Crosscutting Activities Related to Quality, Effectiveness, and Efficiency Research
In addition to our research portfolios, funds are provided in HCQO to support a variety of research projects that support all of our research portfolios. Projects that support all portfolios are kept with the Crosscutting Activities Related to Quality, Effectiveness and Efficiency portfolio. In order to meet its outcome goals, AHRQ has developed a set of research contract and grant mechanisms that support the work of the portfolios. These activities include investigator-initiated research, data collection, measurement, dissemination and translation, program evaluation, grant review support, and other crosscutting contracts.
Examples of projects that help portfolios with data and measurement in health care include the Consumer Assessment of Healthcare Providers and Systems (CAHPS), Healthcare Cost and Utilization Project (HCUP), Quality Indicators (QIs), and the National Healthcare Disparities and Quality Reports (NHDR/QR). Additional information about these activities is found in the next section.
Creation of new knowledge is critical to AHRQ's ability to answer questions related to improving the quality of health care. Investigator-initiated research and training projects that have over-arching research topics—not specific to one portfolio—are kept within Crosscutting Activities. In addition, research portfolios use other activities to ensure that their research is being disseminated to the appropriate health care stakeholder and translated to usable information so health care is directly improved. Examples of activities that help with dissemination and translation are the Eisenberg Center, Evidence-based Practice Centers (EPCs), marketing outreach activities, clearinghouses, and direct dissemination and knowledge transfer activities. Finally, crosscutting activities support rapid cycle research and include Accelerating Change and Transformation in Organizations and Networks (ACTION), Centers for Education & Research on Therapeutics (CERTs), Primary Care Practice-Based Research Networks (PBRNs), and Developing Evidence to Inform Decisions about Effectiveness (DeCIDE Network). These rapid cycle research activities are found both in Crosscutting Activities and within our research portfolios—depending on the topic.
Research and Training Grants
AHRQ supports two targeted grant programs within Crosscutting Activities: CAHPS® and CERTs. Details about these two programs are provided below. In addition, AHRQ-supported grantees in this portfolio are working to answer questions about: cost, organization and socio-economics; long-term care; pharmaceutical outcomes; training; quality of care; and system capacity and bioterrorism through our investigator-initiated grant program.
- CAHPS®. CAHPS® is a multi-year initiative of AHRQ. Originally, "CAHPS" referred to AHRQ's "Consumer Assessment of Health Plans Study." However, in 2005, AHRQ changed this to "Consumer Assessment of Health Providers and Systems." This name better reflects the evolution of CAHPS® from its initial focus on enrollees' experiences with health plans to a broader focus on consumer experience with health care providers and facilities. AHRQ first launched the program in October 1995 in response to concerns about the lack of reliable information about the quality of health plans from the enrollees' perspective. The survey was adopted by the Centers for Medicare & Medicaid Services (CMS), U.S. Office of Personnel Management, and the National Committee for Quality Assurance for public reporting and accreditation purposes. As of 2007, 138,000,000 Americans were enrolled in health plans for which CAHPS® data were collected. Over time, the program has expanded beyond its original focus on health plans to address a range of health care services and meet the various needs of health care consumers, purchasers, health plans, providers, and policymakers. In June 2007, AHRQ funded the third iteration of CAHPS® grants to two organizations: RAND and the Yale School of Public Health. Though instrument development is a part of CAHPS® 3, there is a heavier emphasis on using CAHPS® data for quality improvement and expanding our knowledge of how to report quality data to consumers and other audiences. In FY 2010 and FY 2011, AHRQ support for CAHPS® grants will total $2.9 million. Here are some highlights of the past fiscal year:
- TalkingQuality. TalkingQualilty is a Web site developed by the CAHPS® consortium (AHRQ, the CAHPS® grantees, and the CAHPS® support contractor). This Web site assembles existing research and best practices about reporting quality information to consumers and other audiences. The intended users are people and organizations who design health care quality reports. In the past year, the team has begun a large-scale revision to this site, including updating of all information, designating priority content, improvements to site, including updating of all information, designating priority content and improvement to site. The production team has reviewed a beta-version of the improved Web site; we will launch it at the CAHPS®/SOPS (Surveys of Patient Safety Culture) User Meeting in Baltimore in April 2010.
- CAHPS® Clinician and Group Survey. This survey, which we released in spring 2007, asks patients about their recent experiences with physicians and other office staff. In response to user requests, the team developed two versions of this survey: a visit-specific version (where users focus on their last visit to a provider rather than care received during a longer time period) and a version with a different response option (4 to 6 point scale). We are also considering development of a 'hybrid' instrument, which would include some question from the visit-specific version along with some using the 4 to 6 point scale.
In 2009, the CAHPS® team presented two webinars related to the Clinician and Group Survey. The first, held in June, provided an update on instrument design, implementation and comparative data. Two hundred ninety four people participated in this webinar; 56% rated it "very helpful," 42% rated it "somewhat helpful." The second, presented in September, concerned physician practice use of CAHPS® C&G data for quality improvement. Three hundred seventeen people participated in this webinar; 50% rated it "very helpful," 36% rated it "somewhat helpful."
The Washington DC-based Center for the Study of Services (CSS) used a slightly-modified version of Clinician/Group CAHPS® to obtain assessment of physicians in three cities (Denver, Kansas City and Memphis). They then published these data on a Web site that was initially available only to physicians and is now available to patients (available at http://www.cssresearch.org/srv_svyPatPhy.cfm). This is the first large collecting and presenting CAHPS® data to users.
- CAHPS® Home Health Care Survey.The National Quality Forum (NQF) endorsed the CAHPS® Home Health Care Survey in 2009, making it a voluntary consensus standard for measuring the quality of care delivered by home health care agencies. The CAHPS® Home Health Care Survey asks about the experiences of patients who receive at least some skilled home health care services, such as from nurses, physical, occupational, and speech-language therapists, and nurse aide care.
The Centers for Medicare & Medicaid Services (CMS) began inviting voluntary submission of CAHPS® Home Health Care data in October, 2009. Agencies who want to receive their full market basket update need to participate in a 'dry run' of data submission for the first quarter of 2010 and to continue submitting data on a quarterly basis thereafter. CMS plans to begin publishing these data for use by consumers and others in January 2011.
CAHPS® Health Plan Survey Online Database Reporting. In September 2009, AHRQ posted this year's CAHPS® Health Plan Survey results in a new online reporting system. This reporting system presents national summary-level results for the commercial, Medicaid, and Medicare sectors for the years 2009 and 2008. Users are able to select specific composites or questions to view and build their own reports. They are also able to construct their own version of the Health Plan Survey Chartbook. Also, Medicaid Survey users who contributed data are now able to access individual results through the secure, password-protected area of the online system, which enables them to view their own results compared to selected benchmarks.
The long-term goals of CAHPS® are to ensure that: consumers/patients have accurate and timely information about health care providers and facilities to inform their selection decisions, and providers and health care facilities have accurate information from their patients to use as a basis for quality improvement efforts. CAHPS® has set a program performance goal of ensuring that CAHPS® data will be more easily available to the user community and the number of consumers who have accessed CAHPS® information to make health care choices will increase by over 50 percent from the FY 2002 baseline of 100 million. By moving to create surveys for a range of providers beyond the widely used CAHPS® health plan surveys, including clinicians, hospitals, nursing homes, and dialysis facilities, CAHPS® is rapidly expanding the capacity to collect data that can be utilized to make more informed choices by the purchasers who contract with and the consumers who visit these providers.
- CERTs. The Centers for Education & Research on Therapeutics (CERTs) program is a 10 year old, national initiative to conduct research and provide education that advances the optimal use of therapeutics (i.e., drugs, medical devices, and biological products), improve patient health outcomes, and improve the quality of health care while reducing its costs. The program currently consists of 14 research centers and a Coordinating Center and is funded and run as a cooperative agreement research program by AHRQ in consultation with the U.S. Food and Drug Administration (FDA.) The CERTs receive funds from both public and private sources, with AHRQ providing core infrastructure financial support - $11.5 million in both FY 2009 and FY 2010, with additional specific AHRQ Portfolio investments from Patient Safety and Health Information Technology. In FY 2011 the current CERTs grants end. The FY 2011 Request level will support new CERTs supported in other AHRQ portfolios, including Comparative Effectiveness and Patient Safety, for a total level of support of approximately $7 million in FY 2011.
The clinical research conducted by the CERTs program addresses three major aims:
- To increase awareness of new, effective, and low-risk uses of new drugs and drug combinations, biological products, and devices, as well as of mechanisms (encompassing patient-, provider-, and systems-based interventions) to improve their safe and effective use.
- To provide clinical information to patients and consumers; health care providers; pharmacists, pharmacy benefit managers, and purchasers; health maintenance organizations and health care delivery systems; insurers; and government agencies.
- To improve quality while reducing cost of care by increasing the appropriate use of drugs, biological products, and devices and by preventing their adverse effects and consequences of these effects (such as unnecessary hospitalizations).
The cross-cutting CERTs have a distinctive niche in therapeutics research of diverse and integrated activities that support multiple AHRQ portfolios at the same time. Individual and cross-cutting CERTs Centers' activities innovate, pilot, and thereby generate valuable new evidence to increase the effectiveness and safety of therapeutics use by patients, providers, and systems of care and payment.
- For patients, the CERTs identify and pilot actionable interventions (such as targeted prescribing, patient education or behavioral support) to optimize adherence, compliance, and the clinical and genetic heterogeneity of vulnerable subgroups and individuals
- For providers, the CERTs explore ways to fill knowledge and practice gaps in therapeutics use to improve benefits of underutilized drugs (such as beta-blockers after heart attacks), avoid harms through judicious use of commonly prescribed drugs (such as GI bleeding from warfarin overdosing or gastric insults from antiplatelet drugs or nonsteroidal anti-inflammatory drugs or NSAIDs), and reduce errors due to medication duplication or confusion from fractionated medical care (for example, by outpatient medication reconciliation done after new medications are introduced during hospitalization.)
- For systems of care and payment, the CERTs explore multiple factors, such health information technology or payment structures, that influence the appropriate use of therapeutics. Examples include medication ordering systems to encourage judicious use of powerful antibiotics or the influence of co-payments and step-therapy processes upon chronic medication adherence or discontinuities in treatment.
The cross-cutting CERTs generate critical and applied information to support salutary changes in all aspects of the health care system. They focus on special populations with complex, multifactorial health care management issues, such as the elderly and children with chronic diseases. They develop, analyze, and apply findings from complex data infrastructures to support the needs of key constituencies, such as the safety concerns of the Food and Drug Administration and the quality of care concerns of Medicaid Medical Directors' regarding current practices in using highly expensive drugs with uncertain benefit/harm balances, such as tumor necrosis factor blockers or atypical antipsychotic medications.
Lastly, the cross-cutting CERTs conduct research and education to offer AHRQ and HHS a unique opportunity to foster innovative educational and behavioral supports to promote optimal therapeutics. Through their numerous partnerships with local and National organizations, the cross-cutting CERTs offer a rich network of players as well as means to promulgate evidence-based, high quality, effective, and safe health care through the use of therapeutics.
CERTS: Inappropriate Antibiotic Use in Children: Measure 4.4.1
Results show that from FY 2005 through FY 2008, the average number of antibiotic prescriptions for U.S. children ages 1-14 has fluctuated, with no statistically significant net change. In FY 2004, baselines rates were established (0.56 prescriptions per child). In FY 2008 the target was a 1.8% drop (0.53 prescriptions per child); the actual result was 0.58 prescriptions per child (95% CI: 0.53-0.62). In FY 2009, the target was a 1.8% drop (0.51 prescriptions per child), and the actual result was 0.55 prescriptions per child (95% CI: 0.49-0.60. The result for FY 2009 (0.55 prescriptions per child) does not show a statistically significant difference from the FY 2004 baseline estimate (0.56 prescriptions per child)
Notwithstanding annual fluctuations, the target has remained at a 1.8% drop each year. Continued examination of trends over time will assist in determining whether the targeted decline in use is realistic, achievable, and accurately reflects "appropriate" levels of prescribing. During FY 2009, the targeted number of prescriptions fell within the confidence interval of the measurement, although the point estimate was larger. This illustrates one aspect of this measure which deserves attention for future refinement, as identified during the course of an outside evaluation. The targeted changes can not be confidently measured at the annual level of precision that was established.
This goal includes children, a priority population for AHRQ. Reduction in antibiotic use by children is expected to reduce adverse reactions associated with medications and the cost of medical care. Reduced use may also lessen the rates of resistant organisms, an important public health problem. A two-pronged approach to reduced use is needed, through both the clinician and the caregiver.
Overall, at least four cross-cutting CERTs Research Centers are working to reduce inappropriate use of antibiotics. Broadly, their activities include microbial stewardship and efforts to minimize inappropriate antibiotic treatments for pediatric infections by accurate diagnoses and application of treatment guidelines from the Centers for Disease Control and the American Academy of Pediatrics. Products from work performed by the CERTs research centers include publications in peer-reviewed journals, as well as presentations at national meetings of healthcare professional organizations. An example is work conducted by one of the research centers to evaluate an antimicrobial stewardship program (ASP) at a pediatric teaching hospital in Philadelphia. This project concluded that an ASP improves the appropriate use of antimicrobials medications in hospitalized children, and the results were published in the Pediatric Infectious Disease Journal in 2008 as well as presented at the Society of Healthcare Epidemiology of America (SHEA) in 2009. Another CERT research center wrote a commentary in 2009 in the Journal of the American Medical Association (JAMA) for clinicians on the use of more conservative prescribing practices. The publication specifically mentions the challenges in antibiotic prescribing and the risk of antimicrobial resistance. The ongoing dissemination of this information through participating professional organizations should assist the implementation of research findings to facilitate appropriate management and thus positively influence antibiotic utilization. Refinement of this measure in the coming year should lead to a proposal for a more clearly targeted performance measure that will reflect the goal of 4.4.1: reduce antibiotic inappropriate use in children between the ages of one and fourteen.
CERTs: Congestive Heart Failure Readmission Rates: Measure 4.4.2
Results show that from FY 2005 through FY 2007, the actual rates of readmission for congestive heart failure during the first six months in those between 65 and 85 years of age have trended consistently downward. In FY 2004, baselines rates were established (38% readmission rate). In FY 2006, the target was a 2.7% drop and the actual result was a 0.7% drop (36.74% readmission rate). In FY 2007, the target was a 1.4% drop and the actual result was a 0.6% drop (36.51% readmission rate). In FY 2008, the target was a 1.4% drop and the actual result was a 4.4% drop (34.89% readmission rate).
The most recent results from FY 2009 show a 1.7% increase in the readmission rate (to 35.48%) relative to 2008, where the FY 2009 target was a 1.4% drop. Because of the large absolute and relative decline in the CHF readmission rate in 2008 and the possibility of an anomaly in the data measurement for that year, we compared the 2009 readmission rate (35.48%) to the 2007 value (36.51%) and found a 2.9% decline over the 2 year period. This two-year rate of decline is consistent with two consecutive years of the 1.4% annual decline that was targeted for 2008 and 2009. An additional year of data and closer examination of the four large U.S. states that make up the annual measurement should assist in determining whether the measurement instrument should be revised to provide a more robust national measurement of CHF readmissions. The independent evaluation done in 2009 noted limitations in using 4 states to represent national trends, and also anticipated reimbursement and performance-based activities in coming years that might motivate further declines in the rate of hospital readmissions, although countervailing economic forces were noted. For example, the current economic recession may push readmissions upward due to decreased medication use and/or decreased contacts with the medical system for preventive or treatment measures. Monitoring and consideration of secular and clinical influences are planned as part of the annual examination of this target.
In FY 2008, efforts have continued to reduce the congestive heart failure hospital readmission rates in those between 65 and 85 years of age. One of the cross-cutting CERTs research centers is working in close coordination with national partners to improve and promote adoption of evidence based heart failure therapy . As part of these efforts, they are continuing their ongoing study to create a hybrid national surveillance system to monitor the safety and effectiveness of heart failure therapies using augmented American Heart Association's Get with the Guidelines—Heart Failure (AHA GWTG-HF) database with longitudinal links to Medicare claims data. Also continuing are researchers' efforts to evaluate a personalized feedback, education and quality improvement system for improving heart failure care. This project, once complete and disseminated through peer-reviewed publications and close partnerships with participating National professional organizations, is likely to assist attainment of AHRQ performance measure 4.4.2: reduce congestive heart failure hospital readmission rates during the first six months in those between 65 and 85 years of age by implementing the research findings.
CERTs: Upper GI (Gastrointestinal) Bleeding: Measures 4.4.3 and 4.4.4:
Results show that from FY 2006 through FY 2008, the actual rate of hospitalizations for upper GI bleeding due to adverse effects of medication or inappropriate treatment of peptic ulcer disease in those between 65 and 85 years of age have consistently met or slightly exceeded the targets. In FY 2004, baselines rates were established (55/10,000). In FY 2007, the target was a 2-percent drop and the actual result was a 5.2-percent drop (51.56/10,000). In FY 2008, the target was a 1.8-percent drop and the actual result was a 3.5-percent drop (49.75/10,000).
The most recent results from FY 2009 also met the corresponding target. In FY 2009, the target was a 1.8-percent drop and the actual result was a 3-percent drop (48.25/10,000). Although FY 2007 and FY 2008 had approximately double the targeted decrease in hospitalizations for GI bleeding, we retained the previously modeled FY 2009 target of a 3-percent decrease. AHRQ does not advise revising this target in light of findings from an external evaluation that anticipate the likelihood of a population increase in the risk of GI bleeding due to multiple factors. These include: the aging of the U.S. population, anticipated decline in proton pump inhibitor use due to FDA advisories regarding their use with antiplatelet drugs such as clopidogrel, and the current economic recession which will likely lead to lessened medical contact and use of gastroprotective agents, and at the same time, likely increase population consumption of alcoholic products.
Results show that from FY 2006 through FY 2008, the number of admissions for GI bleeding have generated a per year drop in per capita charges for GI bleeding and our targets have consistently been met. In FY 2004, baseline rates were established ($96.54 per capita). In FY 2007, the target was a 4% drop ($92.68) and the actual result was a 4.9% drop ($91.81 per capita). In FY 2008, the target was a 5% drop ($91.71) and the actual result was a 9.8% drop ($87.10 per capita).3
The most recent results from FY 2009 met and exceeded the corresponding target. In FY 2009, the target was a 6% drop ($90.75) and the actual result was a 13.2% drop ($83.81 per capita). This per capita cost surpasses the absolute target for per capita costs ($86.89) that was set for FY2012. Again, we do not know the reason(s) for the unexpected steep percentage drop in per capita costs in FY 2008 and FY2009, and cannot reliably predict that rate of decline will continue in the future. Given the extensive decline through FY2009, we believe that it is reasonable to retain the absolute target of $89.78 per capita costs for FY 2010, We will reevaluate performance of this measure in 2011 to determine if the factors suggested by our outside evaluation will slow or reverse the rate of decline seen over the past several years. To reiterate, the recent economic downturn will likely inhibit people from using gastrointestinal protective agents due to the increasing number of unemployed workers who will be unable to afford prescription and over-the-counter proton pump inhibitors and H2 receptor blockers because of lost jobs, drug coverage, and decreased disposable income. Recessions typically increase population use of alcoholic beverages, which are known gastric irritants. Thus, we cannot predict that the historic or recent past performance achievements will continue.
In support of this measure and its improvement in 2009, at least 4 cross-cutting CERTs Centers are working on projects that either directly or indirectly influence the risk of GI bleeding. These include multiple efforts to optimize the use of the anticoagulant warfarin, including efforts to educate clinicians and patients about how to achieve stable warfarin blood levels and therapeutic action, and to improve its monitoring so that excessive anticoagulation is avoided. Multiple other efforts address improved use of gastric irritants, such as non-steroidal anti-inflammatory drugs (NSAIDs.) AHRQ has continued and expanded its efforts to educate the public about safely using blood thinner pills, especially the commonly used drug warfarin. AHRQ updated its previous educational offering on blood thinners and added a Spanish language version and a video. As we noted last year, thousands of consumers are prescribed the anti-clotting drug warfarin (Brand name: Coumadin®), which is a dangerous medication that requires close monitoring and can lead to uncontrolled bleeding, including GI Bleeding. Blood Thinner Pills: Your Guide to Using Them Safely, an updated 24-page booklet, explains how these pills can help prevent dangerous blood clots from forming and what to expect when taking these medicines. Staying Active and Healthy with Blood Thinners, a 10-minute video, features easy-to-understand explanations of how blood thinners work and why it's important to take them correctly. AHRQ is working to disseminate these patient education tools to consumers, hospitals and other providers. Information on these products, which are offered in both English and Spanish versions, is available at: http://www.ahrq.gov/consumer/btpills.htm#videos
We anticipate this educational effort, along with numerous other activities of the cross-cutting CERTs, will help to reduce hospitalization for upper GI bleeding due to the adverse effects of medication or inappropriate treatment of peptic ulcer disease, in those between 65 and 85 years of age. The overall direction of AHRQ's performance measure 4.4.3 will, however, be influenced by economic and health care trends that may offset or overwhelm the salutary efforts of multiple cross-cutting CERTs.
CERTs, as part of the now obsolete Pharmaceutical Outcomes program, underwent a program assessment in 2004. The program received a Moderately Effective rating. The assessment cited research to be conducted by AHRQ's CERTS program to reduce antibiotic inappropriate use in children, congestive heart failure hospital readmission rates, and hospitalizations for upper gastrointestinal bleeding due to the adverse effects of medication or inappropriate treatment of peptic ulcer disease. As a result of the program assessment, the CERTs is taking actions to: (1) analyze trends to determine if targets for measures need to be adjusted; and (2) produce reports on best practices in observational methods research.
- Investigator-initiated Research. New investigator-initiated research and training grants are essential to health services research - they ensure that an adequate number of both new ideas and new investigators are created each year. It represents the Agency's investment for future advances upon which the applied research of the future will be built. Early AHRQ-supported research by Dr. Lucian Leape and others at Harvard University demonstrated that "errors in care are prevalent and often preventable." This early research provided the basis for AHRQ's current patient safety initiatives. The topics addressed by unsolicited investigator-initiated research proposals reflect timely issues and ideas from the top health services researchers. Usually, researchers develop their investigator-initiated proposals in response to program announcements that broadly describe the Agency's areas of interest. Examples of successful investigator-initiated research grants funded in prior years include:
- A new study shows that many children who undergo tympanostomy tube insertion (surgery for otitis media or middle ear inflammation) do not meet the criteria for receiving ear tubes: they generally did not have recurrent ear infections with fluid in both ears for 3 or more months and had no hearing loss. Researchers reviewed the cases of 682 children who had ear tubes inserted surgically. According to expert panel criteria, just 7 percent (48 cases) of the surgeries were appropriate, and nearly 70 percent (475 cases) were inappropriate. When the clinical characteristics of the children were compared to 1994 national clinical guidelines, the authors found 7.5 percent of the tubes insertions met guideline criteria and nearly 93 percent did not. (See "Overuse of typanostomy tubes in New York metropolitan area: Evidence from five hospital cohort," by Salomeh Keyhani, M.D., M.P.H., Lawrence C. Kleinman, M.D., M.P.H., Michael Rothschild, M.D., and others in the October 3, 2008, British Medical Journal 337, pp. a1607, available at http://www.bmj.com.)
- When patients who are at low risk for coronary artery disease present at the emergency department (ED) with chest pain, physicians often admit them to observation units (OU) for evaluation. Patients who complete their OU evaluation with a positive or indeterminate stress test are admitted to the hospital and often undergo cardiac catheterization with negative results (i.e., less than 50 percent stenosis, absence of three-vessel disease, and no percutaneous intervention completed) which, in turn, significantly increases costs. For patients who had positive or indeterminate stress tests and subsequent negative catheterizations, costs increased across the board. When compared with costs for patients with negative stress tests, these patients had increases in ED ($520 vs. $467) and OU ($440 vs. $307) costs, total costs ($7,298 vs. $1,562), and total charges ($23,499 vs. $6,973). (See "Diagnostic uncertainty and costs associated with current emergency department evaluation of low risk chest pain," by Rahul K. Khare, M.D., F.A.C.E.P., Emilie S. Powell, M.D., M.B.A., Arjun K. Venkatesh, M.B.A., and D. Mark Courtney, M.D., F.A.C.E.P., in the September 2008 Critical Pathways in Cardiology 7, pp. 191-196.)
- A preliminary study shows promising results for a recently developed tool that may be useful for evaluating interventions to prevent poor surgical outcomes. The Surgical Apgar Score calculates a patient's blood loss, lowest heart rate, and lowest mean arterial pressure during an operation to identify patients at risk for major complications and/or death within 30 days after surgery. Researchers found that of 1,441 patients with Surgical Apgar Scores of 9 or 10 (best scores), 5 percent developed major complications within 30 days, including two deaths (0.1 percent). By comparison, among 128 patients with scores of 4 or less, 56.3 percent developed major complications and 25 (19.5 percent) died. Each of the three scores was a significant predictor of complications and death. (See "Utility of the surgical Apgar score," by Scott E. Regenbogen, M.D., M.P.H., Jesse M. Ehrenfeld, M.D., Stuart R. Lipsitz, Sc.D., and others in the January 2009 Archives of Surgery 144(1), pp. 30-36).
3 In the 2008 Citizen's Report, the percentage reduction from based was erroneously reported as 5.1%; the correct percentage reduction from baseline was 9.8%.
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