1. Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov Using evidence to inform and improve clinical prevention 2007 AHRQ Annual Conference Bethesda Maryland September 27, 2007

2. Advancing Excellence in Health Care Presenters Ron Finch Ron Finch Susan D. Horn Susan D. Horn William Spector William Spector Tricia L. Trinité Tricia L. Trinité

3. Advancing Excellence in Health Care Using prevention products and tools at different levels Science informed policy and coverage decisions Science informed policy and coverage decisions – A Purchaser’s Guide to Clinical Preventive Services: Moving Science into Coverage Support clinical decision-making in primary care Support clinical decision-making in primary care – electronic Preventive Services Selector (ePSS) – Guide to Clinical Preventive Services Support redesign of healthcare delivery processes to improve quality of care Support redesign of healthcare delivery processes to improve quality of care – On-Time Prevention of Pressure Ulcers

4. Advancing Excellence in Health Care One Source of Evidence: US Preventive Services Task Force Supported by the Agency for Healthcare Research and Quality Supported by the Agency for Healthcare Research and Quality Independent and multidisciplinary panel of experts in primary care and prevention Independent and multidisciplinary panel of experts in primary care and prevention Provides evidence-based, impartial scientific reviews of preventive health services for use in primary healthcare delivery settings Provides evidence-based, impartial scientific reviews of preventive health services for use in primary healthcare delivery settings Considered “gold standard” for evidence- based preventive services recommendations Considered “gold standard” for evidence- based preventive services recommendations

5. Advancing Excellence in Health Care USPSTF Process for Development of Recommendations Define question and outcomes of interest Define question and outcomes of interest – Search for benefits and harms of the service Evaluate QUALITY of individual studies Evaluate QUALITY of individual studies Synthesize and judge STRENGTH of available evidence Synthesize and judge STRENGTH of available evidence Determine balance of BENEFITS and HARMS Determine balance of BENEFITS and HARMS Link recommendation to judgment about net benefits Link recommendation to judgment about net benefits

6. Advancing Excellence in Health Care Using prevention products and tools at different levels Science informed policy and coverage decisions Science informed policy and coverage decisions – A Purchaser’s Guide to Clinical Preventive Services: Moving Science into Coverage Support clinical decision-making in primary care Support clinical decision-making in primary care Support redesign of healthcare delivery processes to improve quality of care Support redesign of healthcare delivery processes to improve quality of care

7. Advancing Excellence in Health Care Science informed policy and coverage decisions A Purchaser’s Guide to Clinical Preventive Services: Moving Science into Coverage Ron Finch., EdD Vice-President National Business Group on Health

8. Advancing Excellence in Health Care Background Changing the paradigm Changing the paradigm – From a focus on treatment – To a focus on prevention and behavior change Prevention Prevention – Primary (e.g., immunizations) – Secondary (e.g., hypertension treatment) – Tertiary (e.g., medical foods for children with PKU)

9. Advancing Excellence in Health Care Who Ensures Prevention? Healthcare companies innovate procedures and products Healthcare companies innovate procedures and products Consultants and employers design benefits Consultants and employers design benefits Employers purchase benefits Employers purchase benefits Plans and providers deliver services Plans and providers deliver services

10. Advancing Excellence in Health Care Coverage Among Large (500+) Employers Insurance coverage makes a difference in whether people receive preventive services Insurance coverage makes a difference in whether people receive preventive services Coverage of physical exams, screening, and immunizations fair, coverage of lifestyle modification / counseling services poor: Coverage of physical exams, screening, and immunizations fair, coverage of lifestyle modification / counseling services poor: – Healthy diet -21% – Weight loss -18% – Alcohol misuse - 19% – Comprehensive tobacco treatment benefits – 4% Source: Results from survey completed by 2,180 employers in 2001.Bondi MA, Harris JR, et al. Employer coverage of clinical preventive services in the United States. American Journal of Health Promotion 2006; 20(3): 214-222.

11. Advancing Excellence in Health Care Delivery and Utilization Barely half (52%) of adults receive preventive care according to guidelines for their age and sex. 1 Barely half (52%) of adults receive preventive care according to guidelines for their age and sex. 1 2006 NCQA State of Healthcare Quality Report 2 2006 NCQA State of Healthcare Quality Report 2 – 82% of women (18-64) screened for cervical cancer – 72% of women screening for breast cancer – 52% of adults 50+ screened for colorectal cancer – 36% of adults immunized against influenza – 34% of women (16-20) screened for Chlamydia Source: 1. The Commonwealth Fund Commission on a High Performance Healthcare System, Sept 2006; 2. The State of health care quality: Industry trends and analysis. National Committee for Quality Assurance (NCQA). The state of health care quality: 2006. National Committee for Quality Assurance (NCQA); Washington, DC: 2006.

12. Advancing Excellence in Health Care The Purchaser’s Guide

13. Advancing Excellence in Health Care Purpose of the Purchaser’s Guide Translate science into coverage Translate science into coverage – Promote preventive medical benefits that are based on evidence & shift benefit criteria from arbitrary thresholds and cost sensitivities to beneficiary need Provide information needed to select, define, prioritize, and implement preventive medical benefits Provide information needed to select, define, prioritize, and implement preventive medical benefits – SPDs, CPT codes, prioritization methods

14. Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov Part 1: Knowledge The Role of Clinical Preventive Services in Disease Prevention and Early Detection

15. Advancing Excellence in Health Care Rethinking Current Approaches 80% of Costs Stem from preventable chronic conditions 75% of costs 20% of claimants Primary cost drivers are chronic disease and serious acute conditions; many are preventable.

16. Advancing Excellence in Health Care Rethinking Current Approaches Source: CDC *All data are adjusted to 2005 U.S. population Percent of all deaths Causes of Death in the United States Most Common, 1999*

17. Advancing Excellence in Health Care Rethinking Current Approaches Source: Mokdad A, Marks JS, Stroup DE, Gerberding JL. Actual causes of death in the United States. JAMA 2004; 291(10):1238-1245. Correction published JAMA 2005; 293(3): 293-294. Underlying Causes of Death, United States 2000 Causes of Death, United States 2000 Diseases of the heart = 30.4% Cancers = 23.0% Stroke = 7% COPD = 5.2%

18. Advancing Excellence in Health Care The importance of preventing chronic disease The importance of preventing chronic disease General information on the value of prevention General information on the value of prevention Employer Action Employer Action 1. Offer a structured set of clinical preventive service benefits. 2. Inform employees, dependents, and retirees about the availability of preventive benefits and promote consistent and appropriate use. 3. Implement programs that promote healthy lifestyles and provide opportunities for employees to engage in disease prevention and health promotion outside of the clinical setting. 4. Support community-based and worksite-based preventive service interventions. The Role of Clinical Preventive Services in Disease Prevention and Early Detection

19. Advancing Excellence in Health Care The Role of Clinical Preventive Services in Disease Prevention and Early Detection Health Plan Action Health Plan Action 1. Offer preventive medical benefits in “off the shelf” plans for small and medium-sized employers. 2. Encourage large/self-funded employers to incorporate preventive benefits in all plan types. 3. Ensure providers offer recommended clinical preventive services to patients. 4. Educate beneficiaries/plan participants on available services (reminders, etc).

20. Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov Part 2: Coverage Summary Plan Description (SPD) Language Statements for Recommended Clinical Preventive Service Benefits

21. Advancing Excellence in Health Care Federal regulation and preventive services Federal regulation and preventive services – Preventive medications and preventive treatments – Employers can shape plans to promote delivery and use HDHPs and “safe-harbor” coverage HDHPs and “safe-harbor” coverage 1. Waive deductible and eliminate copays 2. Waive deductible and reduce copays 3. Waive plan deductible and require standard copay 4. Apply standard deductible but provide separate financial benefit for preventive services – Implications for health plans? Summary Plan Description (SPD) Language

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23. Summary Plan Description (SPD) Language Tobacco Use Treatment Screening Screening – Coverage begins at age 18 (coverage provided for younger populations depending on medical need) – Eligible at every medical encounter Counseling Counseling – Brief counseling (in-person) and intensive counseling (in-person or telephonic) – 2 courses of 6 counseling session each calendar year (total of 12 sessions per year) Treatment Treatment – All FDA-approved nicotine replacement products and tobacco cessation medications, as prescribed by a clinician

24. Advancing Excellence in Health Care Summary Plan Description (SPD) Language Breast Cancer: Normal Risk Screening Screening – Mammography and CBE for average risk women aged 40 to 80 once per calendar year. Younger women may qualify for screening if medically indicated. Breast Cancer: High-Risk Counseling on Testing & Preventive Medication and Preventive Treatment Counseling on Testing & Preventive Medication and Preventive Treatment – Counseling provided as medically indicated and at least once before and once after a BRCA mutation test BRCA Mutation Testing BRCA Mutation Testing – Once per lifetime Preventive Treatment Preventive Treatment – Surgical removal of the breast(s) with or without reconstructive surgery – Surgical removal of the ovaries Preventive Medication Preventive Medication – All FDA-approved breast cancer preventive medications (e.g., tamoxifen) for 5 years - may be extended if medically necessary

25. Advancing Excellence in Health Care Current Procedural Terminology (CPT) Codes

26. Agency for Healthcare Research and Quality Advancing Excellence in Health Care www.ahrq.gov Part 3: Evidence Evidence-Statements for Recommended Clinical Preventive Service Benefits

27. Advancing Excellence in Health Care Forms of Evidence Used in the Purchaser’s Guide U.S. Preventive Service Task Force (USPSTF) recommendations U.S. Preventive Service Task Force (USPSTF) recommendations CDC CDC Other U.S. Department of Health and Human Services Other U.S. Department of Health and Human Services – U.S. Public Health Service – U.S. Surgeon General – National Heart, Lung, and Blood Institute (NHLBI) Professional Organizations Professional Organizations – American Academy of Pediatrics (AAP) – American Academy of Family Physicians (AAFP) – Many others Respected associations Respected associations Why use evidence as a criterion? Why use evidence as a criterion?

28. Advancing Excellence in Health Care Evidence: USPSTF A- Strongly recommend Good evidence that the benefits substantially outweigh harms B - Recommend At least fair evidence that benefits outweigh harms At least fair evidence that benefits outweigh harms C - USPSTF makes no recommendation Recommend against routinely providing X service for Y population. There may be considerations supporting the provision of the service in an individual patient. D - Recommend against routine use Ineffective or harms outweigh potential benefits I - Insufficient evidence to make a recommendation I - Insufficient evidence to make a recommendation No evidence or poor quality evidence

29. Advancing Excellence in Health Care Examples of USPSTF Recommendations The USPSTF strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. (A Recommendation) The USPSTF strongly recommends that clinicians screen all adults for tobacco use and provide tobacco cessation interventions for those who use tobacco products. (A Recommendation) The USPSTF strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix. (A Recommendation) The USPSTF strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix. (A Recommendation) The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer. (D Recommendation) The USPSTF recommends against routinely screening women older than age 65 for cervical cancer if they have had adequate recent screening with normal Pap smears and are not otherwise at high risk for cervical cancer. (D Recommendation)

30. Advancing Excellence in Health Care Evidence-Statements for Recommended Clinical Preventive Service Benefits 72 screening, counseling, testing, immunization, preventive medication, preventive treatment recommendations in 46 topic areas 72 screening, counseling, testing, immunization, preventive medication, preventive treatment recommendations in 46 topic areas Recommendation statement Recommendation statement Condition / disease specific information Condition / disease specific information – Epidemiology – Risk factors

31. Advancing Excellence in Health Care Evidence-Statements for Recommended Clinical Preventive Service Benefits Value of prevention Value of prevention – Economic burden – Workplace burden – Economic benefit of preventive intervention – Estimated cost of preventive intervention 2004 paid claims average from the Medstat Marketscan database (commercially insured population) 2004 paid claims average from the Medstat Marketscan database (commercially insured population) – Cost-effectiveness / cost-benefit Preventive intervention information Preventive intervention information – Purpose – Process – Benefits and risks of intervention – Population, initiation/cessation, frequency of benefit – Treatment information

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33. The Problem “The use of tobacco…conquers men with a certain secret pleasure so that those who have once become accustomed thereto can hardly be restrained therefrom.” Sir Francis Bacon 1622AD

34. Advancing Excellence in Health Care Uses of the Guide Downloaded over 300,000 times Downloaded over 300,000 times Gap Analysis Gap Analysis Business Planning Business Planning Health and Productivity Plans and Services Health and Productivity Plans and Services Environment of Business Setting Environment of Business Setting

35. Advancing Excellence in Health Care Using prevention products and tools at different levels Science informed policy and coverage decisions Science informed policy and coverage decisions Support clinical decision-making in primary care Support clinical decision-making in primary care – Point of Care decision support Support redesign of healthcare delivery processes to improve quality of care Support redesign of healthcare delivery processes to improve quality of care

36. Advancing Excellence in Health Care Support clinical decision-making at the point of care Guide to Clinical Preventive Services ePSS: electronic Preventive Services Selector CAPT Tricia L. Trinité, APRN, MSPH Director, Prevention Dissemination & Implementation Center for Primary Care, Prevention & Clinical Partnerships Agency for Healthcare Research & Quality

37. Advancing Excellence in Health Care US Preventive Services Task Force Provides evidence-based, impartial scientific reviews of preventive health services for use in primary healthcare delivery settings Provides evidence-based, impartial scientific reviews of preventive health services for use in primary healthcare delivery settings Independent and multidisciplinary panel of experts in primary care and prevention Independent and multidisciplinary panel of experts in primary care and prevention Supported by AHRQ Supported by AHRQ

38. Advancing Excellence in Health Care USPSTF Makes recommendations on whether a clinical preventive service should be routinely delivered to a population without signs or symptoms of illness Makes recommendations on whether a clinical preventive service should be routinely delivered to a population without signs or symptoms of illness Recommendations include: – Screening tests – Health counseling delivered in clinical setting – Preventive medications

39. Advancing Excellence in Health Care Communicating evidence-based recommendations from the USPSTF A- Strongly recommend Good evidence that the benefits substantially outweigh harms B - Recommend At least fair evidence that benefits outweigh harms At least fair evidence that benefits outweigh harms C - USPSTF makes no recommendation Fair to good evidence that the benefits and harms are closely balanced D - Recommend against routine use Ineffective or harms outweigh potential benefits I - Insufficient evidence to make a recommendation I - Insufficient evidence to make a recommendation No evidence or poor quality evidence

40. Advancing Excellence in Health Care Annual Guide for Clinicians USPSTF recommendations adapted for a pocket-size book. Recommendations are presented in an indexed, easy- to-use format. Making it easier for clinicians to consult the recommendations in their daily practice. Focus group tested with primary care providers.

41. Advancing Excellence in Health Care Electronic tool for Primary Care Clinicians ePSS – electronic Preventive Services Selector ePSS – electronic Preventive Services Selector – Search USPSTF recommendations by age, sex and risk factors – Available as a web-based tool or can be downloaded to your PDA – www.epss.ahrq.gov www.epss.ahrq.gov

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47. Locating Clinical Decision Support Tools AHRQ Conference Innovations Café AHRQ Conference Innovations Café Annual Clinical Guide Annual Clinical Guide – www.ahrq.gov/clinic/pocketgd.htm Electronic Preventive Services Selector (ePSS) Electronic Preventive Services Selector (ePSS) – www.ePSS.ahrq.gov www.preventiveservices.ahrq.gov

48. Advancing Excellence in Health Care Using prevention products and tools at different levels Science informed policy and coverage decisions Science informed policy and coverage decisions Support clinical decision-making in primary care Support clinical decision-making in primary care Support redesign of healthcare delivery processes to improve quality of care Support redesign of healthcare delivery processes to improve quality of care

49. Advancing Excellence in Health Care Support redesign of health care delivery processes to improve quality On-Time Prevention of Pressure Ulcers in Nursing Homes Susan D. Horn, PhD Institute for Clinical Outcomes Research 699 E. South Temple, Suite 100 Salt Lake City, Utah 84102-1282 Salt Lake City, Utah 84102-1282 801-466-5595 (T) 801-466-6685 (F) shorn@isisicor.com

50. Advancing Excellence in Health Care Build partnerships / Develop interdisciplinary team capacity to promote faster QI in LTC Build partnerships / Develop interdisciplinary team capacity to promote faster QI in LTC Integrate evidence-based research on pressure ulcer prevention into long term care daily workflow Integrate evidence-based research on pressure ulcer prevention into long term care daily workflow Redesign clinical care planning processes using standardized documentation and timely feedback reports Redesign clinical care planning processes using standardized documentation and timely feedback reports Objectives ON-TIME PREVENTION OF PRESSURE ULCERS IN NURSING HOMES

51. Advancing Excellence in Health Care Research Based Best Practices Nursing Home Study (NPULS) 1996-1997 6 long-term care provider organizations 6 long-term care provider organizations 109 facilities 109 facilities 2,490 residents studied 2,490 residents studied 1,343 residents with pressure ulcer; 1,147 at risk 1,343 residents with pressure ulcer; 1,147 at risk 70% female, 30% male 70% female, 30% male Average age = 79.8 years Average age = 79.8 years Funded by Ross Products Division, Abbott Laboratories

52. Advancing Excellence in Health Care Long Term Care CPI Results Outcome: Develop Pressure Ulcer General Assessment Assessment IncontinenceInterventions Nutrition NutritionInterventionsStaffingInterventions + Age  85 + Male + Severity of Illness + History of PU + Dependency in >= 7 ADLs >= 7 ADLs + Diabetes + History of tobacco use + Dehydration + Weight loss + Mechanical devices for the containment of urine (catheters) - Disposable briefs - Toileting Program - RN hours per resident day >=0.5 - CNA hours per resident day >= 2.25 Medications - SSRI + Antipsychotic Horn et al, J. Amer Geriatric Soc March 2004; 52(3):359-367 - Fluid Order - Nutritional Supplements standard medical standard medical - Enteral Supplements disease-specific disease-specific high calorie/high high calorie/high protein protein

53. Advancing Excellence in Health Care Common Challenges Across Facilities 1. Inefficient Processes 2. Incomplete Documentation 3. CNAs: untapped resource 4. Communication Breakdowns / Lack Standard Processes 5. Clinical Decision Support Needs

54. Advancing Excellence in Health Care Step 1: Build Partnerships Empower all members of a facility team Empower all members of a facility team Front-line workers actively participate in QI activities, including CNAs: bottom-up approach Front-line workers actively participate in QI activities, including CNAs: bottom-up approach Share across facilities Share across facilities

55. Advancing Excellence in Health Care Step 2: Standardize Documentation Comprehensive documentation for front-line workers Comprehensive documentation for front-line workers Redesign work flow – consolidate documentation Redesign work flow – consolidate documentation Allow individual facility customization Allow individual facility customization Encourage inter-facility sharing Encourage inter-facility sharing Observe facilities come to consensus over time Observe facilities come to consensus over time

56. Advancing Excellence in Health Care Comprehensive Standardized Documentation CNA Daily flow sheet Daily flow sheet Single form replaced multiple logs, clipboards, bedside charts Single form replaced multiple logs, clipboards, bedside charts Reduced redundant documentation “document one time, in one place” Reduced redundant documentation “document one time, in one place” PrU Tracking Sheet Wound RN standardized PrU documentation: tracks resident risk and pressure ulcer status Wound RN standardized PrU documentation: tracks resident risk and pressure ulcer status Information used to compile summary reports Information used to compile summary reports

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59. Step 3: Timely Feedback Reports Use comprehensive standardized documentation data Use comprehensive standardized documentation data First reports provide feedback on documentation completeness First reports provide feedback on documentation completeness Other reports target alerts for specific components of care Other reports target alerts for specific components of care Summarize clinical information in variety of formats for use by RNs, MDS coordinators, dieticians, CNAs, wound RN, etc. Summarize clinical information in variety of formats for use by RNs, MDS coordinators, dieticians, CNAs, wound RN, etc. Reports contribute to individualized care planning processes Reports contribute to individualized care planning processes

60. Advancing Excellence in Health Care Timely Reports focus on Pressure Ulcer Prevention Weekly Reports  Nutrition Report / Weight Summary  Behavior Report  Pressure Ulcer Report  Priority Report Monthly Reports  Health Status Summary Report

61. Advancing Excellence in Health Care Nutrition Summary Nutrition Summary – Meal intake for 4 weeks – Fluid intake for 4 weeks – Diet order – Supplement product – Weight change since last week – Psychiatric medications received Weight Summary Weight Summary – Weight 180 days prior – Weight 30 days prior – Weight for each of past 4 weeks – Weight change since last week – 5-10% weight loss past 30 days – >10% weight loss past 180 days – Psychiatric medications received Example: Nutrition Report Stratified by Risk Provide ‘BIG picture’ over time, not just snapshot of one shift or one day

62. Advancing Excellence in Health Care Nutrition Report How to use the Nutrition Report? Identify which meals are not being eaten Identify which meals are not being eaten Promote use of nutritional supplements Promote use of nutritional supplements Identify need for consistent weights Identify need for consistent weights

63. Advancing Excellence in Health Care Decreased meal intake Decreased meal intake Weight loss Weight loss Increased incontinence episodes Increased incontinence episodes Increased behavior problems Increased behavior problems Existing red areas on skin Existing red areas on skin History of pressure ulcer in last 90 days History of pressure ulcer in last 90 days Example: Priority Report Identifies residents at risk

64. Advancing Excellence in Health Care Benefits of Timely Feedback Reports Access to summarized information for clinical decision-making Access to summarized information for clinical decision-making Improve response time between identification of resident need and intervention Improve response time between identification of resident need and intervention –Identify residents at risk for pressure ulcer development Transform from paper to data culture Transform from paper to data culture –Link reports to documentation elements

65. Advancing Excellence in Health Care Step 4 : Integrate into Daily Workflow Comprehensive forms replace (not supplement) previous forms Comprehensive forms replace (not supplement) previous forms Importance of front-line CNA observations stressed Importance of front-line CNA observations stressed Feedback is based on documentation Feedback is based on documentation Feedback contributes to care plan updates Feedback contributes to care plan updates

66. Advancing Excellence in Health Care Results  Decrease Pressure Ulcer Development  Increase Adherence to Best Practices  Increase Staff Accountability and Satisfaction Inclusion of front-line workers in QI efforts Inclusion of front-line workers in QI efforts Comprehensive documentation at point of care Comprehensive documentation at point of care Communication among care team improved Communication among care team improved  Reduce Inefficiencies # documentation forms for CNAs # documentation forms for CNAs CNA time looking for documentation book CNA time looking for documentation book Time to compile reports for State Regulators and MDS Time to compile reports for State Regulators and MDS Time for Wound RN to summarize and report data Time for Wound RN to summarize and report data  Improve State Survey Process  Establish a foundation for EHR

67. Advancing Excellence in Health Care Impact On Pressure Ulcer QMs Source: CMS Nursing Home Compare; Facility QM data reports The combined facilities’ average shows an overall reduction of 33% in the QM % of high risk residents with pressure ulcer from pre-implementation to initial post-implementation time periods Combined Facilities National Norm Q4 03 – Q3 05% Change = - 33%

68. Advancing Excellence in Health Care Summary of Key Program Benefits Improve Quality  Improve clinical decision making: integrate reports into day-to-day workflow  Identify residents at high risk early  Timely communication among multi-disciplinary team members QI Collaboration  Receive technical assistance from QI experts  Collaborate with peers to share experiences and best practices

69. Advancing Excellence in Health Care Summary of Key Program Benefits (cont) Improve CNA Documentation  Consolidate current documentation  Standardize data elements and eliminate redundancy  Audit and train for accuracy Gain Efficiency  Reduce time spent searching for multiple sources of information  Automated reports replace manual compilation of resident information Increase Morale  Empower multidisciplinary teams with CNAs as important members  CNAs see importance of their work

70. Advancing Excellence in Health Care Available On-Time Tools  CNA documentation  http://ahrq.gov/research/ltc/pucnaform.pdf  On-Time Reports  http://ahrq.gov/research/ltc/pusamplerep.pdf  Video and other resources  http://ahrq.gov/research/puwebcast.htm

71. Advancing Excellence in Health Care QUESTIONS? Ron Finch – National Business Group on Health Ron Finch – National Business Group on Health Susan D. Horn - Institute for Clinical Outcomes Research Susan D. Horn - Institute for Clinical Outcomes Research William Spector – AHRQ William Spector – AHRQ Tricia L. Trinité - AHRQ Tricia L. Trinité - AHRQ