Meeting Minutes, July 2016

Contents

Summary
Call to Order and Approval of April 20, 2016, Summary Report
Director's Update
Update on the Synthesis of Evidence
Results from the Medical Expenditure Panel Survey 2015 Insurance Component
AHRQ’s Role in Quality Measurement
Public Comment
Adjournment

Summary

NAC Members Present

Elizabeth A. McGlynn, Ph.D., Kaiser Permanente (Chair)
David J. Ballard, M.D., Ph.D., M.S.P.H., FACP, STEEEP Global Institute, Baylor Scott & White Health
Christina J. Calamaro, Ph.D., CRNP, Nemours/Alfred I. duPont Hospital for Children
Shari Davidson, National Business Group on Health (via telephone)
Jennifer E. DeVoe, M.D., D.Phil., M.Phil., M.C.R., Oregon Health & Science University (via telephone)
Robert S. Dittus, M.D., M.P.H., Vanderbilt University Medical Center
José Julio Escarce, M.D., Ph.D., University of California, Los Angeles (via telephone)
Donald A. Goldmann, M.D., Institute for Healthcare Improvement, Harvard Medical School
Kevin L. Grumbach, M.D., School of Medicine, University of California, San Francisco
Ann L. Hendrich, Ph.D., R.N., FAAN, Ascension Health
Mary D. Naylor, Ph.D., R.N., FAAN, University of Pennsylvania School of Nursing
Monica E. Peek, M.D., M.P.H., M.Sc., The University of Chicago
Lucy A. Savitz, Ph.D., M.B.A., Intermountain Healthcare (via telephone)
J. Sanford Schwartz, M.D., University of Pennsylvania
Paul E. Sherman, M.D., M.H.A., CPE, FAAP, Group Health Physicians
Patricia J. Skolnik, Citizens for Patient Safety
Jed Weissberg, M.D., FACP, Institute for Clinical and Economic Review

Alternates Present

Liza M. Catucci, U.S. Department of Veterans Affairs (for David Atkins, M.D.)
Paul E. McGann, M.D., Centers for Medicare & Medicaid Services (for Patrick Conway, M.D.)
Charles J. Rothwell, M.B.A., M.S., National Center for Health Statistics, Centers for Disease Control and Prevention
Nancy E. Miller, Ph.D., National Institutes of Health

AHRQ Staff Members Present

Andrew B. Bindman, M.D., Director
Sharon B. Arnold, Ph.D., Acting Director
Jaime Zimmerman, M.P.H., PMP, Designated Management Official
Karen Brooks, CMP, NAC Coordinator

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Call to Order and Approval of April 20, 2016, Summary Report

Elizabeth A. McGlynn, Ph.D., Chair of the National Advisory Council (NAC), Agency for Healthcare Research and Quality (AHRQ), called the group to order at 8:35 a.m. and welcomed the NAC members, other participants, and visitors, including viewers of the meeting’s Webcast. She referred to the draft minutes of the previous NAC meeting (April 20, 2016) and asked for changes and approval. The NAC members voted unanimously to approve the April meeting minutes with no changes.

Dr. McGlynn welcomed new NAC member Robert S. Dittus, M.D., M.P.H., of Vanderbilt University, who was attending his first NAC meeting. She asked the NAC members to introduce themselves and noted that the meeting’s agenda would include two periods for public comment.

Dr. McGlynn introduced Andrew B. Bindman, M.D., who became the new Director of AHRQ on May 2, 2016. Dr. Bindman has served as Professor of Medicine and Epidemiology & Biostatistics at the University of California, San Francisco, and has deep experience in health services research and the area of health care quality. He is a primary care physician and, as a researcher, has focused on health care access for people of low socioeconomic status. His areas of expertise also include the training of physicians and health services researchers, developing policy, and translating policy into practice. Dr. Bindman has advised various Federal planning groups, including the House Energy and Commerce Committee, the Assistant Secretary for Planning and Evaluation’s Office of Health Policy, and the Centers for Medicare & Medicaid Services (CMS).

Dr. McGlynn noted that she and Dr. Bindman hope to discuss with the NAC members ways in which the NAC can engage better outside NAC meetings, especially about issues of Patient-Centered Outcomes Research (PCOR). That could include the formation of a subcommittee and interacting with the PCOR Institute (PCORI).

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Director's Update

Andrew B. Bindman, M.D., Director, AHRQ

Dr. Bindman welcomed the NAC members, speakers, and other guests. He thanked the council members for the time they devote to advising the agency, and he thanked AHRQ staff for contributing to the ease of his transition. He cited his past experience with AHRQ’s work, including consulting with former AHRQ directors, Dr. John Eisenberg, Dr. Carolyn Clancy, and Dr. Richard Kronick.

Dr. Bindman reported that the agency recently received feedback from NAC members, encouraging it to create continuity for the topics of NAC discussions, to make the NAC meetings more interactive and less didactic, to forward background and links prior to meetings, and to improve the usability of the AHRQ Web site. He reported that the agency has been responding to suggestions made in the previous NAC meeting, developing information about paylines for AHRQ grants, seeking input for meeting topics, and planning new documents about AHRQ tools and resources for specific audiences.

Transitions and News

Dr. Bindman noted the following agency transitions and news:

• Mary D. Naylor, Ph.D., R.N., FAAN, recently won the 2016 Distinguished Investigator Award at the AcademyHealth Annual Research Meeting.
• Dr. McGlynn recently became Chair of the American Board of Internal Medicine Foundation.
• Dr. Robert S. Dittus was appointed to the NAC.
• Paul Ginsburg, Ph.D., recently was appointed to the Medicare Payment Advisory Commission and resigned from the NAC.
• AHRQ created a Web site featuring profiles of and interviews with grantees whose work has led to changes in policy and influenced research and practice.
• AHRQ recruited Theodore G. Ganiats, M.D., to be the new Director of the National Center of Excellence in Primary Care.
• AHRQ is planning a research summit titled “Improving Diagnosis in Health Care,” to be held at AHRQ headquarters September 28, 2016. Goals of the summit include highlighting AHRQ’s unique role; exploring the state of the science of diagnosis in health care; and identifying research, evidence, tools, training, measures, and data needed to improve diagnostic performance.

Agency Budget

Dr. Bindman stated that the FY 2016 AHRQ budget is $334 million, which is $29.7 million less than the previous year’s budget (an 8% drop). Because of the decrease, AHRQ is eliminating the Quality Measures Clearinghouse, MONAHRQ (My Own Network, Powered by AHRQ), and the Health Care Innovations Exchange. It has been seeking efficiencies in the production of the National Healthcare Quality and Disparities Report. There will be no new evidence reviews (except for a review of opioid research), no new implementation and rapid-cycle research projects, no program evaluations, and decreased dissemination and implementation activities. There will be no new research related to multiple chronic conditions, and the grant funding for research to reduce the abuse of opioid drugs will be reduced by $1 million.

FY 2016 new grants include 21 awards for research to improve health care quality by implementing PCOR; 53 awards for research to make health care safer; 11 awards for research to increase accessibility as it relates to insurance coverage; and 42 awards for research to improve health care affordability, efficiency, and cost transparency.

For FY 2017, the President requested $363.7 million in discretionary funding for AHRQ. AHRQ’s total program level request is $469.7 million, which includes $106 million in mandatory funds from the PCOR Trust Fund. The House Appropriations Committee has recommended $280.2 million for FY 2017. It did not propose terminating or defunding AHRQ. The Senate Subcommittee on Labor, Health, and Human Services recommended $324 million. Dr. Bindman stated his belief that support for AHRQ has become stronger in Congress and the U.S. Department of Health and Human Services.

Patient-Centered Outcomes Research Activities

Dr. Bindman presented the following updates for AHRQ’s work in PCOR:

• AHRQ is inviting researchers and other stakeholders to nominate PCOR findings that deserve further investment to achieve widespread adoption. It will consider them for dissemination and implementation activities. It will support scaling up.
• AHRQ released a special emphasis notice: "Advancing the Collection and Use of Patient-Reported Outcomes and Patient Contextual Data To Improve Quality and Outcomes in Ambulatory Care Through Health Information Technology."
• AHRQ launched the PCOR Clinical Decision Support Learning Network, awarding a cooperative agreement to the Research Triangle Institute in April. The program will engage stakeholders to identify and disseminate best practices for using clinical decision support as a tool to incorporate PCOR findings into clinical practice. Information can be found at http://www.pcorcds-ln.org. Two funding grant opportunities are available.

Dr. Bindman asked the NAC members to consider the possible formation of a subcommittee devoted to PCOR. Dr. Dittus supported the idea, stating that patient-centered outcomes and patient-contextual variables need to be identified. Variations toward improvements need to be explained. Dr. Naylor cautioned that a NAC/PCOR subcommittee will need to avoid bureaucratic redundancy. It could address issues regarding social determinants. Lucy A. Savitz, Ph.D., M.B.A., proposed that such a subcommittee include a focus on the patient perspective. The NAC members voted to create a NAC subcommittee for PCOR issues.

How AHRQ Makes a Difference

Dr. Bindman stated that AHRQ invests in research and evidence to understand how to make health care safer and improve quality. It creates materials to teach and train health care systems and professionals to catalyze improvements in care. It generates measures and data used to track and improve performance and to evaluate progress. Dr. Bindman presented the following agency updates:

Research and Evidence

• AHRQ released a new Special Emphasis Notice to fund exploration of how enhanced care planning can improve care for people living with multiple chronic conditions. It released a new Funding Opportunity Announcement for a cooperative agreement to support the dissemination and implementation of a subset of new child health quality measures developed by the Pediatric Quality Measures Program—Centers of Excellence.
• The agency will use $9 million over 3 years to support, with grants, primary care practices and rural communities in delivering medication-assisted treatment to patients. Grantees include the American Institutes of Research; the University of Colorado, Denver; and the Pennsylvania State Department of Human Services.
• In recent months, the U.S. Preventive Services Task Force (USPSTF) released final recommendations for screening for syphilis infection in nonpregnant adults and adolescents and screening for colorectal cancer. Draft recommendations in a number of areas also were made (e.g., primary care interventions to support breastfeeding, screening for celiac disease).
• The Evidence-based Practice Centers (EPCs) performed systematic reviews in areas including diabetes medications, disparities for serious mental illness, and imaging for staging of small-cell lung cancer. Methods Reports included the topics of AHRQ end-user perspectives of rapid reviews and the use of text-mining software in reviews.
• AHRQ released a new Technical Report titled Telehealth: Mapping the Evidence for Patient Outcomes From Systematic Reviews. The report states that 1) there is evidence to support the effectiveness of telehealth for remote monitoring, 2) research should shift from assessment to promoting broader implementation, and 3) systematic reviews for some specific topics would be helpful.

Tools and Training

• AHRQ produced an online toolkit (Communication and Optimal Resolution, or CANDOR) to help hospital leaders and clinicians communicate accurately and openly with patients and families when harm occurs.
• The AHRQ-supported Comprehensive Unit-Based Safety Program has been used to reduce urinary tract infections in hospitals, with infections in departments outside of the intensive care unit being reduced by 32 percent.
• With AHRQ support, researchers developed a new tool to retrospectively identify adverse events in pediatric hospital patients. The Global Assessment of Pediatric Patient Safety, or GAPPS, tool uses either electronic or written data.
• AHRQ is supporting the Academic Community, an online community that brings together individuals and practices interested in delivering comprehensive, integrated health care. The agency developed an Integration Playbook, or how-to guide (also online), for integrating behavioral health and primary care.
• AHRQ supported an independent evaluation of its Career Development (K) Award program, focusing on research career outcomes and impacts on research, practice, and policy. One finding was that successful applicants experienced more subsequent research funding and higher publication rates (when compared with unsuccessful candidates).
• AHRQ released a Funding Announcement for a Career Development Award (K01) to help emerging independent health services research investigators prepare for careers focusing on the quality, safety, efficiency, equity, and effectiveness of health care.

Data and Methods

• AHRQ’s program to identify, classify, and compare health care delivery systems to accelerate the dissemination and implementation of PCOR evidence has moved forward. This program in comparative health system performance features the use of $58 million over 5 years for cooperative agreements with three Centers of Excellence (Dartmouth/Berkeley, NBER/HRET, and RAND/Penn State). A contract to create a coordinating center was awarded to Mathematica Policy Research in January. Workgroups have been developed, and an annual grantee workshop will take place in September. Many grants have been assigned by the centers. A result of the program will be development of a compendium on comparative health system performance, including lists of health systems and physicians, data, descriptive statistics, and identified characteristics of high-performance health systems.
• An AHRQ-supported report found that since the Affordable Care Act went into effect, the rate of uninsured Americans younger than 65 decreased from 18 to 10 percent.

Discussion

Regarding the AHRQ budget trend, Dr. Bindman encouraged the NAC members to be aware of AHRQ programs and to be ready to communicate their impact and describe AHRQ’s special role. Sharon B. Arnold, Ph.D., cited a strong role of AHRQ’s Action Network (accelerating the diffusion of research into practice) and AHRQ’s ability to disseminate PCOR information. Dr. Dittus suggested that AHRQ build on the National Institutes of Health’s Precision Medicine Initiative. Donald A. Goldmann, M.D., encouraged the agency to share with the NAC members its concerns, including the impact of current budget reductions.

Francis Chesley, Jr., M.D., Director of AHRQ’s Office of Extramural Research, Education, and Priority Populations, noted that the evaluation of the K training awards program also looked at the numbers of awardees still engaged in research and at subsequent tenure and promotion. J. Sanford Schwartz, M.D., stressed the importance of such assessments. Dr. Bindman suggested that the topic of measuring program impact in general be addressed in a future NAC meeting.

Dr. Goldmann added the idea of measuring the benefits of AHRQ partnerships (as in information technology partnerships).

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Update on the Synthesis of Evidence

Arlene S. Bierman, M.D., M.S., Director, Center for Evidence and Practice Improvement, AHRQ

Dr. Bierman described AHRQ’s EPC Program. The program features a cohort of contracted centers, which perform reviews of the scientific literature. Established in 1997, the program now comprises 13 EPC sites and a Scientific Resource Center. The EPC reviews are stakeholder-driven, scientifically rigorous, independent, and unbiased. They play an important role in the development of evidence-based medical practice.

The program produces written systematic reviews, technical briefs, methods reports, and technology assessment reports. It seeks to globalize the evidence while allowing partners to localize decisions. Stakeholders include research funders, policymakers, health care organizations, guideline developers, knowledge translation groups, clinicians, and consumers. The process for producing the reviews/reports includes topic generation, topic refinement, review of the research, report translation, and dissemination. The following are examples of the uses of EPC products in recent years:

• Used by Kaiser Permanente in developing clinical guidelines.
• Used by the USPSTF and the Community Preventive Services Task Force in developing guidelines.
• Used in government conferences/deliberations, such as those of the Office of Medical Applications of Research.
• Used for meetings of the Medicare Evidence Development & Coverage Advisory Committee.
• Used as a basis for benefit guides for the National Business Group on Health.
• Used by CMS in developing its Medicare High-Cost Drugs Dashboard.

Dr. Bierman noted AHRQ’s support for methods used by the program, including development of a methods guide and a data repository based on past reviews. Some high-impact reviews are updated continuously in a 5-year cycle. Dr. Bierman asked the NAC members to comment on the program and discuss issues such as the difficulty in making recommendations when interventions are complex and heterogeneous. What is AHRQ’s role? How should it partner strategically to maximize the impact of EPC reports?

Discussion

Dr. Bindman noted that PCORI has a need for evidence-based reviews. AHRQ must work with PCORI while avoiding redundancies. Monica E. Peek, M.D., M.P.H., M.Sc., added that there are many ways to develop evidence. In response to a question, Dr. Bierman stated that the EPC Program engages with developers of drugs and devices and works with the U.S. Food and Drug Administration and other government agencies. One large challenge for the program is the varying quality of studies that are examined.

Drs. Dittus and Naylor expressed enthusiasm for AHRQ’s key role as a standard for this process. How might the agency build on that? One critical direction for the future features dealing with complex medical interventions and synthesizing evidence. How might nonrandomized data and observational data be integrated into reviews? AHRQ could develop a methodology for that. Dr. Goldmann suggested exploring the use of data visualization techniques and considering needs of both patients and providers. Dr. Bierman stated that many review results miss aspects of a topic. The reports tend to be dense and difficult for readers to access. Dr. Goldmann suggested making use of small text boxes that point to the significance of particular points.

Christina J. Calamaro, Ph.D., CRNP, suggested that AHRQ play a larger role in determining what topics are relevant or critical. What deserves to be updated? Kevin L. Grumbach, M.D., asked what the criteria are for actionable evidence.

The NAC members agreed that AHRQ should work to communicate better the results of reviews. It should consult with stakeholders to identify strategies for encouraging results to be used. Dr. Bierman noted that ARHQ is considering the integration of digital resources, as in creating links to specific reports.

Dr. Savitz wondered whether certain organizations could become champions for AHRQ and its products. Shari Davidson offered to forward data from the National Business Group on Health to AHRQ for dissemination. Dr. McGlynn stated that her group (Kaiser Permanente) has a program that examines why some ideas fail to spread or become accepted. The answer can involve system factors. She called for the production of real-world evidence in addition to trial results. She emphasized the need to use a preanalytic framework that will allow small studies to be brought together.

Dr. Bindman stated that AHRQ is considering the stages of production and working to ensure that the systematic reviews find application. The agency needs strategic direction regarding priorities. It must invest wisely, demonstrate impact, and help to sustain efforts over time.

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Results from the Medical Expenditure Panel Survey 2015 Insurance Component

Joel E. Cohen, Ph.D., Director, Center for Financing, Access, and Cost Trends, AHRQ

Dr. Cohen presented recent reports from the Insurance Component of the Medical Expenditure Panel Survey (MEPS-IC). The MEPS-IC is an annual accounting of insurance offered by private-sector establishments and State and local governments. It provides estimates of premiums, contributions, offerings, eligibility, and enrollment. Results are posted on the AHRQ Web site as a statistical brief and in a larger chartbook (to come). They reveal national trends.

Dr. Cohen presented a data graph showing that enrollment of private-sector employees in employee-sponsored health insurance has declined very slightly over the past few years, yet remains near 50 percent. The decline for small businesses (fewer than 50 employees) is slightly steeper than the declines for large and medium-sized businesses.

Other areas that have demonstrated stability over the past few years are the percentage of private-sector employees eligible for health insurance at establishments that offer health insurance and the percentage of eligible private-sector employees who are enrolled in health insurance at establishments that offer health insurance. The average total single premium per enrolled private-sector employee rose in a steady fashion from 2008 to 2015. The same was true for the average annual employee contribution for single coverage, for employee-plus-one coverage, and for family coverage. There were slight differences based on the size of the firm.

Discussion

The NAC members asked whether the MEPS Program can get at finer structures, or aspects, of plans, such as their generosity. Ms. Davidson offered to forward to AHRQ data on numbers of employees in family plans. Dr. Schwartz suggested that AHRQ deserves more credit for the MEPS, which has great value. The MEPS-IC Program perhaps should consider additional related measures, such as trends in employee income or family income. Dr. Cohen stated that the program does collect some information on incomes and attempts to consider what policymakers and other stakeholders need to know. Charles J. Rothwell, M.B.A., M.S., suggested that data from the other MEPS projects could help to illuminate the trends in the MEPS-IC.

Dr. McGlynn asked the NAC members to consider further the topic of research that relates to comparative systems. Dr. Naylor stated that such research needs to consider the partners in the health care process and the various instances of integration. Dr. Bindman cited the difficulty in defining the health care system. We must consider the markets and the presence of multiple insurers. How do systems work in light of the possible use of evidence to affect outcomes? Dr. McGlynn cited the importance of linkages in a community, including data linkages.

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AHRQ’s Role in Quality Measurement

Elizabeth A. McGlynn, Ph.D., NAC Chair, and Sharon B. Arnold, Ph.D., AHRQ Deputy Director

Dr. McGlynn presented questions that must be considered in arriving at health care quality measures that matter to patients and the public.

• What does one mean by measures that matter?
• What types of decisions are relevant?
• What kinds of measures are to be considered?
• Are there differences between the public and patients with respect to what matters?
• What do we know already?

Measures matter differently for patients and the public. Measures stimulate health systems to pay attention to performance in key areas. They are useful for decisionmaking. However, target audiences are heterogeneous, and there is a wide array of potential decisions for which information might be useful. A variety of measures lie within areas, including standardized clinical measures, patient-reported outcomes, patient experiences, and costs of care. The public wants the best doctors, hospitals, nursing homes, home health agencies, health plans, and more to be recognized and paid appropriately. It wants the whole system to be improved. In contradistinction, patients seek to find the doctor, hospital, nursing home, home health agency, or health plan best for themselves.

Dr. McGlynn listed the various uses of measures by patients and the public and the different attributes of measures that apply to either patients or the public. Quality rankings are rarely used by patients. Dr. McGlynn stated that we need to learn more about how patients make decisions, what information is most useful, and how information is obtained. She suggested that one large improvement in research design would be the engagement of real people in the research.

Discussion

Dr. Calamaro cited the importance of speaking to patients about alternative interventions. Dr. Dittus stressed the importance of the manner of presenting information. Patricia J. Skolnik suggested that most patients are unaware of the existence of measures and measurements. Physicians ought to explain them to patients. Dr. Goldmann stated that most people have difficulty finding ratings for specific procedures. He suggested that health care ratings based on measures are not appreciated in the way that, for example, restaurant ratings are appreciated. That should be studied.

Dr. Arnold described AHRQ’s role in health care quality measurement. "Quality" in AHRQ’s name refers to quality improvement, quality measurement, and quality reporting. The agency supports the following:

• Research and data development.
• Measure development.
• Measure stewardship.
• Measure dissemination and implementation.

AHRQ’s work in measure development and stewardship has been growing in recent years. Dr. Arnold listed current AHRQ activities devoted to the four areas listed. AHRQ’s Quality Indicators are measures of health care quality that make use of readily available hospital inpatient administrative data. There are more than 101 Quality Indicators, 40 of which have been endorsed by the National Quality Forum.

AHRQ’s Consumer Assessment of Healthcare Providers and Systems Program features surveys of consumers and patients, who describe their health care experiences. The surveys focus on aspects of quality. AHRQ has been developing a Pediatric Quality Measures Program with an emphasis on stewardship of the measures. Dr. Arnold asked the NAC members to discuss whether quality measurement should remain a part of AHRQ’s portfolio and where AHRQ should focus its resources.

Jennifer E. DeVoe, M.D., D.Phil., M.C.R., raised the issues of population disparities and heterogeneity and how they affect measurement. That is one reason people ignore measures. We need, as one example, more research on risk adjustment. Dr. Goldmann stressed the problem of maintaining measurement once it is developed. We need to learn from the testing of prototypes. The National Quality Forum has a focus on accountability, which can be helpful. It is important to define measures as targeting quality improvement.

Dr. Grumbach mentioned the difficulty in distinguishing between improvement and accountability. He asked how one balances optimizing assets at hand and engaging in science. AHRQ should be strategic in identifying new measures. Dr. Savitz, in referring to patient-reported measures of quality of life, noted the difficulty in interpreting the clinical significance of changes in measures. Dr. Naylor encouraged AHRQ to develop evidence relating to measurement and its complexity (e.g., linkages). Dr. Dittus agreed, suggesting the agency consider a four-dimensional matrix featuring problems and solutions. Jed Weissberg, M.D., FACP, lamented the rise in costs of treatment, leading to gaps in quality measurement.

Dr. Bindman noted that AHRQ develops quality measures, then loses the branding to, for example, the National Quality Forum. Another issue is that measure creation has become consensus-driven rather than purely scientific. David J. Ballard, M.D., Ph.D., M.S.P.H., FACP, noted that many efforts in measure development are moving into the electronic health record space. He expressed skepticism of the job done there by vendors. Some NAC members wondered whether maintenance of measures of patient safety culture should be shifted from AHRQ to CMS.

Paul E. McGann, M.D., encouraged AHRQ to be very selective when pursuing measure development, asking whether the measure drives improvement. Dr. Goldmann proposed that the Department of Health and Human Services determine who should develop and maintain measures. Which agencies are best suited? Dr. Weissberg proposed that AHRQ build measures, validate them, and hand them off to others to maintain. Dr. Savitz raised the problem of measures that are not based on current data or medical practice.

Dr. McGlynn stated that we are at a pivot point in quality measurement. She proposed that AHRQ and the NAC consider the patient-centered way and novel data sources, seeking a new perspective on health care.

Dr. Bindman asked the NAC members to consider possible mechanisms that could produce a more systematized receipt of the transaction of AHRQ products, thereby suggesting AHRQ’s impact.

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Public Comment

There were no public comments.

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Adjournment

Dr. McGlynn asked the council members to forward any ideas for the agenda of the next meeting, which will take place on November 2, 2016. She stated that the NAC members will be informed of progress in developing the subcommittee for PCOR. She and Dr. Bindman thanked the NAC members, speakers, and other guests and adjourned the meeting.

Respectfully submitted,

Elizabeth A. McGlynn, Ph.D., Chair
National Advisory Council
Agency for Healthcare Research and Quality

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