Critical Outcomes Report Analysis May 2008. Agenda Some Logistics Overview of why reports are wrong...

Critical Outcomes Report Analysis

May 2008

Agenda

• Some Logistics• Overview of why reports are wrong and

how to fix them– This will help somewhat in reading them and

in contracting for DM but critical outcomes report analysis is about learning how to read these things generally

• Sample Questions• The Test

Logistics

• You can then either “officially” take the test or not.– There is no downside to taking it except that you can’t take it again

for 6 months

• If you don’t want to take the test, you can either “play along at home” or if there is a group which wants to work together on the questions you can do that

• Or, you can go to the ROI precon next door (about 20% overlap in my slides)

• You can’t take the test home with you. You can request the non-test portion of the slides via email to [email protected] or visit the website www.dismgmt.com and hit “contact us.”

mailto:[email protected]

http://www.dismgmt.com/

If you pass…

• You may apply for individual certification for $500 for two years. You get listed on the DMPC website (see next page) announced on the listserve, and may be used as a professional credential– You will also be much better at reading these

reports.

• Corporate certification is $2000

Beginning of List on Website

Individual Corporate Affiliation (note: Boldface indicates Corporate Certification in addition to individual)

Ed Baas

HealthMedia, Inc.

Steve Bennett

HealthMedia, Inc.

David Brumley MD

Blue Cross of Massachusetts

John Charde MD

Enhanced Care Initiatives, Inc.

Brian Doran

Quantum Health Inc.

Laurie Doran

Boston Medical Center Health Plan

Thomas Hawkins

Blue Cross of Massachusetts

Sharon Hewner

Independent Health Plan

Overview of Why Reports are wrong and how to fix them and be a

hero to your organization…

…Rather than rely on others for your measurement

http://www.rippedacademy.com/images/user_gallery/VernonJohn_large.jpg

http://www.rippedacademy.com/images/user_gallery/VernonJohn_large.jpg

Reasons Why Reporting is often Wrong

• Look at these “checks and balances,” and ask yourself, why aren’t you already doing this in contracts with your vendor?

Plenty of Other Reasons too

These Reasons

Other Reasons

Slice 3

Slice 4

Without further ado, three reasons reports are wrong: The Following don’t get done

(except by DMPC-Certified Payors)• The Dummy Year Analysis

– The exact same methodology applied to a year in which you did not have disease management

• Plausibility Testing

• Critical Outcomes Report Analysis

Dummy Year Analysis

• Most contracts have a baseline period to which a contract period is compared (adjusted for trend)– Raise your hand if you don’t

Dummy Year Analysis

• Most contracts have a baseline period to which a contract period is compared (adjusted for trend)– Hand-raising time

• Watch what happens when you have a baseline and then compare a contract period (adjusted for trend)– Just the analysis, no program

In this Dummy Year Analysis example

• Assume that “trend” is already taken into account

• Focus on the baseline and contract period comparison

Base Case: Example from AsthmaFirst asthmatic has a $1000 IP claim in 2005

2005(baseline)

2006(contract)

Asthmatic #1 1000

Asthmatic #2

Cost/asthmatic

Example from AsthmaSecond asthmatic has an IP claim in 2006 while

first asthmatic goes on drugs (common post-event)

2005(baseline)

2006(contract)

Asthmatic #1 1000 100

Asthmatic #2 0 1000

Cost/asthmaticWhat is the

Cost/asthmaticIn the baseline?

Cost/asthmatic in baseline?

2005(baseline)

2006(contract)


Asthmatic #2 0 1000

Cost/asthmatic $1000Vendors don’t count #2 in 2005 bec. he can’t be found

Cost/asthmatic in contract period?

2005(baseline)

2006(contract)


Asthmatic #2 0 1000

Cost/asthmatic $1000 $550

Base Case: How Dummy Year Analysis (DYA) fixes it

2005(baseline)

2006(contract)


Asthmatic #2 0 1000

Cost/asthmatic

$1000 $550

In this case, a “dummy population” falls 45% on its own without DM

So…

• If you were to do an asthma program the vendor should not get credit for the reduction that happens anyway– But they do– How do we know that? With a plausibility test,

to be discussed later– First, some real-world Dummy Year Analyses

(DYAs)

DYA real-world Result: Excerpt from Regence Blue Cross-DMPC study for

Health Affairs released recentlyRTM Example: Sickest 6% Patients PMPY

Identified by Predictive Model

$-

$5,000

$10,000

$15,000

$20,000

$25,000

2004 costs 2005 costs 2005 inflationexpectation

Per

Mem

ber

Per

Yea

r

regressionto mean

expected by 10% inflation

DYA Result By Disease (using 1-year baseline and standard DMPC algorithms) –

what is the difference which is caused automatically by just trending forward?

0

20

40

60

80

100

120

asthma CAD diabetes CHF

Old baseline indexedto 100

Taking out regressionto the mean with DYA

DYA Result in Wellness

0

10

20

30

40

50

60

First Measure SecondMeasure

High-RiskLow-Risk

Source: Ariel Linden – citationOn request

There was no program in this case – just two samplings and the average stayed the same

0

10

20

30

40

50

60

First Measure SecondMeasure

High-RiskLow-Risk

Source: Ariel Linden – citation on request

Other evidence for Dummy Year Analysis (DYA)

• CMS studies – very carefully designed -- get results opposite those done without DYAs, and consistent with those done with DYAs

• Most Vendors oppose DYAs (and they aren’t in the DMAA guidelines)

• ROIs without DYA adjustment flunk plausibility testing…

Reason #2

• The Dummy Year Analysis

• …Plausibility Testing


What is a plausibility test?

• You do it all the time…outside DM• An easy way to directionally check results• Measure total event rates for diseases being

managed, like you’d measure a birth rate. Couldn’t be easier– Ask me for the specific directions. They’re free from

DMPC (and now DMAA). See next page

• Example from previous asthma hypothetical

Event rates tracked by disease: the Plausibility Indicators

Disease Program Category ICD9s (all .xx unless otherwise indicated)

Asthma 493.xx (including 493.2x[1])

Chronic Obstructive Pulmonary Disease 491.1, 491.2, 491.8, 491.9,. 492, 494, 496, 506.4

Coronary Artery Disease (and related heart-health issues)

410, 411, 413, 414

Diabetes 250

Heart Failure 428, 404.01, 404.03, 404.11, 404.13, 404.91, 404.93, 425.0, 425.4

[1] 493.2x is asthma with COPD. It could fit under either category but for simplicity we are keeping it with asthma

Cost/asthmatic in contract period?

2005(baseline)

2006(contract)


Asthmatic #2 0 1000

Cost/asthmatic $1000 $550

Asthma events in the payor as a whole

2005(baseline)

2006(contract)


Asthmatic #2 0 1000

Inpatient events/year

1 1

Plausible?

• How can you reduce asthma costs 45% without reducing planwide asthma event rate?

• Answer: You can’t. Not plausible

Several Examples of Plausibility Analysis

• Pacificare

• Some which didn’t turn out so well

• Plausibility-testing generally and benchmarks

PacifiCare HF Results

Enterprise Commercial Shared Risk CHF

0.00

0.20

0.40

0.60

0.80

I-2 I-1 I I+1 I+2

Intervention Time Period

IP C

ost

Equi

vale

nt

-20%

-10%

0%

10%

20%

30%

Perc

ent

Chan

ge

IP Cost Equivalent Year over Year % change

Enterprise Secure Horizons Shared Risk CHF

15.0016.0017.0018.0019.0020.0021.00

I-2 I-1 I I+1 I+2

Intervention Time PeriodIP

Cos

t Eq

uiva

lent

-30%

-20%

-10%

0%

10%

Perc

ent

Chan

ge

IP Cost Equivalent Year over Year % change

Several Examples of Plausibility Analysis

• Pacificare

• Some which didn’t turn out so well

Example of just looking at Diagnosed people: Vendor Claims for Asthma Cost/patient Reductions

-25%

-20%

-15%

-10%

-5%

0%

1st year 2nd year

ER ER

IP

IP

What we did to plausibility-test…

• We looked at the actual codes across the plan

• This includes everyone

• Two years of codes pre-program to establish trend

• Then two program years

Baseline trend for asthma ER and IP Utilization 493.xx ER visits and IP stays/1000 planwide

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

1999(baseline)

2000(baseline)

ER ER

IP IP

Expectation is something like…493.xx ER visits and IP stays/1000 planwide

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

1999(baseline)

2000(baseline)

2001 (study)2002 (study)

ER ER ER ER

IP IP IP IP

Plausibility indicator Actual: Validation for Asthma savings from same plan

including ALL CLAIMS for asthma, not just claims from people already known about493.xx ER visits and IP stays/1000 planwide

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

1999(baseline)

2000(baseline)


ER ER ER ER

IP IP IP IP

How could the vendor’s methodology have been so far off?

We then went back and looked…

• …at which claims the vendor included in the analysis…

We were shocked, shocked to learn that the uncounted claims on previously undiagnosed people accounted for virtually all the “savings”

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

1999(baseline)

2000(baseline)


ER ER ER ER

IP IP IP IP

PreviouslyUndiagnosedAre aboveThe lines

Is it fair…

• To count the people the vendor didn’t know about?

You should be able to reduce visits in the known group by enough so that adding back the new group yields the reduction you claimed –

otherwise you didn’t do anything

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

1999(baseline)

2000(baseline)


ER ER ER ER

IP IP IP IP

PreviouslyUndiagnosedAre aboveThe lines

Applying Plausibility to Mercer presentation which found a “range” of possible savings in

Respiratory DM• Mercer’s view:

“Varying the methodology has a significant impact on the results” Results “somewhere in that range”

• Our View: There is only one right answer and a Plausibility test will point to it

$0

$1,000,000

$2,000,000

$3,000,000

$4,000,000

$5,000,000

$6,000,000

$7,000,000

LowEnd

HighEnd

How Mercer could do a plausibility test on asthma

• Take two-three years of claims history in all primary-coded 493.xx claims for ER and IP

• Add together and divide by # of covered lives to get a rate

• Then Ask: What happens in the program year?

Possible trend prior to program

0

0.5

1

1.5

2

2.5

3

3.5

2001 2002 2003 2004 2005 2006

Total # asthma ER/IPclaims/1000

For the program to have saved $6-million, this indicator would have to plunge

(it didn’t)

0

0.5

1

1.5

2

2.5

3

3.5

2001 2002 2003 2004 2005 2006

Total # asthma ER/IPclaims/1000

Let’s Macro-Plausibility-Test Wellness

• The Dummy Year Analysis

• Plausibility Testing– For Wellness


Macro Plausibility for WellnessHere’s how you know wellness reports are inflated or

impossible

• Compare all these reported dramatic results in smoking cessation and weight loss to CDC statistics for the US as a whole– Even as most large (and many smaller)

companies are “producing” these results, obesity continues to climb and the drop in adult smoking rates has stalled

October 26, 2006

Drop in Adult Smoking Rate StallsTHURSDAY, Oct. 26 (HealthDay News) -- The number of adult smokers in the United States did not change from 2004 to 2005, suggesting that the decline in smoking over the past seven years has stalled, a new federal report found.In 2005, 45.1 million adults, or 20.9 percent, were cigarette smokers – 23.9 percent of men and 18.1 percent of women. In addition, 2.2 percent of U.S. adults were cigar smokers and 2.3 percent used smokeless tobacco, according the report."After years of progress, what we are seeing is no change in adult prevalence of smoking between 2004 and 2005," said report author Terry Pechacek, the associate director for science at the U.S. Centers for Disease Control and Prevention's Office on Smoking and Health.

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14%



No Data <10% 10%–14% 15%–19%



No Data <10% 10%–14% 15%–19% ≥20%



No Data <10% 10%–14% 15%–19% 20%–24% ≥25%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%



No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Agenda

• Some Logistics• Overview of why reports are wrong and

how to fix them– This will help somewhat in reading them and

in contracting for DM but critical outcomes report analysis is about learning how to read these things generally

• Sample Questions• The Test

Sample Question #1

• Look at each of these slides and both together to find major reporting concerns if any

Table 1: Inpatient Impact of Program (Year One)

Disease Baseline IP days/1000

Program IP days/1000

Change

Asthma 996 747 -25%

CAD 1897 1391 -27%

CHF 9722 8581 -29%

COPD 2512 2151 -14%

Diabetes 1534 1522 -1%

Table 2: Impact on Physician Visits

Disease Baseline MD visits/1000

Program MD Visits/1000

Change

Asthma 6990 5907 -15%

CAD 8829 8580 -3%

CHF 7876 7506 -5%

COPD 8481 8090 -4%

Diabetes 7927 7737 -2%

What you might have noticed – first slide

• No plausibility test for very high utilization reduction

• Asthmatics don’t have 996 days per 1000– Not clear whether they are referring to days

per 1000 disease members or days per 1000 overall (either way, it’s wrong)

• Nor does CHF have so many days per 1000

• CHF days did not decline 29%

Second slide, and both combined

• Ridiculously high number of doctor visits

• Doctor visits should be going up or staying the same, not going down– This suggests strongly that a DYA is needed

because they seem to have selected a high-using sample as a baseline

• No correlation between MD-intensity and IP-intensity of diseases

Sample #2: Comment on these CHF measures

0%10%20%30%40%50%60%70%80%90%

2x/year MD visit

ACE Scripts

BUN Test

Creatinine test

Potassium Test

200320042005

Sample #3: Improvement in Plan A of HEDIS Scores: Why is/isn’t

this a valid improvement?HEDIS EFFECTIVENESS OF CARE MEASURES

Commercial 2003 2004 2005

Controlling High Blood Pressure 62.2 66.8 68.8

Beta blocker after AMI 69.8 72.5 77.7

Diabetes: HbA1c Testing 84.6 86.5 87.5

Diabetes: Lipid Control (<100 mg/dL) 34.7 40.2 43.8

Medical Assistance with Smoking Cessation 68.6 69.6 71.2

Medicare 2003 2004 2005

Controlling High Blood Pressure 61.4 64.6 66.4

Beta blocker after AMI 92.9 94 93.8

Diabetes: HbA1c Testing 87.9 89.1 88.9

Diabetes: Lipid Control (<100 mg/dL) 41.9 47.5 50

Medical Assistance with Smoking Cessation 63.3 64.7 75.5

Asthma Plausibility Test

Baseline vs PY01

Program Year

Baseline PY01 Variance

Net Paid $6,671,855 $9,656,959 44.7%

Events 3,416 4,346 27.2%

Days 3,875 5,183 33.8%

Risk MM's 874,878 1,245,783 42.4%

PMPM $7.63 $7.75 1.6%

Events / 1000 46.85 41.86 -10.7%

Days / 1000 53.15 49.93 -6.1%

Cost / Day $1,722 $1,863 8.2%

Sample #4: Does this one pass the Sniff test?

Sample #5: Does this pass the sniff test for diabetes?

Disease Management Conditions

0.6%0.9%

1.5% 1.4%

Percent of TotalBenefits Paid

Percent of TotalEpisodes

Actual

Expected

Sample #6 small group bid

• Comment on this bid for a group of 80,000 people

Cost/case assumptions as follows: prevaenceasthma 2,500$ 3.0%cad 7,000$ 1.0%chf 22,000$ 0.2%copd 14,000$ 0.3%diabetes 8,000$ 2.2%

6.7%Total DM vendor DM FeesYear 1 $4,959,800 multiplied by 80000 people

equals: total spending by disease OPT-OUTGross $ savings PER MONTH

asthma 6,000,000$ Year 1 $12,513,308 cad 5,600,000$

chf 3,520,000$ copd 3,360,000$ diabetes 14,080,000$

Net $ savings 32,560,000$ total chronic spend

Year 1 $7,553,508

ROI 2.5 x

Agenda

• Some Logistics• Overview of why reports are wrong and how to

fix them– This will help somewhat in reading them and in

contracting for DM but critical outcomes report analysis is about learning how to read these things generally

• Sample Questions• Break • The Test

Test Overview

Answer each question by number by saying what’s wrong or indicating that it can be concluded, based on the data provided, that nothing major is obviously wrong. Keep it concise. Don’t just automatically say no DYA or plausibility test

Scoring:3 points for each item found which DMPC missed2 points for each major item found1 point for each minor item and watch-out found0 points for each item where there was none -1 point for each item found which were really OK enough

to be plausible but which were identified

Answer Sheet (if you are taking the test and want to be scored)

• Name_____________

• Organization_____________

• Email________________

• Phone_______________

Make sure to number each question and put the sheets in order on top of this oneAnd just in case they get separated put your NAME or identifier on each page. Then clip them together at the end using the handy clip provided

Question 1 – comment on this website

Question #2

• In the following example, utilization figures were multiplied by the (assume to be correct) cost figures to get a savings– Note that the savings is the difference

between the two bars

• Assume (correctly) no other changes were talking place

Savings by Category of Utilization per 1000 members per month (2004 vs. 2003)

(note: The difference between the bars is the savings)

$0

$500

$1,000

$1,500

$2,000

$2,500

IPAdmits

ERVisits

OPFacility

MDVisits

Drug Other

2003

2004

Question 3

• Assume on the next slide that the admission reductions are calculated validly and are the result of the program

Question #3: Comment on the plausibility of this Cigna report (assume a reasonable valid methodology was used

to calculate admission reduction)

Disease Category

All-cause Admission Reduction per disease member

All-cause Claims Cost Reduction per disease member

Asthma 2% 12%

cardiology 5% 15%

Question 4

• Comment on the Indiana Medicaid results

Indiana MedicaidCHF Study Group vs. Usual Care

$0

$500

$1,000

$1,500

$2,000

$2,500

Overall High Risk Low Risk

Per

CH

F P

erso

n p

er m

on

th

Total N = 186

Issue-Spotter #4: What is wrong with this slide

Overall savings of $758 PMPM

Question #5

• Comment on these results reported to a major employer (assume here as in all cases that low-risk and high-risk sum to the total managed population AND that these are asthma-specific changes)

AsthmaHospital Days and Admissions

0

100

200

300

400

500

600

700

per 1

000

mem

bers

Baseline 223 656 186

Reporting 114 197 107

HMO total High Risk Low Risk

-48%

-70%

-43%0

20

40

60

80

100

120

140

per 1

000 m

embe

rsBaseline 77 131 72

Reporting 33 115 26


DAYSADMISSIONS

Question #6

• The next two slides with all-in admissions and ER visits are from the same payor, same study – Find a major issue(s) which invalidates the

result or indicate that the result is probably reasonably valid

• “R#1” and “R#2” refer to reporting periods of one year each

CHF Group #1Emergency Room Visits/Year

0

1,000

2,000

3,000

4,000

5,000

6,000

per

1000 m

em

bers

Baseline 3,081 4,940 2,526

R#1 2,739 4,366 2,254

R#2 2,801 4,918 2,169


Total N = 1166 High Risk N = 268 Low Risk N = 898

CHF Group #1Inpatient Admissions/Year

0

100

200

300

400

500

600

per

1000 m

em

bers

Baseline 350 494 252

R#1 273 478 195

R#2 280 491 216



CHF Group #1Inpatient Admissions/Year

0

100

200

300

400

500

600

per 1

000 m

embe

rsBaseline 350 494 252

R#1 273 478 195

R#2 280 491 216



0

1,000

2,000

3,000

4,000

5,000

6,000

per 1

000

mem

bers

Baseline 3,081 4,940 2,526

R#1 2,739 4,366 2,254

R#2 2,801 4,918 2,169


Question #7

• Find the mistake(s) if any (assume inflation adjustment is done correctly)

Pre-post comparison: Asthma Medicaid Disabled Population

Baseline Period 1/03-12/03 paid through 6/30/04

Study Period 1/04-12/04, paid through 2/28/05

Member-months

15047 31884

PDMPM $432 $391

Gross savings & ROI

$2,400,125

2.72 – to -1

Question #8

• Comment on multiple issues on the following two slides representing the same study. Notes:– “Core Conditions” are the sum of the conditions above

the line– “Extended Conditions” are managed conditions other

than the Core Conditions– “Care Support” is disease managed group– Under each of the 3 categories, the two columns are

comparisons between the baseline and reporting periods for the study and concurrent control groups

Cohort Study Results (all claims, all members)

ROI and PMPM reductions at 6 Months

• Reporting Period – July - December 2002

• Base Period – July - December 2001

• Total ROI 2.48 : 1– Extended Conditions

4.23 : 1– Core Conditions

1.86 : 1

• “Our Auditors validated a $42 PMPM reduction due to this program”

Combined

• Reporting Period – July - December 2002

• Base Period – July - December 2001

• Total ROI 2.48 : 1– Extended Conditions 4.23

: 1– Core Conditions 1.86 : 1

• Auditors validated a $42 PMPM savings

Sidebar Note

• Even though the previous slides were published I am not using the name because it wouldn’t be fair to the health plan which has subsequently dramatically improved its methodology(ies)– So if you recognize it don’t hold it against

them. They would win a “most improved measurement” award

Question 9

• Comment on the likely validity of the following slide

Program Year One – Clinical IndicatorsProgram Year One – Clinical Indicators

Clinical Outcomes:

Base Post Year 1 Improvement

% of CHD Members with an LDL screen 75.0% 77.0% 2.0%

% of CHD Members with at least one claim for a Statin 69.0% 70.5% 1.5%

% of CHD Members receiving an ACE inhibitor or alternative 43.5% 44.7% 1.2%

% of CHD Members post-MI with at least one claim for a beta-blocker

0.89 0.89 0.0%

Hospitalizations/1,000 CHD Members for a primary diagnosis of Myocardial Infarction*

47.60 24.38 -48.8%

*measure based on total membership, not just "continuously enrolled" membership

Percentage of Continuously Enrolled Members

Question #10

• Comment on the following slide – CAD disease management program

Top Ten 2003 Diagnoses—admissions per 100 Cardio Disease Management Members

(pre- and post-DM – savings is difference)“Symptoms” really is a nICD9 code

0

50

100

150

200

250

300

350

Angina

Sympto

ms

CAD

Dorsopat

hies

Hyperte

nsion

Arthro

pathie

s

persons

without r

eporte

d Dx

Oth

er m

etab

olic

rheu

amtis

m, e

xcl.

back

2003--pre

2004--post

Question 11—Comment on CT Medicaid Current RFP

• May be a little hard to read

• I will display on Word

APPENDIX XII – Disease Management Data

Cardiovascular disease (cardiology, vascular diseases, vascular surgery, and Cardiopulmonary) 346

Below data is for State Fiscal Year 2005-2006

The below information for recipients with the diagnosis specified. One recipient may have more than one diagnosis and so would be represented in more that one cell below.

Congestive Heart Failure ICD-9 428

Under 21 yrs of Age

Recipients Units of Service Amount Paid

Fee-for-Service 5 52 $709 HUSKY A 41 385 $13,630

21 yrs. or older Recipients Units of Service Amount Paid

Fee-for-Service 1,314 67,929 $793,970 HUSKY A 121 903 $33,608

Other Heart Disease Diagnosis (21 yrs or older) Fee-for-Service Recipients Units of Service Amount Paid Dysrhythmias 4,160 234,723 $3,077,251 current heart attack

904 194,390 $2,221,051

Hypertension 18,350 796,318 $10,233,495 Ischemic 6,863 425,910 $5,731,919 MCO Dysrhythmias 640 8,201 $418,374 current heart attack

73 12,487 $174,012

Hypertension 5,945 30,717 $845,856 Ischemic 851 18,320 $845,800

Services covered include many types of care from a hospital day to a fifteen-minute home health service. Excludes: Nursing Home Services and services to clients in Nursing Facilites the whole year.

Question 12: Comment on this release

• IRVING, Texas--(BUSINESS WIRE)--Nov. 18 --A pediatric asthma disease management program offered by AdvancePCS saved the State of North Carolina nearly one-third of the amount the government health plan expected to spend on children diagnosed with the disease

Question 13: Comment on validity of this statement by a major

commercial health plan• “Over a 10-year period, we have reduced

the rate of heart attacks by 5 per 100 people”

Date post:	12-Jan-2016
Category:	Documents
Upload:	scot-martin-price
View:	218 times
Download:	0 times

Critical Outcomes Report Analysis May 2008. Agenda Some Logistics Overview of why reports are wrong...

Documents