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Developing Tools and Data for Research and Policymaking
Efforts to improve the quality and efficiency of health care and reduce disparities in the United States must be based on a thorough understanding of how the Nation's health systems work and how different organizational and financial arrangements affect health care. AHRQ has a broad portfolio of data on costs, access to health care, quality, and outcomes that can be used for research and policymaking.
Medical Expenditure Panel Survey
The Medical Expenditure Panel Survey (MEPS) is the only national source of annual data on the specific health services that Americans use, how frequently the services are used, the cost of the services, and the methods of paying for those services. MEPS is designed to help us understand how the growth of managed care, changes in private health insurance, and other dynamics of today's market-driven health care delivery system have affected health care in America. MEPS provides the foundation for estimating the impact of changes on different economic groups or special populations such as the poor, elderly, veterans, the uninsured, or racial/ethnic groups.
MEPS consists of a family of surveys, which includes families and individuals, their medical providers, and employers across the United States. The MEPS Household Component full year public use data files released in 2007 cover the calendar year 2005. These data files include medical conditions, hospital inpatient stays, prescribed medicines, office-based medical provider visits, outpatient visits, emergency room visits, home health, other medical expenses, dental visits, full-year population characteristics, and job information.
The MEPS Insurance Component (MEPS-IC) collects data from a sample of private and public sector employers on the health insurance plans they offer their employees. The collected data include the number and types of private insurance plans offered (if any), premiums, contributions by employers and employees, eligibility requirements, benefits associated with these plans, and employer characteristics. MEPS-IC estimates are available on the MEPS Web site in tabular form for national, regional, state, and metropolitan areas, as well as in publications using MEPS-IC data and interactive data tools.
MEPS data helps estimate the economic impact of diabetes
Economic data derived from MEPS on the prevalence of diabetes-related complications were used in a report titled, The State of Diabetes Complications in America. Issued by the American Association of Clinical Endocrinologists, in partnership with the Amputee Coalition of America, Mended Hearts, the National Federation of the Blind, and the National Kidney Foundation, the report is an analysis of national health and economic data specific to type 2 diabetes complications. The report synthesized economic data from the 2000, 2002, and 2004 MEPS with data on prevalence of diabetes-related complications from the 1999-2004 National Health and Nutrition Examination Survey. It shows that an estimated 57.9 percent of the people with type 2 diabetes have at least one other serious health problem commonly associated with the disease, and that these health problems are taking a heavy financial toll. In 2006, the nation spent an estimated $22.9 billion on direct medical costs related to diabetes complications.
MEPS publishes various reports including statistical briefs, research findings, methodology reports, and chartbooks. These analytic publications are based on data collected through MEPS. For example:
- In 2005, prescription drugs represented about 20.8 percent of all medical expenditures for persons under age 65.
- In 2005, hospital inpatient expenses comprised the largest share of expenses for persons age 65 and over, while expenses for ambulatory care in office and hospital outpatient settings comprised the largest share for persons under age 65.
- From 1996 to 2006, the percentage of uninsured children declined from 15.7 percent to 11.0 percent. Hispanic or Latino children were the most likely to be uninsured in each year from 1996 to 2006 (19.9 percent in 2006).
- From 1997 to 2004, total expenditures for outpatient prescription drugs increased over 160 percent from $72.3 billion to $191.0 billion. The average expenditure for persons with a prescription medicine purchase age 65 and older increased approximately 130 percent (from $819 to $1,914), and approximately 140 percent (from $347 to $838) for persons under age 65 when comparing 1997 to 2004.
These reports, data files, and additional information on MEPS are available online at www.meps.ahrq.gov/.
Healthcare Cost and Utilization Project
The Healthcare Cost and Utilization Project (HCUP) is a family of health care databases and related software tools and products developed through a Federal-State-industry partnership and sponsored by AHRQ. HCUP databases bring together the data collection efforts of 38 State data organizations, hospital associations, private data organizations, and the Federal government to create a national information resource of patient-level health care data. HCUP includes the largest collection of all-payer encounter-level longitudinal hospital care data in the United States, beginning in 1988. These databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to health care programs, and outcomes of treatments at the national, State, and local market levels.
Infections with Methicillin-Resistant Staphylococcus Aureus (MRSA) in U.S. Hospitals, 1993 2005, Statistical Brief #35
- In 2005, there were about 368,600 hospital stays for infections with MRSA. In that year, hospital stays for these infections were more than three times higher than in 2000 and nearly ten times higher than in 1995.
- On average, hospital stays for MRSA infections cost $14,000, compared with $7,600 for all other stays, and the length of hospitalization was more than double—10 days for MRSA infections versus 4.6 days for all other stays.
- The in-hospital death rate for MRSA stays was 4.7 percent compared with 2.1 percent for non-MRSA stays.
Outpatient Data Initiatives
The largest growth in HCUP has been in outpatient data initiatives—the acquisition of additional State Ambulatory Surgery Databases and State Emergency Department Databases, partnership discussions about improving outpatient data collection and measurement of the quality of outpatient care, and dissemination of outpatient data and its capacity. In 2007, 25 States contributed data on ambulatory surgery and other outpatient services for a combined total of 37,158,615 visits in over 3,849 facilities. In addition, 24 States contributed outpatient emergency department (ED) data, for a combined total of 52,502,037 visits in 2,434 hospitals. Analysis began in 2007 to assess the feasibility and advisability of creating a nationwide ED database.
HCUP Statistical Briefs
The HCUP Statistical Briefs are a series of Web-based publications containing information from HCUP. These publications provide concise, easy-to- read information on hospital care, costs, quality, utilization, access, and trends for all payers (including Medicare, Medicaid, private insurance, and the uninsured). Each Statistical Brief covers an important health care issue. For example:
- The National Hospital Bill. In 2005, the national hospital bill totaled nearly $875 billion for 39 million hospital stays. This represents an increase of 89 percent since 1997. During this same time period the number of admissions increased from 34.7 million annually to 39.2 million—a 13 percent increase.
- Hospital Stays Related to Depression. In 2005, nearly 10 percent of all hospital admissions—2.9 million stays—were related to depression and totaled $21.8 billion in hospital costs.
- HIV Hospitalizations. Hospitalizations with a principal HIV diagnosis decreased by 21 percent from 93,870 in 1998 to 74,604 in 2005.
- Trends in Potentially Preventable Hospitalizations among Adults and Children. In 2004, hospital costs for potentially preventable conditions totaled nearly $29 billion or 1 out of every 10 dollars of total hospital expenditures. As many as 4.4 million hospital stays could possibly be prevented with better ambulatory care, improved access to effective treatment, or patient adoption of healthy behaviors.
AHRQ Quality Indicators
AHRQ has developed an array of health care decisionmaking and research tools that can be used by audiences such as program managers, purchasers, researchers, government agencies, and others. The AHRQ Quality Indicators (QIs) tool is widely used to highlight potential quality concerns, identify areas that need further study and investigation, and track changes over time.
The AHRQ QIs are a set of indicators organized into four modules, each of which measures quality associated with the delivery of care occurring in either an outpatient or an inpatient setting. In 2007, AHRQ released Version 3.1, an update of all four modules:
- Prevention Quality Indictors (PQIs) are ambulatory care-sensitive conditions that identify adult hospital admissions that evidence suggests could have been avoided, at least in part, through high-quality outpatient care.
- Inpatient Quality Indicators (IQIs) reflect quality of care for adults inside hospitals and include: inpatient mortality for medical conditions; inpatient mortality for surgical procedures; utilization of procedures for which there are questions of overuse, underuse, or misuse; and volume of procedures for which there is evidence that a higher volume of procedures may be associated with lower mortality.
- Patient Safety Indicators (PSIs) also reflect quality of care for adults inside hospitals, but focus on potentially avoidable complications and iatrogenic events.
- Pediatric Quality Indicators (PedQIs) are indicators of children's health care that can be used with inpatient discharge data. They are designed to help hospitals examine both the quality of inpatient care and the quality of outpatient care that can be inferred from inpatient data, such as potentially preventable hospitalizations.
The AHRQ QIs are being used for national, State-level, and hospital-level public reporting and tracking. For example, AHRQ's National Healthcare Quality and Disparities Reports and their derivative products incorporate many PQIs and PSIs for tracking and reporting at the national level. In addition, the demand for information to better inform consumers has increased—specifically the demand for standardized hospital-level comparative data as a result of concern over quality and patient safety in the hospital setting. Currently, there are 11 States that report some or all of the AHRQ QIs: Vermont, Texas, New York, Wisconsin, Massachusetts, Oregon, California, Utah, Florida, Kentucky, and Iowa.
Quality Indicators User Meeting
The Quality Indicators User Meeting was held in conjunction with AHRQ's 2007 Annual Meeting. Intended for both active users of the QIs and for those interested in how the QIs might be used in their organizations, sessions focused on:
- Validation studies in the literature and current research activities.
- Results from the AHRQ QI Validation Collaborative Pilot for selected Patient Safety Indictors.
- Guidance on use of the AHRQ QI medical record data collection tools to improve data quality and processes of care.
- Future directions for collaborative validation studies of the AHRQ QIs.
Preventable Hospitalization Costs
In October 2007, AHRQ released Preventable Hospitalization Costs: A County-Level Mapping Tool, a SAS software program that maps selected AHRQ QIs for a State (by county) and estimates the cost savings associated with reducing the level of potentially avoidable hospitalizations. The tool assists health care decisionmakers in identifying communities for future interventions, such as improving preventive and primary care services or improving patient safety, and tracking the impact of such interventions over time.
More information on the AHRQ QIs can be found on the Web site at www.qualityindicators.ahrq.gov.
PSIs and QIs form the basis of a Canadian hospital report card
The Fraser Institute in Canada has issued a hospital report card and
interactive Web site assessing 50 measures of patient safety and quality of
care for every acute care hospital in Ontario. The report uses AHRQ's Patient
Safety Indicators (PSIs) and Quality Indicators (QIs) as the basis for its
methodology. Both Fraser's report card and Web site include information for
all 136 acute care hospitals in Ontario from 1997 to 2005, comprising more
than 8.5 million patient records. Forty-three hospitals agreed to have their
institutions identified by name; other hospitals are shown anonymously in the
report by number. Using AHRQ PSIs and QIs, the report is based on anonymous
purchased from the Canadian Institute for Health Information (CIHI). These
data are used to produce various CIHI reports and indicators.
Consumer Assessment of Healthcare Providers and Systems
AHRQ has been the lead Federal agency in developing and distributing standardized, evidence-based surveys and related tools for assessing patients' experiences with the U.S. health care system. The Agency's Consumer Assessment of Health Care Providers and Systems (CAHPS) program has become the focal point of a national effort to measure, report on, and improve the quality of health care from the perspective of consumers and patients. CAHPS develops and supports the use of a comprehensive and evolving family of standardized surveys that ask consumers and patients to report on and evaluate their experiences with health care. The program was originally launched as the Consumer Assessment of Health Plans Study but as the products have evolved beyond health plans, the name has evolved as well to capture the full range of survey products and tools.
CAHPS® Hospital Survey Chartbook
In 2007, CAHPS® released the CAHPS® Hospital Survey Chartbook, which presents summary-level results from the CAHPS® Hospital Survey (HCAHPS) voluntarily submitted by 927 hospitals representing a total of 190,690 respondents across the country in 2006. AHRQ's National CAHPS® Benchmarking Database (the CAHPS® Database) compiled these summary data for use by hospitals and their vendors for comparison to their own results prior to the public reporting of H-CAHPS by the Centers for Medicare & Medicaid Services (CMS) in March of 2008. Highlights of the survey results presented in this report include:
- High ratings for hospital care by a majority of survey respondents with 60 percent of survey respondents rated their hospitals either "9" or "10" on a 10-point scale where "0" is the "worst possible hospital" and "10" is the "best possible hospital."
- Highest scores for communication with doctors and nurses with 84 percent and 77 percent of respondents reporting that doctors and nurses (respectively) always treated them with courtesy and respect.
- Lowest scores for communication about medications and discharge information with 26 percent of respondents reporting that hospital staff never described possible side effects of new medications in a way they could understand.
- High-to-moderate scores for pain management and the hospital physical environment with 72 percent of respondents reporting that hospital staff always did everything they could to help with pain. However, only 59 percent reported that their pain was always well controlled when they needed pain medication.
Interactive Chartbook: CAHPS® Hospital Survey
CAHPS® released the CAHPS® Hospital Survey Chartbook, which presents summary-level results from the CAHPS® Hospital Survey (H-CAHPS) in 2006. In 2007, CAHPS® released an Interactive Chartbook designed to present summary level H-CAHPS results by selected hospital characteristics (region, bed size, teaching status, and ownership and control) or by selected respondent characteristics (gender, age, race, and self-reported health status). The Interactive Chartbook includes a question bank so that users can view the following:
- A list of questions from the H-CAHPS or frequency of responses for a particular question.
- Question level frequencies and cross tabulations for individual survey questions.
- Bar charts showing the distribution of survey results for each of the H-CAHPS composites and question items.
CAHPS® Health Plan Survey Chartbook
The 2007 CAHPS® Health Plan Survey Chartbook presents national summary-level results for the CAHPS® Health Plan Survey 3.0 and 4.0 versions. Data for the adult commercial, adult and child Medicaid, and Medicare Managed Care sectors are presented. Key findings related to the 4.0 survey results include:
- The majority of survey respondents rate their medical care providers highly. Fully 60
percent or more of respondents across all sectors rated their personal doctors and specialists either "9" or "10" on a 10-point scale where "0" is the worst possible and "10" is the best possible.
- Respondents rate their health plans and overall health care lower than they rate their personal doctors and specialists. Commercial plan enrollees rate their health plans the lowest across the sectors, with only 40 percent of respondents scoring their plans a "9" or "10."
- Respondents report the most positive experiences for questions related to "how well doctors communicate." Nearly 70 percent or more of all respondents report that their doctors "always" explain things, listen carefully, and show respect for what they had to say.
- Respondents report the least positive experiences for questions about "health plan customer service." Less than half of commercial plan respondents report "always" getting needed help or information from their health plan.
CAHPS® Item Set for Children with Chronic Conditions
To better address the needs of children with chronic conditions, the CAHPS® Consortium adopted an extensive set of items that would enable users to assess the experiences of this population with health plans and health care services. This supplemental set allows sponsors to compare the experiences of children with special health care needs with those of similar children in other health plans and/or the general population of children in the same plan. In July 2007, the CAHPS® Consortium released an updated item set for the CAHPS® Health Plan Survey 4.0.
Clinician & Group Survey and Reporting Kit 2007
The CAHPS® Clinician & Group Survey and Reporting Kit 2007 provides access to the CAHPS® Clinician & Group Survey as well as several documents designed to assist users in administering the survey and analyzing the results. The CAHPS® Clinician & Group Survey asks patients to report on and rate their experiences with a specific physician and that physician's practice. Questionnaires are available in English and Spanish for adults and children who have visited a physician in adult primary or specialty care and child primary care.
Talking Quality's Report Card Compendium
AHRQ developed a new Web tool demonstrating a variety of approaches for health quality report cards.
The new Health Care Report Card Compendium is a searchable directory of over 200 samples of report
cards produced by a variety of organizations. It can inform and support the various organizations that
develop health care quality reports, provide easy access to examples of different approaches to content
and presentation, and meet the needs of health services researchers. The compendium was developed
as a resource for report sponsors to supplement guidance provided on AHRQ's TalkingQuality Web site
(http://www.ahrq.gov/professionals/quality-patient-safety/talkingquality/index.html). The Health Care Report Card Compendium can be found at https://www.talkingquality.ahrq.gov/content/reportcard/search.aspx.
CAHPS® Health Plan Survey and Reporting Kit 2007
The CAHPS® Health Plan Survey and Reporting Kit 2007 includes both the 3.0 and the new 4.0 versions of the CAHPS® Health Plan Survey. The contents include questionnaires for adults and children enrolled in commercial or Medicaid plans in both English and Spanish.
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Preparing for Public Health Emergencies
AHRQ supports research and the development of models, tools, and reports to assess, plan, and improve the ability of the U.S. health care system to respond to public health emergencies that result from natural, biological, chemical, nuclear, and infectious disease events. These initiatives focus on an array of issues related to clinicians, hospitals, and health care systems, including the need to establish linkages among these providers with local and State public health departments, emergency management personnel, and others preparing to respond to events that have the potential to cause mass casualties. In 2007, AHRQ released several new resources for emergency response planners and health care providers.
Mass Medical Care with Scarce Resources
Mass Medical Care with Scarce Resources is a guide to provide planners at the facility, community, State, and Federal levels with valuable information that will help them plan for and respond to a mass casualty event (MCE). The guide was written by leading experts in six areas related to mass casualty care: prehospital care, hospital and acute care, alternative care sites, palliative care, ethical issues, and legal considerations. This guide provides information on:
- The circumstances that communities likely would face as a result of an MCE.
- Key constructs, principles, and structures to be incorporated into planning for an MCE.
- Approaches and strategies that could be used to provide the most appropriate standards of care possible under the circumstances.
- Examples of tools and resources available to help States and communities in their planning process.
- Illustrative examples of how certain health systems, communities, or States have approached certain issues as part of their MCE-related planning efforts.
Preparedness for Chemical, Biological, Radiological, Nuclear, and Explosive Events: Questionnaire for Health Care Facilities
States, localities, and hospitals can use this questionnaire in assessing emergency preparedness. The fully functional, downloadable questionnaire is designed to collect information on preparedness and response activities that are the responsibility of and under the control of hospital leadership. The questionnaire covers activities that could be executed by hospitals and was developed for two types of users:
- States, localities, and multi-hospital systems can administer the survey to hospitals and health care facilities to assess overall hospital emergency preparedness.
- Individual hospitals or health care facilities can use the questionnaire as a checklist of areas that should be considered as a facility develops or improves emergency preparedness and response plans. The questionnaire also serves as a checklist for planning, performing, and evaluating drills or exercises.
The questionnaire is available on AHRQ's Web
site at www.archive.ahrq.gov/prep/cbrne/.
Cross Training Respiratory Extenders for Medical Emergencies (Project XTREME)
AHRQ released a DVD titled "Cross Training Respiratory Extenders for Medical Emergencies (Project XTREME)," to train health care professionals who are not respiratory care specialists to provide basic respiratory care and ventilator management to adult patients in any mass casualty event. The DVD includes six training modules with interactive quizzes to test viewers' knowledge. The modules cover infection control, respiratory care terms and definitions, manual ventilation, mechanical ventilation, airway maintenance, and airway suctioning.
Emergency Preparedness Atlas: U.S. Nursing Home and Hospital Facilities
The Emergency Preparedness Atlas: U.S. Nursing Home and Hospital Facilities publication is intended to help local communities identify the health care facilities that could be available and prepared to provide assistance under emergency conditions in their communities. The Emergency Preparedness Atlas includes six case studies in North Carolina, Oregon, Pennsylvania, southern California, Washington, and Utah with a series of maps depicting the locations and capacity of nursing homes and hospitals as well as their geographic relationship to emergency management and bioterrorism preparedness regions, such as HAZMAT response regions, emergency management regions, and Red Cross chapters.
Also published with the Atlas is a report, Nursing Homes in Public Health Emergencies, which presents the results of a series of focus groups convened to collect information about disaster-and bioterrorism-related planning activities among nursing homes in the same six States used in the Atlas case study series. The report addresses the roles that nursing homes could play in regional preparedness.
Adapting Community Call Centers for Crisis Support: A Model for Home-based Care and Monitoring
This report, Adapting Community Call Centers for Crisis Support: A Model for Home-based Care and Monitoring, recommends expanding the capabilities of poison control centers, nurse advice lines, and drug information centers and health agency hotlines to assist persons at home or in public shelters in the event of public health emergencies. The report and its four appendices include strategies for using these types of community call centers in the event of aerosol anthrax attacks, pandemic influenza, plague, or food contamination.
The strategies and tools are designed to help community call centers respond to callers concerned about their health risks; collect disease surveillance data; assist with sorting calls according to urgency and decision support for health concerns; assist with monitoring or contacting persons quarantined at home; help callers identify dispensed drugs, provide instructions on how to take them, and explain potential adverse reactions; and train health call center staff to identify callers who may benefit from referral to mental health care providers.
Recent Research Findings on Public Health Emergency Preparedness
- Researchers examined hospital emergency department (ED) daily surge as a foundation to more accurately predict how well hospital EDs will respond to a catastrophic surge in demand for their services. The researchers propose that daily and catastrophic ED surge can be measured by the magnitude of the surge, as well as by the nature and severity of the illnesses and injuries of arriving patients. The magnitude of an ED surge can be measured by the patient arrival rate per hour. The nature and severity of the surge can be measured by the type (for example, trauma, infection, or biohazard) and acuity (triage level) of the surge.
- A proposed system that identifies patients who can be discharged early can improve hospital surge capacity. Researchers developed a classification system that categorizes inpatients according to suitability for immediate discharge, a type of reverse triage. Patients with a risk too high for a simple discharge home are patients potentially suitable for transfer to another medical facility. Patients at high risk can be transferred to a major acute facility only. Finally, very high-risk patients are patients who might be too unstable or critically ill even for transfer to another facility. AHRQ has funded more than 60 emergency preparedness-related studies, workshops, and conferences to help hospitals and health care systems prepare for public health emergencies. More information about these projects can be found online at www.archive.ahrq.gov/prep/.
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Looking to the Future
In 2008, AHRQ will continue its mission to improve the quality, safety, and cost-effectiveness of health care in America with a focus on greater uptake and use of its tools and research. Examples from key programs and initiatives follow.
Patient Safety Culture Surveys
Using the Hospital Survey on Patient Safety Culture as a starting point, new surveys addressing resident safety culture in nursing homes and patient safety culture in ambulatory outpatient medical offices are under development. Each of the new surveys will contain new and revised items assessing dimensions that more accurately apply to each setting.
New Priority Topics for the Effective Health Care Program
Through discussion with and extensive input from stakeholders, the Secretary of the Department of Health and Human Services chose 10 priority conditions to guide this work in 2008:
- Arthritis and nontraumatic joint disorders (Muscle, bone, and joint conditions).
- Cancer (Cancer).
- Chronic obstructive pulmonary disease and asthma (Breathing conditions).
- Dementia including Alzheimer's disease (Brain and nerve conditions).
- Depression and other mood disorders (Mental health).
- Diabetes mellitus (Diabetes).
- Ischemic heart disease (Heart and blood vessel conditions).
- Peptic ulcer disease and dyspepsia (Digestive-system conditions).
- Pneumonia (Breathing conditions).
- Stroke and hypertension (Heart and blood vessel conditions).
Collaboration to Study Possible Heart Risks with ADHD Medications
AHRQ and the Food and Drug Administration will collaborate in the most comprehensive study to date of prescription medications used to treat attention deficit hyperactivity disorder (ADHD) and the potential for increased risk of heart attack, stroke or other cardiovascular problems. Researchers will examine the clinical data of about 500,000 children and adults who have taken medications used to treat ADHD to determine whether those drugs increase cardiovascular risks.
Evidence-based Practice Centers Topics In Progress
The Evidence-based Practice Centers are expected to release a number of new reports in 2008. The following is a list of some of the topics for which work has begun on evidence reports:
- Regulation of Healthcare Costs. This report will examine the effects of mandates on health insurance/health maintenance organization premiums, insurer administrative costs, the likelihood of being uninsured, and access to providers.
- Barriers and Drivers of Health IT Use for the Elderly, Chronically Ill, and Underserved. This report will examine the current level of use of consumer health IT in the elderly, chronically ill, and medically-underserved populations, its effectiveness in improving outcomes, barriers, and what facilitators may stimulate the use of consumer health IT.
- Effectiveness of Weight Reduction Programs in Children. This report will examine what is known about the effectiveness and safety of weight reduction programs, drug therapies, and surgical therapies for treatment of overweight or obese children.
The CAHPS® Team has initiated the development of new sets of supplemental survey items in development during 2007 and expected to be released in 2008:
- CAHPS® Health Literacy Item Set. This set of supplemental items will ask adults to report on their providers' efforts to improve their health literacy.
- CAHPS® Health Information Technology Item Set. This item set will ask patients about their experiences with health information technology in the context of care from a physician.
The evidence developed through AHRQ sponsored research and analyses helps everyone involved in patient care make more informed choices about what treatments work, for whom, when, and at what cost. Health care quality is improving, but much more remains to be done to achieve optimal quality. AHRQ will continue to invest in successful programs that develop and translate useful knowledge and tools so that the end result of the Agency's research will be measurable improvements in health care in America through improved quality of care and patient outcomes and value gained for what we spend.
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Current as of July 2007