (CSPI), each with N10 years PCC experience, independently reviewed pertinent informa- tion abstracted from the ED charts and provided their management site recommendations (onsite or refer to healthcare facility) for each case based on national and local PCC guidelines and professional expe- rience. If the CSPI management site recommendations were in disagree- ment, a third CSPI provided a management site recommendation to reconcile the dispute. CSPIs were blinded to type of PCC contact for each case and other information that would not typically be available during a phone consultation, including hospital transport, patient eth- nicity, insurance status, facility costs, and admission status. The cases classified as “caregiver self-referred” were used for the CSPI recommen- dation analysis.

Statistical analysis

Descriptive statistics (frequencies, mean, and standard deviation) of demographic and clinical characteristics were performed for the total study population and stratified by actual management site. The cases in which the patient or caregiver self-referred to the ED were stratified by CSPI management site recommendation. Ages were categorized into groups: ages two years and younger, three to five years, six to 12 years, and 13 to 18 years. Comparisons of demographic and clinical character- istics across actual management site and CSPI recommendations were made with Chi-square or Fisher’s Exact Test and Mann-Whitney U tests, as appropriate. Simple and multiple logistic regression models were used to determine the impact of the individual and combined characteristics on the odds (OR) and adjusted odds (AOR) of recommending onsite management. We modeled these relationships only using relevant variables available to CSPIs plus means of transport (e.g., ambulance) as a proxy for patients’ perceived acuity of the situa- tion. Significant predictors (? b 0.05) in the simple logistic regression model were included in the multiple logistic regression model. Interrater agreement and sources of disagreement were also assessed using the kappa (K) statistic [4]. Data were analyzed during 2018 and 2019 in SAS v9.4 (SAS Institute Inc., Cary, NC) and R v3.2.4 (Vienna, Austria). This study was reviewed and approved by the Institutional Re- view Boards at the University of Utah and Primary Children’s Hospital.


There were 231 total patients identified between the billing codes and the electronic medical records. In the total study population, slightly fewer than half were female (46.3%), the majority were identi- fied as White (87.9%), and nearly half were covered by commercial in- surance (47.6%) (Table 1). The majority of patients were ages 2 or younger (62.3%), followed by ages 13 to 18 (14.7%) ages 3 to 5

(14.3%), and ages 6 to 12 (8.7%). Nearly three-fourths of exposures were to pharmaceuticals.

When stratified by those who were PCC triaged (n = 98, 42.4%) ver- sus those whose caregiver self-referred to the ED (n = 133, 57.6% [HCF contact, self-referral after PCC contact, no contact]), some significant dif- ferences emerged. A greater proportion of patients identified as White (93.9% vs 83.5%, p-value = 0.03) and having Commercial insurance (60.2% vs 38.4%, p-value = 0.003) were triaged through the PCC.

For those who self-referred, the CSPIs recommended that 62 (46.6%) could have been managed onsite whereas the remaining 71 (53.4%) were recommended to be referred to a healthcare facility. Among these patients, demographic and clinical characteristics differed. For those that were recommended to be managed onsite, the patients tended to have a younger age distribution (3.1 years for onsite vs 6.6 years for HCF, p-value = 0.02), have much lower admission rates (1.6% vs 62%, p-value b0.001), lower rate of pharmaceutical exposure (56.5% vs 84.5%, p-value b0.001), and a greater proportion of patients who were identified as Hispanic (38.7% vs 15.50%, p-value = 0.002). Mean facility costs were significantly lower for patients recommended for on-site management compared to those recommended for HCF re- ferral ($272.1 vs $4332.8, p-value b0.001).

In the simple logistic regression models (Table 2), significant predic- tors of recommending onsite management included being female, ages 13 to 18 as compared to ages 0 to 2, ambulance utilization, and non- pharmaceutical exposure. In the multiple regression model, female as compared to male, ages 13-18 as compared to ages 0 to 2, ambulance utilization vs self-transport had significantly lower odds of recommending onsite management whereas non-pharmaceutical ex- posure compared to pharmaceutical exposure had a significantly higher odds.

Of the 133 patients who self-referred to the health care facility, 109 (81.9%) had agreement between the two CSPIs on the recommended management site. The remaining required a third arbiter to classify

Table 1

Demographic and clinical characteristics, stratified by referral type and CSPI management recommendation.

Total study population Caregiver self-referred only




Caregiver self-referred


CSPI onsite recommendation

CSPI refer to HCF recommendation








Female (%)

107 (46.32)

43 (43.88)

64 (48.12)


24 (38.71)

40 (56.34)


Mean age (st dev) Age (%)

Ages 0-2

4.39 (4.84)

144 (62.34)

3.55 (3.97)

68 (69.39)

5.01 (5.32)

76 (57.14)



3.15 (3.21)

42 (67.74)

6.60 (6.21)

34 (47.89)



Ages 3-5

33 (14.29)


18 (13.53)

11 (17.74)

7 (9.86)

Ages 6-12

20 (8.66)

6 (6.12)

14 (10.53)

7 (11.29)

7 (9.86)

Ages 13-18

34 (14.72)

9 (9.18)

25 (18.80)

2 (3.23)

23 (32.39)

White (%)

203 (87.88)

92 (93.88)

111 (83.46)


53 (85.48)

58 (81.69)


Hispanic (%)

51 (22.08)

16 (16.33)

35 (26.32)


24 (38.71)

11 (15.49)


Commercial insurance (%)

110 (47.62)

59 (60.20)

51 (38.35)


23 (37.10)

28 (39.44)


Hospital admission (%)

78 (33.77)

33 (33.67)

45 (33.83)


1 (1.61)

44 (61.97)


Mean cost (st dev)

1865.80 (9063.57)

1086.8 (1394.6)

2439.8 (10,595.6)


272.1 (406.6)

4332.8 (16,056.3)


Median cost (IQR)

372.8 (1483.4)

432.6 (1376.3)

343.6 (1479.9)


159.2 (132.6)

1610.4 (1769.5)


Pharmaceuticals (%)

175 (75.76)

80 (81.63)

95 (71.43)


35 (56.45)

60 (84.51)


Mean number of substances (st dev)

1.30 (1.43)

1.42 (2.00)

1.22 (0.77)


1.06 (0.31)

1.35 (1.00)


Ambulance (%)

70 (30.30)

24 (24.49)

46 (34.59)


8 (12.90)

38 (53.52)


Time of day of ED visit (%)

Q1 (0000-0559)

18 (7.79)

6 (6.12)

12 (9.02)


3 (4.84)

9 (12.68)


Q2 (0600-1159)

37 (16.02)

15 (15.31)

22 (16.54)

9 (14.52)

13 (18.31)

Q3 (1200-1959)

90 (38.96)

41 (41.84)

49 (36.84)

28 (45.16)

21 (29.58)

Q4 (1800-2359)

86 (37.23)

36 (36.73)

50 (37.59)

22 (35.48)

28 (39.44)

the management site. The two primary CSPIs demonstrated moderate yet significant agreement per the kappa statistic (K = 0.63).

Analgesics were the most common pharmaceutical involved in ex-

posures for both patients recommended for onsite management and those recommended to be referred to a HCF (Table 3). All analgesic ex-

The results from this study should inform health education interven- tions and Policy changes to optimize the services that poison centers offer.

Table 3

Exposure substances stratified by CSPI management recommendation.

posures recommended for onsite management were to over-the-

counter (OTC) products (acetaminophen and ibuprofen) compared to OTC analgesics (57.9%) and Prescription opioids (42.1%) in the HCF re- ferral group. Household cleaning products were the most common

Substance category CSPI management

Pharmaceuticals Onsite,

n = 66 (%)a

Refer to HCF, n = 96 (%)a

non-pharmaceuticals involved in exposures for both management groups. All- purpose cleaners (27.3%) and bleach (27.3%) were the most common household cleaning substances for patients with onsite management recommendations compared to laundry detergent pods (57.1%) in those recommended to be referred to a healthcare facility.


This study examined electronic medical charts from patients with poison-related emergency department visits without initial PCC con- sultation and determined whether patients could have been managed successfully at home (i.e., onsite). The results indicated that 46.6% of patients in the study population would have been recommended to be managed onsite instead of presenting at the ED for medical care. The largest predictors of determining onsite management included age and exposure type (pharmaceutical vs non-pharmaceutical).

Table 2

Simple and multiple logistic regression results on the predictors of managing onsite.

Analgesics – OTC and RX 10 (15.15) 19 (19.79)

Anticoagulant – 1 (1.04)

Anticonvulsants 2 (3.03) 3 (3.13)

Antidepressants – 5 (5.21)

Antihistamines 1 (1.52) 2 (2.08)

Antimicrobials 3 (4.55) –

Antipsychotics – 3(3.13)

Cardiovascular 5 (7.58) 14 (14.58)

Cold and cough 2 (3.03) 2 (2.08)

Dietary supplements/herbals 2 (3.03) –

Electrolytes/minerals/vitamins 1 (1.52) 2 (2.08)

Eye/ear/nose/throat preparations – 2 (2.08)

Gastrointestinal preparations 2 (3.03) 3 (3.13)

Hormone and hormone antagonists 3 (4.55) 6 (6.25)

Muscle relaxants – 2 (2.08)

Sedative/hypnotics 2 (3.03) 4 (4.17)

Stimulants 2 (3.03) 4 (4.17)

Street drugs – 6 (6.25)

Topical preparations 3 (4.55) 1 (1.04)

Uric acid reducer 1 (1.52) –

Unknown – 5 (5.21)


Adhesives/glues 2 (3.03) –

Q4 (1800-2359) 0.59 0.27-1.31



95% CI


95% CI


Cosmetics/personal care products

2 (3.03)

5 (7.58)

3 (3.13)







1 (1.52)

Age category (ref = ages 0 to 2)


1 (1.52)

Ages 3 to 5





Household cleaning substances

11 (16.67)

7 (7.29)

Ages 6 to 12





Ice melt

1 (1.52)

Ages 13 to 18






1 (1.52)






Paints and stripping agents

1 (1.52)

Non-pharmaceutical exposure






1 (1.04)

Time quarter (ref = afternoon/evening)


1 (1.52)

Q1 (0000-0559)



Tobacco/nicotine/cigarette products

1 (1.52)

Q2 (0600-1159)




1 (1.04)

Bolded numbers represent statistically significant estimates at ? N 0.05.

a Percentages do not add to 100% of study sample as more than one exposure per case was possible.

This study adds to the growing literature on the value of PCCs and other interventions in the prevention of unnecessary ED visits. A study by Jackson et al. examined the appropriateness of Emergency medical care referrals for patients with poisoning-related exposures [3]. For pa- tients referred by PCCs, nearly all were deemed appropriate whereas for those without a PCC referral, 69.5% were considered appropriate (30.5% preventable). In a more recent prospective study by Zed et al., patients ages six and younger were evaluated upon presenting at an ED for a medication-related purpose [5]. Of these cases, 65% were deemed pre- ventable. Our results align closely with these findings. The differences herein may be a reflection of our specific sample of poison exposures (e.g., pharmaceuticals, chemicals and fumes/vapors), differences in the determination of “preventable”, or other unknown differences.

Previous investigations have examined the potential cost-savings from PCC services in the prevention of unnecessary ED visits [6-9]. One analysis found that the median hospital charges for ED visits relating to unintentional poison exposures ranged from $759 to $2368, depending on year and insurance status [10]. Although the facility costs in this anal- ysis are lower for patients recommended to be managed onsite, the pre- vention of even the least costly ED visits may result in significant per- patient cost-savings for all payers, public and private. Across the entire study sample, preventing ED visits for those recommended to be man- aged onsite would have saved $16,869 in facilities costs alone. Using ex- trapolated figures from other analyses [10], preventing ED utilization for the 62 patients recommended for onsite management during the course of the year would have prevented between $48,058 and $146,816 in healthcare expenditures. In this analysis, public payers comprised nearly 60% of the caregiver self-referred patients’ insurance, suggesting that the majority of cost-savings for preventing unnecessary ED visits that are oc- curring may be directed toward public payers.

This study found that although nearly 50% of the total study sample had commercial insurance, this was disproportionally distributed among the patients who had contacted the PCC and were referred to ED (PCC-referred: 60.2%; Self-referred: 38.4%). Other differences across PCC contact strata include a greater proportion of patients identifying as white and a lower proportion of patients identifying as Hispanic. Previ- ous studies have established that factors such as insurance status and race are associated with varying levels of PCC utilization [11-13]. Among the barriers cited for PCC underutilization by minority and groups of low socio-economic status are lack of awareness of PCC re- sources, concern for health outcome, fear of perceived parental negli- gence, and lack of confidence due to language or other barriers. Within this study’s sample, differences in poisoning exposures were found across racial/ethnic strata and by insurance status, suggesting dif- ferential utilization of the PCC. educational interventions alone may be insufficient to promote PCC utilization [14]; interventions improving self-efficacy may be required [11].

Among the self-referred patients, we found that of those who were determined to be candidates for onsite management, 85% were aged 5 or younger compared to 57.7% for those determined to be recom- mended for additional medical care. This difference may be due to a number of factors, including severity of exposure and unclear intent. This is consistent with national data that suggest the majority of cases reported to PCCs regard younger patients [15], the vast majority of whom have unintentional exposures that result in little to no adverse effect [16]. This is reinforced by examining other variables in this analy- sis, such as the low facility costs associated with those recommended to be managed onsite, likely indicating less-severe cases.

In this study, we were able to leverage the clinical expertise of two CSPIs as reviewers on all cases, and a third CSPI on cases of disagreement, to determine the management site of patients who self-referred to the ED. This reflects a real-world scenario at PCCs and represents a first po- tential point of contact for the prevention of unnecessary ED visits. We found the interrater agreement of the two CSPIs was overall moderate, but significant. Upon further investigation, differences in interrater agreement arose on cases that were likely more complex. For example,

the interrater agreement decreases and becomes non-significant as age increases, which may be associated with more complex situations. The two raters tended to agree on when to refer to the ED but differed more often on cases that were ultimately determined to be managed onsite (p-value = 0.0004). It is unknown how CSPI professional back- ground, training, or environment may influence these differences.


There are some notable limitations to this analysis. First, poisoning exposures described in this analysis were queried using ICD-9-CM bill- ing codes. There are limitations with using ICD-9-CM or ICD-10-CM codes to identify poisoning exposures and it is likely that not all poison- ing exposures were identified. We found a large number of cases within the PCC electronic medical record (n = 131) that were not captured by ICD-9-CM codes utilized in this study. For PCC cases that could be iden- tified within the ED electronic medical record (n = 118), we analyzed their corresponding ICD-9-CM codes to determine reasons for the low match rate. A majority of these cases had no poison-related ICD-9-CM code associated with their ED visit (76/118; 64.4%). The other cases had some type of billing poison code associated to their visit. Nineteen (16.1%) cases met the study’s inclusion criterion of relevant ICD-9-CM billing codes, but did not present at the ED (e.g., were transferred from an outside facility and bypassed the ED). The remaining patients (23/118, 19.5%) had only E (external causes of injury) and V (supple- mental codes for circumstantial encounters) poison codes related to their visits. When CSPIs evaluated the “caregiver self-referred” cases (n = 75) of this subset, the on-site management rate was similar to those cases that matched (29/75, 38.67%).

Moreover, we intended to analyze only unintentional poisoning ex- posures as intentional poisonings would not be managed onsite by a PCC. After reviewing medical records, we found that 20 visits would have been classified by a PCC as an intentional exposure. Poison control centers define an intentional exposure as an “exposure resulting from a purposeful action” compared to an unintentional exposure which is de- fined as an “exposure resulting from an unforeseen or unplanned event.” Generally, PCCs refer intentional exposures to the ED for medical evaluation followed by behavioral health intervention, and thus, consul- tation with a PCC would not have prevented an ED visit. In this analysis, all 20 intentional exposure cases examined by the CSPIs were recom- mended for management at a healthcare facility. It is unclear how often PCC-defined intentional exposures are classified as intentional by ICD-9-CM or ICD-10-CM codes.

Many factors determine triage of patients with poisoning exposures who call into the poison center. For the CSPI triage determination, elec- tronic medical charts from the patients’ Hospital visits were used. Al- though we attempted to replicate what information would be available during a phone call to the PCC, it is possible that there is some bias as what was recorded may not reflect what the patient would say during the phone call. Specialists rely on objective informa- tion about the exposure substance such as strength/concentration, amount, and time since exposure to determine the amount of risk there is to watch a patient onsite (home). In our study, we found prod- uct strength, amount, and time post exposure missing from the patient chart more often in cases CSPIs referred compared to those CSPIs recom- mended on-site management. It is unknown if this information was missing from the medical chart because of healthcare provider docu- mentation or if the information was unknown to the caregiver.

It is likely that some recording bias, referring to incomplete docu- mentation of the patient’s condition by both healthcare provider and poison specialist exists. Missing or inaccurate chart information may have changed triage determination.

The proportion of unnecessary ED visits reflects only what the CSPIs recommended. In a real-world scenario, this proportion likely reflects an optimal extent of the PCC in the prevention of ED visits as some pa- tients may not follow the CSPI recommendations. We found during this

chart review that some patients (n = 6) self-referred to the ED even after being managed onsite with the PCC. While it is possible that the patients’ exposure or situation may have changed during the time inter- val after the phone call and prior to the ED presentation, we found that all six of these cases were ultimately deemed by the CSPIs, without dis- agreement, to be manageable onsite.

Finally, the results herein describe the determination of CSPIs at one PCC for one patient population. It is unknown how determination would different among different CSPIs in different populations. National guidelines and PCC specific guidelines exist to standardize PCC hospital referral thresholds; however, they are available only for relatively few substances [17-33]. Various poison exposures may be more prevalent in some regions vs others; it is important to investigate these differ- ences to assess the proportion of self-referred patients who may be managed onsite. Moreover, CSPIs, primarily nurses and pharmacists, across PCCs in the US have a variety of backgrounds. Understanding the effect of these backgrounds on triage determinations may assist poi- son centers with standardization while drawing on the strengths that these health professionals offer.


The majority of pediatric patients presenting to an emergency de- partment for unintentional poisoning exposures during a one-year pe- riod were self-referred. Upon review of these visits, CSPIs determined 46.6% of these ED visits could have been avoided by contacting a PCC prior to ED presentation. Educational and self-efficacy based interven- tions are needed to expand the public’s use of PCC services.

Financial disclosure

No financial disclosures were reported by the authors of this paper.

Declaration of competing interest

The authors have no conflicts of interest relevant to this article to disclose.

Contributions statement

Dr. Johnson conceptualized and designed the study, coordinated and supervised data collection, drafted the initial manuscript, and reviewed and revised the manuscript.

Dr. Tak designed the study, performed the data analysis, drafted the initial manuscript, and reviewed and revised the manuscript.

Drs. Anderson and Dahl, and Ms. Smith collected data, and reviewed and revised the manuscript.

Dr. Crouch conceptualized and designed the study, coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content.

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.


The use of REDCap in this investigation was supported by the Uni- versity of Utah population health Research (PHR) Foundation, with funding in part from the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Insti- tutes of Health, through Grant 5UL1TR001067-05 (formerly 8UL1TR000105 and UL1RR025764).

Funding sources

This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.


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