Data quality review program: the Society of Thoracic Surgeons Adult Cardiac National Database

Value in acute care surgery, part 2: Defining and measuring quality outcomes

ABSTRACT

The prior article in this series delved into measuring cost in acute care surgery, and this subsequent work explains in detail how quality is measured. Specifically, objective quality is based on outcome measures, both from administrative and clinical registry databases from a multitude of sources. Risk stratification is key in comparing similar populations across diseases and procedures. Importantly, a move toward focusing on subjective outcomes like patient-reported outcomes measures and financial well-being are vital to evolving surgical quality measures for the 21st century.

Performance Measures in Dermatologic Surgery: A Review of the Literature and Future Directions

BACKGROUND

In recent years, health care reform initiatives have aimed to assess quality of care through the use of performance measures. Multiple specialties, including dermatology, have implemented registries to track and report health care quality.

OBJECTIVE

The authors review the history and rationale for assessing quality in dermatologic surgery. The authors also discuss the different types of performance measures and the current efforts to develop clinically relevant dermatologic surgery-specific measures.

MATERIALS AND METHODS

An extensive literature review was conducted using OVID, MEDLINE, PubMed, and government and health care-related websites to identify articles related to surgical performance measures.

RESULTS

Few performance measures are established to assess quality in dermatologic surgery. The authors propose specific candidate measures and discuss how clinical registries can capture measures that meet federal reporting requirements.

CONCLUSION

Assessment of health care quality will become increasingly important in health care reform. Physicians need to take an active role in selecting appropriate, clinically relevant performance measures that will help improve patient care while containing health care costs and meeting government-mandated reporting requirements.

Evaluating the quality of data from the Japanese National Clinical Database 2011 via a comparison with regional government report data and medical charts

PURPOSE

The aim of this study was to examine the quality of data from the National Clinical Database (NCD) via a comparison with regional government report data and medical charts.

METHODS

A total of 1,165,790 surgical cases from 3007 hospitals were registered in the NCD in 2011. To evaluate the NCD's data coverage, we retrieved regional government report data for specified lung and esophageal surgeries and compared the number with registered cases in the NCD for corresponding procedures. We also randomly selected 21 sites for on-site data verification of eight demographic and surgical data components to assess the accuracy of data entry.

RESULTS

The numbers of patients registered in the NCD and regional government report were 46,143 and 48,716, respectively, for lung surgeries and 7494 and 8399, respectively, for esophageal surgeries, leading to estimated coverages of 94.7% for lung surgeries and 89.2% for esophageal surgeries. According to on-site verification of 609 cases at 18 sites, the overall agreement between the NCD data components and medical charts was 97.8%.

CONCLUSION

Approximately, 90-95% of the specified lung surgeries and esophageal surgeries performed in Japan were registered in the NCD in 2011. The NCD data were accurate relative to medical charts.

The Chinese Cardiac Surgery Registry: Design and Data Audit

BACKGROUND

In light of the burgeoning volume and certain variation of in-hospital outcomes of cardiac operations in China, a large patient-level registry was needed. We generated the Chinese Cardiac Surgery Registry (CCSR) database in 2013 to benchmark, continuously monitor, and provide feedback of the quality of adult cardiac operations. We report on the design of this database and provide an overview of participating sites and quality of data.

METHODS

We established a network of participating sites with an adult cardiac surgery volume of more than 100 operations per year for continuous web-based registry of in-hospital and follow-up data of coronary artery bypass grafting (CABG) and valve operations. After a routine data quality audit, we report the performance and quality of care back to the participating sites.

RESULTS

In total, 87 centers participated and submitted 46,303 surgical procedures from January 2013 to December 2014. The timeliness rates of the short-list and in-hospital data submitted were 73.6% and 70.2%, respectively. The completeness and accuracy rates of the in-hospital data were 97.6% and 95.1%, respectively. We have provided 2 reports for each site and 1 national report regarding the performance of isolated CABG and valve operations.

CONCLUSIONS

The newly launched CCSR with a national representativeness network and good data quality has the potential to act as an important platform for monitoring and improving cardiac surgical care in mainland China, as well as facilitating research projects, establishing benchmarking standards, and identifying potential areas for quality improvements (ClinicalTrials.gov No. NCT02400125).

Identifying and defining complications of dermatologic surgery to be tracked in the American College of Mohs Surgery (ACMS) Registry

BACKGROUND

In recent years, increasing emphasis has been placed on value-based health care delivery. Dermatology must develop performance measures to judge the quality of services provided. The implementation of a national complication registry is one such method of tracking surgical outcomes and monitoring the safety of the specialty.

OBJECTIVE

The purpose of this study was to define critical outcome measures to be included in the complications registry of the American College of Mohs Surgery (ACMS).

METHODS

A Delphi process was used to reach consensus on the complications to be recorded.

RESULTS

Four major and one minor complications were selected: death, bleeding requiring additional intervention, functional loss attributable to surgery, hospitalization for an operative complication, and surgical site infection.

LIMITATIONS

This article addresses only one aspect of registry development: identifying and defining surgical complications.

CONCLUSION

The ACMS Registry aims to gather data to monitor the safety and value of dermatologic surgery. Determining and defining the outcomes to be included in the registry is an important foundation toward this endeavor.

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: The Driving Force for Improvement in Cardiac Surgery

Initiated in 1989, the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) includes more than 1085 participating centers, representing 90%-95% of current US-based adult cardiac surgery hospitals. Since its inception, the primary goal of the STS ACSD has been to use clinical data to track and improve cardiac surgical outcomes. Patients' preoperative risk characteristics, procedure-related processes of care, and clinical outcomes data have been captured and analyzed, with timely risk-adjusted feedback reports to participating providers. In 2006, STS initiated an external audit process to evaluate STS ACSD completeness and accuracy. Given the extremely high inter-rater reliability and completeness rates of STS ACSD, it is widely regarded as the "gold standard" for benchmarking cardiac surgery risk-adjusted outcomes. Over time, STS ACSD has expanded its quality horizons beyond the traditional focus on isolated, risk-adjusted short-term outcomes such as perioperative morbidity and mortality. New quality indicators have evolved including composite measures of key processes of care and outcomes (risk-adjusted morbidity and risk-adjusted mortality), longer-term outcomes, and readmissions. Resource use and patient-reported outcomes would be added in the future. These additional metrics provide a more comprehensive perspective on quality as well as additional end points. Widespread acceptance and use of STS ACSD has led to a cultural transformation within cardiac surgery by providing nationally benchmarked data for internal quality assessment, aiding data-driven quality improvement activities, serving as the basis for a voluntary public reporting program, advancing cardiac surgery care through STS ACSD-based research, and facilitating data-driven informed consent dialogues and alternative treatment-related discussions.

Redundancy and variability in quality and outcome reporting for cardiac and thoracic surgery

Health care is evolving into a value-based reimbursement system focused on quality and outcomes. Reported outcomes from national databases are used for quality improvement projects and public reporting. This study compared reported outcomes in cardiac and thoracic surgery from two validated reporting databases-the Society of Thoracic Surgeons (STS) database and the National Surgical Quality Improvement Program (NSQIP)-from January 2011 to June 2012. Quality metrics and outcomes included mortality, wound infection, prolonged ventilation, pneumonia, renal failure, stroke, and cardiac arrest. Comparison was made by chi-square analysis. A total of 737 and 177 cardiac surgery cases and 451 and 105 thoracic surgery cases were captured by the STS database and NSQIP, respectively. Within cardiac surgery, there was a statistically significant difference in the reported rates of prolonged ventilation, renal failure, and mortality. No significant differences were found for the thoracic surgery data. In conclusion, our data indicated a significant discordance in quality reporting for cardiac surgery between the NSQIP and the STS databases. The disparity between databases and duplicate participation strongly indicates that a unified national quality reporting program is required. Consolidation of reporting databases and standardization of morbidity definitions across all databases may improve participation and reduce hospital cost.

Patient-prosthesis mismatch in patients with aortic valve replacement

OBJECTIVE

Patient-prosthesis mismatch (PPM) may affect clinical outcomes in patients with aortic valve replacement (AVR). We retrospectively examined the PPM in patients with isolated AVR in the Japan Adult Cardiovascular Surgery Database (JACVSD).

METHODS

We examined all patients with isolated AVR between January 1, 2008 and December 31, 2009. The JACVSD data collection form has a total of 255 variables. We defined PPM as an effective orifice area index of ≤ 0.85 m(2)/cm(2).

RESULTS

PPM was observed in 306 of 3,609 cases analyzed, PPM rate was 8.5 %. Body surface area was larger and body mass index was higher in the PPM group than the non-PPM group (P < 0.001). Patients with PPM were older (P = 0.001) and had a higher prevalence of diabetes (P = 0.004), dyslipidemia (P < 0.001), hypertension (P < 0.001), cerebrovascular disease (P = 0.031), old myocardial infarction (P = 0.006), previous percutaneous coronary artery intervention (P = 0.001), coronary artery disease (P = 0.018), and aortic valve stenosis (P < 0.001). Perioperative blood transfusion (P < 0.001) and dialysis (P = 0.005) were more frequent in the PPM group. Postoperative ventilation (P = 0.004) and intensive care unit stay (P = 0.004) were significantly longer in the PPM group.

CONCLUSIONS

Age, aortic valve stenosis, dyslipidemia, hypertension, old myocardial infarction, previous percutaneous coronary artery intervention, diabetes mellitus, cerebrovascular disease, and high body mass index were the risk factors for PPM. PPM was not an independent risk factor for short-term mortality.

Cardiovascular surgery risk prediction from the patient's perspective

OBJECTIVE

Previous studies have developed cardiovascular surgery outcome prediction models using only patient risk factors, but surgery outcomes from the patient's perspective seem to differ between hospitals. We have developed outcome prediction models that incorporate preoperative patient risks, as well as hospital processes and structure.

METHODS

Data were collected from the Japan Cardiovascular Database for patients scheduled for cardiovascular surgery between January 2005 and December 2007. We analyzed 33,821 procedures in 102 hospitals. Logistic regression was used to generate risk models, which were then validated through split-sample validation.

RESULTS

Odds ratios, 95% confidence intervals, and P values for structures and processes in the mortality prediction model were as follows: "hospital annual adult cardiac surgery volume (continuous; every 1 procedure increase per year)" (odds ratio, 0.998; confidence interval, 0.997-0.999; P < .001); "recommended staffing and equipment" (odds ratio, 0.75; confidence interval, 0.64-0.87; P < .001); "daily conferences with cardiologists" (odds ratio, 0.79; confidence interval, 0.60-1.02; P = .073); "intensivists involved in postsurgical management" (odds ratio, 0.89; confidence interval, 0.77-1.02; P = .90); "public hospitals" (odds ratio, 0.80; confidence interval, 0.70-0.93; P = .003); "surgeons lacking miscellaneous duties" (odds ratio, 0.80; confidence interval, 0.70-0.93; P = .003); and "surgeons who work no more than 32 hours per week" (odds ratio, 0.55; confidence interval, 0.32-0.95; P = .032). The mortality prediction model had a C-index of 0.85 and a Hosmer-Lemeshow P value of .79.

CONCLUSIONS

Our models yielded good discrimination and calibration, so they may prove useful for hospital selection based on individual patient risks and circumstances. Improved surgeon work environments were also shown to be important for both surgeons and patients.

A short history of the Society of Thoracic Surgeons national cardiac database: perceptions of a practicing surgeon

The Society of Thoracic Surgeons database was developed as an initiative to standardize nationwide outcomes in adult cardiac surgery, and it has currently expanded into general thoracic and congenital cardiac surgery databases. For more than 19 years since its inception, the Society of Thoracic Surgeons database has grown as a powerful source of risk-adjusted outcomes, large scale scientific contributions, and invaluable information for healthcare policy making. This review article provides a snapshot of the genesis, history, growth, and scientific contributions of the Society of Thoracic Surgeons database to stimulate the participation of thoracic surgery programs and maximize its future use for investigational purposes.

Improving the quality of data entry in a low-budget head injury database

BACKGROUND

To assess the efficacy of a centralised review of a voluntary low-budget head injury database with a retrospective analysis of data before and after a centralised review.

METHOD

A computerised data collection (Neurolink) on traumatic brain injury cases admitted to three neuro-intensive care units in Milan (Italy): analysis of a three-year period (1999-2001). Data from 499 patients (epidemiology, type of lesion, clinical course, monitoring, treatment, complications and outcome). The audit involved a review of forms relating to patients enrolled in the three-year period, with the aim of improving the quality of data entry. Missing data in all empty fields were identified; evident errors and contradictory data were identified and corrected; missing and final data were analysed to test the efficacy of the review.

FINDINGS

The total post-review missing data rate was significantly lower than the paired pre-review missing data rate (p = 0.001). The same was confirmed for each of the 3 years (p = 0.001 for each year). The missing data rate significantly improved over the three-year period (p = 0.001). Data for the pre-hospitalisation period had the highest missing rates; data regarding the ICU stay showed the greatest improvement after the review. A total of 407 items (0.44%) were identified as errors.

CONCLUSIONS

Data quality is fundamental to avoid information bias in database analysis. This study indicates that it is possible to generate a serious data collection without significant resources. Audit seems to be an important tool before the final data is used for scientific projects.

Timing of Chest Tube Removal After Coronary Artery Bypass Surgery

AIM

Assessing the impact of chest tube removal timing following a coronary artery bypass grafting surgery on the clinical outcome.

METHODS

Eighty-three consecutive patients were randomly assigned to either have the chest tube removed 24 hours (Group A) or 48 hours (Group B) postoperatively. Chest tubes were removed on the condition that drainage was less than 100 cc for the last 8 hours. Pre- and postoperative data were analyzed.

RESULTS

The following preoperative and intraoperative risk factors were more prevalent among Group A patients: previous MI (60.5% vs 40.7%, p = 0.11), previous CVA (9.1% vs 0%, p = 0.11), hypertension (72.7% vs 55.6%, p = 0.14), pump time (111.6 min vs 96.8 min, p = 0.07), and cross-clamp time (73.8 min vs 64.4 min, p = 0.07). Postoperatively, there was a lower demand for analgesics in Group A (2.1 times for 12 hours at 36 hours vs 3.6 p = 0.09), lower white blood cell count (10,947 at 48 hours vs 11,576, p = 0.39) a higher oxygen saturation (91.9% at 48 hours vs 88.9%, p = 0.07), higher expiratory volumes (594 mL at 36 hours vs 514 mL p = 0.08) and earlier mobilization (23% walking at 48 hours vs 4%, p = 0.01). Pleural effusion and atelectasis were less frequent in Group A in both chest X-rays (66% vs 73%, p = 0.6 and 64% vs 75%, p = 0.47, respectively) and CT scans (19% vs 41%, p = 0.1 and 84% vs 96%, p = 0.42, respectively). There was no difference between the two groups in the prevalence of serous wound discharge and the length of hospital stay and there were no reported cases of pneumonia throughout the study.

CONCLUSION

In cases where no excessive drainage accumulates, early removal of the chest tubes was found to be a policy that improves the postoperative outcome and decreases the need for supportive treatment such as analgetics, physiotherapy, nurse care, and oxygen. This policy did not involve significant residual effusions.

Improving the Quality of Data in Your Database: Lessons from a Cardiovascular Center

BACKGROUND

Creating and having a database should not be an end goal but rather a source of valid data and a means for generating information by which to assess process, performance, and outcome quality. The Cardiovascular Center at Shands Jacksonville (Florida) made measurable improvements in the quality of data in national registries and internally available software tools for collection of patient care data.

METHODS

The process of data flow was mapped from source to report submission to identify input timing and process gaps, data sources, and responsible individuals. Cycles of change in data collection and entry were developed and the improvements were tracked.

RESULTS

Data accuracy was improved by involving all caregivers in datasheet completion and assisting them with data-field definitions. Using hospital electronic databases decreased the need for manual retrospective review of medical records for datasheet completion. The number of fields with missing values decreased by 83.6%, and the number of missing values decreased from 31.2% to 1.9%. Data accuracy rose dramatically by realtime data entry at point of care.

DISCUSSION

Key components to ensuring data quality for process and outcome improvement are (1) education of the caregiver team, (2) process supervision by a database manager, (3) commitment and explicit support from leadership,(4) increased and improved use of electronic data sources, and (5) data entry at point of care.

Are unaudited records from an outcomes registry database accurate?

BACKGROUND

Data from outcomes registry databases are being increasingly used for peer review and public reporting. However, administrative and clinical databases are mostly unaudited; thus, their accuracy has not been verified.

METHODS

Outcomes data from all coronary artery bypass operations from a single cardiac surgery practice were entered into The Society of Thoracic Surgeons (STS) National Cardiac Database. From our practice of 18 surgeons, we audited 247 (10%) of the clinical records of patients undergoing surgery in 2001 and correlated them with all 315 elements of the STS National Cardiac Database for verification of accuracy. Inaccuracies were defined as a disagreement with a nominal or categorical variable or, for continuous variables, as the value not being within a predetermined window. When discrepancies existed, the hospital clinical record was assumed to be accurate. Outcomes discrepancies were then analyzed by four major categories: components of the preoperative risk algorithm, operative mortality, major complications, and other outcomes.

RESULTS

Discrepancies were noted in 5% (16) or fewer of the audited fields for 98.8% of the records. Of the 32 variables in the mortality risk algorithms, discrepancies were present in fewer than 10% of the audits on 30 of the 32 variables. More than 95% of the audited charts had zero or one discrepancy in the seven most important variables in the mortality risk models. Operative mortality was determined to be completely accurate with no discrepancies between the database and the audited clinical record. Among major complications, the error rate was less than 1% for all complications except prolonged ventilation (4.0%). A higher rate of discrepancies did exist in some of the other variables, including discharge medications (14.1%) and ventilator time (36.4%).

CONCLUSIONS

A detailed audit of a clinical outcomes registry database demonstrated that the major fields within this specific database including operative mortality, major complications, and the significant factors in the risk algorithm were highly accurate. Process improvement factors were identified to further increase the accuracy of data collection.

The Society of Thoracic Surgeons: 30-day operative mortality and morbidity risk models

BACKGROUND

Although 30 day risk-adjusted operative mortality (ROM) has been used for quality assessment, it is not sufficient to describe the outcomes after coronary artery bypass grafting (CABG) surgery. Risk-adjusted major morbidity may differentially impact quality of care (as complications occur more frequently than death) and enhance a surgical team's ability to assess their quality. This study identified the preoperative risk factors associated with several complications and a composite outcome (the presence of any major morbidity or 30-day operative mortality or both).

METHODS

For CABG procedures, the 1997 to 1999 Society of Thoracic Surgeons (STS) National Adult Cardiac Surgery Database was used to develop ROM and risk-adjusted morbidity (ROMB) models. Risk factors were selected using standard STS univariate screening and multivariate logistic regression approaches. Risk model performance was assessed. Across STS participating sites, the association of observed-to-expected (O/E) ratios for ROM and ROMB was evaluated.

RESULTS

The 30-day operative death and major complication rates for STS CABG procedures were 3.05% and 13.40%, respectively (503,478 CABG procedures), including stroke (1.63%), renal failure (3.53%), reoperation (5.17%), prolonged ventilation (5.96%), and sternal infection (0.63%). Risk models were developed (c-indexes for stroke [0.72], renal failure [0.76], reoperation [0.64], prolonged ventilation [0.75], sternal infection [0.66], and the composite endpoint [0.71]). Only a slight correlation was found, however, between ROMB and ROM indicators.

CONCLUSIONS

Used in combination, ROMB and ROM may provide the surgical team with additional information to evaluate the quality of their care as well as valuable insights to allow them to focus on areas for improvement.

Defining and improving data quality in medical registries: a literature review, case study, and generic framework

Over the past years the number of medical registries has increased sharply. Their value strongly depends on the quality of the data contained in the registry. To optimize data quality, special procedures have to be followed. A literature review and a case study of data quality formed the basis for the development of a framework of procedures for data quality assurance in medical registries. Procedures in the framework have been divided into procedures for the co-ordinating center of the registry (central) and procedures for the centers where the data are collected (local). These central and local procedures are further subdivided into (a) the prevention of insufficient data quality, (b) the detection of imperfect data and their causes, and (c) actions to be taken / corrections. The framework can be used to set up a new registry or to identify procedures in existing registries that need adjustment to improve data quality.

Outcomes of coronary artery bypass grafting: A 3 year analysis using the society of thoracic surgeons database

BACKGROUND

Accurate risk factor analysis is a critical element in contemporary cardiac surgical practice. In the USA, the Society of Thoracic Surgeons Database allows institutions and individual surgeons to carry out detailed patient risk assessment and to review their cardiac surgical outcomes in a comparative fashion.

METHODS

To evaluate outcomes of isolated coronary artery bypass grafting, data from all patients operated upon at the Alfred Hospital, Melbourne, Australia, over a 3 year period were entered into the Society of Thoracic Surgeons Database.

RESULTS

Our results (mortality and morbidity) compared favourably with those contained within this large international database.

CONCLUSION

It is hoped that a similar Australasian database can be established to facilitate a meaningful local risk assessment and a comparative analysis of outcomes of cardiac surgical procedures.

The STS National Database: current changes and challenges for the new millennium. Committee to Establish a National Database in Cardiothoracic Surgery, The Society of Thoracic Surgeons

BACKGROUND

The Society of Thoracic Surgeons (STS) established the National Database (NDB) for Cardiac Surgery in 1989. Since then it has grown to be the largest database of its kind in medicine. The NDB has been one of the pioneers in the analysis and reporting of risk-adjusted outcomes in cardiothoracic surgery.

METHODS AND RESULTS

This report explains the numerous changes in the NDB and its structure that have occurred over the past 2 years. It highlights the benefits of these changes, both to the individual member participants and to the STS overall. Additionally, the vision changes to the NDB and reporting structure are identified. The individuals who have participated in this effort since 1989 are acknowledged, and the STS owes an enormous debt of gratitude to each of them.

CONCLUSIONS

Because of their collective efforts, the goal to establish the STS NDB as a "gold standard" worldwide for process and outcomes analysis related to cardiothoracic surgery is becoming a reality.

Clinical research databases and clinical decision making in chronic diseases

Chronic diseases are the major source of morbidity, mortality, and resource utilization. Large-scale longitudinal databases are rapidly proliferating in both single- and multi-institutional settings, providing clinical data on a broad range of patients who receive 'real world' management. Although bias and changing medical management may limit the types of questions that can be addressed using the data contained in longitudinal clinical databases, many initial hypotheses can be generated from the data. Because chronic diseases persist over long periods of time, understanding the impact of temporal relationships, and of concurrent clinical events and contexts is critical to meaningful interpretation of clinical data. Adapting techniques initially developed for the physical sciences and for statistical process control can produce visual displays of clinical data that capture complex temporal and contextual information. With these tools, investigators can quickly explore vast quantities of clinical data, and discover new temporal relationships and emerging trends.

Preoperative predictors of cost in Medicare-age patients undergoing coronary artery bypass grafting

BACKGROUND

Identification of preoperative factors that contribute to the cost of coronary artery bypass grafting could aid in predicting the procedure's expense. In this study, 30 sociodemographic and clinical preoperative factors were examined with "survival analysis" techniques to determine characteristics related to total hospital cost.

METHODS

Characteristics of all patients age 65 or older undergoing isolated coronary artery bypass grafting from July 1993 to April 1995 (n = 757) were recorded. Software was developed within the hospital's Transitions Systems, Inc, database to calculate the outcome variable of total cost. Nonparametric methods were used for the univariate analysis of the data, and the Cox proportional hazards model was used for the multivariable analysis, censoring 25 patients who died in the hospital.

RESULTS

Median hospital cost from the day of the operation until discharge was $15,198. Median length of stay after the operation was 6 days. Multivariable analysis revealed that age, preoperative renal failure, history of cerebrovascular accident, low ejection fraction, and surgical urgency were independent predictors of total cost.

CONCLUSIONS

This study, using an accurate representation of true hospital cost and a modeling technique that accounts for the confounding effect of in-hospital death on cost, provides a template for analysis of cost in other patient groups.

Updates to the Data Quality Review Program: the Society of Thoracic Surgeons Adult Cardiac National Database

To ensure the credibility of this voluntary database, The Society of Thoracic Surgeons' National Database Audit and Validation Sub-Committee has been working during the past year to update and expand the group practice-based indicators used to assess the completeness, accuracy, and generalizability of the Adult Cardiac National Database. With increasing frequency, questions have been raised by third-party payors and regional/state-based groups as to the integrity of the data retained in the Adult Cardiac National Database. To work in conjunction with the Audit and Validation Sub-Committee to explicitly examine these issues, The Society of Thoracic Surgeons initiated a new Expert Advisory Panel review mechanism. This article describes the expanded data completeness and quality criteria that will be implemented in the coming year and summarizes the Expert Advisory Panel's recommendations for improvement.