Tag Archive | AAOS

Appropriate Use Criteria for Carpal Tunnel Syndrome

Benson Headshot.jpgOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Leon S. Benson, MD.

Appropriate Use Criteria (AUC) are suggested treatment algorithms for a variety of common orthopaedic conditions, published by the American Academy of Orthopaedic Surgeons.
These algorithms follow logically from the AAOS’s earlier work in publishing Clinical Practice Guidelines, and the methodology behind development of Appropriate Use Criteria is available in great detail on the AAOS website.

It is clear that the recent creation of Appropriate Use Criteria for carpal tunnel syndrome (CTS), like the other AUC algorithms, was very thoughtful and included the input of numerous experts. It is also clear that these criteria reflect an enormous amount of time and energy on the part of the AUC workgroup in attempting to reflect the best available evidence in managing carpal tunnel syndrome, while also allowing reasonable latitude in judgment on the part of the treating clinician.

The CTS AUC, like all AAOS AUC, are available as a downloadable application for virtually any computer or mobile platform. Using the AUC app is simple. The clinician selects items that correspond to elements of the patient’s history, physical examination, and testing/imaging findings, and then the AUC app categorizes various treatment (and/or workup) options as “appropriate,” “may be appropriate,” or “rarely appropriate.”

However, a few quirks of the CTS AUC may annoy some experienced clinicians. For example, in grading the patient’s history, the app requires that the clinician use either the Katz Hand Symptom Diagram or the CTS-6 history survey. I doubt that most seasoned hand surgeons routinely use these history tools unless their patient is enrolled in a research study. Additionally, the CTS-6 history survey lists “nocturnal numbness” as a choice; carpal tunnel patients typically report nocturnal pain that awakens them from sleep, not numbness (which is usually noticed upon awakening in the morning). In fact, nocturnal pain is probably the most reliable historical detail in confirming carpal tunnel syndrome. The CTS-6 criteria also give considerable weight to the presence of a positive Phalen’s test and Tinel’s sign even though these findings are commonly present in patients who have no pathology. The absence of these physical findings in patients who are suspected of carpal tunnel syndrome is probably more meaningful.

For the most part, though, the CTS AUC get a lot right about currently accepted treatment pathways for carpal tunnel syndrome. Playing around with the app, I was unable to create a combination of history, physical findings, and test data that produced treatment options with which I couldn’t agree. Furthermore, the AUC permit enough latitude in treatment recommendations to encompass the personal preferences of the vast majority of hand surgeons.

But perhaps the most compelling question is — why do we need an AUC app in the first place?  Doctors crave autonomy for many reasons, not the least of which are the extreme time commitment and intellectual demands of medical training, including residency and fellowship. Furthermore, orthopaedic judgment is refined through years of practical experience accrued over the course of a career. How can that be simulated with a simplified decision tree that boils everything down to a handful of categories?  And few fellowship-trained hand surgeons will immediately like the idea of an amorphous body of “experts” coming up with an iPhone app to tell them how to treat carpal tunnel syndrome.

However, there is another, critically important theme to the AUC story.  Our colleagues who contribute their expertise to the AAOS AUC projects are actually providing a huge service to orthopaedic patients nationwide.  As health-care delivery in the United States evolves, third-party payors and policy decision-makers are demanding that treatments be evidence based and consistent with expert consensus of “best practices.”  If doctors themselves do not weigh in on this topic, stakeholders who are neither patients nor providers will make up the rules. Most certainly, that would be less optimal for patients than physician experts helping craft treatment parameters, even if the parameters so created are not perfect or applicable to every imaginable clinical scenario.

With this perspective in mind, the CTS AUC have achieved reasonable goals, and they support most of the commonly recommended treatment approaches to managing carpal tunnel syndrome.  More importantly, the AUC-development process allows the community of orthopaedic specialists to have a seat at the table when value-based medicine is demanded, as it should be, by both our patients and policy-makers.

Although my pride might be a little bruised when I imagine practicing medicine by checking off boxes on a mobile app, I can handle it if it strengthens the identity of orthopaedic surgeons as leaders in doing what’s best for our patients.

Leon S. Benson, MD is chief of the Division of Hand Surgery at NorthShore University Healthsystem, professor of clinical orthopaedic surgery at the University of Chicago Pritzker School of Medicine, and a hand surgeon at the Illinois Bone and Joint Institute. He is also a JBJS associate editor.

Guest Post: New AUC for Surgical Management of Knee OA

knee-spotlight-image.pngOrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Richard Yoon, MD and Grigory Gershkovich, MD.

The AAOS recently reviewed the evidence for surgical management of osteoarthritis of the knee (SMOAK) and issued a set of appropriate use criteria (AUC) that help determine the appropriateness of clinical practice guidelines (CPGs). These AUC can be accessed on the OrthoGuidelines website: www.orthoguidelines.org/auc.

The AUC were developed after a panel of specialists reviewed the 2015 CPGs on SMOAK and made appropriateness assessments for a multitude of clinical scenarios and treatments. The panel found 21% of the voted-on items “appropriate”; 25% were designated “maybe appropriate,” and 54% were ranked as “rarely appropriate.”

Importantly, these AUC do not provide a substitute for surgical decision making. The physician should always determine treatment on an individual basis, ideally with the patient fully engaged in the decision.

This OrthoBuzz post summarizes some of the updated conclusions according to three clinical time points—pre-operative, peri-operative, and postoperative—specifying the strength of supporting evidence.  This post is not intended to review appropriateness for every clinical scenario. We encourage physicians to explore the OrthoGuidelines website for complete AUC information.

Pre-operative

Strong evidence: Obese patients exhibit minimal improvement after total knee arthroplasty
(TKA), and such patients should be counseled accordingly.

Moderate evidence: Diabetic patients have a higher risk of complications after TKA.

Moderate evidence: An 8-month delay to TKA does not worsen outcomes.

Peri-operative

Strong evidence: Both peri-articular local anesthetics and peripheral nerve blocks decrease postoperative pain and opioid requirements.

Moderate evidence: Neuraxial anesthesia may decrease complication rates and improve select peri-operative outcomes.

Moderate evidence: Judicious use of tourniquets decreases blood loss, but tourniquets may also increase short-term post-operative pain.

Strong evidence:  The use of tranexamic acid (TXA) reduces post-operative blood loss and the need for transfusions.

Strong evidence: Drains do not help reduce complications or improve outcomes.

Strong evidence: There is no difference in outcomes between cruciate-retaining and posterior stabilized implants.

Strong evidence: All-polyethylene and modular components yield similar outcomes.

Strong, moderate, and limited evidence to support either cemented or cementless techniques, as similar outcomes and complication rates were found.

Strong evidence: There is no difference in pain/function with patellar resurfacing.

Moderate evidence: Patellar resurfacing decreases 5-year re-operation rates.

Moderate evidence shows no difference between unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO).

Moderate evidence favors TKA over UKA to avoid future revisions.

Strong evidence against the use of intraoperative navigation and patient-specific instrumentation, as no difference in outcomes has been observed.

Postoperative

Strong evidence:  Rehab/PT started on day of surgery reduces length of stay.

Moderate evidence: Rehab/PT started on day of surgery reduces pain and improves function.

Strong evidence: The use of continuous passive motion machines does not improve outcomes after TKA.

Richard Yoon, MD is a fellow in orthopaedic traumatology and complex adult reconstruction at Orlando Regional Medical Center.

Grigory Gershkovich, MD is chief resident at Albert Einstein Medical Center in Philadelphia. He will be completing a hand fellowship at the University of Chicago in 2017-2018.

Dispatch from South Africa: COMOC 2016

Cape Town.jpgI recently returned from the 13th meeting of the Combined Orthopaedic Associations, affectionately known as COMOC 2016. This meeting is unique in that it brings together seven different national orthopaedic organizations from six countries (America, Australia, Britain, Canada, New Zealand, and South Africa).

The concept for this combined meeting originated with R.I. Harris, a Canadian orthopaedic surgeon who had been the president of both the Canadian Orthopaedic Association and the American Orthopaedic Association (AOA). Dr. Harris felt that improved communication between American, British, and Canadian orthopaedic surgeons would be of benefit to all. He was also responsible for the institution of the American-British-Canadian (ABC) Traveling Fellowship.

The first combined meeting involved only US, Canadian, and British orthopaedic surgeons. At that time travel would have been by ship or train. The original idea was to hold this meeting every six years and to move the venue from country to country on a predetermined schedule. This year, COMOC was held in Cape Town, South Africa, and in six years the US will be the host country.

The structure of the meeting is unique in that countries are given a forum to present orthopaedic issues most relevant to their national organizations. On Monday, April 11, both the American Academy of Orthopaedic Surgeons and the AOA presented plenary sessions. On Tuesday Australia took its turn in the morning, and New Zealand presented in the afternoon. Wednesday saw a presentation from the United Kingdom, with Canada taking the podium on Thursday. The plenaries wrapped up on Friday with the host South African Orthopaedic Association.

This meeting is an enduring link with the past and the future, continuing the orthopaedic tradition of fellowship and friendship that is the hallmark of our specialty. The Cape Town meeting was exceptional in venue, content, and organization.  The Local Organizing Committee and Programme Committee are to be congratulated for an exceptional job in developing a program that maintained significant audience interest despite the competing attractions of Cape Town and the South African countryside.

When COMOC comes to America in 2022, I hope North American orthopaedists—especially younger ones—will take the once-in-a-career opportunity to meet and talk with musculoskeletal colleagues from all over the world.

James P. Waddell, MD, FRCSC

JBJS Deputy Editor

CMS Delays Start of Joint-Replacement Bundled Payments til April 1, 2016

The final rule from the Centers for Medicare & Medicaid Services (CMS) regulating “episode-of-care” Medicare payments to hospitals for hip and knee replacements includes a postponed start date of April 1, 2016. The originally proposed implementation date was January 1, 2016.

Approximately 800 hospitals nationwide are subject to the new payment model, which makes hospitals eligible for bonuses or penalties, depending on their quality and cost performance from the day of patient admission to 90 days post-discharge. Based on comments about the initial rule by 400 key stakeholders, CMS also agreed to eliminate penalty payments during the first year of implementation.

Because the CMS model—dubbed Comprehensive Care for Joint Replacement, or CJR—permits gainsharing, individual orthopaedic surgeons could benefit financially if hospitals they are affiliated with receive bonuses. The AAOS commended CMS for revising the methodology for calculating the composite quality score and said that the delayed implementation “adds some flexibility,” but the group is still calling for CMS to “postpose the mandatory implementation feature of the program until at least 85 percent of providers have attained meaningful use [of EHRs] or another metric of infrastructure readiness.”

JBJS Editor’s Choice—Clinical Practice Guidelines: What Good Are They?

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Over the last 10 years, the AAOS has invested a great deal of effort and resources into developing Clinical Practice Guidelines (CPGs) and Appropriate Use Criteria. One rationale for these efforts was to follow the lead of our cardiovascular brethren, who have disseminated the highest level of evidence available to their community to help ensure that clinical decision making, in collaboration with the patient and family, is supported by the most solid science.

The paper published in the October 21, 2015 edition of JBJS by Oetgen et al. provides us with an evaluation of the impact of CPGs in managing femoral shaft fractures in children. The authors performed detailed chart reviews on 361 patients treated for a pediatric diaphyseal femoral fracture between 2007 and 2012. They analyzed each patient record to determine whether age-specific CPGs—which were published for this condition in 2009—were followed.

The results are somewhat discouraging. Oetgen et al. identified little if any impact of the CPG on clinical practice. Is that because surgeons are unaware of these tools? Or do they feel they know better than the literature synthesis at their disposal? Without more research, we will not know the answer to that question, but I suspect that recognition of the utility of CPGs will take a decade at least. I have the impression that younger surgeons are more accepting of the concepts of meta-analysis and levels of evidence as they influence clinical decision making—and as they were utilized to develop CPGs.  Waiting longer to make judgments about the impact of CPGs seems appropriate.

There is another factor also. These documents are guidelines, not restrictive formulas. Oetgen et al. emphasize that point in their introduction. Physicians everywhere wish to retain the privilege of making the best educated decision for each patient and family; this fact is partly responsible for the pushback that AAOS leadership received when starting down the CPG path. Additionally, during decision making for children with femoral shaft fractures, parental preferences will play a very strong role, regardless of the guidelines. This reality may ultimately limit efforts to accurately measure the clinical impact of CPGs by analyzing administrative databases.

So let’s give these guidelines a little more time to mature, and let’s give our orthopaedic community more time to become familiar with the utility of these documents. And, above all, let’s not turn guidelines into “cookbook” patterns of clinical decision making. Inputs from the treating physician, patient, and family should always be preeminent.

Marc Swiontkowski, MD

JBJS Editor-in-Chief

AAOS Issues Statement on Opioids in Orthopaedics

The current prescription-opioid/heroin epidemic in the US has been much publicized of late. According to a recent AAOS information statement, the nearly 100-percent increase in the number of narcotic pain-medication prescriptions between 2008 and 2011 corresponds to an increase in opioid diversion to nonmedical users as well as a resurgence in heroin use.

Among the strategies the AAOS statement calls for to stem the tide of opioid abuse and manage patient pain more safely and effectively are the following:

  • Opioid-prescription policies at the practice level that
    • set ranges for acceptable amounts and durations of opioids for various musculoskeletal conditions,
    • limit opioid prescription sizes to only the amount of medication expected to be used,
    • strictly limit prescriptions for extended-release opioids, and
    • restrict opioid prescriptions for nonsurgical patients with chronic degenerative conditions.
  • Tools (such as the opioid risk tool at MDCalc) that identify patients at risk for greater opioid use.
  • Empathic communication with patients, who “use fewer opiates when they know their doctor cares about them as individuals,” according to the statement.
  • An interstate tracking system that would allow surgeons and pharmacists to see all prescriptions filled in all states by a single patient.
  • CME standards that require periodic physician CME on opioid safety and optimal pain management strategies.

Noting that stress, depression, and ineffective coping strategies tend to intensify a person’s experience of pain, the statement concludes that “peace of mind is the strongest pain reliever.”

Calculating Individual Complication Rates Is Complicated

Rating hospitals on the basis of complications is one thing, but when you publish complication-rate scorecards for individual surgeons, as ProPublica did recently with nearly 17,000 surgeons nationwide, things can get personal.

ProPublica, an independent investigative-journalism group, examined five years of Medicare records for eight common elective procedures, three of which—knee and hip replacements and spinal fusions—orthopaedists perform. For each of the eight procedures, a panel of at least five physicians, including relevant specialists, reviewed 30-day readmission data to determine whether the readmission represented a complication; if a majority agreement was not achieved, the case was excluded from analysis. The analysis also excluded trauma and other high-risk cases, along with cases that originated in emergency departments.

Overall, complication rates were 2% to 4%. About 11% of the doctors accounted for about 25% of the complications.

In a ProPublica article about the scorecard, Dr. Charles Mick, former president of the North American Spine Society, is quoted as saying, “Hopefully, [the scorecard] will be a step toward a culture where transparency and open discussion of mistakes, complications, and errors will be the norm and not something that’s hidden.”  For its part, the AAOS responded with a press release that welcomed transparency but cautioned that “the surgical complication issue is much more complex, and cannot be effectively addressed without considering all of the variables that impact surgery, care, and outcomes.”

Pre-emptively, ProPublica clarified its methods in a separate article. Any 30-day readmission that the panel determined to be a complication was assigned to the surgeon who performed the original procedure. After compiling a raw complication rate for each doctor, researchers screened each patient’s health record and assigned a “health score.” That health score was used as part of a mixed-effects statistical model to determine an individual’s adjusted complication rate. No rate is reported if a surgeon performed a procedure fewer than 20 times.

Over the years, physician groups have complained that conclusions derived from Medicare data are inherently flawed, an argument that one orthopaedist made in the ProPublica article, citing the “multitude of inaccurate and confusing information that is provided to state and federal organizations.” Interestingly, two renowned patient-outcome experts cited in the ProPublica article came to separate conclusions. Dr. Thomas Lee, chief medical officer at healthcare-metrics consultancy Press Ganey, was quoted as saying that “the methodology was rigorous and conservative,” while Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins, told ProPublica in an email just prior to the scorecard release that “it would be highly irresponsible to present this to the public in its current form, or to make an example of any surgeon based on faulty data analysis.”

In another take on ProPublica’s ratings, radiologist Saurabh Jha spins a yarn on KevinMD  of two fictional orthopaedists, Dr. Cherry Picker and Dr. Morbidity Hunter. The moral of this tale, Dr. Jha says, is that ProPublica’s scorecard is “a reservoir of Sampson’s paradox…when the data says ‘bad surgeon,’ the surgeon might in fact be a Top Gun—a technically gifted Morbidity Hunter—the last hope of the poor and sick.”

Obviously the ProPublica scorecard has touched many a nerve among hip/knee-reconstruction and spine surgeons. Have you looked at your numbers? What do you think? Please join the discussion by clicking on the “Leave a comment” button in the box above, next to the article title.

Coming Soon: Medicare Appropriate Use Criteria for Advanced Imaging

For most physicians, HR 4302, federal legislation signed into law on April 1, 2014, was important because it delayed until March 1, 2015 drastic SGR-imposed cuts to Medicare physician payments. While many people are wondering what the next chapter of that saga will bring as the deadline approaches, tucked away in Section 218 of HR 4302 is another provision that could have far-reaching effects on daily orthopaedic practice: a Medicare requirement tying payment for advanced diagnostic imaging to appropriate use criteria (AUC).

That section of the legislation requires providers who order advanced diagnostic imaging for Medicare patients—such as CT and MRI—to consult physician-developed AUC, and document such consultation, beginning on January 1, 2017. Beginning on January 1, 2020, 5% of the ordering clinicians deemed to be “outliers” will be subject to a prior-authorization requirement.

In the meantime, the bill requires the Centers for Medicare and Medicaid Services (CMS) to issue rules for imaging AUC, “developed or endorsed by national professional medical specialty societies or other provider-led entities,” no later than November 2015.  It also directs the Health and Human Services Secretary to identify, by April 1, 2016, clinical decision-support tools to help physicians navigate the appropriateness criteria.

The goal of appropriateness criteria is to encourage clinicians to practice evidence-based medicine for improved patient outcomes and to use limited healthcare resources more efficiently. But, like any “administrative” task appended to already-complex medical practices, AUC for diagnostic imaging are controversial.

To find out more about the development of imaging AUC and what this pending requirement might mean for orthopaedists, OrthoBuzz recently spoke with three experts:

DDavid Jevsevar, MD, MBAavid Jevsevar, MD, MBA, chair of the American Academy of Orthopaedic Surgeons’ (AAOS) Committee on Evidence-Based Quality and Value and vice-chair of orthopaedics at Dartmouth-Hitchcock Medical Center

 

AlAlexandra Page, MDexandra Page, MD, chair of the AAOS Health Care Systems Committee and an orthopaedic surgeon at Kaiser Permanente

 

Geraldine McGinty, MD, MBAGeraldine McGinty, MD, MBA, chair of the Economics Commission at the American College of Radiology (ACR) and assistant professor of radiology at Weill Cornell Medical College

 

From these interviews, three themes emerged:

  • The need for collaboration among radiologists and orthopaedists in developing imaging AUC
  • The potential benefits of imaging AUC
  • The need for imaging AUC to be as user-friendly as possible

Development through Collaboration

The AAOS has a comprehensive process for developing AUC, but collaboration with other specialty societies is essential. Ideally, AUC are developed from a peer-reviewed evidence base, but such evidence is not always available.

Dr. Jevsevar: As much as we want AUC to be “evidence based,” there’s not a whole lot of imaging-related evidence out there. Ordering a plain radiograph of a patient who presents with symptoms of knee osteoarthritis seems self-evident and is diagnostically useful, but there’s no published evidence to support the practice. Consequently, most of the AUC already in use are based on a consensus methodology.

Dr. McGinty: The ACR’s AUC are evidence-based when there is evidence and consensus-based when there’s not. We also constantly revisit AUC in light of new evidence. When necessary, our AUC committees deploy “rapid response teams” to make sure guidelines are updated quickly and accurately.

Over the last 20 years the ACR has developed AUC for many clinical scenarios, and the process has always involved collaboration with other relevant specialties. The 24 musculoskeletal AUC that we already have established were developed in collaboration with physicians from the AAOS. Collaboration is essential because the evidence from which AUC are developed has to be representative of the specialty that’s going to use them.

Dr. Page: Cross-specialty collaboration among physicians allows us to be stronger negotiators with CMS and other large entities. My interactions with the ACR have always been with people more interested in how we can work together than in the “territorial” issues.

At Kaiser, we also collaborate with primary care doctors to establish AUC for musculoskeletal and other imaging. For example, we agree that advanced imaging is not appropriate in a primary care setting for an initial presentation of routine low back or knee pain. Collaboration helped make this an educational experience rather than an adversarial one.

Dr. Jevsevar:  With imaging, interdisciplinary input is necessary for developing AUC because we all see patients through our own lenses. AAOS representation on the ACR working groups to develop AUC ensures that both perspectives are represented. The AAOS has also successfully collaborated with primary care specialties to develop AUC for diagnosis and initial treatment of distal radius fractures, osteochondritis dissecans, and knee osteoarthritis.

AUC Benefits

The putative benefits of imaging AUC fall into two main areas: improved patient outcomes and lower health-system costs.

Dr. McGinty: Institutions and health systems that have already implemented imaging AUC have shown that they reduce costs to the system, including costs related to unnecessary imaging. We also expect that patient outcomes will improve due to decreased complications from inappropriate surgery.

Dr. Jevsevar: Imaging AUC will also help physicians measure themselves transparently. It will help identify outliers who order more imaging studies than necessary. But instead of a punitive response to that, we’re aiming for an educational response: Why is someone an outlier, and what education can we provide so that person can change behaviors?

Dr. Page: The collaborative process of developing AUC in and of itself makes us better clinicians and more empowered to provide better patient care.

Ease-of-Use Essential

All three experts whom we interviewed insisted that imaging AUC will have to be seamlessly integrated into usual clinical workflows. Extra steps that are not “automatic” will be received unhappily.

Dr. McGinty: The user-friendliness of the platform is key. Ideally, AUC filters would be embedded into the EHR system so they are seamless to the clinician. Even better would be systems that automatically track clinician adherence to AUC for reporting purposes. But for all that to happen, there will have to be ongoing collaboration with EHR vendors.

Dr. Jevsevar: Any process that’s onerous will not be good for anybody. If a procedural step is pushed to doctors, they’ll be more likely to perform it than if they have to go out and get it. I like the AAOS AUC app, but even consulting that requires an additional step. I envision an EHR-based AUC tool that will initially block a doctor from ordering an imaging study that’s not “appropriate.” Or an embedded pop-up message will remind a doctor who’s about to order an MRI or CT in a specific clinical scenario what the evidence base says.

Having said that, even if AUC are seamlessly integrated into the EHR, I don’t think they should be unreasonably rigid.  Almost all practice guidelines assume a “routine patient.” But we often see patients who are not routine, so AUC need to allow for flexibility. We’re all trying to find the right balance between providing the best care at the population and system levels and at the same time delivering the best patient-centered care to each individual.

Doctor Shopping for Narcotics Common among Trauma Patients

A study in the August 6, 2014 JBJS revealed that the prevalence of postoperative “doctor shopping” among a cohort of 130 orthopaedic trauma patients in Tennessee was a surprisingly high 20.8%. This study used the state-controlled substance monitoring database to identify the narcotic prescriptions filled by patients three months prior to surgery and up to six months after discharge. The study segmented the test group into those who received prescriptions only from the treating surgeon or healthcare extender and those who got prescriptions from multiple doctors and extenders.

According to the study, patients who doctor shopped received an average of seven prescriptions for narcotics compared to an average of two prescriptions among those who got prescriptions from a single provider. Those with a high-school education or less were three times more likely to seek out multiple providers. According to Dr. Douglas Lundy, a spokesperson for the American Academy of Orthopedic Surgeons, “I think what the study tells us is there is a subgroup of patients you need to be a little more vigilant on, that they may be taking more drugs than you think they’re taking.”

Value of Orthopaedics; A Major Focus in Washington

In May, more than 300 orthopaedic surgeons attended the National Orthopaedic Leadership Conference in Washington, DC. During the conference, attendees took time to recognize the success of the AAOS Project Value initiative, which was started by former AAOS president John R. Tongue, MD. The initiative’s project team set out to quantify the social and economic benefits of musculoskeletal health care.

Four studies have been published as a result of this effort, three of which were published in JBJS:

AAOS also hosts a website to highlight the notion of value in orthopaedics: www.ANationInMotion.org/value.