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Effective Health Care Program Listening Session

Transcript


The U.S. Department of Health and Human Services hosted a listening session on Wednesday, January 11, 2006, to solicit input on research priorities for the Effective Health Care Program.

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Introduction / Comments


Introduction

Dr. Straube

If I could ask people to take their seats, please, we'll try to go ahead and get started. Good morning. I want to welcome everybody here in the room, and the folks on the telephone line, and thank you for participating in this listening session this morning regarding next steps in effective health care research and evidence development at the Department of Health and Human Services. These activities are very important to every health agency in HHS and to the entire American health care system.

My name is Dr. Barry Straube. I am the Acting Chief Medical Officer and the Acting Director of the Office of Clinical Standards and Quality of the Centers for Medicare and Medicaid Services. And I would like to welcome you this morning, and I'm very pleased to have been asked to moderate the session this morning. I'm joined here this morning by Dr. John Agwunobi, who is HHS's new Assistant Secretary for Health, and Dr. Carolyn Clancy, who is the Director of the Agency for Health Care Research and Quality, also within HHS where the new Effective Health Care Program is currently housed. I wanted to add that the secretary of HHS, Mike Leavitt, and my boss Mark McClellan are extremely interested in the proceedings here this morning, but they were unable to be here. I particularly send Mark McClellan's regrets. I was in touch with him around midnight last night and he was still concerned that he really wanted to be here but wasn't able to do so. So I send his greetings to all of you for sure. In addition to those of us here in the room-we have at least 50 people I would say here in the room. We're joined by over 250 people on the telephone lines who will be participating with the session this morning from around the country.

This is the second listening session that we've had, to obtain input on priority areas for the effective health care activities that were authorized under section 1013 of the Medicare Modernization Act that came out at the end of 2003. The purpose of this meeting is to provide an open door forum, if you will, for public input in order to help the Department of Health and Human Services as we review the priority conditions that should be included in our next round of effective health care research and synthesis. The first listening session took place in May of 2004. And it was part of the open process that resulted in the Secretary's selection of ten priority conditions for the first phase of the comparative effectiveness review process. The first ten conditions were focused on the Medicare program in particular, and that first list of conditions was published publicly in November of 2004.

The Effective Health Care Program was then established at AHRQ and the reviews have subsequently been launched. For those of you who are following things closely, the first Comparative Effectiveness Review under this program was issued last month and is published on the AHRQ Web site. Nine more reviews are currently being developed. And a new set of topics for the next set of reviews is currently being proposed on the Web site which is http://www.effectivehealthcare.ahrq.gov. That next set of reviews will also be based on the initial list of ten priority conditions.

Our purpose here this morning is to look beyond these initial reviews and to consider what addition or other changes may be needed in the list of priority conditions for future years. In particular, we want to review whether there are conditions of special importance, not only to the Medicare program, which we focused on in the first ten conditions, but the Medicaid and the State Children's Health Insurance Programs which are also covered under this program. This is the beginning of a process of reviewing the priority conditions. We don't have any preconceived ideas about what should be and should not be identified as priorities, and how many should be included. But we welcome the ideas of everybody in the room here and on the telephone in guiding us in picking additional priorities. We also welcome your comments on the program as it's developed so far and any other ideas you may have on the future of the program. Let me remind everyone that with this program you can participate very actively by going to the Web site that I mentioned previously, signing up at the Web site. You can get regular communications from the program on what's happening. In addition, you also have the opportunity on the Web site to make comments and give suggestions at whatever time point you want. It doesn't have to be restricted to open door sessions such as the one today. The Department of Health and Human Services wants this to be a very transparent and open process, and I think the Web site and these open sessions are a part of that. And the Web site, again, is http://www.effectivehealthcare.ahrq.gov. Now before we begin our public comments this morning, I'd like to invite my colleagues at the table here to say a few introductory words, and I'll be making some also from Dr. McClellan. And I'll begin with Dr. Agwunobi on my left here. As the new assistant secretary of health for the Department, Dr. Agwunobi assists Dr. Leavitt in managing the agencies of the U.S. public health service as well as formulating and carrying out public health policy. So I'd like you to welcome and introduce Dr. Agwunobi.

Dr. Agwunobi

My name is John Agwunobi. And as my colleague just indicated, I serve as the Assistant Secretary for Health in the Department. I recognize that there's work to be done today, and that this is truly a work session. To some degree, I'm but the garnish, and so I'm going to keep my comments nice and short so we can move on to the real purpose for which you're here. It's pretty clear, and Carolyn and I have had these conversations over the years, that as our Secretary has built transforming health care into his 500 day plan, his 5,000 day plan, as he has clearly stated across the agency that he wants to leave the department when he's done having impacted the health care of our nation in a positive way. That it's incumbent upon all of us who work within the department and all of you, the community, the larger community, its incumbent that we holler the word quality wherever we can and whenever we can. It's important that those plans to transform our health care system, our health system in the larger sense, always have the goal of improving quality. I'm very grateful to be here, although I must admit I'm not an expert in the field. I am a practicing, or have been in the past, a practicing pediatrician. I have been on that front line. And I recognize and understand that sometimes in the fog of the clinical war, it's easy for us to reach out to tradition and to common practice and to the quickest source of information that we can find.

The truth of the matter is we are a health system that has—suffers from both too much and too little information. Too much in that there is so much research, there's so much progress. We live in an era where there is so much going on in both research and clinical medicine. So little because it's hard to access. Sometimes it's hard to find the answers to critical questions. There are gaps in research. It's hard to tell where they are. And this process of trying to find a way to compare therapies, compare interventions, rank opportunities, offers us an ability to better organize all of that information, an opportunity to make for a much better quality of health care delivery. Steven Wolfe wrote an article-he's with the Virginia Commonwealth University-in the Washington Post Outlook section, that hallowed journal of science, last Sunday. And in it I think he stressed the point that we definitely as a larger community need to push for greater efforts to help our health care system deliver the best quality care to America's patients.

As we watch the sunrise on this dawning of genomics and the pushing into new frontiers for clinical science, it becomes even more important that we understand how these new opportunities rank relative to each other. Now that I think about it, many of the old tried, true, and tested therapies and interventions have never really been compared in a real scientific way against each other in different settings for different individuals and for different populations. And that's the challenge that we face. Mark McClellan often says that high quality of care is absolutely essential to any strong plan to transform the health care system. But he also goes on to say as he is known that we can't afford to do it any other way. It really is about money as well. That it's not just about clinical outcomes, but a truly transformed health care system holds quality first, but it's efficient. It's productive. We have to work together. And I recognize that we haven't always made these kinds of comparisons, these kinds of decisions out in the open. I blame Carolyn for the culture of transparency, the culture of openness that she's pushing, in trying to do this task. She wants your opinion. She recognizes that there may not be consensus as we begin the discussion on a particular subject. But she wants that lack of consensus to be apparent. I urge you not to just listen. I think we're the ones that are supposed to be listening in this particular forum. Participate. Don't throw anything at us, however. The right place to start, you know, we have to find a way to figure out where do you begin? It's a long journey. The vast number of opportunities in terms of comparing therapies, in terms of the ability to look at the difference and the relative value of interventions. There are so many opportunities today, and as science progresses, there will be so many tomorrow. So we have to figure out a way, a strategy, to be able to select where we're going to begin. What are the priorities? Now once again, I've sat next to Carolyn, Dr. Clancy, on many different panels and settings, and I've always felt a little inadequate beside her because of her intense intelligence, and her understanding of research and the broader issues that are involved in nurturing a research community. I'm told, however, that she's not the smartest in her team. That there are many just like her on her team. And it's true that we could turn this task over to them and they'd come up with a solid product, a strategy, a plan, and they'd be done in maybe all of three days. But it wouldn't include you, and it wouldn't include your perspectives, and it wouldn't include your points of view. So I applaud this method of getting it done.

This open approach to trying to develop a strategy. The work is already underway, and you've already participated. I would urge you to stay the course, stick with us, and see it through to the end. And if there are others on the outside that you think need to be a part of this, invite them to these forums. Invite them into the debates. It is a listening session. So I would urge you to also listen to what others are saying. You can learn as much as we can from listening to a colleague from across the room. I think as we look at this program we're seeing an important part of the future of health care. This concept of not just knowing what's a quality drug, what's a quality intervention, what's a quality piece of equipment I guess would also be included, but also comparing one quality product, one quality drug, one quality therapy to another to try to figure out which works best in a given setting, which works best on a given population for a given disease or intervention need. That's the way of the future. I think the other piece in that test is getting to those answers by including everyone. It's also relatively new. Over the past two decades we've learned about the wide variation in medical practice, and we've learned that there all too often is very little rationale for the things that we do, or at least for the variation in the ways that we apply those interventions. I was reading an article recently that talked about the fact that we all too often over-research long after we've proven a point, long after it's well established that an intervention is effective, or not. We keep flogging that horse to see if it will move any faster. I'm hoping that this process and others will be a way for us to rationalize and to, not reign in, but at least put a semblance of structure on that process. And you can only get there by involving everyone. There's no way you could do this in some regulatory office in the back room of a large stone mausoleum-type building on Independence. You really have to come out and have a discussion. I'm happy to see a systematic movement towards effective health care taking root in our public health service agencies for which I have now been given the unique honor of being a part of. I've actually only been on the job for a few days. I congratulate AHRQ, and I congratulate Carolyn, for their work and for their accomplishments in this young new program. I look forward to the comments that we'll hear today. I'll be leaving a little early, but we'll leave someone behind so they can brief me later on what exactly was said. But focus on AHRQ, and on CMS, and on your colleagues. I think the reverberations of the conversations, they may not be loud noises that you hear, but I think the waves will travel far. I do know, and I'll end on this, that the Secretary himself plans on using the priority lists. For example, he asks every once in a while what are the five most important diseases afflicting our community today? And every once in a while he updates that. His 500 day plan contemplates those kinds of discussions. And I'm hoping that we talk not only about what are the priority conditions, how should we select interventions to be measured and ranked against each other, to be compared in a relative way against each other. I know for a fact that our secretary is going to be looking to AHRQ for input as he tries to formulate his strategies and his priorities for the future. And that you will influence him in these conversations, so let it out as I know you have. Thank you very much.

Dr. Straube

Thanks very much, Dr. Agwunobi. I'd like to put into context what CMS is doing and how the Effective Health Care Program fits in with what we're doing and try to put this in a national context too to show how important we believe this program is. I'm going to talk through-I have some slides here for people in the room on Power Point, and I'll try to talk through these for folks on the phone lines. First of all, again, Mark McClellan sends his regrets. He really did want to be here this morning, but much of what I will be saying here comes from the leadership of Mark and the direction that he's put CMS in. I think first and foremost, Mark has expanded the image, and the perception, and the vision of what CMS is meant to do above and beyond our just serving as a payer organization, as a beneficiary rights protector, and as a quality improvement type organization. And what I'm referring to specifically is the concept of CMS as a public health agency. And this I don't mean going out and doing flu clinics and providing preventive care services, which are all important activities.

This is a much broader grander view. It's using the agency's influence and the fact that we spend $600 billion a year on health care services to our beneficiaries in our various programs to leverage and transform the entire health care system. So we're going to be focused on working with other folks to not affect just the Medicare and Medicaid programs, but the entire U.S. health care system. The focus in this vision is not just for high quality, although I've listed that here as the first priority. I think we also focused on value, on efficiency, on cost effectiveness. And as Dr. Agwunobi mentioned to you, these are all issues that Mark has been very passionate about and has instilled in the rest of us in the agency. And tied in with this is the need, in order to achieve those goals, to assist patients and providers in receiving evidence-based technologically advanced care while reducing avoidable complications and unnecessary costs. I think that phrase really captures all of the points that Mark has stressed to us inside CMS, and that directly relate back to the Effective Health Care Program we're here to talk about this morning.

Just to put in international context, this is just showing the growing number of Medicare beneficiaries over the years. And you can see projected to year 2030. There is somewhat of an asymptotic rise here in the number of beneficiaries. The other points I'm about to make are especially relevant to us in our Medicare population, but it's also relevant to the Medicaid, SCHIP, and the commercial health care sector, as well as the uninsured in this country. This shows-the slide that I'm projecting right now shows what we spend in the United States as a percentage of gross domestic product compared to other industrialized nations in the world. And as we all know, I think, in this room and on the phone, the United States spends more as a percentage of GDP than other industrialized nations. This is juxtaposed to the fact that-I'm now projecting a slide which shows the results of a seminal study that Beth McGlynn and folks at the Rand Corporation did, published in the New England Journal about two and one-half years ago now where they judged patients coming in to a doctor's office, whether they received the type of care the national consensus guidelines would suggest they should receive. And Dr. McGlynn's study showed that about just barely over half of patients coming to a doctor's office on average received recommended care. The slide also projects here variation with respect to individual disease states. The best that was listed in the study was cancer care where 76 percent of women received recommended care. But I would flip that and say 24 percent, even in the best condition, did not receive the type of care that they would be expected to receive under guidelines. And when you go to some other disease states such as hip replacements, pneumonia care, et cetera, as you can see on this slide, the care received was clearly way out of conformance with recommended guidelines.

This slide shows-what I'm projecting now for the folks on the line is again, Jack Linberg's, one of his typical geographic variations across the United States. This projects differences of the amount of money spent for hospital care for Medicare beneficiaries across the country. Now for those folks in the room, the dark red colors reflect high levels of spending, on average about $3,500 per beneficiary per year. The whiter colors reflect lower spending, an average about $1,500 per beneficiary per year. And for the folks on the phone, there's great variation. There are concentrations of very high spending, not surprisingly in some urban areas like Los Angeles, New York, Chicago, the Bay Area in California, et cetera. But surprisingly there are many rural areas where the expenditures for hospital care are very high also. But the main message from this slide is that there is gross variation in the dollars being spent for health care across the United States. Now if you keep in mind this slide for those of you in the room, and for those folks on the phone, I'm now showing a slide which reflects the quality of care based on CMS hospital quality metrics received across the United States. And on this slide it's in black and white. The dark areas are in fact the lowest quartile of performers, that is, the worst amount of care. The white areas are the highest quartiles. And if you remember back to the prior slide and for the folks on the phone, there seems to be some relationship between high expenditures and poor care outcomes conversely to the areas that are the lowest spenders that have the highest quality of care outcomes. So again, gross variation in expenditures across the country, gross variation in quality outcomes, and perhaps some inverse relationship between the amount of money spent and the quality of care that we receive in the end.

CMS developed-this past summer we published a CMS quality road map. And our vision is to have the right care for every person every time. We have six aims which align with the Institute of Medicine's six aims of safety, effectiveness, efficient care, patient-centered care, timely care, and equitable care. And we have five strategies that we intend to roll out, our quality agenda in 2006 and beyond. I've listed them here on the slide. The first, which is germane to this session, is to work through partnerships to achieve specific quality goals. And again, we have to have broad open consensus efforts with multiple stakeholders at the table in order to achieve our quality goals across the United States. And this forum is an example of that. We also believe very strongly in publishing quality measures and information as a basis for supporting more effective quality improvement efforts. Again, germane to this session because of the effective health care studies that Carolyn and her team are developing, and the need to publish those, and get them out to providers and beneficiaries. The third strategy is the need for us to reform our payment system. Again, we're not going to be talking about that today. But clearly the evidence that comes out of these reviews can be used in a variety of ways in so called pay-for-performance initiatives and can be tied in in other ways to the reforms that we're going to be making and that Congress will make in our payment system in which we pay health care providers. The fourth strategy is we need to assist practitioners in making care more effective and less costly, particularly through the development of health information technology. And I think that health information technology is going to be very, very important to disseminate the results of the effectiveness reviews that are being done by AHRQ. As an example, the Web site already is a very effective tool in trying to include many, many folks and assist practitioners in providing better care. And then last but not least, we're focused on a fifth strategy which is trying to bring effective new treatments, but also effective assessments of those treatments to patients and providers in a more rapid manner, to develop better evidence so that doctors and patients can work together to use medical technologies in treatments in a more effective manner, and to improve the quality of the care while avoiding unnecessary costs and complications, as I mentioned earlier.

Again, I'm going to let Carolyn in her remarks talk more about MMA section 1013 so I'll skip over that. But, we did in conjunction with AHRQ and some other stakeholders select ten conditions that affect Medicare beneficiaries in particular, and people will be commenting about those and others this morning. I've listed them here: ischemic heart disease, cancer, chronic obstructive pulmonary disease, stroke, arthritis and non-traumatic joint disorders, diabetes mellitus, dementia, pneumonia, peptic ulcer disease, and depression and other mood disorders. Clearly conditions that affect the Medicare population.

Our partnership with AHRQ, we have been represented on the review committee that has looked at proposals for the DEcIDE research centers that I suspect Carolyn will talk about and people will comment on today. We've also been supporting the registry project which is addressing topics of registry creation, registry operations, and the evaluation of the design and operations of registries. And as I said, Carolyn will likely review other aspects of the Effective Health Care Program.

Why do we need-why do we at CMS believe we need comparative effectiveness reviews? Well, several points to be made. First, they provide a sound foundation of evidence about which treatments work best. And we believe that this is essential to help doctors and patients achieve the best quality health care. We need to have such information available in useful and understandable formats. And I think again, the first report that's been put out and the presentation on the Web site, et cetera, is evidence of where we need to be heading. We think that AHRQ's issuance of the first review and subsequent reviews are simply a milestone in achieving our goals at CMS, but likewise everybody in the health care system achieving their goals. And we feel that because of these reviews, that Medicare beneficiaries and their doctors and other clinicians clearly have better information now about costs and benefits of treatment for now one condition, but soon to be many, many other conditions in which multiple treatment options are available. We think that better evidence is a centerpiece of the prescription drug program which we've just launched, and other reforms which are being implemented by CMS right now to try to bring the Medicare program up to date. So this Effective Health Care Program is essential to help us achieve that. We need to do more to learn about and measure the effectiveness of alternative treatments for common health problems. And this is the first step in that regard. We also need to do more to help patients and doctors get unbiased practical useful information on benefits, risks, and costs.

I've listed on this slide, and for the people on the line I don't want to go into great detail, but we have a number of other initiatives at CMS dealing with evidence collection, evidence development, and evidence implementation. And they include the use in our national coverage decision process including our most recent coverage under evidence development process which we have just implemented over the past year. We clearly are using evidence development to help us in developing quality measures and benchmarks both for quality improvement efforts as well as pay-for-performance programs which are becoming more and more known to the American public. We clearly use evidence in selection of new medical technologies and innovations within the Medicare and Medicaid programs. We've been listing medical evidence information for our beneficiary and provider use and consumer use on our Web sites, the Medicare Compare ones in particular. We use them in medical guidelines, clinical guidelines, dissemination is a key part of our quality improvement programs. We use them in the prescription drug program we just launched. We use them in the Medicare Advantage Program. We use them in our health information technology strategies and e-prescribing that are currently being provided. And the list goes on and on and on. So in summary I think again that the use of better evidence in clinical care and health policy decision making will improve the quality of care, will improve health outcomes, and well-being of patients. It will achieve better value for health care dollars spent, and it will promote better health care partnerships between patients, and doctors, nurses, and other clinicians. And we at CMS certainly look forward to today's sessions with the identification of new topics for effectiveness reviews. That's the CMS perspective.

And I now take great pleasure in introducing Dr. Carolyn Clancy who is the Director of the Agency for Health Care Research and Quality. Carolyn is a leader in health care in the United States. She's certainly a colleague that I respect and look to for counsel many times, and certainly helps us at CMS in innumerable ways in improving our quality agenda. Dr. Clancy.

Dr. Clancy

Thank you, Barry, and good morning. I think you can see how much we enjoy collaborating with CMS on a regular basis, and why I was so excited. One of my best Christmas gifts was learning that Dr. Agwunobi had been confirmed about a week before the holidays. So I want to welcome all of you here in the room and on the phone to the second listening session for the effective health care program. I'm really pleased at the turnout. This is not a great weather day, but including everyone here, I've been looking forward to this, to a way to continue our work as the Secretary identifies the next round of priorities. What's new about this new authority in the Medicare Modernization Act are a couple of things. It's all about informed choices. Today Americans have many, many situations where there are two or more options for them to choose from. And the information that is going to be produced from this program is actually going to help them make better choices about what's right for them as individuals. This program does not make recommendations or prescriptions. It's not about guidelines. It's about presenting people with the facts in a way that they can understand. It's also very much about ongoing engagement with all of you. So I think John Agwunobi emphasized that very, very clearly. So again, it's part of the reason I'm thrilled that you're here today. So let me wish all of you a happy new year and tell you that the timing for today's session couldn't be better.

It's a new year, and it's just a few weeks after the release of our first comparative effectiveness review on GERD, or gastroesophageal reflux disease, for those of you who occasionally leave the world of acronyms. I want to say-express my thanks and gratitude for all the work our stakeholders have done both in preparing this report and helping us to spread the word about the findings which shows that certain drugs can be as effective as surgery in the treatment of GERD which affects more than 10 million Americans. And I'm really very, very pleased by the response from CMS to this report as well as from a broad array of stakeholders across the health care industry. By comparing treatment alternatives for GERD, examining their effectiveness, and reporting the findings in a way that is immediately useful to patients, providers, and payers, we believe that the program has already begun to demonstrate its value right out of the gate and there's a whole lot more to come.

In the coming months we're going to be releasing a series of reports of comparative effectiveness reviews on high priority topics that include breast cancer diagnostics, heart disease, stroke, and depression. So let me tell you right now a few areas that we would love to hear from you. Before I do that, I'm going to just walk you through one of the three components of the program. The priority setting is a very, very clear part of it, and as Dr. Agwunobi mentioned, there was a very nice article also from that journal, the Washington Post, recently making the case that we would be much better off as a country if all of our investments in very large trials and very large clinical studies were preceded by systematic reviews. And that's exactly how this program is set up. We start with systematic reviews, establish priorities, start with systematic reviews. Those reviews will identify what we know, and will also identify very important research gaps at which point we will then be turning in two directions.

One is to a new research network called DEcIDE that Barry mentioned very briefly which takes advantage of the fact that many health care organizations have already begun making big investments in electronic health care data at the patient level. So we're going to take advantage of that. Sometimes that network will help us fill gaps, other times we're going to have to turn to partners in the public and private sectors to address the research gaps that are most important to address. But any time we do establish those partnerships to launch very significant studies, we'll do it with the confidence that we know that we've already done the systematic review to know that we're not flogging a dead horse as Dr. Agwunobi said a few minutes ago. The third part is the English to English translation part. No researcher on the planet thinks that they're not putting things incredibly clearly. And they are. Often for the researchers it is very, very difficult to communicate scientific information in a way that everyone can understand and use and understand what it means for them. To that end in recognizing how challenging it is we've established a new center out at the University of Oregon which will help us get better and smarter at this. In your book you'll see the summary of the first review as well as the patient page. That's only the beginning. We're also going to be looking for partnerships to be able to get this information into personal health records, into a variety of venues so people can use it when they need the information. This center was named in honor of our prior director, Dr. John Eisenberg. So we're hoping that we get better over time in terms of making this information actionable and understandable to a broad array of audiences. Now for systematic reviews, choosing the topic area is very, very important, again why I'm glad that you're all here today.

Secondly, though, is actually getting the questions right. Right now on our Web site there are some key questions that we're putting out for public comment. And some specific areas I just wanted to mention to you. One is the comparative benefits and harms of drugs for Alzheimer's disease. Another is the comparative long term benefits and harms of ACE inhibitors versus angiotensin receptor blockers, or ARBs, for treating hypertension. Another is comparative effectiveness of review of coronary artery stents versus bypass surgery. And the list will go on and grow over time. So please know that in addition to giving us feedback about priorities, in addition to the opportunity to weigh in on the draft reports, we also want your input so that we make sure we get the questions as correct as possible.

My expectations today are great for several reasons. One, all of you are here and on the phone. Secondly, after the first session I think all of us left terribly energized. This program will be successful to the extent that we can continue to engage all of you throughout the process. And so far, I think we're doing very, very well. We very much appreciate your commitment and combined wisdom, and your collaboration is going to help us ensure the long term success of this program. And we think we're off to a good start. The second reason I'm confident about the success of this program is the equality of the process we're using. Dr. Agwunobi emphasized the notion of transparency, and every step of this process will be transparent, from establishing priorities to the opportunity to comment on questions, to the opportunity to comment on draft reviews. I should note that we actually solicit reviews as well. But any citizen can actually go to our Web site. For those of you in the room, that page is in your book, effectivehealthcare.ahrq.gov. For those of you on the phone, I think you just heard us say it again, and we'll remind you before the session is over. So as we gear up for the next set of priorities, we're very much looking to all of you to give us the best kind of input possible. Finding ways to deliver effective health care to all Americans is a task that's worthy of all of our efforts and enthusiasm. And I don't think I need to tell all of you that it's a big job. As George Carlin, the humorist, is fond of saying, some people think of the glass as half full, and some people think of it as half empty, and some people see the glass as just plain too big. The glass, if you will, the health care system in front of us is pretty big. But there is no doubt that our commitment to turning evidence into action is much greater. With each topic that we select, with each Comparative Effectiveness Review that we release, with each informed choice made by patients, providers, and payers we serve we're making a difference. Thank you again for joining us today. And now we get to listen. Thanks.

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