QUALITY OF CARE IMPROVING CLINICAL PRACTICE: Connecting Universal Coverage to Better Health Outcomes...

QUALITY OF CARE

IMPROVING CLINICAL PRACTICE:Connecting Universal Coverage to

Better Health Outcomes

John Peabody MD, PhD, FACPProfessor, UCSF and UCLAPresident, QURE Healthcare

World Bank Brown Bag Lunch – 17 September 2015

Contact: [email protected] do not reproduce without permission

UCSF Institute for Global Health, Global Health Sciences

© QURE 2015

AGENDA

• Health policy instruments

− UHC

− Structure versus Process

• Quality of Care Delivery: Structure Process Outcomes

• From Measuring to Changing Practice

• Implications and Summary

© QURE 2015

UHC is Increasing Access and Coverage of Key Care Interventions

Global Tracer Indicators for UHC Coverage

WHO and WB. Tracking universal health coverage: first global monitoring report. Geneva: WHO, 2015

SDG Goal 3.8:

Achieve UHC, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all

WB and WHO assistance on UHC to over 100 countries since 2010.

© QURE 2015

Policy Instruments are Improving Access to Care Across Countries and Settings

• Policy levers and tools being implemented across countries and conditions.

– Universal Health Coverage (2005)

– Program for Results (PforR) (2010)

– Results-based financing (RBF) (2008)

– UNAIDS 90/90/90 Initiative (2014)

– USAID Health systems strengthening (2009-10)

• Common aim is to increase access to health care services.

© QURE 2015

Example: RBF Improving Access vs. Quality

• RBF: Cash or non-monetary transfer made after contractually predefined results verified.

• Objective: Improvements in Population Health Outcomes– Structure (e.g., UHC) and Process Interventions (e.g., P4P)

• RBF improves access and structural quality indicators– Breaks Down Financial Barriers

– Staffing, availability of essential drugs/medical equipment and supplies

• Process interventions are more limited and have had less impact – Compliance to guidelines for service delivery (e.g., disinfection, high-risk

screening, prescription of supplements for pregnant women)

– Functioning of monitoring and evaluation system (e.g., service registers, drug stock management cards)

© QURE 2015

Better Access and Structural Quality Does not Translate into Better Health Outcomes

Ng M, Fullman N, Dieleman JL, Flaxman AD, Murray CJL, et al. (2014) Effective Coverage: A Metric for Monitoring Universal Health Coverage. PLoS Med 11(9): e1001730. doi:10.1371/journal.pmed.1001730http://127.0.0.1:8081/ploscollections/article?id=info:doi/10.1371/journal.pmed.1001730

Crude and effective coverage of hypertension treatment across Mexican

states, 2005–2006.Effect interventions to increase access can be measured in several dimensions, e.g.:• Content of care• Biomarkers• Cohort registration• Risk adjusted

outcomes.

Evidence demonstrates that just providing access does not result in better outcomes.

http://127.0.0.1:8081/ploscollections/article?id=info:doi/10.1371/journal.pmed.1001730

© QURE 2015

RBF Example: Policy Levers Widely Improves One Structural Quality Measures

Source: 2014 RBF Progress Report http://www.hritfreport.org/#chapter-3

Each bar represents a calendar quarter of RBF implementation

Access to an Institutional Delivery Done by a Skilled Birth Attendant

© QURE 2015

Having Skilled Birth Attendants Does Not Mean That They Are Skilled—Unless Someone Measures

Midwives attending a delivery misdiagnose 30%

CPV case % Missed diagnosis

Total misdiagnosis rate

29.8%

Cephalopelvic disproportion

25.2%

Postpartum hemorrhage

33.0%

Pre-eclampsia 31.0%

Lacuna in Diagnosis2

1Peabody et al. 2014 Quality of care in Eastern Europe and Central Asia: Six country report2Shimkhada R et al. 2015 Misdiagnosis of obstetric cases by providers and the clinical and cost consequences to patients in the Philippines. Forthcoming

• Providers who misdiagnosed a simulated CPV vignette were more likely to have patients w/ complications.

• Complicated patients more likely to be sent to the hospital.

• Costs: • Complicated patients received

more hospital care; were more expensive.

• Mothers w/complications less likely to return to work, and lost a significant amount of income (~1,000USD)

© QURE 2015

Why Isn’t Access Enough? Quality Service is the More Proximal Determinant to Outcomes

AccessUtilization

Structural Inputs

QualityClinical PracticeProcess

OutcomesHealth Status

Patient & Population

Factors that affect the context in which care

is delivered The sum of clinical actions by providers that translate

inputs into outputs

Effects of healthcare on patients or populations

Improvements in Quality Leads to Better Health in Months, not Years

© QURE 2015

Thinking in Global Health Is Shifting: Moving from Access/Structural Inputs to Quality Services

In resource-poor settings:

• Quality typically focused on access, investments in equipment

• An implicit assumption scarcity of qualified health providers and a lack of infrastructure, equipment & access are primary drivers of low-quality care

Missing from this debate is systematic evidence on the quality of care that patients actually receive when they enter a clinic.

- Jishnu Das et al, 2012

© QURE 2015

• In Papua New Guinea, 69% of HCW checked for 2 or fewer physical in patients presenting with pneumonia.

• In Ghana, only 24% of HCW could indicate correct treatment for malaria.

• In Pakistan, 56% of providers could diagnose diarrhea.

• In India, only 6% of private practitioners followed diagnostic standards for TB management.

Enthusiasm growing for systematic assessment and international benchmarking

We Know that Quality Services (Process) Are Poor… Everywhere

Beracochea et al, 1995; Thaver et al 1998; Achanta et al, 2013; OECD Health at a Glance: Europe, 2012; CMS Medicare Hospital Quality Chartbook, 2010

Distribution of Hospital Risk Stand. Mortality Rate,

2006-8

© QURE 2015

Variance Of Quality Services—Defines the Quality Problem: Shows What Improvement is Possible

Variation in procedure rates (services) is an indicator of healthcare quality

– Variation itself is simultaneously clinically helpful, harmful and costly

– Comparisons done properly are powerful

2013 Health Affairs study:Cesarean Delivery Rates Vary 10X Among US Hospitals; Reducing Variation May Address Quality And Cost Issues

Kozhimannil KB, Law MR, Virnig BA. Cesarean Delivery Rates Vary Tenfold Among US Hospitals; Reducing Variation May Address Quality And Cost Issues. Health Aff (Millwood). 2013 Mar;32(3):527-35.

© QURE 2015

AGENDA





© QURE 2015

Different Perspectives on What Quality Means: One Word, 20 Places to Start

• Delivery Systems

– Access, utilization

– Public and/or private

• Policy

– Regulations, incentives, mandates

– Organization

• Structural/Inputs

– Facilities, equipment, supplies

• Platform

– Public health

– Payment and insurance

• Patient

“What Providers Do When they See Patients is”:

• Influenced by policy

• Requires inputs• Incented by

platforms• Provided by

delivery system Focused on the

impact on the patient

© QURE 2015

The Quality of Care Framework from DCP-3

2015--DCP3

Policy Levers:

Access: Coverage, Benefits

Patient-level Engagement, Behavior,

Adherence

Health Care Access

Structure, Systems, Human Resources

Process, Clinical Care

Provider: Clinical skill, adherence to guidelines, diagnostic accuracy, communication

Equity

1. Platform Level:Aggregate System

2. Provider Level Practice, Behavior

Political Factors

Institutional Factors

Social/Cultural Factors

Environmental Factors

Health Outcomes

3. Payment Systems

© QURE 2015

Poor Quality Exists Across Developing Countries, All Countries

Peabody JW, Florentino A Liu. ”A Cross-national comparison of quality of clinical care using vignettes.” Health Policy and Planning. 2007 ; 22: 294-302.

Comparison of overall scores across countries

China El Salvador India Mexico Philippines

5 Country Cross-National

Comparison

– Diarrheal disease

– Prenatal care, TB

• Limited differences intercountry

• Wide variation within countries

• 30% vs 93%

© QURE 2015

Low Quality Service—Disproportionately Affecting the Poor

Barber, Gertler and Harimurti. 2007. Differences in Access to High Quality Outpatient Care in Indonesia. Health Affairs 26(3): 352-366.Barber, Bertozzi and Gertler. 2007. Variations in prenatal care quality for the rural poor in Mexico. Health Affairs. 26: 310-23.Hansen et al. 2008. Determinants of primary care service in Afghanistan. Int J for Quality in Health Care. 20(6): 375-383.Das J, Hammer J. Location, location, location: residence, wealth, and the quality of medical care in Delhi, India. Health Aff (Millwood). 2007 May-Jun;26(3):w338-51 and Das J, Holla A, Das V, Mohanan M, Tabak D, Chan B. In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps. Health Aff (Millwood). 2012 Dec;31(12):2774-84.

• Procedures self-reported by providers, in government and private facilities:

• Quality lower in poor compared to wealthier areas. (p<0.05)

• Similar access to quality for poor and affluent women • Poorer women

received fewer prenatal services.

Indonesia:

• Government clinics • Lower quality of care

for patients in poorer neighborhoods (composite index of quality) (p>0.05).

\• Gaps in aggregate measure of

Quality exist in basic care • Quality (competence) of

private providers located in poorer areas of the city significantly lower than those in richer neighborhoods

Afghanistan

Mexico

India

© QURE 2015

Perceived Quality Affects Utilization

Kruk ME, Mbaruku G, McCord CW, Moran M, Rockers PC, Galea S. Bypassing primary care facilities for childbirth: a population-based study in rural Tanzania. Health Policy Plan. 2009 Jul;24(4):279-88Peabody J., Gertler P., Liebowitz A. The Policy Implications of Better Structure and Process on Birth Outcomes in Jamaica. Health Policy. 1998;43(1):1–13.

• Patients in Tanzania preferred to travel to more distant facilities if those facilities perceived to provide higher quality care

– Availability of drugs, perceived quality, trust were other important reasons

• In Jamaica, quality was higher at facilities with fewer drugs

From: Kruk et al, 2009

Multivariable associations between participant and nearest health facility characteristics and by-passer status for a population-based sample of women from Kasulu District. Western Tanzania, 2007 (n=387)

© QURE 2015

Studies Show that Physician Skill Is Where Improvement is Needed

• Das et al (2012): Correct diagnosis only 8-18% the time.

• Achanta et al (2012): Poor adherence to TB guidelines (diagnostic and treatment)

– E.g. only 6% of private practitioners followed diagnostic standards in TB management

Das J, Holla A, Das V, et al. In urban and rural India, a standardized patient study showed low levels of provider training and huge quality gaps. Health Aff (Millwood). 2012 Dec;31(12):2774-84.

Achanta S, Jaju J, Kumar AM, et al, Tuberculosis management practices by private practitioners in Andhra Pradesh, India. PLoS One. 2013 Aug 13;8(8):e71119.

From Das et al. (2012)

© QURE 2015

Accumulating, Hard to Obtain Evidence: Higher Quality Service Means Better Outcomes

Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med. 2013;369:1434–42.

If We Could Change Practice and Raise Quality, Would Complications Go Down?

• Surgeons asked to representative videotape performing a laparoscopic gastric bypass.

• Each videotape rated 1 to 5 on various domains of technical skill

Quality integral to decreasing postoperative complications? • The bottom quartile of surgical skill, was

associated with higher complication rates (14.5% vs. 5.2%, P<0.001) and higher mortality (0.26% vs. 0.05%, P=0.01).

• The lowest quartile of skill was also associated with longer operations (137 minutes vs. 98 minutes, P<0.001) and higher rates of reoperation (3.4% vs. 1.6%, P=0.01) and readmission (6.3% vs. 2.7%) (P<0.001).

RESULTS

© QURE 2015

AGENDA





© QURE 2015

Bridging the Gap Between Measuring Practice and Actually Changing Practice

1. Transparency and feedback

– To the provider, decision-makers

2. Timely

– Measurement that can be acted on (e.g. clinical decision making with feedback, training) early-on

3. Repeatable/serial

– Measurement that is done over time to identify trends, improvement

4. Actionable

– Measurement that can be put into policy action, intervention

– Affordable

Starts with Measurement: 4 key requirements for measurements to impact outcomes

© QURE 2012

“…it's hard to improve, and to demonstrate what's best, unless everyone does it the same way”

-Brent James, MD,, Intermountain Healthcare

1

2

3

4

© QURE 2015

Current Methods for Measuring Quality Are Not up to the Task of Changing Behavior

1. Patient Exit Interviews

• Self-reported status; response bias; anchoring bias

2. Formal Testing-Licensing

• Single best answer questions; gaming

3. Scenarios

• Knowledge focused, Effort level higher

4. Direct Observations

• Hawthorne effect

5. Medical Chart Abstraction

• The current standard, inaccurate and time consuming

6. Standardized Patient

• The gold standard but hard to reproduce

© QURE 2015

Medical Chart Abstraction is Problematic

Chart abstraction- Analyzing individual doctor’s charts

- Requires trained abstractor

- Messy and prone to false positives

- Doesn’t account for case-mix

- Time consuming

- Retrospective

To change behavior we want a measure that is:

1. Valid, reliable and consistent determination of actual clinical practice

2. Case mix adjusted so comparisons among physicians and disparate sites and health care systems can be made

3. Inexpensive and can be used for repeated measures

Example of a doctor’s chart

© QURE 2015

Actor/Standardized Patients Measuring Quality

Standardized patients can capture physician practice

variation, and are an alternative to direct

observation (DO)

Researchers in Indonesia, India and Tanzania posed

as patients across a variety of conditions (child diarrhea, pregnant woman

with pre-eclampsia)

Overall quality was shown to be low: for a

diarrhea case, only 18-58% of necessary

care was provided across the 3 countries

Doctors in Tanzania completed less than

24% of essential “checklist” items for

malaria

Das, J & Gertler PJ. Variations In Practice Quality In Five Low-Income Countries: A Conceptual Overview. Health Aff. May 2007: 26(3):W296-309.

© QURE 2015

From an Actor Patient… To a “Virtual Patient”

Actor Patients Taught us that a Virtual Patient (VP):

– Needs to be a standardized patient

• Case mix adjusted

– Can be done anywhere on anyone

• Paper or Plastic

– Match clinical setting, provide phased disclosures to evaluate judgment and not just knowledge

– Valid, reliable and consistent determination of actual clinical practice

– Inexpensive

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CPV Vignette Provides a Standard Measure of Practice

• CPV virtual patient presents with symptoms in the hospital, ED or any outpatient setting.

• The provider cares for a variety of clinical cases (>200) as they would in their practice

• Provider goes through the 5 clinical domains every provider does when they see a patient:

– Taking a history– Conducting a

physical examination

– Ordering tests– Making a diagnosis– Providing

treatment

© QURE 201528

CPV’s Vignettes Have Been Validated to Measure Actual Practice

Peabody JW, Luck J, Glassman P, Jain S, Spell M and Hansen J. “A Prospective Multi-Site Evaluation of Vignettes: Validating an Innovative Method for Measuring the Quality of Physician Practice.” Annals of Internal Medicine. Vol. 141(10):771-80, November 2004.

All Diseases COPD Diabetes Vascular Disease

Depression0

10

20

30

40

50

60

70

80

73 6973 76 73

68 6573 70

6563 62 6468

59

Standardized Patients

Vignettes

Charts

Validated CPVs Do Not Overestimate Actual Service Quality

Corr

ect

%

CPV® vignettes:

• Superior to chart abstraction (CA)

• Close to standard patients (SP)

• More practical and less expensive than both SP and CA

© QURE 2015

QURE develops cases targeting high priority needs

Report Out Practice Change Case Writing

Desired Results Observed

CPV® vignettes Feedback

Serially Implementation of CPV® Measurement and Feedback

© QURE 2015

CPV® Vignette Global Applications

Vignettes used to address different service problem areas:

• RBF policy impact (e.g. practice change in Africa)

• Guideline adherence for treatment (e.g. WHO);

• Overuse of diagnostics (e.g. CT imaging in China);

• Ensure right diagnoses (e.g., early referral of High Risk OB);

• Cross national studies (e.g. monitoring quality of care progress)

Over 20,000 CPV® vignettes have been completed worldwide

• 30 countries

There are more than 200 CPV clinical conditions ranging from Asthma to Zoonosis.

© QURE 2015

Quality of Care in Eastern Europe and Central Asia (ECA-6)

• Countries in this region face twin burden of disease:

– Problems of low-middle-income countries, such as poor maternal and neonatal care

– Problems of industrial countries, such as heart attack and cardio-vascular risk factors

• 10 CPVs designed to capture quality of care and clinical challenges and areas of need in ECA-6 countries

CPV Disease Areas:

Non-communicable Disease

Acute Myocardial InfarctionMultiple Risk Factors

Neonatal CareBirth Asphyxia

Neonatal Pneumonia

ObstetricsPostpartum hemorrhage

© QURE 2015

CPV’s Scale Up Quality Measurement: Recent Experience in a WB Multi-country Study

• A total of 1,039 facilities, 2,855 physicians, 306 midwives

• Albania, Armenia, Georgia, Kazakhstan, Russia, and Tajikistan

• Goals: – Establish a benchmark and track

impact trends

– Motivate best practices

– Guides policy

Using CPVs, The World Bank undertook the largest cross-national evaluation of the quality of care

© QURE 2015

There Are Major Deficits in Quality (just a few findings of many)

All

Albania

Armen

ia

Georgi

a

Kazakh

stan

Russia

Tajik

istan

0%10%20%30%40%50%60%70%80%

Missed Acute MI Diagnosis

• In some countries the diagnosis of an MI (heart attack) is missed >50% of the time

• Highly variable between country

• In asphyxia, >50% of providers fail to check for an open airway.

• Universally poor across all country

All

Albania

Armenia

Georgia

Kazakh

stan

Tajikis

tan0%

20%40%60%80%

100%

Failure to Check for a Patent Airway in Birth

Aphyxia

© QURE 2015

(Too many) Examples of Deficits in Quality Processes

• Cardiovascular disease and diabetes account for the highest burden of global illness

• Cholesterol-lowering drugs and blood pressure lowering drugs are not used correctly >60% of the time.

• Aspirin is affordable and available, but not used >40% of the time in 5 countries

• In Russia, use is high (good)

All

Albania

Armenia

Georgia

Kazakh

stan

Russia

Tajikis

tan0%

20%

40%

60%

80%

Failure to use Apirin for Acute MI

All

Albania

Armenia

Georgia

Kazakh

stan

Russia

Tajikis

tan0%

40%

80%

Failure to use Statins and Anti-hypertensives

statins anti-hypertensives

© QURE 2015

Bonuses Could be Earned for Higher CPV Scores

Can Quality Be Improved Using CPVs in LMIC’s? QIDS: A National Policy Study from the Philippines

36

• Linked patients with physician quality, measured by CPV

• Difference-in-difference models assessed the impact of Bonus on many health outcomes:

– hemoglobin, GSRH, CRP, wasting, and stunting,

• Controlled for patient characteristics, such as age, mother’s education, income, condition, and length of stay

Data Source

Round 1 and 2; Intervention A, C

Data Collection

Patient exits (biomarkers, anthropometrics)

Model

Logit (Yit) = α0 + α1Ni + β0Ti + β1NiTi + ΣθjXjit + Uit

Yit = Health measure of ith individual in survey round tN = dummy variable for intervention siteT = dummy variable for post-intervention periodX = patient and household characteristics (age, illness, severity, household income)

© QURE 2015

QIDS Research Design

• Randomization at the District Level

• Multi-level Design

• Longitudinal Follow-up

37

30 District Hospitals

Round One Data

Insurance

Bonus

Control

Sites Baseline Data Randomize Change Policy Follow-up on Data

Round Two Data

6,000 Children

© QURE 2015

Physicians with Higher CPV Vignette Scores Had Patients with Better Outcomes

• Quality improved by an average of 9.7% in the CPV Vignette linked P4P Intervention arm (p<.001)

• Health Outcomes in the Intervention: Reductions in wasting or reported health status (GSRH) at discharge and 4-10 week follow-up

Difference-in-Difference

Improvement in Round 2 vs Round 1

Wasting General Self Reported Health (at least good)

At time of discharge -6.5 percentage pts * 9.1 percentage pts **

At 8 wk follow-up -11.8 percentage pts **

11.8 percentage pts **

Rate of improvement (discharge to 8 wks) -15.2 percentage pts

**9.5 percentage pts ***p<0.10, **p<0.001

Peabody, John W., Riti Shimkhada, Stella Quimbo, Orville Solon, Xylee Javier, and Charles McCulloch. The impact of performance incentives on child health outcomes: results from a cluster randomized controlled trial in the Philippines. Health Policy and Planning. Health Policy Plan. (2014) 29 (5): 615-621.

© QURE 2015

Philippine QIDS: Quality Improvements Were Sustained Over Time

Quality measurement creates:A new culture of self-awareness and continual improvement

Transformation Culture change Launch Continual measurements

Quimbo S, Wagner N, Florentino J, Solon O , and Peabody J. Do Health Reforms To Improve Quality Have Long-term Effects? Results of a Follow-up on a Randomized Policy Experiment in the Philippines . Health Economics, 2014. Publication pending.

© QURE 2015

Our Discussions on Quality Have Advanced in DCP-3 • We think less about structural measures and more about the clinician -

how does his/her practice compare to the evidence base?

• We spend less time arguing over which measures to use and…

• More time focused on improving clinical care practice and patient outcomes

• Think about how quality affects demand

• Go beyond what is done and think about how clinical information is synthesized

– How does clinician make judgments, diagnosis?

• Active engage policy around the costs of quality, its cost effectiveness and tradeoffs

© QURE 2015

Policy Interventions that Might Improve Quality—With Measurement—There Are Lots to Choose From

Access

Universal coverage,

Non-physician providers,

Facilities, Benefit expansion, CCTs

Quality of Care

Measurement and Feedback

Clinical Practice Organization

Education, Licensing-certification, Continuous Quality

Improvement/PDSA, CME, Organization change/supervision, Accreditation & administrative

regulation,

Peabody J.W, Taguiwalo M.M, Robalino D.A, et al. Improving the Quality of Care in Developing Countries. In: Jamison DT, Breman JG, Measham AR, et al., editors. Disease Control Priorities in Developing Countries. 2nd edition. Washington (DC): World Bank; 2006. Chapter 70.

Quality Interventions Possibly the best opportunity to quickly improve outcomes?

Clinical Practice Incentives

RBF, P4P, Volume of Care, Peer review, Legal mandates, Public–private

quality-based competition

Policy Interventions that Can Improve Quality of Care

© QURE 2015

Potential for Impact of Quality on MDG/SDGs is Enormous• Evidence from the Philippines shows that

increasing quality by just 10% can save 15,000-20,000 lives for the under 5 population.

• Impact can be even greater as burden from chronic, non-communicable disease continues to grow:

– Recent estimates total 764.8 million years of living with disability

– 24 of 25 top causes of YLD are chronic diseases, highly dependent of quality of care

Source: Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. June 2015

© QURE 2015

More Research on Policy and Quality Impact Is Needed

Witter S, Fretheim A, Kessy FL, Lindahl AK. Paying for performance to improve the delivery of health interventions in low- and middle-income countries. Cochrane Database Syst Rev. 2012 Feb 15;2:CD007899.Basinga P, Gertler PJ, Binagwaho A, et al. Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation. The Lancet 2011;377:1421-8.

Basinga et al, 2011. Lancet:Randomized study of performance incentives

in Rwanda

Cochrane Review, 2012 of P4P in LIMC (Witter et al)

- 9 studies (only)- Some positive findings

(randomized studies, such as Basinga et al 2011)

- Authors conclude more robust and comprehensive studies needed

- Effects depend on interaction of several variables, such as design of the intervention (e.g. who receives payments, magnitude, quality measurement)

© QURE 2015

Summary and Implications1. Quality (Process of Care) is poor

and varied

2. Access and Structural elements of quality have improved recently but limited impact on health outcomes

3. Improving Quality of Care Services requires Measurement and Feedback to the provider- Did the clinician make the right

diagnosis, did they decide to operate or not, did they give the correct medicine?

- Look for high impact health outcomes: e.g. pediatrics, obstetrics, surgical complications, avoidance of downstream costs

1. A few different measurement tools are available

2. Multiple Policy levers are available

3. More research at national scale is needed

4. Focus on impact, and comparative effectiveness

5. Expect Quick Results

Thank you

QUALITY OF CARE IMPROVING CLINICAL PRACTICE: Connecting Universal Coverage to Better Health Outcomes...

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