Meeting Minutes, July 24, 2015
National Advisory Council
Minutes from the July 24, 2015, meeting of the Agency for Healthcare Research and Quality's National Advisory Council.
Contents
Summary
Call to Order and Approval of March 27, 2015, Summary Report
Director's Update
2014 National Healthcare Quality and Disparities Report
Update on the Surgeon General's Priorities
Session on Transparency
Public Comments
Chairman's Wrap-Up and NAC Input
Adjournment
Summary
NAC Members Present
Elizabeth A. McGlynn, Ph.D., Kaiser Permanente (Chair)
David J. Ballard, M.D., Ph.D., M.S.P.H., FACP, STEEEP Global Institute, Baylor Scott & White Health
Shari Davidson, National Business Group on Health
Jennifer E. DeVoe, M.D., D.Phil., M.C.R., Oregon Health & Science University
Mary Fermazin, M.D., M.P.A., Health Services Advisory Group, Inc.
Andrea Gelzer, M.D., M.S., FACP, The AmeriHealth Caritas Family of Companies
Paul B. Ginsburg, Ph.D., University of Southern California (by telephone)
Kevin L. Grumbach, M.D., University of California, San Francisco
Leon L. Haley, Jr., M.D., M.H.S.A., CPC, Emory Medical Care Foundation, Emory University
Ann L. Hendrich, Ph.D., R.N., FAAN, Ascension Health (by telephone)
Carol Matyka, M.A., National Breast Cancer Coalition
Mary D. Naylor, Ph.D., R.N., FAAN, University of Pennsylvania School of Nursing
J. Sanford Schwartz, M.D., University of Pennsylvania
Jed Weissberg, M.D., FACP, Institute for Clinical and Economic Review
Alternates Present
David Atkins, M.D., M.P.H., Veterans Health Administration
Shari M. Ling, M.D., Center for Clinical Standards and Quality, Centers for Medicare & Medicaid Services
Charles J. Rothwell, M.B.A., M.S., National Center for Health Statistics, Centers for Disease Control and Prevention
ƵStaff Members Present
Richard Kronick, Ph.D., Director
Sharon Arnold, Ph.D., Deputy Director
Jaime Zimmerman, M.P.H., Designated Management Official
Karen Brooks, CMP, NAC Coordinator
Call to Order and Approval of March 27, 2015, Summary Report
Elizabeth A. McGlynn, Ph.D., Chair of the National Advisory Council (NAC), Agency for Healthcare Research and Quality (AHRQ), called the group to order at 8:30 a.m. and welcomed the NAC members, other participants, and visitors. She welcomed new NAC member Jennifer E. DeVoe, M.D., D.Phil., M.C.R., of Oregon Health & Science University, and alternate Shari M. Ling, M.D., of the Centers for Medicare & Medicaid Services (CMS), subbing for Patrick Conway.
Dr. McGlynn referred to the draft minutes of the previous NAC meeting (March 27, 2015) and asked for changes and approval. The NAC members voted unanimously to approve the March meeting minutes with no changes.
Director's Update
ƵBudget
Richard Kronick, Ph.D., ƵDirector, welcomed the NAC members, speakers, and other guests. He reviewed the recent history of AHRQ's budget, emphasizing the increase in 2009 and subsequent leveling off, which has included very recent increases in funding from the Patient-Centered Outcomes Research Trust Fund (PCORTF). The President's proposed FY2016 budget for Ƶis a total of $479.3 million, an increase of $14.3 million over the FY2015 budget. The proposed budget comprises $363.7 million in discretionary funding and $115.6 million from the PCORTF. It features $112 million devoted to research grants. Dr. Kronick noted that the current House Appropriations Committee has proposed defunding Ƶwhile the current Senate Appropriations Committee has proposed a 35-percent cut in the total budget. He stressed that Ƶhas strong support from U.S. Department of Health and Human Services (HHS) Secretary Sylvia Burwell, Office of Management and Budget (OMB) Director Shaun Donovan, and stakeholder organizations.
Dr. Kronick announced the hiring of Arlene S. Bierman, M.D., M.S., as new director for AHRQ's Center for Evidence and Practice Improvement. Dr. Bierman is a professor at the University of Toronto, holds the Ontario Women's Health Council Chair in Women’s Health, is Senior Scientist at the Li Ka Shing Knowledge Institute at St. Michael's Hospital, and is Principal Investigator for the POWER Study (Project for an Ontario Women's Health Evidence-Based Report Card). Dr. Bierman formerly was a research physician in AHRQ's Center for Outcomes and Effectiveness Research. She will join the agency on August 9. Dr. Kronick recognized David Meyers, M.D., who has been serving as Acting Director of the Center for Evidence and Practice Improvement.
Dr. Kronick stated that the agency will be holding its 2015 ƵResearch Conference on October 4–6, 2015. The conference theme is "Producing Evidence and Engaging Partners to Improve Health Care." AcademyHealth will be co-hosting. The conference will take place at the Crystal Gateway Marriott in Arlington, Virginia. The third day of the conference will feature joint sessions by AHRQ, AcademyHealth, and the Patient-Centered Outcomes Research Institute.
Discussion
Referring to the proposed plans for the Ƶbudget, Dr. Kronick noted that understanding the process includes recognizing a requirement that Congress identify $3.8 billion in savings to address budget caps from the sequester bill. He characterized Ƶas a small investment to help improve the U.S. health care system. He stated that he has observed the opinion that Ƶis doing important work and the opinion that a separate agency is not needed. Ƶdoes not lobby, but it does attempt to explain issues. J. Sanford Schwartz, M.D., wondered whether stakeholders might be encouraged to make their opinions known to their representatives in Congress.
The NAC members wondered what would be lost if Ƶwere defunded. Dr. Kronick cited the ability to develop new evidence about making health care safer, to determine how to improve the quality of care, to improve the measurement of quality, and to understand what health care is delivered and to whom it is delivered. He cited work in central line–associated infections, other hospital adverse events, the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, and the Medical Expenditure Panel Survey (MEPS). He stated that a 35-percent cut in budget would mean the loss of new investment in research on patient safety. Surveys would be cut or eliminated. Funding for grants for the use of health information technology targeting patient safety would be reduced. Efforts in quality indicators would be reduced. An initiative for improving care for chronic conditions would be shelved.
Sharon Arnold, Ph.D., cited an additional concern about the need to facilitate the generation of new ideas from investigators. Andrea Gelzer, M.D., M.S., FACP, suggested that no other entity could produce translational evidence-based guidelines as well as Ƶdoes. Jed Weissberg, M.D., FACP, called on Ƶto frame the issues, David J. Ballard, M.D., Ph.D., M.S.P.H., FACP, suggested creating a tool for communicating talking points about AHRQ, and Dr. Schwartz called for promoting the agency's work in evaluative research and systems design. Perhaps Ƶcould provide information and clarity about the agency's unique efforts and agenda. Ƶfocuses on translation (especially of evidence-based care) rather than discovery.
David Atkins, M.D., M.P.H., stressed the example of AHRQ's work in battling hospital-acquired infections, suggesting that case stories be presented. He suggested that Ƶhas been seen as a surrogate in the effort to advance the Affordable Care Act. Dr. Ling stressed AHRQ’s role in health care quality reporting, providing general perspective on health care delivery. Shari Davidson added the role of AHRQ-derived data in the development of employers’ perspectives. Dr. DeVoe cited the great value of the U.S. Preventive Services Task Force (USPSTF) in reducing morbidity and mortality, and of the Practice-Based Research Networks.
General Update
Dr. Kronick provided updates on Ƶactivities within the four main priorities of the agency.
Priority 1: Produce Evidence to Improve Health Care Quality
- For its EvidenceNOW (advancing heart health in primary care) program, HHS is distributing a total of $112 million in grants to seven regional cooperatives to help physicians in small practices improve heart health in patients. The cooperatives will provide practice facilitation and coaching, data, feedback, benchmarking, consultation, and eHealth record support. The program will feature the ABCs of cardiovascular prevention.
- Ƶis funding three Centers of Excellence (Dartmouth, RAND, and National Bureau of Economic Research) to identify and compare, over 5 years, the characteristics of health systems that successfully disseminate and apply evidence from patient-centered outcomes research (PCOR).
- Ƶreleased the latest National Healthcare Quality and Disparities Report (QDR), as mandated by Congress. The quality and disparities reports have been combined in a single streamlined document and placed online. (See the presentation below.)
- Ƶreleased an evidence-based resource guide titled "Implementing a State-Level Quality Improvement Collaborative." It focuses on strategies to improve children's mental/behavioral health care.
- The USPSTF produced two new final recommendations: screening for thyroid dysfunction and screening for speech and language delay and disorders in children aged 5 years or younger. The Task Force produced draft recommendations on screening for breast cancer, with results similar to the 2009 recommendations. Upcoming draft recommendations include the topics of screening for vision impairment in older adults, adult depression, autism, colorectal cancer, and chronic obstructive pulmonary disease, and aspirin use for preventing cardiovascular disease and cancer.
- Since the previous NAC meeting, the Evidence-based Practice Centers have produced a long list of new systematic reviews, methods reports, and technical briefs.
- Addressing the goal of disseminating PCOR results, Ƶwill fund a cooperative agreement to create a community of stakeholders who increase the use of PCOR in clinical practice. Applications for the program are due by November 13. Ƶalso will offer grants for demonstration and dissemination projects that focus on 1) extending existing Clinical Decision Support (CDS) to multiple settings and 2) creating new PCOR-based CDS.
Priority 2: Produce Evidence to Make Health Care Safer
- The Washington Post supported President Obama's claim, using Ƶdata, suggesting that the Affordable Care Act and the Partnership for Patients program have been reasons for reductions in patient deaths.
- Ƶproduced a survey document/template that can be used by ambulatory surgery centers to collect opinions on patient safety culture, assess areas of strength, identify areas needing improvement, and track improvement over time.
- Ƶis supporting a national action plan to combat antibiotic-resistant bacteria, fueling research and hosting meetings of experts. In FY2015, AHRQ's investment in such research doubled to $6 million. It is working to support the implementation of antibiotic stewardship programs in nursing homes and other settings.
- Ƶreleased a new funding announcement to study the advancement of patient safety implementation through safe medication use. The work will feature demonstration projects in all settings of health care, with emphasis on outpatient care and care transitions.
Priority 3: Produce Evidence to Increase Access to Health Care
- Recently released data from the MEPS-IC (insurance component), focusing on the private sector, showed continuing slow declines in the percentage of employees in establishments offering health insurance in 2014. The average annual single premiums for enrolled employees continued to rise for both large and small firms. The percentage of private-sector establishments that offer health insurance that self-insures at least one plan remained fairly stable, regardless of firm size.
Priority 4: Produce Evidence to Improve Health Care Affordability, Efficiency, and Transparency
- Ƶdeveloped and released a new product/tool from its Healthcare Cost and Utilization Project (HCUP), titled "HCUP Fast Stats." The tool provides easy access to the latest HCUP-based statistics for specific health information topics. It features visual statistical displays that convey complex information readily. The program will update the items regularly, using quarterly or annual data files. The statistics are both national and State-level. The first topic being offered is "Effects of Medicaid Expansion on the Use of Hospital Services."
- HCUP will offer, beginning in the fall, a first all-payer readmissions database, which can be used by researchers to identify the patterns of hospital readmissions nationwide. Data from about 1,800 hospitals will be collected. Discharge weights will allow national and regional estimates of readmissions.
Beyond the Hospital Setting
Dr. Kronick added the news that Ƶhas begun a multiyear initiative to improve patient safety in ambulatory care settings and long-term care facilities. The agency will fund studies to address a broad range of issues, including pressure ulcers and falls in nursing homes and medication safety and diagnostic error in outpatient settings.
Dr. Kronick asked the NAC members to consider other ways in which Ƶmight focus efforts as it expands patient safety efforts beyond the hospital setting. He asked them to consider the idea of a conceptual model of a learning organization and posed these questions:
- Is there value in developing a measure of what a learning health care system is?
- Is there value in doing research on whether a learning health care system produces better outcomes?
Discussion
Dr. Schwartz asked whether Ƶtracks or assesses the users of products such as "HCUP Fast Stats." Dr. Kronick stated that such assessment occurs in some cases and noted a document that tracks the use of MEPS by other Federal agencies. There is tracking of peer-reviewed publications that cite the use of HCUP.
Dr. Weissberg wondered about possible efforts to empower and educate caregivers who are involved in shuttling people in long-term care among sites. Ann L. Hendrich, Ph.D., R.N., FAAN, suggested that, for senior living care facilities, there is a lack of understanding of practices and team-based care. Better attention could reduce readmissions. Kevin L. Grumbach, M.D., added the need to engage patients, with an eye toward safety.
Jeff Brady, M.D., of AHRQ's Center for Quality Improvement and Patient Safety, noted a fairly new Ƶtool titled the "Patient and Family Engagement Guide," which focuses on the hospital setting. The agency will be adding a focus on outpatient settings. Dr. McGlynn noted that the National Academy of Medicine soon will release a report on diagnostic error in outpatient settings and will cite research needs. She added that work in AHRQ-funded Centers of Excellence regarding quality measures for children found that asking people on the front lines of care coordination is key. We need tools to establish baselines for care coordination.
Dr. Schwartz stated the virtue of focusing on both the individual (in long-term care) and the community/population. We should encourage a broad range of research efforts. Rapid cycle evaluation might be used to determine what is helpful. Dr. Ballard cited a need for better evidence-based measures in long-term care.
Mary Fermazin, M.D., M.P.A., stated the importance of diagnostic accuracy and of collecting data on adverse drug events. A culture of not reporting errors exists. Ƶmight study the use of technologies in homes. Dr. DeVoe added the need for tools in predictive analytics in the ambulatory setting. Dr. Ling stressed the importance of shared decisionmaking, including patients and families.
2014 National Healthcare Quality and Disparities Report
Ernest Moy, M.D., M.P.H., Center for Quality Improvement and Patient Safety, AHRQ
Dr. Moy presented an update on the latest version of the QDR, an annual report to Congress that was mandated by the Healthcare Research and Quality Act of 1999. The report (formerly two reports addressing quality and disparities separately) provides a comprehensive overview of the quality of health care received by the general U.S. population and disparities in care experienced by different racial, ethnic, and socioeconomic groups. It identifies areas of strength and weakness in access to health care and quality of health care.
The report's data are based on more than 250 measures of quality and disparities throughout an array of services and settings. New measures have been proposed each year by stakeholders and HHS agencies. An interagency workgroup approves changes in measures and data. Dr. Moy referred to major changes in the 12-year life of the program, such as the introduction of State Snapshots and the creation of an integrated Web site.
The 2014 QDR features significant changes. The quality and disparities documents have been combined into a single document, highlighting the importance of examining quality and disparities together. Information is summarized and organized around issues of access to health care and the National Quality Strategy (NQS) priorities. The new streamlined single document is 30 pages and contrasts with the pair of 250-page documents in past years.
Dr. Moy reported that key findings in the 2014 QDR include the following:
- Access has improved.
- Quality has improved for most of the NQS priorities.
- Few disparities were eliminated.
- Many challenges remain.
The project now includes a series of chartbooks as support material for the main document. The chartbooks provide extensive information on individual measures of quality and disparities and are presented in electronic format. PDF and PowerPoint versions can be downloaded by users. They are organized around the issue of access, the NQS priorities, and priority populations. They are released every 2 weeks for about 6 months.
Dr. Moy presented statistics on visits, views, and downloads of the QDR materials at the Web site. He stated that the next report (2015) will feature new measures on tobacco cessation and breast feeding. The measures in the QDR cover half of the Vital Signs Core Metrics developed by the Institute of Medicine. The QDR can be considered a “check” on the NQS. In moving forward with the program, Ƶhopes to strengthen feedback to users/policymakers, to help facilitate their attempts to address weaker performances.
Discussion
Dr. Schwartz suggested that Ƶdetermine the people/organizations who especially find the information useful. Ƶmight forward links to them when the QDR and chartbooks become available. Dr. Weissberg proposed that Ƶencourage health systems to replicate the analyses, applying their particular populations. Dr. Fermazin proposed that Ƶmake presentations to the Quality Improvement Organizations (QIOs). Dr. Schwartz proposed disseminating the report to key media and people in the medical industry.
Leon L. Haley, Jr., M.D., M.H.S.A., CPC, encouraged Ƶto advance the ability to compare data among the States. In cases where no improvements are observed, the report might indicate tools/links that could be used to address the issues. Dr. Atkins suggested that the report describe variations in the data, by time and by State. Unexpected variations will receive attention. Perhaps the report could indicate how improvements have been made by particular States (with links?). The NAC members agreed on the virtues of the more streamlined document and the benefit of being able to download the information, especially into the PowerPoint slide sets of users.
Update on the Surgeon General's Priorities
Nazleen H. Bharmal, M.D., Ph.D., M.P.P., Office of the Surgeon General
Dr. Bharmal expressed regards from the Surgeon General and stated that the office welcomes all new ideas about developing synergies to improve health. She stated that health insurance coverage is only one step toward better health. We must tackle large issues such as obesity, smoking-related disorders, and mental illness. We have made great advances in health, yet need greater prevention of many conditions. The Surgeon General's office is interested in creating a culture of prevention. It seeks to use its ability to communicate to change attitudes, beliefs, norms, and behaviors. The Surgeon General commands the 6,700 members of the U.S. Public Health Service Commissioned Corps to advance health and safety.
Dr. Bharmal noted a recent effort by the office to increase vaccination rates, using the media to reduce a fear of vaccinations in children. The office is focusing on five campaign areas to increase prevention:
- Living actively (exercise, walkable spaces).
- Being drug free and tobacco free (including opioid abuse).
- Affording mental health (reducing stigma).
- Eating for health.
- Avoiding violence.
An additional focus is on emotional well-being—for example, ensuring a person's sense of belonging and purpose. Levers that the Surgeon General's office can use include communicating using modern technological means, convening partners (figures of communities, sports, and celebrity), forming connections, championing good work, and commanding the U.S. Public Health Service Commissioned Corps to execute the priorities.
Discussion
Dr. Weissberg encouraged the office to work to reduce violence. Dr. Bharmal noted that the office is especially interested in reducing violence against women. Carol Matyka, M.A., wondered about the issue of food deserts. Dr. Bharmal suggested that the office could serve to champion efforts to reduce those areas. People will choose better food if the choice is there.
Mary D. Naylor, Ph.D., R.N., FAAN, asked about efforts to address opioid misuse, and Dr. Kronick noted that Ƶhas begun preliminary discussions toward creating synergies and disseminating information to practitioners. Dr. Fermazin suggested that the Surgeon General's office work with QIOs in, for example, medication safety.
Ms. Davidson noted that many employers now are addressing tobacco use among employees. Charles J. Rothwell, M.B.A., M.S., stated that his office at the CDC would be happy to help the Surgeon General direct messages.
Session on Transparency
Consumer Assessment of Healthcare Providers and Systems
Christine Crofton, Ph.D., Center for Quality Improvement and Patient Safety, AHRQ
Dr. Crofton presented the history of AHRQ's CAHPS program, which began in 1995. The program produces assessments of care from the patient's point of view. It features standardized surveys and products. It focuses on topics for which consumers are the best or only source of information, features patient reports and ratings of experience (not merely satisfaction), and employs rigorous scientific testing.
Dr. Crofton gave examples of survey questions answered by patients and noted that the program ensures that participants understand the questions and that the resulting data are valid and reliable. The CAHPS family of surveys includes surveys of facilities (hospitals and nursing homes) and ambulatory care aspects (health plans, surgical care, behavioral health, dental plans, home health care, American Indian care, clinicians, and groups). Major users of the CAHPS surveys include CMS, the National Committee on Quality Assurance, the Office of Personnel Management, the U.S. Department of Defense, State Medicaid programs, purchasing coalitions, and quality organizations.
Ƶholds the CAHPS trademark and serves as the official source for its information and decisions. It serves as a science partner for CAHPS users, bases product development on the full spectrum of users, and funds research in the surveys. Dr. Crofton noted changes through the years in the use of CAHPS data, leading to its recent use by government and private organizations to determine reimbursement practices. She stated that the program is slow to move to electronic collection methods because of the need to maintain methodological rigor.
Discussion
Dr. Weissberg noted that some hospitals and clinics spend a great deal of money on other survey tools. Dr. Crofton noted that some other surveys might feature questions added to boost their market share/use. She noted that users can add their own questions to the CAHPS surveys, although that can lead to very long surveys. Other surveys often can be used to track improvements (rapid cycle). That tracking is more difficult with CAHPS, because it is an annual survey.
The NAC members suggested that Ƶperform a formal assessment of CAHPS, to learn how the surveys do and do not help users. Perhaps an outside group or consortium should perform the analysis. Perhaps the assessment should be ongoing, with feedback to users. How can CAHPS best help consumers?
My Own Network, Powered by AHRQ
Virginia Mackay-Smith, M.P.H., Center for Delivery, Organization, and Markets, AHRQ
Ms. Mackay-Smith presented history, going back about 6 years, of AHRQ's My Own Network, Powered by Ƶ(MONAHRQ) program. MONƵis an evidence-based tool for creating interactive reports about health care. The public Web sites that the tool develops are adapted to each owner's data-reporting needs. MONƵis easy to set up and use, flexible, and free (including technical assistance). There have been six versions/updates of the tool, which is now used by at least 15 States. There are some private uses, mainly for private analytical needs.
Ms. Mackay-Smith reviewed the process for using MONAHRQ, from downloading the latest version, to loading the desired measures, customizing the Web site, and realizing the output. She demonstrated the program by presenting live the site of the Utah Department of Health. The latest version of MONƵincludes nursing home quality-of-care reporting, physician profiles, trends in utilization, updated measures and data, and new graphical and navigational features for consumers. The next version of MONƵwill include a mobile-device capability, physician quality information, and side-by-side quality and cost reports.
Future Directions
Katherine Hempstead, Ph.D., Robert Wood Johnson Foundation
Dr. Hempstead reported on two programs on which the Robert Wood Johnson Foundation is collaborating with AHRQ. One is adding provider information to the MEPS database, the other is evaluating effects of changes. Both efforts represent advances in transparency. The Foundation also collaborates with a company called ProPublica (a journalism organization) in the assessment of physicians. The efforts have attracted some controversy, but are a first step. Dr. Hempstead wondered whether it might be preferable for Ƶto move into the area of assessing physicians. She added that there is a need to develop new metrics for assessing at the plan level.
Dr. Hempstead encouraged Ƶto work with CMS. People are choosing many new health plans today, which may point to the need for new measures that are meaningful for people choosing plans. How can provider networks be characterized in objective ways? Planned choice and decision support are important concepts. We need network characteristics such as size and narrowness and identified specialists/providers. Dr. Hempstead stated that the Foundation is developing a provider directory and addressing aspects of prescription drugs in plans. The Foundation has sponsored challenges for developers to create apps.
Discussion
Dr. Naylor raised the issue of the availability of data at sites and how that influences the health care transformation across States. Ms. Mackay-Smith stated the need to know how end-users utilize the data. Ƶhas some results from case studies and focus groups. It plans to respond to the interests of consumer advocacy groups.
Dr. Fermazin raised the issue of shared decisionmaking and asked whether the ideas of patients are incorporated in final decisions. Dr. Crofton suggested that such results occur, although it is difficult to develop questions for measurement. Dr. Kronick suggested being procedure-specific.
Dr. Ling raised the issue of engaging patients and families. Can questions relate the two? Dr. Crofton cited patient questionnaires for nursing homes, which address that issue in various ways. Dr. Ling added that a statement of goals of care can be very helpful.
Public Comment
There were no public comments.
Chairman's Wrap-Up and NAC Input
Dr. McGlynn asked the NAC members for final comments and suggestions for the next meeting agenda.
- Dr. Schwartz proposed that a future NAC meeting feature a speaker from the insurance industry or a hospital association to discuss collaborative work.
- Ms. Davidson suggested a focus on public-private collaborations.
- Dr. Grumbach suggested having a presentation on applied health services research. Dr. Kronick agreed and added the topic of health services training. Dr. Grumbach proposed hearing about AHRQ's primary care portfolio.
- Dr. Atkins proposed a focus on the beneficial role of researchers who, because of large long-term funding, can consider work that requires longer periods of time (and can be considered system improvement). Such research could address the use of data over time and how data lead to changes. There also is the issue of the large amounts of data today and what to do with them. Dr. Atkins suggested that Ƶserve to generate enthusiasm for the use of big data.
- Dr. McGlynn raised the topic of increasing the number of people performing analytical work. We need better triaging of questions and challenges, with a goal of targeting the appropriate research teams.
Adjournment
The next NAC meeting will take place on November 3, 2015, at the Hubert H. Humphrey Building in Washington, D.C.
Drs. McGlynn and Kronick thanked the NAC members, speakers, and other guests, and adjourned the meeting at 2:45 p.m.
Respectfully submitted,
Elizabeth A. McGlynn, Ph.D., Chair
National Advisory Council
Agency for Healthcare Research and Quality
