National Advisory Council, November 2010
November 5, 2010
Call to Order; Approval of July 23 Summary Report
Innovators from the Field: Operationalizing the National Quality Strategy
Centers for Medicare & Medicaid Services (CMS) Discussion
AHRQ'S Role in Operationalizing the National Quality Strategy
Chairman's Wrap-Up, Final Comments
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
Robert S. Galvin, M.D., Equity Healthcare
Junius J. Gonzales, M.D., M.B.A., University of South Florida
Helen W. Haskell, Mothers Against Medical Error
Wishwa N. Kapoor, M.D., M.P.H., University of Pittsburgh
Kathleen Lohr, Ph.D., RTI International
Keith J. Mueller, Ph.D., University of Iowa
Welton O'Neal, Jr., Pharm.D., Takeda Pharmaceuticals North America, Inc.
Michael K. Raymond, M.D., NorthShore University HealthSystem
Katherine A. Schneider, M.D., M.Phil., AtlantiCare Health System
Xavier Sevilla, M.D., FAAP, Manatee County Rural Health Services, Inc.
David L. Shern, Ph.D., Mental Health America
William Smith, Pharm.D., Ph.D., FASHP, Virginia Commonwealth University
Myrl Weinberg, CAE, National Health Council
David Atkins, M.D., M.P.H., Veterans Health Administration
AHRQ Members and Staff Present
Carolyn M. Clancy, M.D., Director
Kathleen Kendrick, M.S., C.S., R.N., Deputy Director
Howard Holland, Acting Director, Office of Communications and Knowledge Transfer
William B. Munier, M.D., Director, Center for Quality Improvement and Patient Safety
Jaime Zimmerman, M.P.H., NAC Coordinator
Karen Brooks, CMP, NAC Coordinator
Call to Order; Approval of July 23 Summary Report
Bruce Siegel, M.D., M.P.H., NAC Chair, called the group to order at 8:30 a.m., welcoming the NAC members, other participants, and visitors. He asked the participants to introduce themselves.
Dr. Siegel referred to the draft minutes of the previous NAC meeting (July 23, 2010) and asked for changes and approval. The NAC members approved the July meeting minutes with no changes.
Carolyn M. Clancy, M.D., Director of AHRQ, thanked Dr. Siegel for serving as the new NAC Chair. She noted that the following members were attending their final meeting before rotating off the council: Robert S. Galvin, M.D., Wishwa N. Kapoor, M.D., M.P.H., Kathleen Lohr, Ph.D., Michael K. Raymond, M.D., David L. Shern, Ph.D., William Smith, Pharm.D., Ph.D., FASHP, and Myrl Weinberg, CAE.
The Big Picture
Dr. Clancy stated that the Patient Protection and Affordable Care Act (now Public Law 111-148) contains areas regarding the quality and efficiency of health care that will remain of great importance to the work of AHRQ. As called for in the Act, the Patient- Centered Outcomes Research Institute (PCORI) will be established soon. It will feature a 21-member board, including the directors of AHRQ and the National Institutes of Health (NIH), and will be supported by money from the Medicare trust fund and a tax on self-insured employers and insurers. The PCORI will have an annual budget in the neighborhood of $600 million. The board members were announced in September.
Dr. Clancy noted that the Federal Government will operate under a continuing budget resolution at least until December 3, 2010.
Dr. Clancy stated that funds for AHRQ under the Recovery Act for patient-centered outcomes research include $173 million from the Office of the Secretary—bringing the total to $473 million. The money is supporting grants and contracts that generate and synthesize evidence, translate and disseminate research, train clinicians and researchers, and build databases and software capability. A goal is to give consumers information to support health care decisions based on treatment effectiveness. Dr. Clancy provided the example of an initiative at the University of Washington in Seattle in which AHRQ will test the automation of registry data collection.
AHRQ held its Fourth Annual Conference September 26�29, 2010, with 1,557 people in attendance. Next year's conference will take place September 18�21, 2011.
Dr. Clancy reviewed the following recent accomplishments:
- A report developed by AHRQ's Johns Hopkins University Evidence-based Practice Center found insufficient evidence to support the use of inhaled nitric oxide therapy in preterm infants who require mechanical ventilation to improve survival or decrease pulmonary morbidity or neurodevelopmental impairment.
- AHRQ-funded researchers reported in the New England Journal of Medicine that mistakes that affect multiple patients should be disclosed even when patients are not harmed. Hospitals should develop policies for such disclosure.
- Eight Spanish-language guides from AHRQ's Effective Health Care Program help consumers to speak with clinicians and make health care decisions. Various Effective Health Care Program publications have been disseminated through partnerships, podcasts, in-store audio, press releases, and Twitter. The most popular products include an adult guide focusing on pills for Type 2 diabetes and a guide about medications for adults with depression.
- AHRQ-developed audio messages have been broadcast in grocery stores. Stores also have disseminated guides.
- Dissemination contracts under the Recovery Act included the promotion of comparative effectiveness research and the Effective Health Care Program, outreach to health care organizations, businesses, and more, expansion of continuing education activities, and academic detailing, in which professionals conduct in-person educational meetings with clinicans and others. Recovery Act funds also have been supporting evaluations of programs to measure awareness, understanding, and behavior change.
- A comparative effectiveness review from AHRQ's Effective Health Care Program showed promise in the use of human growth hormone in the treatment of cystic fibrosis.
- A Healthcare Cost and Utilization Project (HCUP) data report revealed that drug-related hospitalizations are rising for persons aged 45 and older.
- AHRQ has been supporting the $34 million program to expand the fight against health care-associated infections. A list of institutions and projects funded is available at http://www.ahrq.gov/qual/haify10.htm.
- In an impact case study, AHRQ patient safety indicators were translated into the British system to develop a tool to compare risk-adjusted outcomes. It supported reports on all national health service hospitals in England.
- In an impact case study, MEPS data were used as a model to develop a medical care expenditure survey for Japan. Use of the survey found that more than 70 percent of respondents had private insurance to cover out-of-pocket expenses.
- The Institute for Healthcare Improvement Open School for Health Professions used ARHQ's WebM&M (Morbidity and Mortality Rounds on the Web).
- In a knowledge-transfer case study, AHRQ workshops successfully encouraged Maine and Tennessee to share their hospital quality data via HCUPnet.
- In a knowledge-transfer case study, the Massachusetts Medicaid program revised prescribing guidelines for antidepressants and determined when to follow a suspicious mammogram with further testing—both based on AHRQ-supported comparative effectiveness reviews.
- In a knowledge-transfer case study, the American Academy of Nurse Practitioners incorporated content from AHRQ's Effective Health Care Program in its comparative effectiveness activities.
- In a knowledge-transfer case study, the Connecticut Department of Public Health used data from AHRQ's Preventable Hospitalization Costs and Mapping Tool to assess health care quality, access to community services, and more.
AHRQ Program Updates
Dr. Clancy provided the following program updates:
- The Subcommittee of the NAC for identifying quality measures for Medicaid-Eligible Adults (SNAC), co-chaired by Elizabeth McGlynn, Ph.D., and Foster Gesten, M.D., has made progress. It met October 18�19, 2010, to refine a core set of voluntary measures, to be posted for comment in the Federal Register by January 1, 2011. A list of current measures was narrowed from 1,000 to 51. These measures address the areas of reproductive health, adult health, mental health and substance abuse, and complex-needs populations.
- AHRQ released new 60-second Spanish-language consumer videos focusing on a variety of health/safety topics.
- An AHRQ-supported project found that standing orders improved quality in primary care, producing an 8- to 17-percent increase in adult immunizations and up to an 18-percent improvement in diabetes care measures.
- An AHRQ-supported study of electronic health records and physicians' practices in southwestern Missouri found that automated data extraction had 100-percent coding completeness whereas manual coding had 20-percent completeness. Automated data extraction was more accurate for reporting results.
- AHRQ has provided health information technology (IT) assistance to the Medicaid program in various ways during the past 3 years, for example, supporting conferences and workshops. The Agency published Using Health IT: Eight Quality Improvement Stories (available at http://healthit.ahrq.gov/SuccessStoriesTHQIT).
- During the summer of 2010, AHRQ issued grants for transforming primary care—14 awards totaling $4.1 million per year. The research will increase understanding of contextual factors in primary care transformation.
- The U.S. Preventive Services Task Force posted, for public comment, draft recommendations on screening for osteoporosis, ocular prophylaxis for gonococcal ophthalmia neonatorum, screening for testicular cancer, and screening for bladder cancer.
- AHRQ has been developing papers on payment reform, to be published in an issue of the Journal of Health Services Research. One paper, for example, investigates the structuring of payment bundles that reduce regional variation without hurting quality.
- More States have been using AHRQ's MONAHRQ tool for setting up Web sites.
- The HCUP program now features 44 State partners providing input data from 2009.
- AHRQ provided a Web-based resource that links to examples of health care provider performance report elements ("Model Public Report Elements: A Sampler").
- There are now 85 Patient Safety Organizations (PSOs) in 30 States and the District of Columbia. AHRQ updated the evidence report Making Health Care Safer: A Critical Analysis of Patient Safety Practices. It awarded seven Partnerships Implementing Patient Safety II (PIPS) grants and continued patient safety contracts in other countries.
- AHRQ received input on its recent National Healthcare Quality and Disparities Reports and completed first drafts, with updates, of the 2010 reports (now in review).
- The National Quality Forum Steering Committee endorsed three nursing home surveys in the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) program. AHRQ is developing a patient-centered medical home CAHPS® survey.
- AHRQ is developing a clinical audit system that captures comprehensive clinical information described in a recent Inspector General's report. This Quality and Safety Review System will be objective, more efficient, and cheaper to operate, compared to traditional chart audits. It will allow reporting on critically important clinical performance based on medical records while we await the penetration of interoperable electronic health records.
- The Medical Expenditure Panel Survey (MEPS) has been enhanced to measure health literacy practices and cancer survivorship and to better measure health insurance status. MEPS State-level premiums have been used to set tax credits for small employers.
- AHRQ has given assistance to HHS in initiatives of the Patient Protection and Affordable Care Act, providing research findings, models of coverage, and more.
- AHRQ developed 13 clinical outcome indicators for the Medicaid Home and Community-Based Services population and shared initial results.
- AHRQ followed up on the Stakeholders/Expert Meeting on Health IT in under-resourced settings, commissioning researchers to develop a roadmap for agencies seeking meaningful disparities reduction through research and translation programs.
- AHRQ produced a booklet entitled Developing Quality of Care Measures for People with Disabilities: Summary of Expert Meeting.
- The AHRQ-CMS partnership continued with the reauthorization of the Children's Health Insurance Program (CHIPRA). This includes support for the National Evaluation of CMS Quality Demonstration Grants and the Pediatric Quality Measures Program. AHRQ is helping to develop a model/format for Medicaid children's electronic health records. AHRQ will design, develop, test, and disseminate the format.
- Eleven new DEcIDE research centers were given awards for consortia focused on patient-centered outcomes research. Areas of emphasis are cardiovascular disease, cancer, data analytics, diabetes, end-stage renal disease, mental health, and comparative effectiveness.
- AHRQ published the second edition of Registries for Evaluating Patient Outcomes: A User's Guide.
Ms. Weinberg encouraged AHRQ to leverage multiple resources to disseminate information. Dr. Kapoor encouraged collaboration with the Office of the National Coordinator for Health Information Technology regarding electronic health records initiatives. AHRQ is working with that office now regarding metrics for meaningful use initiatives. There also is collaboration on AHRQ's National Resource Center.
Helen Darling, M.A., encouraged the Agency to focus on palliative and end-of-life care, with reporting tied to the normal workflow (otherwise the workflow should be reengineered). Should AHRQ consider a clearinghouse for end-of-life and palliative care practices? We need data on children in these areas. Helen Haskell cited the need to increase the accuracy of charts.
Dr. Galvin wondered about the structure of the PCORI, and he encouraged the NAC to provide input for this new institute. Dr. Clancy stated that the PCORI will be a not-for-profit 501(c)(3) organization, and she expressed a desire to share lessons about investments in patient-centered outcomes. Ms. Weinberg noted that the PCORI board will feature stakeholders. As such, it and AHRQ will benefit from an ongoing conversation. Dr. Lohr wondered about the role of the Government Accounting Office (GAO). Dr. Clancy noted that the GAO posted in the Federal Register a solicitation for PCORI's methodology committee. The board will select the executive director. The law encourages PCORI to contract preferentially with AHRQ, NIH, and other government agencies supporting comparative effectiveness research.
Xavier Sevilla, M.D., wondered about the QSRS audit and the role of patient families in clinical auditing. William Munier, M.D., noted that there will be a public comment feature. Dr. Clancy noted that AHRQ will launch a contract seeking to learn how to obtain reports from consumers. AHRQ was encouraged to include interviews with patients in an auditing process.
Nancy Donaldson, D.N.Sc., R.N., raised the issue of data sources for medications and medication errors. In many cases, errors are not recognized. We need to use direct observation to help find errors. Dr. Donaldson suggested that AHRQ support a culture of dissemination of information by making requirements in grant mechanisms.
Innovators from the Field: Operationalizing the National Quality Strategy
Blueprint Integrated Pilot Programs
Craig A. Jones, M.D., Executive Director, Vermont Blueprint for Health
Dr. Jones presented the model of the Vermont Blueprint for Health, a public/private partnership program intended to guide a comprehensive statewide process of transformation to reduce the harmful effects of common chronic conditions and to focus on their prevention. The program features a foundation of medical homes and community health teams that support coordinated care and linkages to services. It includes multi-insurer payment reform, a health information infrastructure (including electronic medical records), and an evaluation infrastructure.
Dr. Jones listed key elements that support a learning health system, including meaningful evaluation and metrics and data sources as part of routine operations. He noted the data sources, measures, and reporting strategies in use in the Blueprint program. Other important features of the program are the use of team-based support, linkages across services, and the use of a core unit with scaled units based on populations. There is a coaching and facilitation team. The goal is a functional community organization. The program seeks to build coordinated health services and to make guidelines "come alive." The sites connect to a central registry, and performance reports/results are integrated, aiding in the assessment of comparative effectiveness.
Catholic Health Partners
Jane Durney Crowley, Executive Vice President and CEO, Catholic Health Partners
Ms. Crowley presented the model of Catholic Health Partners, a multi-State Catholic system of 34 hospitals and related systems, based in Cincinnati. She noted the program's goal of executing the Institute of Medicine's quality agenda. The program has a wide range of participants, including hospitals, long-term care facilities, a PPO health insurance plan, affordable housing, hospice programs, and home health agencies. It features an affiliated physician model. Strategies have included the use of performance improvement collaboratives, partnering with the Institute for Healthcare Improvement, the use of large goals such as lowered mortality, and team training.
Catholic Health Partners' approach features the establishment of systemwide objectives with accountability, use of internal measurement systems with real-time feedback, external benchmarking to identify opportunities, participation in external collaboratives, and the coaching of leaders. An improvement portfolio features the use of the Lean/Six Sigma model, the use of TeamSTEPPS, the use of human factors principles, and the use of just culture policies and practices. One finding of the program is that mortality reduction correlates with a culture that self-identifies harm (i.e., with greater visibility of harms). Ms. Crowley reviewed the program's methods for measuring harm (adverse events and near misses), which feature electronic self-reporting. The program has addressed an opportunity to reduce length of stay by improving care coordination. It has reduced harm, reduced mortality, and reduced length of stay. One area that needs progress is the overall patient care experience. Ms. Crowley provided the following lessons learned:
- Leadership is essential.
- Culture and process must change.
- There must be internal and external transparency.
- It helps to use names rather than rates.
- Experts can convince clinicians.
- Success creates momentum but also can create complacency.
Dr. Siegel asked about the use of quality data and strategies to acknowledge quality efforts. Dr. Jones stated that this is a good time to build quality recommendations into care practices. A national strategy of recommendations could help as a guide. Ms. Crowley cited the benefits of inviting patients' families on safety rounds.
Dr. Sevilla noted the difficulty of getting all payers to the table. Dr. Jones responded that leadership is important. His program found that insurers were supportive once legislation was passed. As for the business case for quality, Ms. Crowley cited money saved by decreased lengths of stay. Her hospitals lose money on rehospitalizations. Electronic medical records can save money, but that is realized only over a long period. Dr. Jones stated that an accountable care organization is one that tracks trends and expenditures and measures the impact of investments.
Dr. Jones explained that the Vermont system will include fee-for-service with enhanced payments to the practices as incentive. Insurers share the cost of the community health team. David Atkins, M.D., cited the challenge of engaging the specialists within the medical home model. Louise-Marie Dembry, M.D., asked about success in engaging physicians in general in the improvement process. Ms. Crowley cited the benefit of using champion physicians, noting that, in her system, this helped to transform half of the perinatal units. The strategy required about 18 months of support to gain success. There is variability among physicians, and champions need support.
Keith Mueller, Ph.D., stated a need to address broader levels for health care quality, such as the built environment, education, and services. Dr. Lohr cited a need for national recommendations regarding meaningful use. How might the AHRQ clearinghouses help? Dr. Jones noted that the Vermont CHIPRA program is playing a role, and its measures will line up with those of the program. Needed still are ways to link measures to clinical assessment.
Dr. Raymond wondered about ways to translate to the outpatient setting. Ms. Crowley noted that her program will feature standard data collection for physician offices beginning this year. Performance measures will be embedded in contracts. Dr. Kapoor asked about generalizability for the programs. Dr. Jones noted that his program designed principles for payment reform that are generalizable. An asthma initiative was found to be generalizable. Implementation and relationships across organizations are key.
Ms. Darling cited a need to indicate downstream savings. Are payers appreciative? Ms. Crowley noted that her program has not been able to obtain financial support from payers. Efforts such as indicating "preferred providers" are difficult to manage.
Dr. Donaldson noted the invisibility of the advanced practice nurses, and she raised the issue of educating, or retooling, the health care leaders, for example, to maintain competence in using data. Dr. Jones stated that advanced practice nurses are part of the teams in his program.
Richard J. Gilfillan, M.D., Acting Director, Center for Medicare and Medicaid Innovation CMS
Dr. Richard Gilfillan stated the CMS goal of being a major force and partner in driving continuous improvement in health care in the United States. Today the health care system is fragmented, with high costs and medium quality. One CMS vision, or objective, is a seamless system providing health care. CMS has potential levers for improving health care delivery, including new levers indicated by the Affordable Care Act. The Center for Medicare and Medicaid Innovation (CMMI) is new. It will seek to identify, validate, and diffuse practical, effective models of care. The models should start with the patient perspective and patient needs and address three levels—the individual level, the systems of care, and the population level (determinants of health). Guiding principles of the new center include the following: (1) context matters, (2) outcomes are central and must be understood, (3) ideas and models should be evaluated rapidly, and (4) innovation capability must be created.
Dr. Siegel raised the issue of determinants of health, which at times extend beyond the health system. Dr. Gilfillan responded that other governmental agencies address areas involving such determinants. It is not the CMS' mission to address all areas. CMS will seek to find areas to which it can lend value. Ms. Weinberg suggested that speed of the CMMI's work will be important.
Dr. Lohr encouraged CMS to listen to the voices of patients and address the concept of quality of life, with a focus on outcomes. Dr. Gilfillan stated that CMS considers patient perspectives to be a major part of the conversation.
Ms. Darling noted that requirements, or constraints, within the Medicare and Medicaid populations can inhibit innovation. Should CMS consider people engaged in wellness plans and link that idea to premiums?
Dr. Galvin proposed creating a formal process for hearing the voices of stakeholders. He asked CMMI to consider the issue of cost-shifting. Dr. Gilfillan stressed that CMS is seeking a seamlessness in the patient's felt experience. CMMI will seek input from all sectors. It will seek to move quickly by, for example, compressing the times for evaluating models.
Dr. Shern cautioned that changes sometimes produce no net savings in light of broad social or societal costs. He encouraged CMMI to consider social frames and costs. Dr. Gilfillan stated that CMMI will consider many models.
AHRQ'S Role in Operationalizing the National Quality Strategy
Dr. Clancy began a session on operationalizing the national quality strategy by stating the goal of avoiding data burdens as the Patient Protection and Affordable Care Act is implemented. The Act calls on the HHS Secretary to establish a national strategy, a plan, and priorities. It requires:
- Agency-specific plans and benchmarks to achieve national priorities.
- Alignment with meaningful use of health information technology.
- Strategies to align private and public payers.
- Collaboration, coordination, and consultation with State agencies.
- Input from multistakeholder entities including the National Quality Forum.
Dr. Clancy stated that the national quality strategy will target person-centeredness, families, and all ages, populations, service locations, and sources of coverage. It will seek to eliminate disparities in care and seek to align efforts of private and public sectors. As the quality strategy moves forward, we will need meaningful partnerships, shared investments, and efforts that will get at improvement. Dr. Donaldson noted that vibrant successful health care networks exist. We should attempt to leverage them.
Dr. Smith asked the NAC members to consider the implementation level, or operational level, beyond the ideas of change. What is AHRQ's role there? AHRQ supports research and produces information, products, and services for providers and health professional students. Dr. Smith proposed that AHRQ help to support the care providers' relevant internal information (internal methods, data, etc.).
Ms. Weinberg wondered about a role for AHRQ in helping to integrate the health care stakeholders regarding implementation strategy. Dr. Clancy suggested that such a role could progress over time, responding to restraints such as resources.
Dr. Kapoor emphasized the problem of quality metrics being placed "on top" of current operations, rather than incorporated in an integrated "bottom up" manner. There remains a need to instill the idea that health care quality is needed. Systems for health care quality improvement should be aligned with studies.
Ms. Darling suggested beginning with the development of a framework, or matrix, to organize all governmental efforts—showing how they fit, where there are gaps. Perhaps, added Dr. Donaldson, we should determine predictors of success. Dr. Sevilla again raised the issue of the broader scene, of health determinants, and he stated the importance of the perceptions of patients. Katherine Schneider, M.D., M.Phil., wondered how a health system can create a strategic plan that matches national priorities. What tools are needed? It is important, noted Dr. Clancy, to inventory what is being done and to know the many terminologies in use.
Welton O'Neal, Jr., Pharm.D., suggested that health information technology be raised to the level of a major national strategy. Dr. Lohr encouraged AHRQ to increase dissemination of information to consumers—including down to early ages, as young as 8. There will be a tension between a new structure's need for large amounts of information and potentially over-requesting data from institutions. There also will be a tension between generalizing implementation and permitting modifications. Contextual factors will be important. Dr. Donaldson cited the importance of incentives, drawing attention, and recognizing teaching thresholds. Dr. Clancy noted that AHRQ is developing a list of its dissemination networks. Dr. Lohr suggested that AHRQ reports include boxes that highlight "what's new" and employ low-literacy methods. Dr. Raymond added that reports should indicate how readers can use them (which relates to effectiveness).
Ms. Weinberg suggested that AHRQ define research priorities in the area of methodologies. Dr. Lohr noted the need for information on subgroups and harms.
There were no public comments.
Chairman's Wrap-Up, Final Comments
Dr. Siegel noted two especially important agenda items for the future:
- Discussion of the PCORI initiative.
- Emphasis on the patient/citizen.
Dr. Siegel also suggested that the NAC members define, in a future meeting, an accountable care organization. He invited the NAC members to make final comments.
- Dr. Donaldson noted that the National Quality Forum harmonization report will be released soon. It will provide perspective on, for example, the interactions of PSOs and registries.
- Ms. Darling stressed that it is important for AHRQ to provide updates on a given health care issue, even when no large changes have occurred. She suggested that the NAC invite an objective analyst to speak about the PCORI at a future NAC meeting.
- Dr. Kapoor welcomed a focus on patients and encouraged AHRQ to support investigator-initiated research.
- Dr. Shern stressed the ideas of a learning community and services research.
- Ms. Weinberg encouraged AHRQ to support a systematic discussion of how information can be disseminated.
- Dr. Lohr agreed with the focus on the patient and encouraged a focus on outcomes and quality of life. AHRQ should support methods research and investigator-initiated research.
- Dr. Mueller stressed that context matters and that scaling might or might not affect expenditures. We should consider where an organization resides now regarding quality. Population health should be expanded to include community well-being.
- Dr. Dembry encouraged a focus on health care-associated infections, which can get at the culture of health care. She suggested discussing the processes of care and how to make people accountable.
- Dr. O'Neal proposed a focus on translational acceleration. Who should receive communications?
- Ms. Haskell suggested looking at the outpatient world. Many patients are lost following hospital stays.
Dr. Clancy thanked the NAC members and speakers. She stated that the issues of PCORI and patient perspectives will be addressed. Dr. Siegel thanked the AHRQ staff and adjourned the meeting at 3:00 p.m.