What AHRQ Learned While Working to Transform Primary Care.

Building on previous efforts to transform primary care, the Agency for Healthcare Research and Quality (AHRQ) launched EvidenceNOW: Advancing Heart Health in 2015. This 3-year initiative provided external quality improvement support to small and medium-size primary care practices to implement evidence-based cardiovascular care. Despite challenges, results from an independent national evaluation demonstrated that the EvidenceNOW model successfully boosted the capacity of primary care practices to improve quality of care, while helping to advance heart health. Reflecting on AHRQ's own learnings as the funder of this work, 3 key lessons emerged: (1) there will always be surprises that will require flexibility and real-time adaptation; (2) primary care transformation is about more than technology; and (3) it takes time and experience to improve care delivery and health outcomes. EvidenceNOW taught us that lasting practice transformation efforts need to be responsive to anticipated and unanticipated changes, relationship-oriented, and not tied to a specific disease or initiative. We believe these lessons argue for a national primary care extension service that provides ongoing support for practice transformation.

A Pragmatic Approach to Identifying and Profiling Primary Care Clinicians and Primary Care Practices in the USA.

BACKGROUND: There are no consistent data on US primary care clinicians and primary care practices owing to the lack of standard methods to identify them, hampering efforts in primary care improvement. METHODS: We develop a pragmatic framework that identifies primary care clinicians and practices in the context of the US healthcare system, and applied the framework to the IQVIA OneKey Healthcare Professional database to identify and profile primary care clinicians and practices in the USA. RESULTS: Our framework prescribes sequential steps to identify primary care clinicians by cross-examining clinician specialties and organizational affiliations, and then identify primary care practices based on organization types and presence of primary care clinicians. Applying this framework to the 2021 IQVIA data, we identified 365,751 physicians with a primary specialty in primary care, and after excluding those who further specialized (24%), served as hospitalists (5%), or worked in non-primary care settings (41%), we determined that 179,369 (49%) of them were actually practicing primary care. We identified 287,506 nurse practitioners and 134,083 physician assistants and determined that 88,574 (31%) and 29,781 (22%), respectively, were delivering primary care. We identified 94,489 primary care practices, and found that 45% of them were with one primary care physician, 15% had two physicians, 12% employed nurse practitioners or physician assistants only, and 19% employed both primary care physicians and specialists. CONCLUSIONS: Our approach offers a pragmatic and consistent alternative to the diverse methods currently used to identify and profile primary care workforce and organizations in the USA.

Workforce Configurations to Provide High-Quality, Comprehensive Primary Care: a Mixed-Method Exploration of Staffing for Four Types of Primary Care Practices.

BACKGROUND: Broad consensus exists about the value and principles of primary care; however, little is known about the workforce configurations required to deliver it. OBJECTIVE: The aim of this study was to explore the team configurations and associated costs required to deliver high-quality, comprehensive primary care. METHODS: We used a mixed-method and consensus-building process to develop staffing models based on data from 73 exemplary practices, findings from 8 site visits, and input from an expert panel. We first defined high-quality, comprehensive primary care and explicated the specific functions needed to deliver it. We translated the functions into full-time-equivalent staffing requirements for a practice serving a panel of 10,000 adults and then revised the models to reflect the divergent needs of practices serving older adults, patients with higher social needs, and a rural community. Finally, we estimated the labor and overhead costs associated with each model. RESULTS: A primary care practice needs a mix of 37 team members, including 8 primary care providers (PCPs), at a cost of $45 per patient per month (PPPM), to provide comprehensive primary care to a panel of 10,000 actively managed adults. A practice requires a team of 52 staff (including 12 PCPs) at $64 PPPM to care for a panel of 10,000 adults with a high proportion of older patients, and 50 staff (with 10 PCPs) at $56 PPPM for a panel of 10,000 with high social needs. In rural areas, a practice needs 22 team members (with 4 PCPs) at $46 PPPM to serve a panel of 5000 adults. CONCLUSIONS: Our estimates provide health care decision-makers with needed guideposts for considering primary care staffing and financing and inform broader discussions on primary care innovations and the necessary resources to provide high-quality, comprehensive primary care in the USA.

How Do Innovative Primary Care Practices Achieve the Quadruple Aim?

The Patient-Centered Medical Home (PCMH) now defines excellent primary care. Recent literature has begun to elucidate the components of PCMHs that improve care and reduce costs, but there is little empiric evidence that helps practices, payers, or policy makers understand how high-performing practices have improved outcomes. We report the findings from 38 such practices that fill this gap. We describe how they execute 8 functions that collectively meet patient needs. They include managing populations, providing self-management support coaching, providing integrated behavioral health care, and managing referrals. The functions provide a more actionable perspective on the work of primary care.

Few Americans Receive All High-Priority, Appropriate Clinical Preventive Services.

As of 2015, only 8 percent of US adults ages thirty-five and older had received all of the high-priority, appropriate clinical preventive services recommended for them. Nearly 5 percent of adults did not receive any such services. Further delivery system-level efforts are needed to increase the use of preventive services.

EvidenceNOW: Balancing Primary Care Implementation and Implementation Research.

The mission of the Agency for Healthcare Research and Quality (AHRQ) is to generate knowledge about how America's health care delivery system can provide high-quality care, and to ensure that health care professionals and systems understand and use this evidence. In 2015 AHRQ invested in the largest primary care research project in its history. EvidenceNOW is a $112 million effort to disseminate and implement patient-centered outcomes research evidence in more than 1,500 primary care practices and to study how quality-improvement support can build the capacity of primary care practices to understand and apply evidence.EvidenceNOW comprises 7 implementation research grants, each funded to provide external quality-improvement support to primary care practices to implement evidence-based cardiovascular care and to conduct rigorous internal evaluations of their work. An independent, external evaluator was funded to conduct an overarching evaluation using harmonized outcome measures and pooled data. The design of EvidenceNOW required resolving tensions between implementation and implementation research goals.EvidenceNOW is poised to develop a blueprint for how stakeholders can invest in strengthening the primary care delivery system and to offer a variety of resources and tools to improve the capacity of primary care to deliver evidence-based care. Federal agencies must maximize the value of research investments to show improvements in the lives and health of Americans and the timeliness of research results. Understanding the process and decisions of a federal agency in designing a large clinical practice transformation initiative may provide researchers, policy makers, and clinicians with insights into future implementation research, as well as improve responsiveness to funding announcements and the implementation of evidence in routine clinical care.

Identification of hospital-acquired catheter-associated urinary tract infections from Medicare claims: sensitivity and positive predictive value.

BACKGROUND AND OBJECTIVE: Hospital-acquired catheter-associated urinary tract infection (CAUTI) is one of the first 6 conditions Medicare is targeting to reduce payment associated with hospital-acquired conditions under Congressional mandate. This study was to determine the positive predictive value (PPV) and sensitivity in identifying patients in Medicare claims who had urinary catheterization and who had hospital-acquired CAUTIs. RESEARCH DESIGN: CAUTIs identified by ICD-9-CM codes in Medicare claims were compared with those revealed by medical record abstraction in random samples of Medicare discharges in 2005 to 2006. Hospital discharge abstracts (2005) from the states of New York and California were used to estimate the potential impact of a present-on-admission (POA) indicator on PPV. RESULTS: ICD-9-CM procedure codes for urinary catheterization appeared in only 1.4% of Medicare claims for patients who had urinary catheters. As a proxy, claims with major surgery had a PPV of 75% and sensitivity of 48%, and claims with any surgical procedure had a PPV of 53% and sensitivity of 79% in identifying urinary catheterization. The PPV and sensitivity for identifying hospital-acquired CAUTIs varied, with the PPV at 30% and sensitivity at 65% in claims with major surgery. About 80% of the secondary diagnosis codes indicating UTIs were flagged as POA, suggesting that the addition of POA indicators in Medicare claims would increase PPV up to 86% and sensitivity up to 79% in identifying hospital-acquired CAUTIs. CONCLUSIONS: The validity in identifying urinary catheter use and CAUTIs from Medicare claims is limited, but will be increased substantially upon addition of a POA indicator.

How useful are voluntary medication error reports? The case of warfarin-related medication errors.

BACKGROUND: A study was conducted to explore the value and limitations of voluntary medical error reports and to learn about common errors in warfarin use. METHODS: Voluntary reports of 8,837 inpatient errors and 820 outpatient errors in warfarin use submitted by 445 hospitals and 192 outpatient facilities participating in MEDMARX, a voluntary medication error reporting system, from 2002 to 2004, were gathered. RESULTS: Overall, errors occurred most often during transcription/documentation (35%) and administration (30%) in hospitals, and during prescribing (31%) and dispensing (39%) in outpatient settings. Dosing errors were the most common type. In hospitals, more than 50% of reported errors were initiated by nurses, and 50% were intercepted by nurses, whereas in outpatient settings, about 50% of reported errors occurred in pharmacies and 50% were intercepted by pharmacists. About 17% of inpatient and 13% of outpatient warfarin errors resulted in changes in patient care, and 42% of inpatient and 62% of outpatient errors resulted in procedural changes. Cascade analysis and textual descriptions further located specific, correctible safety lapses. DISCUSSION: Voluntary medical error reporting systems can, to some extent, provide meaningful and actionable information to guide patient safety improvement, but their usefulness is limited because of a lack of details, incomplete reporting, underreporting, and various reporting biases.

Cardiac device implantation in the United States from 1997 through 2004: a population-based analysis.

OBJECTIVE: Use of cardiac devices has been increasing rapidly along with concerns over their safety and effectiveness. This study used hospital administrative data to assess cardiac device implantations in the United States, selected perioperative outcomes, and associated patient and hospital characteristics. METHODS: We screened hospital discharge abstracts from the 1997-2004 Healthcare Cost and Utilization Project Nationwide Inpatient Samples. Patients who underwent implantation of pacemaker (PM), automatic cardioverter/defibrillator (AICD), or cardiac resynchronization therapy pacemaker (CRT-P) or defibrillator (CRT-D) were identified using ICD-9-CM procedure codes. Outcomes ascertainable from these data and associated hospital and patient characteristics were analyzed. MEASUREMENTS AND MAIN RESULTS: Approximately 67,000 AICDs and 178,000 PMs were implanted in 2004 in the United States, increasing 60% and 19%, respectively, since 1997. After FDA approval in 2001, CRT-D and CRT-P reached 33,000 and 7,000 units per year in the United States in 2004. About 70% of the patients were aged 65 years or older, and more than 75% of the patients had 1 or more comorbid diseases. There were substantial decreases in length of stay, but marked increases in charges, for example, the length of stay of AICD implantations halved (from 9.9 days in 1997 to 5.2 days in 2004), whereas charges nearly doubled (from $66,000 in 1997 to $117,000 in 2004). Rates of in-hospital mortality and complications fluctuated slightly during the period. Overall, adverse outcomes were associated with advanced age, comorbid conditions, and emergency admissions, and there was no consistent volume-outcome relationship across different outcome measures and patient groups. CONCLUSIONS: The numbers of cardiac device implantations in the United States steadily increased from 1997 to 2004, with substantial reductions in length of stay and increases in charges. Rates of in-hospital mortality and complications changed slightly over the years and were associated primarily with patient frailty.

The validity of ICD-9-CM codes in identifying postoperative deep vein thrombosis and pulmonary embolism.

BACKGROUND: Deep vein thrombosis and pulmonary embolism (DVT/PE) are common complications after surgery and are associated with substantial excess mortality and length of stay. International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes recorded in hospital claims have been used to identify and study DVT/PE, but the validity of this method is not well studied. METHODS: Identification of postoperative DVT/PE events were compared using ICD-9-CM codes and medical record abstraction in random samples of hospital discharges of Medicare beneficiaries in 2002-2004. RESULTS: Among 20,868 eligible surgical hospitalizations, 232 DVT cases and 95 PE cases were identified by ICD-9-CM codes; 108 DVT cases and 31 PE cases by medical record abstraction; 72 DVT cases and 23 PE cases by both methods. The resulting estimates of PPV of ICD9-CM coding were 31% (72/232 cases) for DVT, 24% (23/95) for PE, and 29% (90/308) for DVT/PE combined. The resulting sensitivity estimates were 67% (72/108 cases) for DVT, 74% (23/31) for PE, and 68% (90/133) for DVT/PE combined. DISCUSSION: ICD-9-CM codes in Medicare claims are sensitive but have limited predictive validity in identifying postoperative DVT/PE. Improvements in the validity are needed before the indicator can be used for safety performance assessment.

Modifying DRG-PPS to include only diagnoses present on admission: financial implications and challenges.

OBJECTIVE: The inability to distinguish complications acquired in hospital from comorbid conditions that are present on admission (POA) has long hampered the use of claims data in quality and safety research. Now pay-for-performance initiatives and legislation requiring Medicare to reduce payment for acquired infections add imperative for POA coding. This study used data from 2 states currently coding POA to assess the financial impact if Medicare pays based on POA conditions only and to examine the challenges in implementing POA coding. METHODS: Medicare payments were calculated based first on all diagnoses and then on POA diagnoses in the Medicare discharge abstracts from California and New York in 2003, using the Diagnosis Related Group (DRG)-based Prospective Payment System (PPS) formula. The potential savings that result from excluding non-POA diagnoses were calculated. Patterns of POA coding were explored. RESULTS: Medicare could have saved $56 million in California, $51 million in New York, and $800 million nationwide in 2003 had it paid hospital claims based only on POA diagnoses. Approximately 15% of the claims had non-POA codes, but only 1.4% of the claims were reassigned to lower-cost DRGs after excluding non-POA diagnoses. Excluding non-POA diagnoses resulted in reduced payment for operating costs, but increased outlier payments because some of the claims were designated as "unusually high cost" in the lower-cost DRGs. POA coding patterns suggest some problems in current POA coding. CONCLUSIONS: To be consistent with pay-for-performance principles and make claims data more useful for quality assurance, incorporating POA coding into DRG-PPS could produce sizable savings for Medicare.

Incidence and short-term outcomes of primary and revision hip replacement in the United States.

BACKGROUND: The purpose of this study was to use 2003 nationwide United States data to determine the incidences of primary total hip replacement, partial hip replacement, and revision hip replacement and to assess the short-term patient outcomes and factors associated with the outcomes. METHODS: We screened more than eight million hospital discharge abstracts from the 2003 Healthcare Cost and Utilization Project Nationwide Inpatient Sample and approximately nine million discharge abstracts from five state inpatient databases. Patients who had undergone total, partial, or revision hip replacement were identified with use of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes. In-hospital mortality, perioperative complications, readmissions, and the association between these outcomes and certain patient and hospital variables were analyzed. RESULTS: Approximately 200,000 total hip replacements, 100,000 partial hip replacements, and 36,000 revision hip replacements were performed in the United States in 2003. Approximately 60% of the patients were sixty-five years of age or older and at least 75% had one or more comorbid diseases. The in-hospital mortality rates associated with these three procedures were 0.33%, 3.04%, and 0.84%, respectively. The perioperative complication rates associated with the three procedures were 0.68%, 1.36%, and 1.08%, respectively, for deep vein thrombosis or pulmonary embolism; 0.28%, 1.88%, and 1.27% for decubitus ulcer; and 0.05%, 0.06%, and 0.25% for postoperative infection. The rates of readmission, for any cause, within thirty days were 4.91%, 12.15%, and 8.48%, respectively, and the rates of readmissions, within thirty days, that resulted in a surgical procedure on the affected hip were 0.79%, 0.91%, and 1.53%. The rates of readmission, for any cause, within ninety days were 8.94%, 21.14%, and 15.72%, and the rates of readmissions, within ninety days, that resulted in a surgical procedure on the affected hip were 2.15%, 1.61%, and 3.99%. Advanced age and comorbid diseases were associated with worse outcomes, while private insurance coverage and planned admissions were associated with better outcomes. No consistent association between outcomes and hospital characteristics, such as hip procedure volume, was identified. CONCLUSIONS: Total hip replacement, partial hip replacement, and revision hip replacement are associated with different rates of postoperative complications and readmissions. Advanced age, comorbidities, and nonelective admissions are associated with inferior outcomes.

Medicare payment for selected adverse events: building the business case for investing in patient safety.

This study estimates that Medicare extra payments under the hospital prospective payment system (PPS) range from about $700 per case of decubitus ulcer to $9,000 per case of postoperative sepsis in the five types of adverse events identifiable in Medicare claims. Medicare extra payment for the five types of events totals more than $300 million per year, accounting for 0.27 percent of annual Medicare hospital spending. But these extra payments cover less than a third of the extra costs incurred by hospitals in treating these adverse events. We conclude that both Medicare and hospitals gain financially by improving patient safety.

Racial and ethnic differences in patient assessments of interactions with providers: disparities or measurement biases?

Patient assessment surveys have established a primary role in health care quality measurement as evidence has shown that information from patients can affect quality improvement for practitioners and lead to positive marketwide changes. This article presents findings from the recently released National Healthcare Disparities Report revealing that although most clinical quality and access indicators show superior health care for non-Hispanic whites compared with blacks and Hispanics, blacks and Hispanics assess their interactions with providers more positively than non-Hispanic whites do. The article explores possible explanations for these racial/ethnic differences, including potential pitfalls in survey design that draw biased responses by race/ethnicity. The article then suggests strategies for refining future research on racial/ethnic disparities based on patient assessment of health care.

Potential benefits and problems with computerized prescriber order entry: analysis of a voluntary medication error-reporting database.

PURPOSE: The potential benefits and problems associated with computerized prescriber-order-entry (CPOE) systems were studied. METHODS: A national voluntary medication error-reporting database, Medmarx, was used to compare facilities that had CPOE with those that did not have CPOE. The characteristics of medication errors reportedly caused by CPOE were explored, and the text descriptions of these errors were qualitatively analyzed. RESULTS: Facilities with CPOE reported fewer inpatient medication errors and more outpatient medication errors than facilities without CPOE, but the statistical significance of these differences could not be determined. Facilities with CPOE less frequently reported medication errors that reached patients (p < 0.01) or harmed patients (p < 0.01). More than 7000 CPOE-related medication errors were reported over seven months in 2003, and about 0.1% of them resulted in harm or adverse events. The most common CPOE errors were dosing errors (i.e., wrong dose, wrong dosage form, or extra dose). Both quantitative and qualitative analyses indicate that CPOE could lead to medication errors not only because of faulty computer interface, mis-communication with other systems, and lack of adequate decision support but also because of common human errors such as knowledge deficit, distractions, inexperience, and typing errors. CONCLUSION: A national, voluntary medication error-reporting database cannot be used to determine the effectiveness of a CPOE system in reducing medication errors because of the variability in the number of reports from different institutions. However, it may provide valuable information on the specific types of errors related to CPOE systems.

Accidental iatrogenic pneumothorax in hospitalized patients.

OBJECTIVE: Iatrogenic pneumothorax (IP) is an inherent risk to patients who undergo procedures that involve the intentional puncturing of the lung. IP also could occur accidentally to patients who do not undergo such procedures; such accidental IP (AIP) is suggestive of lapses in safe care. This study assessed the risk for AIP in patients hospitalized with specific diagnoses who underwent specific procedures. RESEARCH DESIGN: We analyzed 7.5 million discharge abstracts from 994 short-term acute care hospitals across 28 states in 2000 in the Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project Nationwide Inpatient Sample. AHRQ Patient Safety Indicators (PSIs) were used to identify AIP. AIP incidences and associated diagnoses and procedures were explored. RESULTS: Patients who were admitted for pleurisy, cancer of the kidney and renal pelvis, or conduction disorders and complications of cardiac devices had the highest rates of developing AIP during hospitalization, with AIP rates at 2.24%, 1.14%, and 0.83% respectively. The procedure-specific rates for AIP varied from 2.68% for patients who underwent thoracentesis to 1.30% for those who underwent nephrectomy, to 0.06% for those who underwent gastrostomy. Thoracentesis appeared to be a high-risk procedure for patients who were admitted for secondary malignancies, pleurisy, or pneumonia, with AIP rates at 3.76%, 3.13%, and 2.28%, respectively. CONCLUSIONS: Although AIP is most common after thoracentesis, it is a substantial threat to patients undergoing a wide range of procedures.

Relationship between performance measurement and accreditation: implications for quality of care and patient safety.

This study examined the association between the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accreditation scores and the Agency for Healthcare Research and Quality's Inpatient Quality Indicators and Patient Safety Indicators (IQIs/PSIs). JCAHO accreditation data from 1997 to 1999 were matched with institutional IQI/PSI performance from 24 states in the Healthcare Cost and Utilization Project. Most institutions scored high on JCAHO measures despite IQI/PSI performance variation with no significant relationship between them. Principal component analysis found 1 factor each of the IQIs/PSIs that explained the majority of variance on the IQIs/PSIs. Worse performance on the PSI factor was associated with worse performance on JCAHO scores (P=.02). No significant relationships existed between JCAHO categorical accreditation decisions and IQI/PSI performance. Few relationships exist between JCAHO scores and IQI/PSI performance. There is a need to continuously reevaluate all measurement tools to ensure they are providing the public with reliable, consistent information about health care quality and safety.

Ambulatory care visits for treating adverse drug effects in the United States, 1995-2001.

BACKGROUND: Adverse d[rug events (ADEs) are a well-recognized patient safety 4concern, but their magnitude is unknown. Ambulatory viisits for treating adverse drug effects (VADEs) as recordeed in national surveys offer an alternative way to estimatte the national prevalence of ADEs because each VA]DE indicates that an ADE occurred and was seriousenough to require care. METHODS: A nationallyrepresentative sample of visits to physician offices, hospital outpatient departments, and emergency departments was analyzed. VADEs were identified as tthe first-listed cause of injury. RESULTS: In 2001, there Awere 4.3 million VADEs in the United States, averaging 15 visits per 1,000 population. VADE rates at physicianoffices, hospital outpatient departments, and hospittal emergency departments were at 3.7, 3.4, and 7.3 lper 1,000 visits, respectively. There was an upward tr'end in the total number of VADEs from 1995 to 2001 ((p < .05), but the increases in VADEs per 1000 visits an.d per 1,000 population were not statistically significant. VADEs were lower in children younger than 15 and higher in the elderly aged 65-74 than in adults aged 225-44 (p < .01) and were more frequent in females than irn males (p < .05). DISCUSSION: Although methodologically conservative, the study suggests that ADEs are a significant threat to patient safety in the United States.

Burden of illness for children and where we stand in measuring the quality of this health care.

CONTEXT: Measures of health care quality for children are not as well developed as those for adults. It is also unclear the extent to which the current pool of measures address common causes of illness and health care utilization for children. OBJECTIVE: The goal of this study was to create lists of high-priority conditions for children based on different vantage points for defining burden relative to both inpatient and outpatient care for children. These high-priority conditions were then cross-tabulated with all known existing quality measures for pediatric health care. DATA: High-prevalence conditions for children were identified by using the 2000 National Ambulatory Medical Care Survey, 2000 National Hospital Ambulatory Medical Care Survey, 1999 Medical Expenditure Panel Survey, 2000 Healthcare Cost and Utilization Project's State Inpatient Databases, and 2000 Healthcare Cost and Utilization Project's State Ambulatory Surgery Databases. Burden assessments were done using frequencies of visits, charges, in-hospital deaths. Existing quality measures for children were identified from a recent compendium of such measures and a search of the National Quality Measures Clearinghouse. RESULTS: There are numerous and large gaps in existing quality-of-care measures for children relative to high-burden conditions in both the inpatient and outpatient setting. With the ever increasing efforts to measure and even publicly report on health care, efforts for children need to include focus on building a representative repertoire of quality measures for the high-burden conditions children experience.

Assessing patient safety in the United States: challenges and opportunities.

BACKGROUND: In 1999, the US Congress mandated the Agency for Healthcare Research and Quality (AHRQ), Department of Health and Human Services (DHHS), to report annually to the nation about healthcare quality. One chapter in the National Healthcare Quality Report (NHQR) is focused on patient safety. OBJECTIVES: The objectives of this study were to describe the challenges in reporting the national status on patient safety for the first NHQR and discuss emerging opportunities to improve the comprehensiveness and reliability of future reporting. RESEARCH DESIGN: This study is a selective review of definitions, frameworks, data sources, measures, and emerging developments for assessing patient safety in the United States. RESULTS: Available data and measures for patient safety assessment in the nation are inadequate, especially for comparing regions and subpopulations and for trend analysis. However, many opportunities are emerging from the recently increased investments in patient safety research and many ongoing safety improvement efforts in the private sector and at the federal, state, and local government levels. CONCLUSION: There are many challenges in assessing national performance on patient safety today. Ongoing developments on multiple fronts will provide data and measures for more accurate and more comprehensive assessments of patient safety for future NHQRs.