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Showing papers by "Harlan M. Krumholz published in 2011"



Journal ArticleDOI
19 Oct 2011-JAMA
TL;DR: In this article, changes in patient demographics and comorbidities, heart failure hospitalization rates, and 1-year mortality rates were examined in the United States, nationally and by state or territory.
Abstract: Context It is not known whether recent declines in ischemic heart disease and its risk factors have been accompanied by declines in heart failure (HF) hospitalization and mortality. Objective To examine changes in HF hospitalization rate and 1-year mortality rate in the United States, nationally and by state or territory. Design, Setting, and Participants From acute care hospitals in the United States and Puerto Rico, 55 097 390 fee-for-service Medicare beneficiaries hospitalized between 1998 and 2008 with a principal discharge diagnosis code for HF. Main Outcome Measures Changes in patient demographics and comorbidities, HF hospitalization rates, and 1-year mortality rates. Results The HF hospitalization rate adjusted for age, sex, and race declined from 2845 per 100 000 person-years in 1998 to 2007 per 100 000 person-years in 2008 (P Conclusions The overall HF hospitalization rate declined substantially from 1998 to 2008 but at a lower rate for black men. The overall 1-year mortality rate declined slightly over the past decade but remains high. Changes in HF hospitalization and 1-year mortality rates were uneven across states.

672 citations


Journal Article
TL;DR: The overall HF hospitalization rate declined substantially from 1998 to 2008 but at a lower rate for black men, and the overall 1-year mortality rate declined slightly over the past decade but remains high.
Abstract: Background: Whether recent declines in ischemic heart disease and its risk factors have been accompanied by declines in heart failure (HF) hospitalization and mortality is not known. We sought to e...

568 citations


Journal ArticleDOI
TL;DR: CT use in the emergency department (ED) has increased significantly in recent years across a broad range of presenting complaints, although this effect has stabilized more recently.

338 citations


Journal ArticleDOI
TL;DR: A claims-based model of hospital risk-standardized readmission rates for patients with acute myocardial infarction produces estimates that are excellent surrogates for those produced from a medical record model.
Abstract: Background—National attention has increasingly focused on readmission as a target for quality improvement. We present the development and validation of a model approved by the National Quality Forum and used by the Centers for Medicare & Medicaid Services for hospital-level public reporting of risk-standardized readmission rates for patients discharged from the hospital after an acute myocardial infarction. Methods and Results—We developed a hierarchical logistic regression model to calculate hospital risk-standardized 30-day all-cause readmission rates for patients hospitalized with acute myocardial infarction. The model was derived using Medicare claims data for a 2006 cohort and validated using claims and medical record data. The unadjusted readmission rate was 18.9%. The final model included 31 variables and had discrimination ranging from 8% observed 30-day readmission rate in the lowest predictive decile to 32% in the highest decile and a C statistic of 0.63. The 25th and 75th percentiles of the ris...

309 citations


Journal ArticleDOI
TL;DR: The phenotype of patients with heart failure changed substantially over the last 2 decades, most notably, more recent patients have a higher percentage of very old individuals, and the number of comorbidities and medications increased markedly.

286 citations


Journal ArticleDOI
TL;DR: High-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI care across the hospital, and evidence-based protocols and processes, although important, may not be sufficient for achieving high hospital performance in care for patients with AMI.
Abstract: The reasons for variation among hospitals in mortality rates for patients with acute myocardial infarction are not well-understood. This qualitative study of interviews with staff of high- and low-...

270 citations


Journal ArticleDOI
TL;DR: National progress has been achieved in the timeliness of treatment of patients with ST-segment–elevation myocardial infarction who undergo primary percutaneous coronary intervention.
Abstract: Background—Registry studies have suggested improvements in door-to-balloon times, but a national assessment of the trends in door-to-balloon times is lacking. Moreover, we do not know whether improvements in door-to-balloon times were shared equally among patient and hospital groups. Methods and Results—This analysis includes all patients reported by hospitals to the Centers for Medicare & Medicaid Services for inclusion in the time to percutaneous coronary intervention (acute myocardial infarction-8) inpatient measure from January 1, 2005, through September 30, 2010. For each calendar year, we summarized the characteristics of patients reported for the measure, including the number and percentage in each group, the median time to primary percutaneous coronary intervention, and the percentage with time to primary percutaneous coronary intervention within 75 minutes and within 90 minutes. Door-to-balloon time declined from a median of 96 minutes in the year ending December 31, 2005, to a median of 64 minut...

245 citations


Journal ArticleDOI
TL;DR: The number of older adults in the United States and throughout much of the world has witnessed striking growth in the past decades, largely due to improved public health, nutrition, and medical care.

202 citations


Journal ArticleDOI
22 Jun 2011-JAMA
TL;DR: A DIDO time of 30 minutes or less was observed in only a small proportion of patients transferred for primary PCI but was associated with shorter reperfusion delays and lower in-hospital mortality.
Abstract: Context Patients with ST-elevation myocardial infarction (STEMI) requiring interhospital transfer for primary percutaneous coronary intervention (PCI) often have prolonged overall door-to-balloon (DTB) times from first hospital presentation to second hospital PCI. Door-in to door-out (DIDO) time, defined as the duration of time from arrival to discharge at the first or STEMI referral hospital, is a new clinical performance measure, and a DIDO time of 30 minutes or less is recommended to expedite reperfusion care. Objective To characterize time to reperfusion and patient outcomes associated with a DIDO time of 30 minutes or less. Design, Setting, and Patients Retrospective cohort of 14 821 patients with STEMI transferred to 298 STEMI receiving centers for primary PCI in the ACTION Registry–Get With the Guidelines between January 2007 and March 2010. Main Outcome Measures Factors associated with a DIDO time greater than 30 minutes, overall DTB times, and risk-adjusted in-hospital mortality. Results Median DIDO time was 68 minutes (interquartile range, 43-120 minutes), and only 1627 patients (11%) had DIDO times of 30 minutes or less. Significant factors associated with a DIDO time greater than 30 minutes included older age, female sex, off-hours presentation, and non–emergency medical services transport to the first hospital. Patients with a DIDO time of 30 minutes or less were significantly more likely to have an overall DTB time of 90 minutes or less compared with patients with DIDO times greater than 30 minutes (60% [95% confidence interval {CI}, 57%-62%] vs 13% [95% CI, 12%-13%]; P Conclusion A DIDO time of 30 minutes or less was observed in only a small proportion of patients transferred for primary PCI but was associated with shorter reperfusion delays and lower in-hospital mortality.

180 citations


Journal ArticleDOI
28 Sep 2011-JAMA
TL;DR: Among older patients undergoing carotid stenting, lower annual operator volume and early experience are associated with increased 30-day mortality, which is higher among patients treated by operators with lower annual volumes and in patients treated early during a new operator's experience.
Abstract: Context Although the efficacy of carotid stenting has been established in clinical trials, outcomes of the procedure based on operator experience are less certain in clinical practice. Objective To assess association between outcomes and 2 measures of operator experience: annual volume and experience at the time of the procedure among new operators who first performed carotid stenting after a national coverage decision by the Centers for Medicare & Medicaid Services (CMS). Design, Setting, and Patients Observational study using administrative data on fee-for-service Medicare beneficiaries aged 65 years or older undergoing carotid stenting between 2005 and 2007. Main Outcome Measure Thirty-day mortality stratified by very low, low, medium, and high annual operator volumes ( Results During the study period, 24 701 procedures were performed by 2339 operators. Of these, 11 846 were performed by 1792 new operators who first performed carotid stenting after the CMS national coverage decision. Overall, 30-day mortality was 1.9% (n = 461) and rate of failure to use an embolic protection device was 4.8% (n = 1173) . The median annual operator volume among Medicare beneficiaries was 3.0 per year (interquartile range, 1.4-6.5) and 11.6% of operators performed 12 or more procedures per year during the study period. Observed 30-day mortality was higher among patients treated by operators with lower annual volumes (2.5% [95% CI, 2.1%-2.9%], 1.9% [95% CI, 1.6%-2.3%], 1.6% [95% CI, 1.3%-1.9%], and 1.4% [95% CI, 1.1%-1.7%] across the 4 categories; P Conclusion Among older patients undergoing carotid stenting, lower annual operator volume and early experience are associated with increased 30-day mortality.

Journal ArticleDOI
TL;DR: A risk-standardized measure of hospital readmission rates derived from administrative claims has similar performance characteristics to one based on medical record review.
Abstract: BACKGROUND: Readmission following hospital discharge has become an important target of quality improvement. OBJECTIVE: To describe the development, validation, and results of a risk-standardized measure of hospital readmission rates among elderly patients with pneumonia employed in federal quality measurement and efficiency initiatives. DESIGN: A retrospective cohort study using hospital and outpatient Medicare claims from 2005 and 2006. SETTING: A total of 4675 hospitals in the United States. PATIENTS: Medicare beneficiaries aged >65 years with a principal discharge diagnosis of pneumonia. INTERVENTION: None. MEASUREMENTS: Hospital-specific, risk-standardized 30-day readmission rates calculated as the ratio of predicted-to-expected readmissions, multiplied by the national unadjusted rate. Comparison of the areas under the receiver operating curve (ROC) and measurement of correlation coefficient in development and validation samples. RESULTS: The development sample consisted of 226,545 hospitalizations at 4675 hospitals, with an overall unadjusted 30-day readmission rate of 17.4%. The median risk-standardized hospital readmission rate was 17.3%, and the odds of readmission for a hospital one standard deviation above average was 1.4 times that of a hospital one standard deviation below average. Performance of the medical record and administrative models was similar (areas under the ROC curve 0.59 and 0.63, respectively) and the correlation coefficient of estimated state-specific standardized readmission rates from the administrative and medical record models was 0.96. CONCLUSIONS: Rehospitalization within 30 days of treatment for pneumonia is common, and rates vary across hospitals. A risk-standardized measure of hospital readmission rates derived from administrative claims has similar performance characteristics to one based on medical record review. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine

Journal ArticleDOI
TL;DR: In this paper, the authors determined population-based rates of use of diagnostic imaging procedures with ionizing radiation in children, stratified by age and gender, in the United Kingdom.
Abstract: Objective To determine population-based rates of use of diagnostic imaging procedures with ionizing radiation in children, stratified by age and gender.

Journal ArticleDOI
12 Apr 2011-PLOS ONE
TL;DR: An administrative claims-based model for profiling hospitals for pneumonia mortality performs consistently over several years and produces hospital estimates close to those using a medical record model.
Abstract: Background Outcome measures for patients hospitalized with pneumonia may complement process measures in characterizing quality of care. We sought to develop and validate a hierarchical regression model using Medicare claims data that produces hospital-level, risk-standardized 30-day mortality rates useful for public reporting for patients hospitalized with pneumonia. Methodology/Principal Findings Retrospective study of fee-for-service Medicare beneficiaries age 66 years and older with a principal discharge diagnosis of pneumonia. Candidate risk-adjustment variables included patient demographics, administrative diagnosis codes from the index hospitalization, and all inpatient and outpatient encounters from the year before admission. The model derivation cohort included 224,608 pneumonia cases admitted to 4,664 hospitals in 2000, and validation cohorts included cases from each of years 1998–2003. We compared model-derived state-level standardized mortality estimates with medical record-derived state-level standardized mortality estimates using data from the Medicare National Pneumonia Project on 50,858 patients hospitalized from 1998–2001. The final model included 31 variables and had an area under the Receiver Operating Characteristic curve of 0.72. In each administrative claims validation cohort, model fit was similar to the derivation cohort. The distribution of standardized mortality rates among hospitals ranged from 13.0% to 23.7%, with 25th, 50th, and 75th percentiles of 16.5%, 17.4%, and 18.3%, respectively. Comparing model-derived risk-standardized state mortality rates with medical record-derived estimates, the correlation coefficient was 0.86 (Standard Error = 0.032). Conclusions/Significance An administrative claims-based model for profiling hospitals for pneumonia mortality performs consistently over several years and produces hospital estimates close to those using a medical record model.

Journal ArticleDOI
TL;DR: The authors found that black patients with myocardial infarction (MI) have worse outcomes than white patients, including higher mortality rates, more angina, and worse quality of life.
Abstract: Background—Black patients with myocardial infarction (MI) have worse outcomes than white patients, including higher mortality rates, more angina, and worse quality of life. The Translational Resear...

Journal ArticleDOI
TL;DR: It is highlighted that important racial differences in health literacy and access to care exist among patients with heart failure, and these differences persist even after adjustment for a broad range of potential mediators, including educational attainment, income, and insurance status.

Journal ArticleDOI
TL;DR: This policy statement expands on the previous scientific statement on “Essential Features of a Surveillance System to Support the Prevention and Management of Heart Disease and Stroke” by providing recommendations to policy makers and the healthcare community for expansion of the applications of existing and future clinical registries.
Abstract: Clinical registries play an important role in measuring healthcare delivery and supporting quality improvement for individuals with cardiovascular disease and stroke. Well-designed clinical registry programs provide important mechanisms to monitor patterns of care, evaluate healthcare effectiveness and safety, and improve clinical outcomes. The use of clinical registries is likely to grow given the increasing focus on measuring and improving healthcare delivery and patient outcomes by stakeholders in both the private and public sectors. The American Heart Association (AHA) has a longstanding commitment to promoting the innovative and effective use of clinical registries. The importance of clinical registries was highlighted recently in an AHA Scientific Statement on “Essential Features of a Surveillance System to Support the Prevention and Management of Heart Disease and Stroke” in the United States.1 This policy statement expands on the previous scientific statement by providing recommendations to policy makers and the healthcare community for expansion of the applications of existing and future clinical registries. The term “clinical registry” is defined here as an observational database of a clinical condition, procedure, therapy, or population in which there are often no registry-mandated approaches to therapy and relatively few inclusion or exclusion criteria. The focus of clinical registries is to capture data that reflect “real-world” clinical practice in large patient populations. The data from clinical registries do not replace the need for traditional randomized controlled trials. Rather, registries and trials are complementary approaches, each with unique advantages and imperfections.2 Such clinical registries do not solely contain claims or administrative data yet may be linked to such data sources. There are at least 3 classifications of clinical registries based on the patient population, including procedure/therapy/encounter-based, disease-based, and population-based registries. Registries also can be classified from a functional perspective, such as whether the registry is used to conduct clinical research, …

Journal ArticleDOI
23 Mar 2011-JAMA
TL;DR: During the past decade, prescriptions for fibrates (particularly fenofibrate) increased in the United States, while prescriptions in Canada remained stable, and fibrate expenditures per 100,000 population were 3-fold higher in 2009 in theUnited States compared with Canada.
Abstract: Context Interest in the role of fibrates intensified after the publication of the negative results from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, which assessed therapy with fenofibrate plus statins. The evidence for clinical benefit in outcomes with the use of fibrates is heavily weighted on the use of the older fibrates such as gemfibrozil and clofibrate. Objectives To examine trends in the current use of fibrates and to examine the relationship between differences in the availability and use of brand-name vs generic formulations of fenofibrate and the economic implications in the United States compared with Canada. Design, Setting, and Patients Population-level, observational cohort study using IMS Health data from the United States and Canada of patients prescribed fibrates between January 2002 and December 2009. Main Outcome Measures Fibrate prescriptions dispensed and expenditures. Results In the United States, fibrate prescriptions dispensed increased from 336 prescriptions/100 000 population in January 2002 to 730 prescriptions/100 000 population in December 2009, an increase of 117.1% (95% confidence interval [CI], 116.0%-117.9%), whereas in Canada, fibrate prescriptions increased from 402 prescriptions/100 000 population in January 2002 to 474 prescriptions/100 000 population in December 2009, an increase of 18.1% (95% CI, 17.9%-18.3%) (P Conclusion During the past decade, prescriptions for fibrates (particularly fenofibrate) increased in the United States, while prescriptions for fibrates in Canada remained stable.

Journal ArticleDOI
TL;DR: Cognitive impairment without dementia was associated with less invasive care, less referral and participation in cardiac rehabilitation, and worse risk-adjusted 1-year survival in those with moderate/severe CIND, making it an important condition to consider in optimizing AMI care.

Journal ArticleDOI
TL;DR: Despite robust clinical trial evidence, a substantial number of patients with obstructive CAD remain untreated with statin therapy, and important opportunities to improve lipid management in outpatients with obstructives CAD are illustrated.
Abstract: Background—Clinical trials have shown that statin therapy reduces cardiovascular morbidity and mortality in patients with coronary artery disease (CAD), even among patients with low-density lipoprotein cholesterol levels <100 mg/dL. We sought to determine the extent to which patients with obstructive CAD in routine outpatient care are treated with statins, nonstatins, or no lipid-lowering therapy. Methods and Results—Within the American College of Cardiology's Practice Innovation and Clinical Excellence (PINNACLE) outpatient registry, we examined rates of treatment with statin and nonstatin medications in 38 775 outpatients with obstructive CAD (history of myocardial infarction or coronary revascularization) and without documented contraindications to statin therapy. Among these patients, 30 160 (77.8%) were prescribed statins, 2042 (5.3%) were treated only with nonstatin lipid-lowering medications, and 6573 (17.0%) were untreated. Lack of medical insurance was associated with no statin treatment, and mal...

Journal ArticleDOI
TL;DR: Among patients presenting to emergency departments and requiring transfer to another facility for percutaneous coronary intervention, the DIDO time rarely met the recommended 30 minutes.
Abstract: Background Delays in treatment time are commonplace for patients with ST-segment elevation acute myocardial infarction who must be transferred to another hospital for percutaneous coronary intervention. Experts have recommended that door-in to door-out (DIDO) time (ie, time from arrival at the first hospital to transfer from that hospital to the percutaneous coronary intervention hospital) should not exceed 30 minutes. We sought to describe national performance in DIDO time using a new measure developed by the Centers for Medicare & Medicaid Services. Methods We report national median DIDO time and examine associations with patient characteristics (age, sex, race, contraindication to fibrinolytic therapy, and arrival time) and hospital characteristics (number of beds, geographic region, location [rural or urban], and number of cases reported) using a mixed effects multivariable model. Results Among 13 776 included patients from 1034 hospitals, only 1343 (9.7%) had a DIDO time within 30 minutes, and DIDO exceeded 90 minutes for 4267 patients (31.0%). Mean estimated times (95% CI) to transfer based on multivariable analysis were 8.9 (5.6-12.2) minutes longer for women, 9.1 (2.7-16.0) minutes longer for African Americans, 6.9 (1.6-11.9) minutes longer for patients with contraindication to fibrinolytic therapy, shorter for all age categories (except >75 years) relative to the category of 18 to 35 years, 15.3 (7.3-23.5) minutes longer for rural hospitals, and 14.4 (6.6-21.3) minutes longer for hospitals with 9 or fewer transfers vs 15 or more in 2009 (all P Conclusion Among patients presenting to emergency departments and requiring transfer to another facility for percutaneous coronary intervention, the DIDO time rarely met the recommended 30 minutes.

Journal ArticleDOI
TL;DR: It is concluded that living alone may be associated with poorer angina-related quality of life 1 year after MI but is not associated with mortality, readmission, or other health status measurements after adjusting for other patient and treatment characteristics.
Abstract: Considerable attention has been devoted to the effect of social support on patient outcomes after acute myocardial infarction (AMI). However, little is known about the relation between patient living arrangements and outcomes. Thus, we used data from PREMIER, a registry of patients hospitalized with AMI at 19 United States centers from 2003 through 2004, to assess the association of living alone with outcomes after AMI. Outcome measurements included 4-year mortality, 1-year readmission, and 1-year health status using the Seattle Angina Questionnaire (SAQ) and the Short Form-12 Physical Health Component scales. Patients who lived alone had higher crude 4-year mortality (21.8% vs 14.5%, p

Journal ArticleDOI
TL;DR: It is found that within the twelve-year span of this study, the cardiology workforce grew modestly compared with the primary care physician and total physician workforces, but large segments of the US population continue to have a lower concentration of cardiologists.
Abstract: A sufficient cardiology workforce is necessary to ensure access to cardiovascular care. Specifically, access to cardiologists is important in the management and treatment of chronic cardiovascular disease. Given this, we examined the supply and distribution of the cardiologist workforce. In doing so, we mapped the ratios of cardiologists, primary care physicians, and total physicians to the population age sixty-five or older within different Hospital Referral Regions from the years 1995 and 2007. We found that within the twelve-year span of our study, the cardiology workforce grew modestly compared with the primary care physician and total physician workforces. Also, despite increases in the number of cardiologists, there was a persistent geographic maldistribution of the workforce. For example, approximately 60 percent of the elderly population had access to only 38 percent of the cardiologists. Our results suggest that large segments of the US population, specifically in rural and socioeconomically disa...

Journal ArticleDOI
TL;DR: Thirteen demographic and diagnostic risk factors, as well as longer lengths of stay, were all associated with higher readmission rates and future efforts to reduce readmissions should be directed toward the recognition of patients most at risk, and the reasons they are readmitted.
Abstract: Objectives This study sought to report percutaneous coronary intervention (PCI) 30-day readmission rates, identify the impact of staged (planned) readmissions on overall readmission rates, determine the significant predictors of unstaged readmissions after PCI, and specify the reasons for readmissions. Background Hospital readmissions occur frequently and incur substantial costs. PCI are among the most common and costly procedures, and little is known about the nature and extent of readmissions for PCI. Methods We retrospectively analyzed 30-day readmissions after PCI using the nation's largest statewide PCI registry to identify 40,093 New York State patients who underwent PCI between January 1, 2007, and November 30, 2007. Demographic variables, pre-procedural risk factors, complications of PCI, and length of stay were considered as potential predictors of readmission, and reasons for readmission were identified from New York's administrative database using principal diagnoses. Results A total of 15.6% of all PCI patients were readmitted within 30 days, and 20.6% of these readmissions were staged. Among unstaged readmissions, the most common reasons for readmission were chronic ischemic heart disease (22.5%), chest pain (10.8%), and heart failure (8.2%). A total of 2,015 patients (32.2% of readmissions) underwent a repeat PCI. Thirteen demographic and diagnostic risk factors, as well as longer lengths of stay, were all associated with higher readmission rates. Conclusions Future efforts to reduce readmissions should be directed toward the recognition of patients most at risk, and the reasons they are readmitted. Staging also should be examined from a cost-effectiveness standpoint as a function of patients' unique risk factors.


Journal ArticleDOI
TL;DR: The SAMI study is presented, a national positive deviance study to discover hospital strategies associated with lower 30-day hospital risk-standardized mortality rates (RSMRs) and generates and test hypotheses about factors most strongly associated with exemplary performance based on practices currently in use.

Journal ArticleDOI
TL;DR: In addition to performing less physical activity, obese and overweight children had distinct patterns of MVPA and VPA bouts compared with non-overweight peers.
Abstract: Objective. We determined whether overweight and obese children performed less combined moderate and vigorous physical activity (MVPA), less vigorous physical activity (VPA) alone, and had distinct ...

Journal ArticleDOI
12 Oct 2011-JAMA
TL;DR: Current clinical research standards lack sufficiently strong requirements for transparency and availability, and there are no uniform international standards requiring that study protocols, statistical analysis plans, and study results be made available, nor that completed clinical trial data be posted for independent analysis.
Abstract: Each day, patients and their physicians make treatment decisions with access to only a fraction of the relevant clinical research data. Many clinical studies, including randomized clinical trials, are never published in the biomedical literature.1,2 Among those that are published, key information is often not presented, such as data on specific outcomes and safety endpoints.3,4 Moreover, patient-level data from clinical trials are rarely available, leaving investigators to conduct meta-analyses of summary-level data, an approach with limitations.5 Current clinical research standards lack sufficiently strong requirements for transparency and availability. There are no uniform international standards requiring that study protocols, statistical analysis plans, and study results be made available, nor that completed clinical trial data be posted for independent analysis. Even data submitted to the U.S. Food and Drug Administration are not made publicly available.

Journal ArticleDOI
TL;DR: In stable patients with coronary artery disease after a recent MI, changes in angina control was associated with greater HRQL improvements in older than in younger adults, underscoring the importance of aggressiveAngina control in older patients.

Journal ArticleDOI
17 Aug 2011-JAMA
TL;DR: Outcomes research purposely directs attention to effects in typical patients across a spectrum of venues with emphasis on characteristics that may influence outcomes, and generates information about treatment patterns, risks, benefits, and costs that can be tailored to individuals.
Abstract: The Patient Protection and Affordable Care Act characterizes outcomes research as a field that determines how “diseases, disorders, and other health conditions can effectively and appropriately be prevented, diagnosed, treated, monitored, and managed. . . . ” Stated another way, outcomes research is scientific investigation that generates knowledge to guide health care decisions and promote optimal results from preventive, diagnostic, prognostic, and therapeutic health care strategies. The goal is to increase the likelihood that patients achieve the outcomes they desire through better information, better decisions, and better health care delivery. Toward this end, outcomes research uses a diverse array of study designs and data sources. It draws from clinical medicine, statistics, informatics, epidemiology, and the social sciences. Outcomes research derives directly from real-world practice and policy. It seeks to determine what is being achieved for patients and how clinicians can do better. The emphasis is on outcomes that patients experience, not on measurements that are surrogates for what may happen (eg, biomarkers) because those measures often fail to predict the effect of interventions. Outcomes research purposely directs attention to effects in typical patients across a spectrum of venues with emphasis on characteristics that may influence outcomes. Thus, it generates information about treatment patterns, risks, benefits, and costs that can be tailored to individuals. The questions and priorities of outcomes research ideally derive from partnerships with those (patients, clinicians, purchasers, and policy makers) who may use the results. Such relationships can bridge the gap that often exists between the published research and the information needs of decision makers. Domains of Outcomes Research