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Leapfrog Responses to Public Comments on the 2009 Leapfrog Hospital Survey Number Category Theme of Public Comment Leapfrog Response 1 Common Acute Major changes in measure specifications could make it Only hospitals that do not meet the minimum case size for Conditions - AMI difficult for some hospitals to submit 24 months of data for the 12 month reporting period should use a 24 month some measures. For example, at one point the criteria for period for reporting. Hospitals that do need to report for a AMI 8a was PCI within 120 minutes of arrival, now it is PCI 24 month period should submit the data as they submitted within 90 minutes of arrival. to The Joint Commission or CMS. 2 Common Acute The addition of Normal Deliveries presents an additional Where possible, Leapfrog has identified ICD-9-CM codes Conditions - data abstraction load. Would data abstraction via coding be to assist hospitals in obtaining the required data points to Normal possible? complete the Normal Delivery measures. Deliveries 3 Common Acute Elective primary cesarean sections should be an exclusion The specifications for this measure, including the excluded Conditions - from the NTSV cesarean section rate. populations, match what was endorsed by the National Normal Quality Forum. Deliveries Mothers who elect a cesarean section need to be adequately informed of the potential risks that a cesarean section poses to themselves and their newborn(s). Providers need ...
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Leapfrog Responses to Public Comments on the 2009 Leapfrog Hospital Survey
Number Category Theme of Public Comment Leapfrog Response 1 Common Acute Major changes in measure specifications could make it Only hospitals that do not meet the minimum case size for Conditions - AMI difficult for some hospitals to submit 24 months of data for the 12 month reporting period should use a 24 month some measures. For example, at one point the criteria for period for reporting. Hospitals that do need to report for a AMI 8a was PCI within 120 minutes of arrival, now it is PCI 24 month period should submit the data as they submitted within 90 minutes of arrival. to The Joint Commission or CMS. Common Acute The addition of Normal Deliveries presents an additional Where possible, Leapfrog has identified ICD-9-CM codes Conditions - data abstraction load. Would data abstraction via coding be to assist hospitals in obtaining the required data points to Normal possible? complete the Normal Delivery measures. Deliveries Common Acute Elective primary cesarean sections should be an exclusion The specifications for this measure, including the excluded Conditions - from the NTSV cesarean section rate. populations, match what was endorsed by the National Normal Quality Forum. Deliveries Mothers who elect a cesarean section need to be adequately informed of the potential risks that a cesarean section poses to themselves and their newborn(s). Providers need to take an active role in providing this information to expectant mothers. Common Acute For the newborn bilirubin screening before discharge, is Per the measure specifications, transcutaneous screening Conditions - transcutaneous screening considered an acceptable is considered an acceptable method for screening Normal method? newborns for hyperbilirubinemia. Deliveries Common Acute For the cesarean section rate measure for low risk first birth Leapfrog appreciates that note and revised the measure Conditions - women, why use live births as opposed to deliveries? They specifications to reflect eligible cases as mothers that Normal define the numerator by live births with twins excluded so delivered singletons at or after 37 completed weeks Deliveries the number of live births would be the same as the number gestation during the reporting period. of mothers that delivered and the codes that they are using are maternal codes.
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February 23, 2009 Page 1 of 21
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Leapfrog Responses to Public Comments on the 2009 Leapfrog Hospital Survey
Category Theme of Public Comment Leapfrog Response Common Acute For the cesarean section rate measure for low risk first birth The cesarean section rates will be risk-adjustment for Conditions - women, please provide rationale for breaking the numbers maternal age via indirect standardization to U.S. norms for Normal into the specific age categories. cesarean rates by mothers' age distributions. Maternal Deliveries age is an important independent risk factor for cesarean birth beginning in a woman's mid-20s, and hospitals vary greatly in their birthing population age distributions. Common Acute For the appropriate DVT prophylaxis measure, ACOG Appropriate DVT prophylaxis is recommended for any Conditions - Bulletin #84 references dividing women by risk factors. patient undergoing a surgery longer than 30-45 minutes. ormal Low-risk patients are not included in the VTE prophylaxis. As it is hard to predict in advance the duration of a N Deliveries They do recommend prophylaxis for moderate high-, and cesarean section delivery, the National Quality Forum highest-risk patients. CSAC recommended that all cesarean section patients receive appropriate DVT prophylaxis. Common Acute The Normal Delivery measure specifications indicate that Leapfrog is aware that some of the Normal Delivery Conditions - some data needs to come from administrative data and measures will require chart abstraction, a method of data Normal some needs to come from the medical record or EHR. collection that we try to avoid asking hospitals to do at all Deliveries Gestational age and mom's history (parity, past stillborn costs. But the information these measures will provide to birth, and other history) isn't available electronically for all consumers and purchasers about the current quality of hospitals and will require chart abstraction, which is maternal care is so important that Leapfrog decided the resource intensive and time consuming. A couple of the value of the data was worth making an exception. measures will require some hospitals to look in multiple data sources. We encourage Leapfrog to choose indicators Leapfrog urges hospitals to continue pushing their EHR that that can be measured based on electronically available vendors to create software in which data data. abstraction/reporting is a key component of the software design.
February 23, 2009 Page 2 of 21
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Leapfrog Responses to Public Comments on the 2009 Leapfrog Hospital Survey
Category Theme of Public Comment Leapfrog Response Common Acute We disagree with Leapfrog’s plans to include three of the As part of ACOG’s recommendations on the Prevention of Conditions - four proposed measures for Normal Deliveries: Blood Clots in Gynecologic Surgery Patients, they state “A Normal significant number of lives can be saved by providing Deliveries 1. The measure of appropriate DVT prophylaxis is not relatively simple and safe preventive treatments. Methods supported by the American College of Obstetrics to prevent DVT and PE are well established after years of and Gynecology (ACOG) because of the lack of clinical trials." As the measure specifications indicate, prospective randomized trials with adequate size to hospitals have a variety of methods to prevent blood clots conclude that prophylaxis with unfractionated or low including compression devices and medications. molecular weight heparin is warranted The cesarean rate for low-risk first birth women is one the 2. The measure of Cesarean rate for low-risk first birth CDC Healthy People 2010 leading health indicators and women is not a good measure of the quality of also continues to be a focus for the World Health obstetric care. This measure, as defined by the Organization. As rates of VBACs in the U.S. decline, it National Quality Forum, was not supported by becomes even more important to focus on the rates of first ACOG. birth cesarean section deliveries. Studies have shown poorer outcomes for both mother and baby for deliveries 3. The measure of newborn bilirubin screening prior to by cesarean section. discharge is not supported by the literature. The rate of kernicterus is in the US is not known and Death or serious disability caused by a failure to identify that given current estimates, it could cost tens of and treat hyperbilirubinemia in neonates is one of NQF’s millions of dollars to catch one case. This is not a 28 Serious Reportable Events. Bhutani and Johnson useful measure. (2004) estimated that 1 in 700 well newborns can develop extreme hyperbilirubinemia; these infants can be at major risk for kernicterus if there are no failsafe, system-based protocols. Common Acute For the elective delivery prior to 39 completed weeks While 37 completed weeks is the definition of full term, Conditions - gestation measure -- 37 weeks is considered full term, why studies - including a recently published one in the New Normal was 39 weeks chosen? England Journal of Medicine that looked at elective Deliveries caesarean sections - provide proof that babies born before 39 weeks have higher rates of breathing problems, low blood sugar, neonatal intensive-care unit stays and serious infections.
February 23, 2009 Page 3 of 21
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Leapfrog Responses to Public Comments on the 2009 Leapfrog Hospital Survey
Number Category Theme of Public Comment Leapfrog Response 11 Common Acute We agree with Leapfrog's decision to remain in alignment Leapfrog is committed to aligning with other national Conditions - with CMS and The Joint Commission by removing performance measurement entities when it makes sense. Pneumonia Oxygenation Assessment from the process-of-care quality As a strong majority of hospitals in the United States have measures. As public reporting becomes more pervasive in achieved 100% adherence on the Oxygenation the market place we encourage alignment of definitions and Assessment measure, its removal from the Leapfrog metrics as much as possible to prevent consumer Hospital Survey was appropriate. confusion. Common Acute Recommend specific notation that pediatric hospitals are The seven EBHR high-risk procedures/treatments, the Conditions exempt from the Pneumonia set of measures in the 2009 three common acute conditions, and the original two Pneumonia survey. hospital-acquired conditions are not applicable to pediatric hospitals. CPOE We believe that pharmacy management of certain Leapfrog’s expert panel has advised that physicians need (Computerized medications (including warfarin) under physician approved to confirm a dose before it is sent to the pharmacy -- even Physician Order protocol is safer than direct physician management of if the dose they are confirming is per the protocol. A Entry) individual doses. Through introducing additional control CPOE system should provide the physician the details on points in the pharmacy we will achieve greater success in what the protocol is for that patient type (e.g. age, weight) preventing common serious prescribing errors. and the opportunity for them to change/confirm the dose. In addition, the system should provide the physician an alert if their modifications would potentially harm the patient. The physician has the most knowledge about the patient and whether any adjustments to the protocol need to be made, especially for high-risk, complex medications like warfarin. The pharmacy can obviously double-check with the physician to make sure that any deviations from the protocol were intended, but the responsibility for the order lies with the physician. Leapfrog’s expert panel stressed that this is a medical/legal issue.
February 23, 2009 Page 4 of 21
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Leapfrog Responses to Public Comments on the 2009 Leapfrog Hospital Survey
Category Theme of Public Comment Leapfrog Response CPOE How does a hospital determine if their CPOE system alerts Hospitals demonstrate that their CPOE system alerts (Computerized physicians “to at least 50% of common serious prescribing physicians “to at least 50% of common serious prescribing Physician Order errors"? errors" by completing an appropriate test in the CPOE Entry) Evaluation Tool. A hospital’s CPOE system must alert prescribers to at least 50% of common serious prescribing errors in a predetermined number of medication categories (e.g. drug-drug, drug-diagnosis). CPOE We feel restricting CPOE credit to the in-patient setting will Leapfrog has given hospitals eight years to implement a (Computerized have a negative effect on those hospitals that have CPOE system in at least a single inpatient unit. The Physician Order previously been compliant in implementing a CPOE system survey has always asked hospitals to report the Entry) in the ED. percentage of inpatient medication orders they enter through their CPOE system, so Leapfrog’s focus on the Recommendation: Provide partial credit for ED inpatient setting has always been clear. Leapfrog’s expert implementation and/or extra credit for progress toward the panel has advised that providing credit for ED-only in-patient implementation. It is unfair to provide zero credit implementation no longer makes sense. for the hospitals implementing in the ED. Recommend a transition period before completely phasing out the credit ED CPOE systems are very different than their inpatient for the ED implementation. counterparts. The CPOE Evaluation Tool was designed with inpatient scenarios in mind. CPOE The CPOE Evaluation Tool does not provide hospitals the Leapfrog will be updating the CPOE Evaluation Tool to Evaluation Tool ability to indicate if a route is "hard-coded" within the provide hospitals the ability to indicate if the route of formulary choice, preventing the choice of inappropriate administration specified in the test order is not in the route. hospital’s formulary. CPOE To combat user-fatigue associated with physician alerts, The CPOE Evaluation Tool provides credit for alerts that Evaluation Tool safety-related alerts have been designed to fire to other are delivered to the prescriber, as evidence supports this members of the health care team such as pharmacists and as the most effective approach to eliminating medication nurses, and notification processes/policies implemented errors. To ensure a reasonable evaluation of hospital accordingly. Alerts are an important safety feature of systems, the CPOE Evaluation Tool only tests for alerts CPOE, but the tests in the CPOE Evaluation Tool must be that are considered severe in nature. Organizations may made for a broader alert recipient base. choose to display a wider set of warnings to other providers. .
February 23, 2009 Page 5 of 21
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Leapfrog Responses to Public Comments on the 2009 Leapfrog Hospital Survey
Number Category Theme of Public Comment Leapfrog Response 18 CPOE Our understanding is the CPOE Evaluation Tool tests The CPOE Evaluation Tool is designed to test whether a Evaluation Tool whether a hospital’s CPOE system prevents a provider from hospital’s CPOE system is providing the prescriber the being able to place an order. But hard stopping a provider appropriate alert when a potentially serious error could on every warning leads to provider revolt and isn't practical. occur, not if the hospital’s system has a hardstop in place. Isn't a system safe if it alerts the provider and then lets the Leapfrog agrees that that computer decision support provider use their judgment and training to proceed? (CDS) does not replace provider judgment and training, however, the evidence does show CDS as an incredibly important tool in helping providers prevent medical errors. CPOE The CPOE Evaluation Tool tested a drug-drug pair whose The CPOE Evaluation Tool provides credit for alerts that Evaluation Tool interaction level was rated by our drug data vendor as Level are delivered to the prescriber, as evidence supports this II or Severe, rather than the dozens of drug pairs that are as the most effective approach to eliminating medication Level I (Contraindicated). In our CPOE system, Level II errors. To ensure a reasonable evaluation of hospital alerts display to the pharmacist but not to the physician. systems, the CPOE Evaluation Tool only tests for alerts Since 98% of Level II alerts are dismissed by the that our experts consider severe in nature. pharmacist, we believe that displaying Level II alerts to physicians would result in "alert fatigue" and could possibly The categorization of alerts (Level I vs. Level II) by reduce rather than increase patient safety. formulary vendors has not been a transparent process. Hospitals that have completed a successful evaluation of their CPOE system with the CPOE Evaluation Tool have taken the time to do a through review and recategorization of the alert levels in their vendor-provided database. We urge hospitals to undergo a similar review and/or to work with their formulary vendor on the categorization of alerts. CPOE Our hospital assessed our CPOE system with the CPOE Most hospitals have reported a much smaller time burden Evaluation Tool Evaluation Tool. This is a very resource intensive process. and found the experience to be a worthwhile investment. It took 10 of us to complete the actual evaluation and half of Leapfrog continues to explore opportunities to reduce us 4 additional hours of our time. That is over 50 hour of hospital reporting burden, while still maintaining a robust manpower. This seems excessive to me. evaluation of hospitals’ CPOE systems.
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February 23, 2009 Page 6 of 21
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Leapfrog Responses to Public Comments on the 2009 Leapfrog Hospital Survey
Category Theme of Public Comment Leapfrog Response CPOE We question the purpose of the CPOE test: Is it intended to The CPOE Evaluation Tool is strictly designed to test the Evaluation Tool test our CPOE system, or to test the behavior of our implementation of your hospital’s CPOE system and not ordering providers? provider behavior. The goal of the test is to ensure that your system is alerting providers to common serious prescribing errors. Hospitals should complete the test exactly as instructed. Second guessing the intent of each order has led to poor results on the test. CPOE We question the requirement that hospitals that are unable The CPOE Evaluation Tool currently has a limited number Evaluation Tool to complete the CPOE Evaluation on the first attempt must of test orders. To ensure hospitals do not receive too wait another six months before attempting it again. This many repeating test orders, Leapfrog does limit hospital seems to unfairly penalize those hospitals that make the access to the tool to once every six months. effort to go through the testing process. Hospitals do have the opportunity to take a sample test before taking the actual test. The sample test provides hospitals a run-through of the tool, before they start the real test. In the Tool instructions, Leapfrog is very clear that taking the sample test first is highly recommended. CPOE Will you please explain what seems to be two different Both scoring methodologies are correct. A hospital’s Evaluation Tool scoring methodologies for CPOE: overall score on the CPOE Leap in the 2009 Survey is 1) "Using the scored results from the Leapfrog CPOE going to be based on a combination of the hospital’s Evaluation Tool to assess if a hospital's CPOE system is implementation status (i.e. % of inpatient medication alerting physicians to at least 50% of common serious orders entered through their CPOE system) AND their prescribing errors;" performance on the CPOE Evaluation Tool. and 2) The CPOE "Scoring Algorithm" indicates that "fully To fully meet the CPOE Leap in 2009, hospitals will need meeting standard" of "75% or greater of all inpatient to have over 75% of their inpatient medication orders medication orders entered through CPOE System. entered through their CPOE system AND receive a score of Fully Implemented or Good Progress on the CPOE Which is correct, at least 50% of alerts OR "75% or more Evaluation Tool. orders entered"?
February 23, 2009 Page 7 of 21
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Leapfrog Responses to Public Comments on the 2009 Leapfrog Hospital Survey
Category Theme of Public Comment Leapfrog Response CPOE Allow hospitals to use their 2008 CPOE Evaluation Tool Leapfrog’s expert panel has recommended that hospitals Evaluation Tool results if there have been no changes to the CPOE in 2009 complete an evaluation of their CPOE system at least that would affect alerts. once a year. They expect hospitals will make substantial improvements to their systems over the course of the year and to score better. EBHR - AAA Evidence no longer supports the provision of beta-blockers Leapfrog reviewed this question very carefully and had to all AAA patients at discharge as a "best practice". This significant consultation with experts. As patients who have measure should be excluded from future assessments of had an AAA repair are considered high-risk for another AAA process of care measures. Patients undergoing cardiovascular event, the provision of beta-blockers at vascular surgery who are on beta-blockers pre-operatively discharge continues to make sense. Leapfrog is should be continued peri- and post-op on the beta-blocker. committed to monitoring this measure and the related research. EBHR - CABG For the CABG resource utilization measure, the risk Leapfrog has modified the cohort-of-interest for CABG adjustment model should consider the proportion of cases resource utilization in the 2009 Survey to exclude where a valve procedure was performed in addition to the concomitant valve replacement. CABG. EHBR - All The recently-published POISE study cast some doubt on Leapfrog has actively sought guidance from national Surgeries/Condit the wisdom of routine perioperative beta blockade for experts on the appropriate populations for which ions patients undergoing vascular surgery. This means that the perioperative beta blockader would be beneficial, CABG-3 and AAA-1 process measures need to be re- especially in light of recent findings on this subject. Their examined, possibly re-specified. guidance has been to continue our alignment with other national performance measurement entities. The AAA-1 process measure is the Joint Commission’s SCIP-Card-2 measure, which was updated last year by the Joint Commission to apply only to patients who were taking beta blockers prior to admission. Leapfrog’s measure specifications were modified in 2008 to reflect this change. CABG-3 is a STS measure and STS reviews their measures every three years. Their next review of that measure will be in 2010.
February 23, 2009 Page 8 of 21
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Leapfrog Responses to Public Comments on the 2009 Leapfrog Hospital Survey
Category Theme of Public Comment Leapfrog Response EHBR - All The Survival Predictor methodology was developed using The development of the Survival Predictor models is Surgeries/Condit the MedPAR database which only includes Medicare fee for based on the MedPAR database, which was used to ions service hospitalizations. MedPAR does not include any derive the model’s regression coefficients. While data about the hospitalization of Medicare beneficiaries with MedPAR is a subset of all hospital encounters, Medicare a Medicare Advantage plan. The model admits a weakness data for a hospital has been shown to have a strong by limiting analysis to Medicare beneficiaries as they correlation with all-payer data for the same hospital. represent only a fraction of all hospital encounters, and or f those hospitals with a large population under an Advantage The main inputs into the model hospital volume and raw Plan, the dataset may not represent the general population mortality are based on hospital-reported all-payer data. served by the hospital. EHBR - All The Survival Predictor model has not been endorsed by The Survival Predictor model is currently working its way Surgeries/Condit National Quality Forum or the Agency for Healthcare through the National Quality Forum (NQF) endorsement ions Research and Quality nor has it been vetted in the medical process. It is being considered for endorsement under community beyond its initial publication. It seems the Hospital Outcomes and Efficiency project. unreasonable to assume that this untested predictor should serve as "the single quality measure." Health Affairs has accepted an article on the Survival Predictor model results for publication. In advance of that article, Medical Care has published an article on the Survival Predictor methods. Staiger DO, Dimick JB, Baser O, Fan Z, Birkmeyer JD Empirically derived composite measures of surgical performance. Med Care 2009 Feb; 47(2):226-33. EHBR - All Although changes to measures are necessary on an Leapfrog makes every effort to align its measure Surgeries/Condit ongoing basis, keeping changes to a minimum and specifications with other national performance ions providing advance notification when a change is needed measurement entities (The Joint Commission, AHRQ, enables a more effective planning process. Standardizing STS, ACC, etc.). Where possible, this includes having and consolidating the specifications, definitions, references common specifications for outcome, process, and and rules to identify procedures for process and volume efficiency measures. reporting would greatly facilitate he ability to accurately t report cases. Leapfrog strives to provide as much advance notice on survey changes as is possible, while still maintaining the ability to have the survey reflect the most recent evidence of safe and effective hospital care.
February 23, 2009 Page 9 of 21
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Leapfrog Responses to Public Comments on the 2009 Leapfrog Hospital Survey
Category Theme of Public Comment Leapfrog Response EHBR - All We are concerned that it may be difficult for hospitals to Leapfrog will provide explicit specifications for hospitals to Surgeries/Condit report on "isolated" PCI and CABG procedures based on count procedure volumes. This includes both ICD-9 ions their Administrative data. We encourage Leapfrog to codes and CPT codes, where appropriate. provide explicit specifications defining "isolated" procedures that state which records to include and exclude based on ICD9 and or CPT procedure codes. EHBR - All We are concerned that Survival Predictor composite scores Leapfrog is working with the Survival Predictor model Surgeries/Condit derived from administrative data may not be comparable to developers to ensure that the Survival Predictor scores ions composite scores derived from manually abstracted derived from different data sources are comparable. national registries. We are also concerned that risk adjusted outcomes from one reporting system ( e. ACC) i. will not be comparable to scores from another (i.e. statewide public reporting). EHBR - All Professional societies currently do not identify a significant Leapfrog has always placed a strong emphasis on Surgeries/Condit relationship between mortality rates and the quality of care outcome measures, as purchasers and consumers need to ions provided. The proposed use of a Survival Predictor may be made aware that there can be wide variations in confuse the public as to the actual quality of care provided mortality and morbidity rates between hospitals performing at the facilities. Further discussion with professional the same procedure. Leapfrog continues to review other medical societies should be pursued prior to implementing measures that help represent the full spectrum of care this measure. outcomes (i.e. complication measures). EHBR - All For each of the high-risk procedures on the Leapfrog Similar to the 2008 survey results, Leapfrog will provide an Surgeries/Condit Hospital Survey providing details rather than an overall aggregated quality/resource utilization score (i.e. ions score is essential for health plans for use in quality “Efficiency Score) for CABG, PCI, AMI, and Pneumonia. initiatives. The data should breakdown the information In addition, we provide, via a drill down, the individual used for the survival predicator and the resource utilization. quality scores and resource utilization scores for these procedures/conditions. Additional details on both the Survival Predictor calculations and resource utilization measure calculations are provided to each reporting hospital, via a hospital-specific webpage. The hospital-specific webpages are accessed by signing back into the online survey.
February 23, 2009 Page 10 of 21
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Leapfrog Responses to Public Comments on the 2009 Leapfrog Hospital Survey
Number Category Theme of Public Comment Leapfrog Response 35 EHBR - All Many of the high-risk procedures included in the survey, The high-risk procedures Leapfrog includes in the EHBR Surgeries/Condit such as Esophagectomy, Pancreatectomy, and Aortic Valve Leap of its survey are procedures that have high variations ions Replacement, are uncommon and perhaps less useful in mortality between the best and worst performing metrics of quality care. hospitals. For instance, there is four-fold increase in a patient’s odds of dying in the hospital after/during a pancreatectomy in the worst performing hospitals, as compared to the best performing hospitals. EHBR - All We have concerns that replacing the 'traditional quality Leapfrog plans to continue asking hospitals to report on Surgeries/Condit scoring methodology' with Survival Predictor will not capture quality-of-care process measures for CABG, PCI, and ions important aspects of health care quality. In essence this AAA. In the 2009 Survey, hospitals that achieve 80% measure removes any assessment of processes of care adherence on the process measures can earn a one-and focuses on a single outcome measure, mortality. While category improvement in their Survival Predictor rating. mortality is an important outcome, its incidence is low and hence focusing solely on this measure will miss many important quality lapses, some of which might not be associated with surgical mortality. EHBR - All There are available very detailed clinical data through the As hospitals can elect to not participate in national and/or Surgeries/Condit ACC and STS registries which measure important regional registries, the Survival Predictor offers a nationally ions processes and risk adjusted outcomes of care. Use of an standardized method for comparing hospital outcomes. administrative-data based survival calculator for the cardiac procedures seems like a step backward. If the survival predictor is demonstrated to be valid, it could be an important measure of quality, but we do not think it should be the only measure. EHBR All We commend the Leapfrog group in adopting measures Where possible, Leapfrog allows hospitals to report their -Surgeries/Condit which directly measure outcomes. We encourage the use of risk-adjusted data from national and/or regional ions risk adjustment to reflect differences in patients for all performance measurement registries and robust statewide patients including AAA repair, bariatric surgery and aortic reports. Leapfrog allows such reporting for CABG, PCI, valve replacement. and AVR today. Leapfrog continues to look for opportunities for the other four high-risk surgeries.
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