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National Advisory Council

Meeting Summary

April 8, 2011

Minutes from the April 8, 2011, meeting of the Agency for Healthcare Research and Quality's (AHRQ's) National Advisory Council (NAC) are available on this page.

Call to Order; Approval of November 5 Summary Report
Director's Update
National Strategy for Quality Improvement in Health Care
Healthcare-Associated Infections
Public Comment
Chairman's Wrap-Up
Adjournment

NAC Members Present

Bruce Siegel, M.D., M.P.H., National Association of Public Hospitals and Health Systems (Chair)
Helen Darling, M.A., National Business Group on Health
Louise-Marie Dembry, M.D., M.S., M.B.A., Yale New Haven Hospital
Nancy E. Donaldson, D.N.Sc., R.N., FAAN, Center for Nursing Research & Innovation, University of California, San Francisco
Silvia M. Ferretti, D.O., Lake Erie College of Osteopathic Medicine (by telephone)
Arthur Garson, Jr., M.D., M.P.H., University of Virginia
Helen W. Haskell, Mothers Against Medical Error
Lisa M. Latts, M.D., M.B.A., M.S.P.H., WellPoint, Inc.
Keith J. Mueller, Ph.D., University of Iowa
Welton O'Neal, Jr., Pharm.D., Takeda Pharmaceuticals North America, Inc.
Katherine A. Schneider, M.D., M.Phil., AtlantiCare Health System
Xavier Sevilla, M.D., FAAP, Manatee County Rural Health Services, Inc.

Alternate Present

David Atkins, M.D., M.P.H., Veterans Health Administration
Paul McGann, M.D., Centers for Medicare & Medicaid Services (CMS)

AHRQ Members and Staff Present

Carolyn M. Clancy, M.D., Director
Kathleen Kendrick, M.S., C.S., R.N., Deputy Director
William B. Munier, M.D., Director, Center for Quality Improvement and Patient Safety
Nancy J. Wilson, M.D., M.P.H., Senior Advisor to the Director
Jaime Zimmerman, M.P.H., NAC Coordinator
Karen Brooks, CMP, NAC Coordinator

Call to Order; Approval of November 5 Summary Report

Bruce Siegel, M.D., M.P.H., NAC Chair, called the group to order at 8:40 a.m., welcoming the NAC members, other participants, and visitors. He asked the NAC members to introduce themselves.

Dr. Siegel referred to the draft minutes of the previous NAC meeting (November 5, 2010) and asked for changes and approval. The NAC members approved the November meeting minutes with no changes.

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Director's Update

Carolyn M. Clancy, M.D., AHRQ Director, welcomed the NAC members and noted that they were provided with background materials, including AHRQ Annual Highlights 2010 and Highlights: 2010 National Healthcare Quality & Disparities Reports. The latter features a focus on where improvements have occurred.

Dr. Clancy announced that Kathleen Kendrick, M.S., R.N., the AHRQ Deputy Director, will retire on May 1. She praised Ms. Kendrick, who began her AHRQ career in 2000 as a planning and evaluation officer, for helping to make AHRQ such a successful organization throughout the past decade. In light of Ms. Kendrick's retirement, Boyce Ginieczki, Ph.D., will serve as AHRQ Acting Deputy Director, and Jay Toven will serve as AHRQ's Chief Operating Officer.

Dr. Clancy announced seven new NAC members: Mitra Behroozi, J.D., of the 1199 Service Employees International Union National Benefit Fund; Paul N. Casale, M.D., FACC, of The Heart Group; Andrea H. McGuire, M.D., M.B.A., of the American Enterprise Group, Inc.; Christopher Queram, M.A., of the Wisconsin Collaborative for Healthcare Quality; Alan R. Spitzer, M.D., of Pediatrix Medical Group; Jeffery Thompson, M.D., M.P.H., of the Department of Social and Health Services, State of Washington; and Janet S. Wyatt, Ph.D., RN, of the Pediatric Nursing Certification Board.

Current NAC member Katherine A. Schneider, M.D., M.Phil., became Senior Vice President, AtlantiCare Health. Junius J. Gonzales, M.D., M.B.A., became Provost and Vice President of Academic Affairs, University of Texas at El Paso. Welton O'Neal, Jr., Pharm.D., became Director of Medical External Affairs and Clinical Science Outcomes for Takeda Pharmaceuticals North America, Inc. Arthur Garson, Jr., M.D., M.P.H., became Senior Vice President for Health and Policy Systems at the University of Texas Health Science Center at Houston.

The Big Picture

Dr. Clancy stated that President Barack Obama's proposed fiscal year (FY) 2012 budget for AHRQ features $65 million for patient safety research, including $34 million to reduce and prevent healthcare-associated infections (HAIs). The budget also features $46 million for patient-centered health research and $28 million for health information technology.

A report on the proposed National Health Care Quality Strategy, called for in the Affordable Care Act, was submitted to Congress in March 2011. The strategy builds on work of Federal, State, and private initiatives and addresses past successes and the need for improvement. The strategy features a patient-focused approach to health care and responds to a need to replicate cases of improvement. Development of the Patient-Centered Outcomes Research Institute (PCORI), also called for in the Affordable Care Act, is moving forward. PCORI will support research that focuses on differences in the effectiveness of treatments and services within subpopulations, including racial and ethnic minorities; individuals with chronic conditions; genetic and molecular subtypes; and distinctions in age, gender, and quality of life.

Dr. Clancy provided the following news and updates:

Recent News and Accomplishments

A new U.S. Preventive Services Task Force (USPSTF) recommendation called for routine screening of all women 65 and older for osteoporosis. Screening for younger women with certain risk factors also was called for. This was the first USPSTF recommendation to be posted for public comment.
The AHRQ-funded Michigan Keystone Intensive Care Unit (ICU) Project to reduce HAIs in Michigan ICUs produced dramatic results. The overall risk of dying in Michigan ICUs decreased by 24 percent. The protocol featured safety culture, communication/teamwork, and the use of Centers for Disease Control and Prevention (CDC) guidelines and checklists. The rates of ventilator-associated pneumonia in Michigan ICUs were cut by more than 70 percent, and those reductions were sustained for up to 2.5 years.
The 2010 National Healthcare Quality Report revealed that health care quality rose by 2.3 percent, with biggest gains in acute illness and injury. The 2010 National Healthcare Disparities Report revealed that disparities remain unacceptably high, with 60 percent of measures showing no improvement and 40 percent of measures showing deterioration.
The USPSTF named three new members: Virginia A. Moyer, M.D., M.P.H., of Baylor University; Albert L. Siu, M.D., M.S.P.H., of Mount Sinai School of Medicine; and Michael L. LeFevre, M.D., M.S.P.H., of the University of Missouri School of Medicine.
An AHRQ-supported report revealed that health literacy is linked to rates for emergency department visits, hospitalizations, health, and death.
A new comparative effectiveness review from the Effective Health Care program revealed that autism spectrum disorders affect nearly 1 percent of children in the United States. Some medications can reduce selected behaviors but have significant side effects.
An impact case study of the Hospital Quality Alliance, featuring the Hospital Consumer Assessment of Healthcare Providers and Systems (CAHPS®), found that more than 3,700 hospitals report scores through Hospital Compare.
An impact case study in Iowa found the Team Strategies and Tools To Enhance Performance and Patient Safety (TeamSTEPPS) program being used at Covenant Medical Center and Sartori Memorial Hospital.
A knowledge transfer case study of Anaconda Internal Medicine in Montana revealed the successful use of the USPSTF's electronic Preventive Services Selector (featuring preventive care recommendations) in clinical rotations for students. A knowledge-transfer case study of Piedmont Healthcare in Georgia also revealed successful use of the tool, which promoted conversations between clinicians and patients.
A knowledge-transfer case study for the State of Alabama featured the use of AHRQ's Asthma Return-on-Investment Calculator, producing a return on investment of $1.04 for asthma care management for quality improvement. The result indicated a need to reduce costs.

AHRQ Program Updates

Two in-store AHRQ audio promotional campaigns, "Staying Active and Healthy with Blood Thinners" and "Taking Care of Myself: A Guide When I Leave the Hospital," ran in 500 stores in multiple States.
AHRQ's podcasts are sent to more than 1,000 radio stations weekly, and Spanish-language podcasts air on more than 500 radio stations. AHRQ's YouTube channel offers nearly 40 videos and has more than 400 subscribers. AHRQ has more than 4,000 followers on Twitter.
There now are 78 listed Patient Safety Organizations (PSOs). The Skilled Nursing Facility Common Formats were posted for public comment. The third annual PSO meeting will take place May 9-10, 2011, in Rockville, MD. The Department of Health and Human Services (HHS) recently released guidance on PSOs and Food and Drug Administration (FDA) reporting, permitting mandatory reporting by the PSOs to the FDA and allowing the FDA to inspect PSO facilities.
AHRQ worked with the FDA to develop a common format to guide reporting of events in which health information technology plays a role in heightening risk to patient safety. (That is, technology can sometimes interfere with decisionmaking, cause wireless problems, and more.)
A new Health Information Technology CAHPS is in the final stages of development. It will be used with core items from the Clinician and Group Practices CAHPS. A new health care exchanges CAHPS is in development with the Centers for Medicare & Medicaid Services (CMS).
An HHS Data Council, co-chaired by AHRQ and the Assistant Secretary for Planning and Evaluation, created two departmental workgroups. One focuses on research and development for data collection. The other focuses on HHS data integration and alignment.
The Medical Expenditure Panel Survey has been used to inform provisions of the Affordable Care Act. For example, it has been used to determine the amount of the small employer health insurance tax credit.
AHRQ-supported research produced an accounting of trends in stimulant medication use among U.S. children. The results were presented to the FDA Drug Safety Oversight Board and were used to inform the decision on black-box warnings for medications.
The USPSTF has begun to post its draft recommendations for public comment. The first posting was for the new osteoporosis screening guidelines. The second posting was for a recommendation that all children aged 3 to 5 be screened for vision at least once to obtain evidence regarding amblyopia or its risk factors.
AHRQ announced a funding opportunity to establish three research centers for excellence in clinical preventive services. Each center will address one of three programmatic areas: Patient safety, health equity, or health care system implementation. Applications are due by May 23.
As of June 30, 2011, AHRQ is discontinuing its Public Health Emergency Preparedness Research Program. New resources that will be available this spring include Home Health Patient Assessment Tools: Preparing for Emergency Triage, Data Sources to Measure At-Risk Community Patients and Needs, and an updated Emergency Preparedness Resource Inventory. All publications and tools are being transitioned to the CDC, Assistant Secretary for Preparedness and Response, and Department of Homeland Security. An archive of AHRQ tools will be maintained in the National Library of Medicine's Preparedness Resource Library.
AHRQ's Effective Health Care Program released a series of methods research documents, using American Recovery and Reinvestment Act (ARRA) funding.
The Health Care Innovations Exchange Web site was ranked 5th out of 111 Federal Web sites in a customer satisfaction survey. The program also features an award-winning innovator video series. It is developing a Web portal focused on healthy weight.
Two Institute of Medicine (IOM) reports were released in March: Finding What Works in Healthcare: Standards for Systematic Reviews and Clinical Practice Guidelines We Can Trust. In May 2011, there will be an Implementation Workshop on Standards for Systematic Reviews and Clinical Practice Guidelines.
The Centers for Education and Research on Therapeutics program is holding a re-competition for awards in the fourth quarter of FY 2011. This includes two funding opportunity announcements for U19 cooperative agreements with six research center awards.
AHRQ is developing a health information technology workflow toolkit and two evidence-based practice center reports on health information technology (medication management and decisionmaking).
On March 23, 2011, AHRQ held a summit on public reporting for consumers with 130 participants, including NAC members, public and private funders of research, Federal and State policymakers, consumer organizations, providers, and more.
From February 16–17, 2011, AHRQ held a meeting on delivery system research with 75 participants, including ARRA Comparative Effectiveness Research delivery system grantees, stakeholders, and experts.
A revised version of the MONAHRQ (My Own Network, Powered by AHRQ) Web-based hospital reporting and comparing system will be released soon. Four States are using the system, which recently won an HHS innovation award.
AHRQ clinical data pilot projects in three States established the feasibility of linking electronic clinical lab data to discharge data and collecting present-on-admission data. A new lab data toolkit addresses all facets of the data collection process. A present-on-admission toolkit will be available soon.

Dr. Clancy reminded the group that AHRQ will hold its 5th Annual Conference at the Bethesda North Marriott Hotel and Conference Center September 18–21. The theme will be "AHRQ: Leading Through Innovation and Collaboration."

Discussion

Helen Haskell noted a recent article in Health Affairs about adverse events. Dr. Clancy stated that the article used charts at three hospitals in 2004 to assess adverse events and included a consideration of AHRQ safety indicators and voluntary reporting. One conclusion was that the indicators captured only a fraction of total events. One next step should be building a tracking system with common formats. That may lead to a more universal methodology.

Dr. Siegel commended AHRQ for its systematic review of the effects of health literacy. He asked the agency to provide a graph showing the value of the FY 2012 budget proposal in relation to historical budget levels.

Arthur Garson, Jr., M.D., M.P.H., called for greater rigor in practice guidelines. Perhaps each guideline should describe its ultimate use (often guidelines end up determining who gets paid or sued). Dr. Garson suggested that the government convene groups to oversee guidelines after they are released. Dr. Clancy suggested offering ideas at an upcoming IOM symposium.

Lisa Latts, M.D., wondered whether the CAHPS® health information technology survey might be included in regular surveys. Dr. Clancy noted that it was designed as a supplement, which can be added.

Helen Darling, M.A., wondered whether the AHRQ in-store audio campaign has been assessed for effect. Dr. Clancy responded that an evaluation will be performed.

Xavier Sevilla, M.D., noted that PSOs are not funded and could benefit from a business case. Could AHRQ develop tools that help them to become sustainable? Dr. Sevilla also proposed that AHRQ develop a primary care TeamSTEPPS® (tools are being developed).

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National Strategy for Quality Improvement in Health Care

Peter V. Lee, J.D., Center for Medicare and Medicaid Innovation

Dr. Clancy introduced Peter Lee, J.D., who is Acting Deputy Director for Policy and Programs at the Innovation Center, CMS.

Mr. Lee referred to the Affordable Care Act's instruction for HHS to develop a national quality strategy and to identify priorities to improve the delivery of services, outcomes, and health. The resulting National Quality Strategy (NQS) builds on a set of core principles and will be updated annually through a process of consensus-building among stakeholders. The NQS was released on March 21, 2011.

Mr. Lee presented the framework of the NQS, featuring the following main aims:

Better care.
Affordable care.
Healthy individuals and healthy communities.

The NQS adopts the following six interrelated priorities based on broad community input and engagement, research, and best practices:

Make care safer by reducing harm caused in the delivery of care.
Ensure that the person and family are engaged as partners in care.
Promote effective communication and coordination of care.
Promote the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
Work with communities to promote wide use of best practices to enable healthy living.
Make quality care more affordable for individuals, families, employers, and governments by developing and spreading new health care delivery models.

Mr. Lee described each of the six priorities, providing examples of Federal initiatives that have targeted each area. In addition, the new efforts will be guided by the following 10 principles:

Person-centeredness and family engagement, including understanding and valuing patient preferences
Specific health considerations.
Elimination of disparities in care.
Alignment of efforts of the public and private sectors.
Promotion of consistent national standards but also support for local, community, and State-level activities responsive to local circumstances.
A bigger focus on primary care, with attention to vulnerable populations.
Enhanced coordination among primary care, behavioral health, other specialty clinicians, and health systems.
Integration of care delivery with community and public health planning.
Clear information with which patients, providers, and payers can make best choices.

Mr. Lee described the working group that helped to develop the NQS and will continue to play a key role during implementation. In addition, a governmental interagency working group is meeting regularly to ensure alignment and coordination of the quality efforts.

Discussion

Dr. Garson stated that the idea of eliminating—as in eliminating care disparities—might be overly ambitious. Dr. Clancy noted that assessment, on a large scale, of potential changes in care delivery will be a challenge.

Dr. Sevilla raised the old and difficult question of "Who is responsible for quality of care?" Mr. Lee suggested that all are accountable, and the Federal Government will have a vehicle to assess its accountability. Nancy Donaldson, D.N.Sc., suggested that the working group consider the goal of eliminating preventable HAIs, which, admittedly, will be difficult to attain. Could there be a program to confront the false assumption that some infections are unavoidably common?

Dr. Sevilla noted that we lack a consistent definition of patient-centered care. Dr. O'Neal proposed the creation of a citizens' forum to develop a definition. The National Quality Forum could serve such a purpose. Nancy Wilson, M.D., of AHRQ, noted that some practical work is underway and involves the development of checklists and hospital criteria.

It was noted that the domain of healthy living lacks a good evidence base. Perhaps the Federal Government could serve to promote the identification of evidence. Otherwise, money would be wasted. Dr. Clancy noted that fostering collaboration with and within communities is difficult, but it can be done. The activities must be evidence-based and supported by data.

Regarding the issue of making care more affordable, it was suggested that changes such as reducing overuse of care and eliminating poor quality could lead to savings. Regarding the 10 principles, Mr. Lee suggested that eliminating disparities refers to both disparities in care and disparities in health. Dr. Garson suggested adding a consideration of the uninsured.

Dr. Sevilla proposed including the issue of access in the priorities and principles. Perhaps principles could be built into purchasing practices. The working group might consider the idea of the spread of practices. It was suggested that there be a requirement that all research include the development of informed decisionmaking tools. Silvia Ferretti, D.O., suggested developing strategies to inform medical students of the quality priorities and principles and eliciting ideas from the students. Dr. Garson added strategies for spreading the principles throughout the medical practice—doctor to nurse practitioner to nurse to other health care worker.

Dr. Schneider suggested that the planners consider potential unintended consequences and perhaps focus on one area of disease, principle, or priority while addressing the tempo of activities. Ms. Haskell cautioned that some programs, such as community health screening, lack evidence of effectiveness and can involve overuse for young persons. Keith Mueller, Ph.D., called for strategies to remove barriers that prevent programs from working together (e.g., funding rules). Dr. Sevilla suggested that the working group emphasize the idea of a team for handling the patient.

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Healthcare-Associated Infections

William B. Munier, M.D., M.B.A., Center for Quality Improvement and Patient Safety, AHRQ, and Peter J. Pronovost, M.D., Ph.D., FCCM, Center for Innovation in Quality Patient Care, Johns Hopkins University

William Munier, M.D., M.B.A., reviewed the issue of healthcare-associated infections (HAIs) and emphasized AHRQ's role in their prevention. A recent accounting by the CDC found a significant reduction in central-line-associated bloodstream infections (CLABSIs) in ICUs between 2001 and 2009. Decreases in the rates of other HAIs also were found. Nevertheless, HAIs affect 1 out of every 20 hospital patients.

AHRQ has been promoting wide-scale application of evidence-based approaches for preventing HAIs. It supports research and demonstration projects and projects to spread evidence-based methods and proven techniques—such as the Michigan Keystone ICU Project. AHRQ supports work in hospitals, ambulatory settings, and long-term care facilities. For FY 2010, it provided $19 million in contracts and $15 million in grants for HAI projects.

The Michigan Keystone project, begun in 2003 and led by Peter Pronovost, was enormously successful in reducing infections in ICUs. The strategy included the use of streamlined CDC protocols, addressing teamwork and human factors, and fostering a culture of safety. Other AHRQ-supported projects have included a comparison of targeted and universal strategies for reducing the incidence of Methicillin-resistant Staphylococcus aureus in ICUs and a nationwide implementation of a Comprehensive Unit-Based Safety Program (CUSP). The latter project, applied in 350 hospitals, has produced reductions in CLABSIs and will be extended to other infection scenarios.

Peter Pronovost, M.D., Ph.D., FCCM, argued that scientists have not been focusing on the endgame of health and the measures of health. A gap exists when researchers finish their work by publishing a paper. Instead, we should envision a desired end regarding health and work backward to support that end. Each year, deaths from CLABSIs are roughly equal to deaths from breast cancer.

Dr. Pronovost reviewed the strategies employed in the Michigan Keystone project, from choosing guidelines, to studying barriers, to working through political dynamics to expand programs throughout the State. The program can be generalized and can serve as a model for moving evidence into practice. One key to success is the use of a CUSP and allowing the doctors and nurses on the frontline to own it. Other keys include the following:

Framing the issues as a solvable social problem owned by the health care workers.
Scoring by using measures the clinicians consider to be valid.
Being guided by science, including implementation science.
Focusing on the technical and the adaptive.
Using top-down measures and practices (e.g., evidence summaries and measures) with local adaptations of the interventions and implementation.
Using both hard and soft "edges" (management tools, social pressure, economic incentives, and regulatory pressure).

Since the success in Michigan, the Keystone strategy has been rolled out in additional States. Dr. Pronovost stated that getting to zero HAIs requires strong commitment from the clinical chief executive officer (CEO) and ICU managers, partnerships, technical expertise, accountability for the infection rates, ease of compliance, nurses integral to compliance with the safety culture, and standardized and audited maintenance policies. All infections must be investigated. Weeks featuring low rates or no infections should be well publicized. Looking toward the future, Dr. Pronovost called for programs to address major causes of preventable deaths, the use of interdisciplinary teams to perform basic research, capacity in training schools and provider organizations, systems integration, the development of behavioral markers for teamwork, and the strategy of peer-to-peer review.

Discussion

Dr. Dembry noted that efforts to make everybody at the bedside accountable are important but resource intensive. We must educate students early about working in teams. Dr. Pronovost noted that analysis in Michigan showed significant cost savings, which passed mainly to the insurers but also to the hospitals. Too few medical centers have instructors who can teach about teamwork. Human factors and systems engineers should perform more studies in that area. Basic research efforts in teamwork (e.g., contextual factors) and patient safety are needed. Dr. Munier cited the effectiveness of the TeamSTEPPS® program.

Dr. Pronovost suggested that perhaps the insurance companies could serve to publicize the programs, helping to make them the polio campaign of modern times. Dr. Munier noted that safety efforts have relied historically on administrative data. Real clinical data would be more helpful. Dr. Pronovost added that local measures are the key. For ambulatory settings, every operation should include a CUSP team and should understand the measures of harm in the setting. Quality Improvement Organizations could play a role in moving the agenda.

Dr. Pronovost stressed that external controls are highly resisted and mostly ineffective. Guidelines often contain ambiguities, leading to noncompliance by doctors and nurses. Dr. Provonost's programs feature the use of strong verbs and definite actions, allowing for variation locally. Another key is to allow the local system to make the effort its own. The issue of standardization versus local control will always be somewhat vexing. Some variation is good. Some variation is not. We need mindful variation. Dr. Pronovost stated that his group asks the hospital to ensure the use of a CUSP team when it attempts to apply the program in departments other than the ICU.

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Public Comment

Cole Zanetti, of the American College of Medical Quality-Medical Student Section, raised the issue of shared and delegated decisionmaking. He asked the NAC to consider the issue of alignment of medical liability with giving patients what they want. He asked the group to consider issues of the integration of primary care and public health, care coordination, supply-sensitive care, and potential cost savings.

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Chairman's Wrap-Up

Dr. Siegel asked the NAC members to make final comments, especially about future NAC meeting agendas. He suggested that a future NAC meeting include discussions of clinical guidelines and the new safety initiative out of HHS (to be announced soon). What might be AHRQ's role in those areas?

Paul McGann, M.D., stated that Dr. Provonost's strategies are at the heart of health care improvement. He suggested that future work of the NAC and AHRQ speak to issues of leadership and governance. Perhaps Joseph McCannon of CMS or Charles Denham, M.D., of the National Quality Forum could be invited to speak to this group.
Ms. Haskell stressed the importance of a quality strategy and patient guidelines.
Dr. Sevilla cited the importance of measuring quality through the eyes of the patient and family. What is being done today?
Dr. Schneider stressed the importance of leadership for change. CEOs should play a significant role in the NQS.
Dr. O'Neal suggested that the NAC members convene a conference call to identify items to address at the next meeting (various new initiatives are imminent).
Dr. Latts suggested that the NAC discuss ways to promote the NQS. The group also might focus on issues in disparities and childhood obesity.
Dr. Mueller suggested discussions about systems, processes, and health systems research. The national quality report might be discussed in relation to the prevention and wellness report.
Dr. Dembry urged the NAC to focus on prevention and basic science. What metrics might be applied to collaborations across groups?
Dr. Clancy remarked that she could provide an update on the work of the PCORI. She asked the NAC members to forward additional ideas for AHRQ actions that can stimulate progress.

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Adjournment

Dr. Siegel stated that the next NAC meeting will take place July 22, 2011, and seven new NAC members will attended . He thanked the NAC members, AHRQ staff, and invited guests and adjourned the meeting.

Current as of August 2011

Internet Citation:

National Advisory Council: Meeting Summary, April 8, 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/nacminutes/nacmin040811.htm