National Academies Of Sciences, Engineering, And Medicine Research Articles

The National Academies of Sciences, Engineering, and Medicine recommendations on Medicaid parity and future of pediatric subspecialty workforce.

Medicaid supports 41% of all births in the US and nearly 347,580 admissions to neonatal intensive care units in 2022. Medicaid reimbursement is critical to child health inclusive of departments of Pediatrics and children's hospitals. Low Medicaid reimbursement is one of the causes for low pediatric subspecialist salaries and has led to workforce challenges. The National Academies of Science, Engineering, and Medicine (NASEM) recently suggested increased Medicaid reimbursement as a strategy to sustain pediatric subspecialist workforce. This review article briefly outlines the importance of Medicaid reimbursement to Neonatal-Perinatal Medicine and its role in providing coverage for preterm births. We also highlight the recommendations of NASEM pertaining to reimbursement that are relevant to neonatal care and its impact on providers, patients, and families. It is imperative that neonatologists join the rest of pediatric subspecialists in lending their support to demonstrate unity in ensuring success in the implementation of the NASEM recommendations.

Triangulation of epidemiological evidence and risk of bias evaluation: A proposed framework and applied example using formaldehyde exposure and risk of myeloid leukemias

Evidence triangulation may help identify the impact of study design elements on study findings and to tease out biased results when evaluating potential causal relationships; however, methods for triangulating epidemiologic evidence are evolving and have not been standardized. Building upon key principles of epidemiologic evidence triangulation and risk of bias assessment, and responding to the National Academies of Sciences, Engineering, and Medicine (NASEM) call for applied triangulation examples, the objective of this manuscript is to propose a triangulation framework and to apply it as an illustrative example to epidemiologic studies examining the possible relationship between occupational formaldehyde exposure and risk of myeloid leukemias (ML) including acute (AML) and chronic (CML) types.A nine-component triangulation framework for epidemiological evidence was developed incorporating study quality and ROB guidance from various federal health agencies (i.e., US EPA TSCA and NTP OHAT). Several components of the triangulation framework also drew from widely used epidemiological analytic tools such as stratified meta-analysis and sensitivity analysis. Regarding the applied example, fourteen studies were identified and assessed using the following primary study quality domains to explore potential key sources of bias: 1) study design and analysis; 2) study participation; 3) exposure assessment; 4) outcome assessment; and 5) potential confounding. Across studies, methodological limitations possibly contributing to biased results were observed within most domains. Interestingly, results from one study – often providing the largest and least-precise relative risk estimates, likely reflecting study biases, deviated from most primary study findings indicating no such associations. Triangulation of epidemiological evidence appears to be helpful in exploring inconsistent results for the identification of study results possibly reflecting various biases. Nonetheless, triangulation methodologies require additional development and application to real-world examples to enhance objectivity and reproducibility.

An Executive Summary of the National Trauma Research Action Plan (NTRAP).

The National Trauma Research Action Plan (NTRAP) project successfully engaged multidisciplinary experts to define opportunities to advance trauma research and has fulfilled the recommendations related to trauma research from the National Academies of Sciences, Engineering and Medicine (NASEM) report. These panels identified more than 4,800 gaps in our knowledge regarding injury prevention and the optimal care of injured patients and laid out a priority framework and tools to support researchers to advance this field. Trauma research funding agencies and researchers can use this executive summary and supporting manuscripts to strategically address and close the highest priority research gaps. Given that this is the most significant public health threat facing our children, young adults, and military service personnel, we must do better in prioritizing these research projects for funding and providing grant support to advance this work. Through the Coalition for National Trauma Research (CNTR), the trauma community is committed to a coordinated, collaborative approach to address these critical knowledge gaps and ultimately reduce the burden of morbidity and mortality faced by our patients.

Refining a Framework to Enhance Communication in the Emergency Department During the Diagnostic Process: An eDelphi Approach

Emergency departments (EDs) are susceptible to diagnostic error. Suboptimal communication between the patient and the interdisciplinary care team increases risk to diagnostic safety. The role of communication remains underrepresented in existing diagnostic decision-making conceptual models. The authors used eDelphi methodology, whereby data are collected electronically, to achieve consensus among an expert panel of 18 clinicians, patients, family members, and other participants on a refined ED-based diagnostic decision-making framework that integrates several potential opportunities for communication to enhance diagnostic quality. This study examined the entire diagnostic process in the ED, from prehospital to discharge or transfer to inpatient care, and identified where communication breakdowns could occur. After four iterative rounds of the eDelphi process, including a final validation round by all participants, the project's a priori consensus threshold of 80% agreement was reached. The authors developed a final framework that positions communication more prominently in the diagnostic process in the ED and enhances the original National Academies of Sciences, Engineering, and Medicine (NASEM) and ED-adapted NASEM frameworks. Specific points in the ED journey were identified where more attention to communication might be helpful. Two specific types of communication-information exchange and shared understanding-were identified as high priority for optimal outcomes. Ideas for communication-focused interventions to prevent diagnostic error in the ED fell into three categories: patient-facing, clinician-facing, and system-facing interventions. This project's refinement of the NASEM framework adapted to the ED can be used to develop communications-focused interventions to reduce diagnostic error in this highly complex and error-prone setting.

Fifth National Climate Assessment Reveals Urgent Action Needed to Reduce Greenhouse Gas Emissions

The Fifth National Climate Assessment (NCA5) was released in November 2023 by the U.S. Global Change Research Program. The Assessment evaluates the impacts of a changing climate across 10 US regions and a wide range of biodiversity and other interests, including water, forests and ecosystems, coasts and oceans, agriculture and rural communities, the built environment, energy and transportation, health and air quality, and economic and social systems. The Assessment is the fifth such report released by the US government since 2000, using science‐based data by more than a dozen US agencies and approximately 750 scientists tracking the impacts of climate change, and peer‐reviewed by the National Academies of Sciences, Engineering and Medicine (NASEM).1 The details outlined within the Assessment are not optimistic. In fact, the extensively peer‐reviewed report further quantifies the need to take immediate actions to reduce greenhouse gas (GHG) emissions into the atmosphere. Immediate actions will require both increased mitigation measures to reduce GHG emissions and adaptation measures as we attempt to live with the impacts of a changing climate.

THE MOVING FORWARD NURSING HOME COALITION: A CALL TO ACTION TO SUPPORT NURSING HOME REFORM

Abstract The Moving Forward Nursing Home Quality Coalition advances the goals outlined by the 2022 National Academies of Sciences, Engineering, and Medicine (NASEM) report aimed at improving nursing home (NH) quality. Over two years, Coalition committee members – along with a network of national leaders, nursing home residents, and the general public – will develop, test and promote action plans that will improve the way the United States finances, delivers, and regulates care in Nursing Homes. The Coalition is comprised of a steering committee and working committees that align with and advance the seven NASEM goals including; 1) advancing delivery of person-centered care; 2) ensuring a well-prepared and compensated workforce; 3) increasing financial transparency and accountability; 4) creating a rational and robust financing system; 5) designing more effective and responsive quality assurance; 6) expanding quality measurement and continuous quality improvement; and 7) adopting health information technology. Coalition committees have engaged in three of four phases of their two-year work plan including convening stakeholders to prioritize and develop action plans to test and promote change. Throughout the work, committee collaboration has ensured action plans are refined and expanded in synergistic ways to shape state and national policy. This presentation will provide an overview of the broader Coalition work and give context for the other presentations which provide an example of collaborative work leading to proposed recommendations for critical policy and regulatory change around person-centered care planning.

POLICY SERIES: THE MOVING FORWARD NURSING HOME COALITION: NURSING HOME REFORM AND THE RESIDENTS’ GOALS, PREFERENCES, AND PRIORITIES

Abstract The 2022 National Academies of Sciences, Engineering, and Medicine (NASEM) report called for nursing facilities to provide “care aligned to the individual’s goals and preferences.” Missing has been an efficient process to uncover the individual’s detailed goals, preferences, and priorities (GPPs). GPPs are a care planning process that translates into actionable interventions, supported by quality measurement to determine whether the care provided aligns with those GPPs, and health information technology to collect GPPs efficiently and to determine if the care provided is concordant with the individual’s GPPs. A diverse set of experts representing the Moving Forward Nursing Home Quality Coalition are collaborating to develop an integrated approach to these shortcomings and will discuss these issues in detail including new approaches to the identification and documentation of GPPs for use in a modified care planning process, the status of health information technologies (HIT) processes being developed to support these changes and the development of new quality measures. While the Moving Forward Coalition is focused on nursing facilities, the approaches being developed here to improve care and to standardize the vocabulary for GPPs are applicable to all care settings. Three committees from the Moving Forward Nursing Home Coalition will present work focused on the development of a standardized GPP care planning process to enhance the identification, documentation, communication, and implementation of resident GPPs, the measurement of the care planning process to support process improvement, and the creation of a HIT-enabled process to measure the concordance of care provided with an individual’s GPPs. This is a collaborative symposium between the Aging Workforce, Hospital Elder Life Program, Measurement, Statistics, and Research Design, Systems Research in Long Term-Care, and Technology and Aging Interest Groups.

MEASURING GOALS, PRIORITIES, AND PREFERENCES: REFORM EFFORTS FOR TRANSPARENCY AND EMPOWERMENT

Abstract Longstanding evidence suggests that the goals, preferences, and priorities (GPP) of individual nursing facility residents may not be adequately addressed during episodes of care. Aligning care with residents’ GPP represents an opportunity to improve outcomes and reduce disparities associated with race, ethnicity, gender orientation, and other characteristics of the resident population. The 2022 National Academies of Sciences, Engineering, and Medicine (NASEM) report recommended improvement in quality measures under the domain of resident and family experience, along with reporting of these measures on Care Compare to improve shared decision-making and transparency. The subcommittee on quality improvement and measurement is focused primarily on measures of GPP as a useful addition to CMS’ plans to expand the Quality Reporting Program (QRP) measure set, which was signaled in the recently issued Skilled Nursing Facility Prospective Payment System (SNF PPS) rule. In this presentation, committee members will discuss the identification and testing plan for one or more resident experience of care measures that assess the experience of care specific to processes of care and the resident’s GPP. This presentation will also discuss the development of a care concordant measure, assessing the relationship between the care provided to the resident and the resident GPPs.

Interprofessional diagnostic management teams: a scoping review protocol

BackgroundDiagnostic errors are a major problem in healthcare. In 2015, the report “Improving Diagnosis in Health Care” by the National Academies of Sciences, Engineering, and Medicine (NASEM) stated that it is likely that most people will experience at least one diagnostic error in their lifetime. The report suggests implementing diagnostic management teams, including patients and their relatives, diagnosticians, and healthcare professionals who support the diagnostic process, to limit diagnostic error and improve patient safety. Implementing interprofessional diagnostic management teams (IDMT), however, is not an easy task due to the complexity of the diagnostic processes and the traditional organization of healthcare with divided departments and healthcare professional who operate in different geographic locations. As this topic is still emerging, a scoping review is ideal to determine the scope of the body of literature on IDMT, indicate the volume of literature and studies available and identify any gaps in knowledge. In a long-term perspective, this scoping review will contribute to prevent diagnostic errors and improve patient safety, for adults and children with physical health issues.MethodsWe will conduct this scoping review in accordance with the JBI methodology and report it based on the PRISMA-ScR. We will systematically search six databases (EMBASE, PubMed, CINAHL, Academic Search Premier, SCOPUS and Web of Science) for papers published between 1985 and 2023 that describe the use of interprofessional diagnostic management teams. The participants included will be adults and children seeking diagnostic care for physical health issues. The concept studied will be interprofessional diagnostic management teams, and the context will be the diagnostic process in the healthcare system. Studies examining the diagnostic process in psychiatry, odontology or complementary medicine will be excluded. Data extraction, including key study characteristics and findings, will be done by two reviewers independently. Any disagreement will be resolved by discussion and eventually by including the two remainder reviewers.DiscussionTo our knowledge, this will be the first scoping review regarding IDMT and the derived effects on diagnostic safety and can therefore be a very important contribution to improve patient safety significantly during the diagnostic process.Protocol registrationThe project is registered at Open Science Framework (OSF) with ID: osf.io/kv2n6.

Proposed Priorities for Low-Dose Radiation Research and Their Relevance to the Practice of Radiology.

Because ionizing radiation is widely used in medical imaging and in military, industry, and commercial applications, programmatic management and advancement in knowledge is needed, especially related to the health effects of low-dose radiation. The U.S. Congress in partnership with the U.S. Department of Energy called on the National Academies of Sciences, Engineering, and Medicine (NASEM) to develop a long-term strategic and prioritized agenda for low-dose radiation research. Low doses were defined as dose amounts less than 100 mGy or low-dose rates less than 5 mGy per hour. The 2022 NASEM report was divided into sections detailing the low-dose radiation exposure and health effects, scientific basis for radiation protection, status of low-dose radiation research, a prioritized radiation research agenda, and essential components of a low-dose radiation research program, including resources needed and recommendations for financial recourse. The purpose of this review is to summarize this report and examine the recommendations to assess how these pertain to the practice of radiology and medicine.

Using in silico tools to predict flame retardant metabolites for more informative exposomics-based approaches.

Introduction: The positive identification of xenobiotics and their metabolites in human biosamples is an integral aspect of exposomics research, yet challenges in compound annotation and identification continue to limit the feasibility of comprehensive identification of total chemical exposure. Nonetheless, the adoption of in silico tools such as metabolite prediction software, QSAR-ready structural conversion workflows, and molecular standards databases can aid in identifying novel compounds in untargeted mass spectral investigations, permitting the assessment of a more expansive pool of compounds for human health hazard. This strategy is particularly applicable when it comes to flame retardant chemicals. The population is ubiquitously exposed to flame retardants, and evidence implicates some of these compounds as developmental neurotoxicants, endocrine disruptors, reproductive toxicants, immunotoxicants, and carcinogens. However, many flame retardants are poorly characterized, have not been linked to a definitive mode of toxic action, and are known to share metabolic breakdown products which may themselves harbor toxicity. As U.S. regulatory bodies begin to pursue a subclass- based risk assessment of organohalogen flame retardants, little consideration has been paid to the role of potentially toxic metabolites, or to expanding the identification of parent flame retardants and their metabolic breakdown products in human biosamples to better inform the human health hazards imposed by these compounds. Methods: The purpose of this study is to utilize publicly available in silico tools to 1) characterize the structural and metabolic fates of proposed flame retardant classes, 2) predict first pass metabolites, 3) ascertain whether metabolic products segregate among parent flame retardant classification patterns, and 4) assess the existing coverage in of these compounds in mass spectral database. Results: We found that flame retardant classes as currently defined by the National Academies of Science, Engineering and Medicine (NASEM) are structurally diverse, with highly variable predicted pharmacokinetic properties and metabolic fates among member compounds. The vast majority of flame retardants (96%) and their predicted metabolites (99%) are not present in spectral databases, posing a challenge for identifying these compounds in human biosamples. However, we also demonstrate the utility of publicly available in silico methods in generating a fit for purpose synthetic spectral library for flame retardants and their metabolites that have yet to be identified in human biosamples. Discussion: In conclusion, exposomics studies making use of fit-for-purpose synthetic spectral databases will better resolve internal exposure and windows of vulnerability associated with complex exposures to flame retardant chemicals and perturbed neurodevelopmental, reproductive, and other associated apical human health impacts.

External evaluation of the prediction equation for milk fat yield by the 2021 NASEM dairy model using data from eastern Canadian dairy herds

In 2021, the National Academies of Sciences, Engineering, and Medicine (NASEM) issued an equation to predict milk fat yield using dairy cow characteristics and diet composition as input variables. This model was evaluated externally using a data set composed of 541 feed and production records obtained from 23 eastern Canadian dairy herds. The use of the developed equation requires the prediction of dry matter intake. Cow intake used in the model assessment has been obtained by NASEM equations based on (1) animal factors, or (2) a combination of feed composition and animal factors. The prediction of milk fat yield was shown to be accurate. The best prediction was obtained using intake estimated based solely on animal factors (concordance correlation coefficient = 0.68).

Improving Graduate Medical Education by Aggregating Data Across the Medical Education Continuum.

Meaningful improvements to graduate medical education (GME) have been achieved in recent decades, yet many GME improvement pilots have been small trials without rigorous outcome measures and with limited generalizability. Thus, lack of access to large-scale data is a key barrier to generating empiric evidence to improve GME. In this article, the authors examine the potential of a national GME data infrastructure to improve GME, review the output of 2 national workshops on this topic, and propose a path toward achieving this goal.The authors envision a future where medical education is shaped by evidence from rigorous research powered by comprehensive, multi-institutional data. To achieve this goal, premedical education, undergraduate medical education, GME, and practicing physician data must be collected using a common data dictionary and standards and longitudinally linked using unique individual identifiers. The envisioned data infrastructure could provide a foundation for evidence-based decisions across all aspects of GME and help optimize the education of individual residents.Two workshops hosted by the National Academies of Sciences, Engineering, and Medicine Board on Health Care Services explored the prospect of better using GME data to improve education and its outcomes. There was broad consensus about the potential value of a longitudinal data infrastructure to improve GME. Significant obstacles were also noted.Suggested next steps outlined by the authors include producing a more complete inventory of data already being collected and managed by key medical education leadership organizations, pursuing a grass-roots data sharing pilot among GME-sponsoring institutions, and formulating the technical and governance frameworks needed to aggregate data across organizations.The power and potential of big data is evident across many disciplines, and the authors believe that harnessing the power of big data in GME is the best next step toward advancing evidence-based physician education.

Estimation of Serum PFOA Concentrations from Drinking and Non-Drinking Water Exposures.

Estimation of Serum PFOA Concentrations from Drinking and Non-Drinking Water Exposures.

The NASEM Report: Are the Solutions Part of the Problem?

The NASEM Report: Are the Solutions Part of the Problem?

Looking to the Year Ahead

Already 2023 is looking to be a great year for AMDA – The Society for Post-Acute and Long-Term Care Medicine. Our Annual Conference, PALTC23, held in Tampa, FL, was a huge success. We welcomed over 1,300 people, including 87 Futures Program participants, to learn and celebrate together, fully in-person for the first time since 2019. Some of the highlights of the conference were enjoying a much-needed laugh with our opening keynote speaker, honoring the Foundation’s award recipients and the giving campaign, and celebrating Chris Laxton’s last meeting as our fearless executive director. We also welcomed our incoming Executive Director Michelle Zinnert, CAE. Michelle officially joined the Society on April 24, 2023, and I am excited to work side by side and to learn from one another’s experiences to move our important strategic plan forward. Our Society has now closely aligned our education and clinical affairs teams. I am confident that this change will elevate the ability of our members to make an even bigger impact in PALTC through more integrated educational experiences and clinical products. We will continue to provide our most popular offerings, such as our various podcasts — which recently boasted over 200,000 downloads! A big thank you goes to Wayne Saltsman, MD, PhD, CMD, for starting the AMDA On-The-Go series, which is now being hosted by the multitalented Diane Sanders-Cepeda, DO, CMD. I also want to thank our other hosts, Karl Steinberg, MD, HMDC, CMD, Christian Bergman, MD, CMD, and Alex Bardakh, MPP, CAE, who work hard to bring important clinical information and news in a timely manner. We will continue to explore other andragogical methods to disseminate content, including interactive web-based education. To give all our members and consumers the best experience with our products, our website is undergoing a much-needed redesign this year, which will make it even easier to find information and engage with the Society. Lastly, if you haven’t yet downloaded our app, I encourage you to do so now. The AMDA App offers instant information right at your fingertips to maximize your work in PALTC. You will find links to clinical tools, our publications, AMDA Social, and the Guide to PALTC Coding, among other offerings. On the advocacy front, we continue to engage with key leaders in the Centers for Medicare & Medicaid Services, the Centers for Disease Control and Prevention, and the U.S. Congress to move key policy initiatives forward. For instance, after the release of the National Academies of Science, Engineering, and Medicine (NASEM) report The National Imperative to Improve Nursing Home Quality (National Academies Press, 2022) and the White House Fact Sheet, “Protecting Seniors by Improving Safety and Quality of Care in the Nation’s Nursing Homes” (February 29, 2020, https://bit.ly/40DPAbM), the Moving Forward Coalition was formed to bring diverse stakeholder input to policy and practice. The Society has participated as a key stakeholder since its inception, with Chris Laxton as our representative. With Chris Laxton’s retirement, I have been appointed as the Society’s official representative on the Moving Forward Coalition’s steering committee. I am looking forward to representing the voice of our Society’s clinical leaders to improve the quality of life and care delivery of our patients and residents. This is only one of the many ways we are working together with partner organizations to meet our Society’s vision and mission. People have been asking me what things I personally hope to accomplish this year. First and foremost, I want to ensure that we have a smooth executive director transition. A new face brings renewed energy and excitement about the work we are doing, but the change includes many logistical challenges that take time and energy. Second, I want to ensure that all our committees have clear direction and strong support to formulate and complete their 2023–2024 work plans. Third, I plan to strengthen and enrich our new and long-standing external stakeholder relationships. We do not practice PALTC medicine in a vacuum — engaging with other medical and health care societies, government entities, and newly formed coalitions such as Moving Forward and Be Well in AL (assisted living) is critical to moving us closer toward completing our mission. I want to close with another expression of gratitude for everyone who has and continues to contribute to the Society’s wonderful work. I serve you all as your official representative, and I am proud to be part of this amazing organization. Dr. Little is an associate professor of geriatric medicine at Duke University. Her scholarly interests include interprofessional health education, deprescribing, and nonpharmacologic management of dementia.

Assisted Living: New Initiatives, Brighter Future

Assisted Living: New Initiatives, Brighter Future

Part I: Interactive case: Menopause

Part I: Interactive case: Menopause

Conflict in the EMS Workforce: An Analysis of an Open-Ended Survey Question Reveals a Complex Assemblage of Stress, Burnout, and Pandemic-Related Factors Influencing Well-Being.

Emergency Medical Services (EMS) clinicians provide patient care within a high-stakes, unpredictable, and complex work environment in which conflict is inevitable. Our objective was to explore the extent to which added stressors of the pandemic exacerbated EMS workplace conflict. We administered our survey to a sample of U.S. nationally certified EMS clinicians during the COVID-19 pandemic in April 2022. Out of 1881 respondents, 46% (n = 857) experienced conflict and 79% (n = 674) provided free-text descriptions of their experience. The responses were analyzed for themes using qualitative content analysis, and they were then sorted into codes using word unit sets. Code counts, frequencies, and rankings were tabulated, enabling quantitative comparisons of the codes. Of the fifteen codes to emerge, stress (a precursor of burnout) and burnout-related fatigue were the key factors contributing to EMS workplace conflict. We mapped our codes to a conceptual model guided by the National Academies of Sciences, Engineering, and Medicine (NASEM) report on using a systems approach to address clinician burnout and professional well-being to explore implications for addressing conflict within that framework. Factors attributed to conflict mapped to all levels of the NASEM model, lending empirical legitimacy to a broad systems approach to fostering worker well-being. Our findings lead us to propose that active surveillance (enhanced management information and feedback systems) of frontline clinicians' experiences during public health emergencies could increase the effectiveness of regulations and policies across the healthcare system. Ideally, the contributions of the occupational health discipline would become a mainstay of a sustained response to promote ongoing worker well-being. The maintenance of a robust EMS workforce, and by extension the health professionals in its operational sphere, is unquestionably essential to our preparedness for the likelihood that pandemic threats may become more commonplace.

A Comprehensive Evaluation of Data Quality in Nutrient Databases.

Nutrient databases are a critical component of nutrition science and the basis of exciting new research in precision nutrition (PN). To identify the most critical components needed for improvement of nutrient databases, food composition data were analyzed for quality, with completeness being the most important measure, and for FAIRness, how well the data conformed with the data science criteria of findable, accessible, interoperable, and reusable (FAIR). Databases were judged complete if they provided data for all 15 nutrition fact panel (NFP) nutrient measures and all 40 National Academies of Sciences, Engineering, and Medicine (NASEM) essential nutrient measures for each food listed. Using the gold standard the USDA standard reference (SR) Legacy database as surrogate, it was found that SR Legacy data were not complete for either NFP or NASEM nutrient measures. In addition, phytonutrient measures in the 4 USDA Special Interest Databases were incomplete. To evaluate data FAIRness, a set of 175 food and nutrient data sources were collected from worldwide. Many opportunities were identified for improving data FAIRness, including creating persistent URLs, prioritizing usable data storage formats, providing Globally Unique Identifiers for all foods and nutrients, and implementing citation standards. This review demonstrates that despite important contributions from the USDA and others, food and nutrient databases in their current forms do not yet provide truly comprehensive food composition data. We propose that to enhance the quality and usage of food and nutrient composition data for research scientists and those fashioning various PN tools, the field of nutrition science must step out of its historical comfort zone and improve the foundational nutrient databases used in research by incorporating data science principles, the most central being data quality and data FAIRness.