Skip to main content
Rural Health Information Hub
Rural Health Information Hub

Rural Healthcare Quality

According to the Institute of Medicine (IOM, now the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine), quality is:

“The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”

Because quality is directly linked to desired health outcomes, healthcare payers are increasingly using quality measures as a factor in determining provider reimbursements.

The 2001 IOM report, Crossing the Quality Chasm: A New Health System for the 21st Century, called for fundamental reform of the U.S. healthcare system to better achieve higher quality standards. This report identified six aims that have been at the heart of U.S. healthcare quality improvement efforts since its release:

  • Safe
  • Effective
  • Patient-centered
  • Timely
  • Efficient
  • Equitable

The 2005 IOM report, Quality Through Collaboration: The Future of Rural Health Care, argued that rural healthcare had largely been on the periphery of national healthcare discussions, saying:

“In general, the smaller, poorer, and more isolated a rural community is, the more difficult it is to ensure the availability of high-quality health services.”

Some of the challenges rural quality improvement efforts face, identified in a 2015 National Quality Forum (NQF) report, Performance Measurement for Rural Low-Volume Providers, include:

  • Fewer healthcare providers
  • Lack of information technology
  • Fewer staff available to meet many different demands
  • Limited resources available for quality improvement
  • Serving a more vulnerable population, with poorer health status and behaviors
  • Exclusion from some quality initiatives for providers such as Critical Access Hospitals, Rural Health Clinics, and Federally Qualified Health Centers, which are paid differently

Rural providers also have strengths related to quality, particularly in how rural individuals and organizations pull together for a common goal and make the most of limited resources. A 2014 Centers for Disease Control and Prevention (CDC) report, Implementation of Antibiotic Stewardship Core Elements at Small and Critical Access Hospitals, identifies rural hospitals as often being tight-knit communities where collaboration is the norm, a strength in supporting quality improvement efforts.

Currently, there are efforts underway to better understand the challenges rural providers face in reporting on quality measures and engaging in quality initiatives. The NQF's Measure Applications Partnership (MAP) Rural Health Workgroup has developed and is continuing to refine a core set of rural-relevant quality measures, based on insights from a multi-stakeholder group. Its 2018 report, A Core Set of Rural-Relevant Measures and Measuring and Improving Access to Care: 2018 Recommendations from the MAP Rural Health Workgroup, identified the following criteria for measure selection:

  • NQF-endorsed
  • Cross-cutting, so not condition-specific or procedure-specific
  • Resistant to low case-volume
  • Addressing care transitions

The workgroup's 2022 Key Rural Measures: An Updated List of Measures to Advance Rural Health Priorities also considered outcome or patient-reported outcome performance measures and active utilization of measures in federal programs.

The workgroup continues to examine quality related to certain conditions and services that impact rural populations:

  • Mental health
  • Substance use
  • Medication reconciliation
  • Diabetes, hypertension, and chronic obstructive pulmonary disease (COPD)
  • Hospital readmissions
  • Perinatal and pediatric conditions and services
  • Telehealth
  • Healthcare system readiness

Frequently Asked Questions

How is Medicare reimbursement tied to healthcare quality?

The Centers for Medicare & Medicaid Services (CMS) has been shifting payments from volume-based to value-based care through a range of different quality reporting programs that seek to provide better care for patients, improve population health, and lower cost. These programs are typically phased in over time, beginning with required quality data reporting, then followed by incentives for good performance and/or penalties for poor performance.

Because certain rural healthcare facilities, such as Critical Access Hospitals, Rural Health Clinics, and Federally Qualified Health Centers, are reimbursed differently than Prospective Payment System (PPS) hospitals, they have been excluded from most of the CMS value-based programs. NQF's 2015 report, Performance Measurement for Rural Low-Volume Providers, discusses the importance of including rural providers in CMS quality improvement programs.

For facilities such as Critical Access Hospitals and Rural Health Clinics that are not currently required by CMS to report quality data, the expectation is that they will need to do so in the future, as the health system's transition to value-based reimbursement continues.

The Quality Payment Program (QPP) is a CMS program that rewards Medicare clinicians providing high-quality, high-value care with increased payments. Two tracks are available:

  • The Merit-Based Incentive Payment System (MIPS) is aimed at clinicians that meet a low volume threshold. It measures quality, improvement activities, advancing care information, and cost. Beginning in 2023, providers can meet MIPS reporting requirements by participating in the MIPS Value Pathways (MVPs). MVPs are subsets of quality measures for different specialties, medical conditions, or populations.
  • Advanced Alternative Payment Models (Advanced APMs) are payment approaches that provide additional incentive payments for high-quality and cost-efficient care.

To learn about support for rural providers related to QPP, see What programs, resources, and technical assistance are available to support quality improvement efforts in rural healthcare facilities?

The CMS Promoting Interoperability Program, formerly the Medicare Electronic Health Record (EHR) Incentive Program, requires that Critical Access Hospitals and other eligible hospitals report electronic clinical quality measures (eCQMs) to demonstrate meaningful use of electronic health record technology. A Critical Access Hospital eCQM Resource List is available to help CAHs meet these reporting requirements. See the 2022 Medicare Promoting Interoperability Program Scoring Methodology Fact Sheet for details on how these requirements impact reimbursement. Additional resources on this topic are available in the eCQI Resource Center.

Which quality reporting or monitoring programs apply to rural facilities?

Quality reporting requirements vary for different types of healthcare facilities. Regardless of what is specifically required, facilities often have the option to voluntarily report quality data beyond what is required, which can help potential patients make assessments about the care provided when using Medicare’s Care Compare tool and similar resources.

Rural Prospective Payment System (PPS) Hospitals

Hospitals paid through the prospective payment system (PPS) are required to report quality measures to CMS through the Hospital Inpatient Quality Reporting Program (IQR) and Hospital Outpatient Quality Reporting Program (OQR) in order to maximize their reimbursement. PPS hospitals are subject to penalties and bonus payments from CMS in relation to the Hospital Value-Based Purchasing Program (VBP), and subject to penalties through the Hospital Acquired Conditions Reduction Program (HACRP) and the Hospital Readmissions Reduction Program (HRRP). Rural PPS hospitals have a Hospital VBP total performance score calculated if they meet the minimum number of cases and measures, and are also included in the HACRP and HRRP program if they meet minimum case thresholds.

Critical Access Hospitals

Critical Access Hospitals (CAHs) are not required by CMS to participate in the Inpatient or Outpatient quality reporting programs, nor are they eligible for the Hospital VBP, HACRP, or HRRP. CAHs are allowed to voluntarily report to CMS and are encouraged to do so through a variety of initiatives, but it does not affect their Medicare reimbursement.

The Medicare Rural Hospital Flexibility (Flex) Program, designed to support Critical Access Hospitals and funded by the Federal Office of Rural Health Policy (FORHP), prioritizes quality and performance improvement activities through the Medicare Beneficiary Quality Improvement Project (MBQIP). MBQIP is a quality improvement program that supports CAHs in reporting quality measures and using the data to help improve quality of care. Participating hospitals voluntarily report quality data and work to drive quality improvement. The Medicare Beneficiary Quality Improvement Project (MBQIP) Quality Reporting Guide, developed by Stratis Health, a FORHP awardee, offers Flex Coordinators, CAH staff, and others who are working with MBQIP information to better understand the measure reporting process. MBQIP has traditionally focused on measures in four domains: patient safety/inpatient, patient engagement, care transitions, and outpatient. As the program continues to evolve, new measures will be integrated into MBQIP.

Rural Health Clinics

Rural Health Clinics (RHCs) are excluded from many Medicare quality programs such as the Merit-Based Incentive Payment System (MIPS). For more information about RHCs and MIPS, see the Rural Health Clinic topic guide. The CMS Conditions of Participation for RHCs includes an annual program evaluation requirement, which is the only current quality requirement for RHCs. The evaluation must look at appropriate utilization of clinic services and whether established clinic policies were followed. The requirement may be met by having a quality assessment and performance improvement (QAPI) program in place. For more on the RHC program evaluation requirements, as well as background information on quality improvement and RHCs, see RHC Technical Assistance Educational Series Module 5: RHC Performance Measurement and Quality Improvement from the National Organization of State Offices of Rural Health.

A February 2016 policy brief from the Maine Rural Health Research Center, Pilot Testing a Rural Health Clinic Quality Measurement Reporting System, discusses the feasibility of implementing an RHC quality measurement and benchmarking (QM/BM) system, based on a pilot study. The brief documents both the barriers and benefits RHCs experienced implementing and reporting on a QM/BM system, as well as opportunities to improve quality reporting for RHCs in the future. Rural Health Clinic Participation in the Merit-Based Incentive System and Other Quality Reporting Initiatives: Challenges and Opportunities, a 2018 brief, explores barriers RHC face in voluntarily participating in the Merit-Based Incentive Payment System (MIPS) and other quality reporting programs, including guidance from the Centers for Medicare & Medicaid Services, costs to retrieve and report data, added workload, and difficulty extracting data from patient records for facilities without electronic health records (EHRs).

Federally Qualified Health Centers

Federally Qualified Health Centers (FQHCs) are largely excluded from Medicare reporting programs, but have quality reporting requirements as part of the Health Center Program. Participation in the federal Health Center Program requires an ongoing quality improvement/assurance (QI/QA) program. The QI/QA program must address quality and utilization of services, patient satisfaction, and patient safety. Health Centers also submit quality measures as part of the Uniform Data Set (UDS) program. To learn more about UDS quality measures and how they align with CMS quality reporting programs, see the 2023 Uniform Data Set (UDS) Measure Crosswalk to Other Quality Reporting Programs. For more information on quality initiatives related for FQHCs, see Health Center Quality Improvement.

What are the challenges that rural providers face for quality reporting?

The August 2018 report from the MAP Rural Health Workgroup, A Core Set of Rural-Relevant Measures and Measuring and Improving Access to Care: 2018 Recommendations from the MAP Rural Health Workgroup, identifies the following measurement challenges rural providers face:

  • Limited experience with performance measurement and reporting because they are not eligible for most CMS quality programs even though many participate voluntarily
  • Challenges with claims-based performance measures due to low patient volumes and data limitations for rural providers who do not receive claims-based reimbursement and so may not include comprehensive data on their claims
  • Limited time, staff, and financial resources available for quality improvement activities

A September 2020 report, Rural-Relevant Quality Measures for Testing of Statistical Approaches to Address Low Case-Volume, outlines 15 quality measures susceptible to low case-volume challenges that could be used to test statistical approaches designed to address this problem, as well as reporting challenges for rural providers and gaps in rural health care quality measurement.

Rural providers lack the economies of scale that allow larger health systems, and rural facilities that are part of larger systems, to address quality reporting requirements. They have fewer staff members to spread around the additional work and are less likely to be able to dedicate a specific staff member or team to focus on quality initiatives. Even the time needed to train staff on new requirements takes away from other tasks. For example, while CMS does not require CAH participation in formal quality reporting and pay-for-performance programs, there are a number of initiatives focused on engaging CAHs in quality reporting and improvement. These initiatives often have disparate measures and reporting processes, which can increase reporting burden and complicate CAH quality efforts.

Rural facilities may also lack the technical resources to insert new processes and data collection in their existing health information technology (HIT) systems to meet changing requirements. Pilot Testing a Rural Health Clinic Quality Measurement Reporting System discusses challenges RHCs faced related to a pilot quality reporting program. The top reporting challenges identified in this study include extracting data from the electronic health record and from paper records, and availability of staff time to collect and report measures.

What do we know about rural facilities and quality of care?

Rural-specific research on quality can be challenging to find due to low volumes, as well as the fact that reporting is voluntary for many types of rural facilities. However, some organizations do focus on analysis of rural-specific quality data.

The Flex Monitoring Team, for example, is funded by the Federal Office of Rural Health Policy (FORHP) to analyze and evaluate the Medicare Rural Hospital Flexibility (Flex) Program. It produces annual quality reports for each of the 45 states participating in the Flex Program. Reports released in 2023 (reporting 2022 data) and 2022 (reporting 2021 data) include voluntarily reported data by Critical Access Hospitals (CAHs) across the country and compare CAH reporting and results across a variety of inpatient and outpatient quality measures.

FORHP also supports a number of rural health research centers that conduct a variety of research, including studies of rural healthcare quality. The Rural Health Research Gateway is funded by FORHP to disseminate the publications developed by the rural health research centers. Research specific to rural health quality can be found on the Rural Health Research Gateway’s Quality topic page.

A number of studies highlight positive quality outcomes in rural settings, including a 2016 JAMA article, Association of Hospital Critical Access Status with Surgical Outcomes and Expenditures Among Medicare Beneficiaries, and a 2017 Journal of Rural Health article, Surgical Patient Safety Outcomes in Critical Access Hospitals: How Do They Compare?

Fundamental differences in how healthcare is provided between rural and urban settings, as well as socioeconomic and cultural differences of the populations served, make it challenging to compare healthcare quality. Understanding these differences is one of the greatest challenges to comparing quality outcomes.

These differences were highlighted by formal responses to a 2013 JAMA article, Mortality Rates for Medicare Beneficiaries Admitted to Critical Access and Non–Critical Access Hospitals, 2002-2010. The article garnered formal response by the Flex Monitoring Team and two informal responses by Dr. Wayne Myers in the Daily Yonder and the Rural Monitor.

As summarized in the Flex Monitoring Team response, understanding the rural context is key:

“Researchers who analyze rural health policy issues need to understand the rural health care environment. If not, their research has the potential to harm rather than help rural hospitals and health care professionals in providing high-quality care for their patients.”

Key differences highlighted in the responses to the article include:

  • Differences in volume and services
    Rural healthcare facilities see a much smaller volume of patients than their urban counterparts, making it a challenge to compare quality between the two types of facilities. With a small sample size for any one procedure or treatment, quality data can be skewed, leaving a high probability of misinterpretation. Due to their small size and remote nature, CAHs often don't offer the advanced procedures available at larger urban facilities. For example, few rural hospitals provide cardiac catheterization; they instead focus on stabilization and transfer of patients in need of such services.
  • Differences in patient demographics and choices
    Patients have a choice in how they receive care and their preferences can directly contribute to quality outcomes. A patient may choose to be treated near their home at a rural facility, knowingly forgoing a higher level of care that could be provided at a larger facility. In some instances, rural patients may use rural hospitals when hospice services are not available so they can remain near their home and family at the end of their life.
  • Differences in transfer rates
    According to Which Medicare Patients Are Transferred from Rural Emergency Departments?, small rural hospitals transfer patients at higher rates than larger facilities, especially for some serious medical conditions such as emergency cardiac care. Outcomes of rural hospitals may vary depending on whether transferred patients are excluded, assigned to the initial hospital, or to the receiving hospital.

What programs, resources, and technical assistance are available to support quality improvement efforts in rural healthcare facilities?

A wide range of resources, funding programs, and initiatives are available to help rural healthcare providers develop quality improvement programs.

State Flex Programs

The Medicare Rural Hospital Flexibility (Flex) Program funds State Flex Programs that provide support to Critical Access Hospitals on a variety of topics, including quality and performance improvement. In particular, Flex Program staff can help CAHs understand and meet Medicare Beneficiary Quality Improvement Project (MBQIP) requirements.

Small Health Care Provider Quality Improvement Program

The Small Health Care Provider Quality Improvement Grant Program (SHCPQI) is a FORHP-funded program that provides support to rural primary care providers, CAHs, RHCs, or networks of small rural providers for planning and implementation of quality improvement activities. A February 2016 Rural Monitor article, Small Health Care Provider Quality Improvement Grant: A Cultural Shift in Quality for Providers, provides an overview of the program and highlights SHCPQI projects in Colorado, New Hampshire, North Carolina, and Oregon. Two additional SHCPQI programs are featured in RHIhub's Rural Health Models and Innovations:

Rural Health Networks

Rural health networks, such as statewide CAH quality networks, can voluntarily organize themselves to work collaboratively to improve healthcare quality. Quality networks share useful information such as best practices to achieve quality outcomes and encourage data reporting by members. Member organizations often submit quality data to be analyzed and benchmarked against network, state, and national aggregates to inform quality improvement efforts at each member facility.

Quality Improvement Organizations

Quality Improvement Organizations (QIOs) work with healthcare facilities and providers on behalf of CMS to improve healthcare delivery to ensure high-quality, cost-efficient care. Additionally, QIOs investigate complaints made by beneficiaries concerning quality of care. The work of QIOs is state-focused and organized under regional contracts. Two Beneficiary and Family Centered Care-QIOs (BFCC-QIOs) manage all beneficiary complaints and appeals. Fourteen Quality Innovation Networks-QIOs (QIN-QIOs) help healthcare providers with quality initiatives by promoting evidence-based improvement strategies and support for peer-to-peer learning. Locate your QIO to learn about how to partner with a QIO and more.

Hospital Quality Improvement Contractors (HQIC)

Hospital Quality Improvement Contractors (HQICs) provide free quality improvement consultation and expertise to Critical Access Hospitals (CAHs) and other small and rural facilities. HQIC is a four-year program within the CMS Quality Improvement Organization program that consists of nine HQICs.

Quality Payment Program's Support for Small Practices

The Quality Payment Program (QPP) is a CMS program that awards increased payments to Medicare clinicians providing high-quality, high-value care. The QPP Small Practices website provides free resources for practices with 15 or fewer clinicians and small practices. QPP Help and Support offers additional resources to understand the QPP, including videos, online courses, and more.

Additional QPP resources focused on rural practices:

How can the use of rural-relevant quality measures help us understand and improve rural quality of care?

The NQF's Measure Applications Partnership (MAP) Rural Health Workgroup has developed and continues to refine a core set of rural-relevant quality measures that, among other things, are resistant to low case-volume and address topics of particular importance to rural areas. 2022 Key Rural Measures: An Updated List of Measures to Advance Rural Health Priorities updates a 2018 NQF list of key rural measures focused on rural access to care. By focusing on measures that rural facilities can collect in a manner that is valid and reliable, they are giving rural facilities a tool both to improve their performance and to demonstrate that performance to payers. In addition, Rural-Relevant Quality Measures for Testing of Statistical Approaches to Address Low Case-Volume identifies 15 quality measures that could be used to test statistical approaches to address low case-volume challenges. At a time when the healthcare system is transitioning to pay for value, it is important that rural facilities can show the value they provide, using measures that consider the particular circumstances they face.

How are rural facilities working to implement antibiotic stewardship?

Antibiotic stewardship (AS) programs seek to improve antibiotic use at healthcare facilities. According to the CDC's Antibiotic Use in the United States, 2021 Update: Progress and Opportunities, this can help improve quality of care through better treatment and reduced antibiotic resistance. In September 2019, CMS released a rule that requires hospitals and CAHs to implement AS programs as a Condition of Participation. In addition, as of January 1, 2023, all Joint Commission-accredited hospitals and CAHs are subject to revised antibiotic stewardship requirements.

A March 2017 Rural Monitor article, Strategies for Superbugs: Antibiotic Stewardship for Rural Hospitals, provides an overview of AS issues in rural areas. It features AS programs at Critical Access Hospitals (CAHs) in Idaho and Colorado and a health system AS program in Utah that includes 11 small hospitals and 5 CAHs. The work of the Colorado CAH is also featured in Southwest Health System Antibiotic Stewardship Program.

Resources have been developed to help rural facilities develop AS programs, including:

In addition, several Flex programs shared information on AS work in their states at a July 2018 Flex Program Reverse Site Visit meeting:

CAHs participating in MBQIP are expected to fully implement an antibiotic stewardship program. This is measured through the CDC's National Healthcare Safety Network Annual Facility Survey, which includes questions on antibiotic stewardship in its Patient Safety Component. For more information, see the CDC's Patient Safety Component (PSC) Training website.

What are some other examples of how rural facilities are addressing healthcare quality?

A wide range of rural projects have been developed to address healthcare quality. Many have been highlighted throughout this guide related to specific programs.

Profiles of quality activities at high performing CAHs, featured in “CAHs Can!” articles in the MBQIP Monthly newsletter produced by Rural Quality Improvement Technical Assistance, a program by Stratis Health.

More examples are included in the Models & Innovations section of this guide and in Other Case Studies and Collections of Program Examples: Healthcare quality.

How are Accountable Care Organizations (ACOs) and other value-based service delivery models impacting quality in rural areas?

As the U.S. healthcare system continues to evolve from paying for services by volume to paying for value, the Centers for Medicare & Medicaid Services (CMS), with technical assistance from the Health Resources and Services Administration (HRSA), has developed new payment and service delivery models to improve the quality of care. Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs) are two noteworthy service delivery models that aim to improve healthcare quality through a value-based strategy. Both models aim to improve outcomes by more closely coordinating care among providers and facilities to improve quality outcomes.

ACOs are groups of physicians, facilities, and other healthcare providers who voluntarily enter into a partnership to provide coordinated care with incentives for quality and efficiency. As an incentive to provide high-quality care, CMS and some commercial payers will share cost savings with the ACO. The 2021 CMS Innovation Center Strategy Refresh outlines the CMS aim to have all Medicare beneficiaries in Parts A and B, and the vast majority of Medicaid beneficiaries, in accountable care relationships by 2030. The ACO Investment Model was an ACO initiative established by CMS in 2015 that continued in 2016 to encourage participation among rural providers. This model was developed to operate with the Medicare Shared Savings Program and was developed in response to concerns over small and rural providers lacking the adequate resources to establish the necessary infrastructure for successfully implementing a population care management program. Evaluation of the Accountable Care Organization Investment Model: Final Report highlights that some AIM ACOs that reduced total Medicare spending also performed as well or better on quality measures compared to similar ACOs in the Medicare Shared Savings Program. According to Shared Savings Program Fast Facts, 513 Critical Access Hospitals and 2,571 Rural Health Clinics were part of a Medicare Shared Savings Program ACO as of January 2024.

The PCMH is another model for providing patient care that is comprehensive, patient-centered, coordinated, accessible, and high quality. This model emphasizes a long-term relationship between the patient and a team of professionals, led by the patient's physician, which works to provide and coordinate care. Despite challenges to implementing the PCMH model in rural areas, optimism exists for its ability to achieve financial savings and reach quality improvement targets in rural areas, according to Rural Health Clinic Readiness for Patient-Centered Medical Home Recognition: Preparing for the Evolving Healthcare Marketplace.

Rural Health Value's Catalog of Value-Based Initiatives for Rural Providers provides a comprehensive list of rural-relevant, value-based programs currently or recently implemented by the U.S. Department of Health and Human Services (HHS). For more information on these and other emerging, rural-relevant payment and service delivery models, see the Testing New Approaches page.

How can the use of health information technology (HIT) and telehealth impact the quality of care delivered in rural areas?

Telehealth and HIT are technology-based tools that can improve care and care coordination in rural communities. As the 2021 Rural Monitor article Understanding the “Tool-ish-ness” of Telehealth: Q&A with Dr. Jonathan Neufeld describes, these technologies can play a significant role in improving quality of care in rural communities.

Because of its role in reporting on quality measures, HIT is often listed as a challenge for rural facilities implementing quality initiatives. However, the expansion of electronic health records (EHR) and the sharing of EHR data through health information exchanges can be particularly useful to rural facilities that may have patients transitioning to and from urban hospitals. Clinical quality and safety is a major focus of HIT efforts. CMS and the Office of the National Coordinator for Health Information Technology provide a range of information and educational resources related to electronic clinical quality measures (eCQMs) in the eCQI (Electronic Clinical Quality Improvement) Resource Center including information on Eligible Hospital/Critical Access Hospital eCQMs.

Telehealth: Mapping the Evidence for Patient Outcomes from Systematic Reviews, a 2016 Agency for Healthcare Research and Quality (AHRQ) brief, reports that telehealth is effective in helping patients with chronic conditions through remote patient monitoring and communication and counseling and is also effective in the provision of psychotherapy. A 2013 AHRQ report, Findings and Lessons from the Improving Quality Through Clinician Use of Health IT Grant Initiative, identifies ways that HIT can help improve quality of care by supporting:

  • Clinician and patient decision-making, for example providing guidance related to medication management
  • Clinical workflow, for example reminder systems for clinicians
  • Care coordination, such as a notification system to alert primary care providers about patient discharges from the hospital

Telehealth can both improve the care rural patients receive by providing access to specialty care and help rural primary care providers through case-based learning and mentorship from specialists, via programs like Project ECHO. Making the EHR Work: Rural Healthcare Organizations Use Data Extraction to Improve Patient Care, a 2018 Rural Monitor article, highlights a variety of ways rural providers are using electronic health records to improve patient care and outcomes.

For more information, see our topic guide on Telehealth and Health Information Technology in Rural Healthcare.

Last Updated: 3/19/2024
Last Reviewed: 12/19/2022