National Academy Of Medicine Research Articles

Systematic Review of Evidence-Based Guidelines for Prehospital Care

Introduction: Multiple national organizations have identified a need to incorporate more evidence-based medicine in emergency medical services (EMS) through the creation of evidence-based guidelines (EBGs). Tools like the Appraisal of Guidelines for Research and Evaluation (AGREE) II and criteria outlined by the National Academy of Medicine (NAM) have established concrete recommendations for the development of high-quality guidelines. While many guidelines have been created that address topics within EMS medicine, neither the quantity nor quality of prehospital EBGs have been previously reported. Objectives: To perform a systematic review to identify existing EBGs related to prehospital care and evaluate the quality of these guidelines using the AGREE II tool and criteria for clinical guidelines described by the NAM. Methods: We performed a systematic search of the literature in MEDLINE, EMBASE, PubMED, Trip, and guidelines.gov, through September 2018. Guideline topics were categorized based on the 2019 Core Content of EMS Medicine. Two independent reviewers screened titles for relevance and then abstracts for essential guideline features. Included guidelines were appraised with the AGREE II tool across 6 domains by 3 independent reviewers and scores averaged. Two additional reviewers determined if each guideline reported the key elements of clinical practice guidelines recommended by the NAM via consensus. Results: We identified 71 guidelines, of which 89% addressed clinical aspects of EMS medicine. Only 9 guidelines scored >75% across AGREE II domains and most (63%) scored between 50 and 75%. Domain 4 (Clarity of Presentation) had the highest (79.7%) and domain 5 (Applicability) had the lowest average score across EMS guidelines. Only 38% of EMS guidelines included a reporting of all criteria identified by the NAM for clinical practice guidelines, with elements of a systematic review of the literature most commonly missing. Conclusions: EBGs exist addressing a variety of topics in EMS medicine. This systematic review and appraisal of EMS guidelines identified a wide range in the quality of these guidelines and variable reporting of key elements of clinical guidelines. Future guideline developers should consider established methodological and reporting recommendations to improve the quality of EMS guidelines.

Endocrinologist Burnout: We Need to Tackle It and Bring Joy to Work

Physician burnout is a national problem that has gained increasing attention among the medical community. Many organizations like the American Medical Association, American College of Physicians, and the National Academy of Medicine are taking action. Endocrinologists and other members of the endocrine community are not immune to burnout. Approximately 47% of endocrinologists report feeling burnt out or have experienced symptoms of burnout, and this number is rising. The consequences of burnout include personal factors such as stress, depression, and risk of suicide as well as organizational impacts like decreased quality of care, increased clinical errors, reduced empathy for patients, decreased patient satisfaction, and higher turnover rates, with some physicians leaving practice altogether. Burnout has substantial economic impacts at an organizational level, and high costs are associated with replacing, recruiting, and retraining endocrinologists. Endocrinologists identified feeling a lack of respect from administration, excessive bureaucratic tasks, increased computerization, emphasis on profit that has contributed to loss of control over schedules, and insufficient compensation as top contributors to burnout. One strategy to address burnout is to focus on the promotion of joy in work. Joy in work is guided by 4 key themes: meaning, camaraderie, choice, and equity. Each of these themes can be implemented through cocreating solutions. We discuss how each theme can be addressed among endocrine practices. Ultimately, initiatives need to be implemented across the endocrinology community to cultivate joy and reduce burnout.

“We’re Not Ready, But I Don’t Think You’re Ever Ready.” Clinician Perspectives on Implementation of Crisis Standards of Care

Background: The COVID-19 pandemic has highlighted health care systems’ vulnerabilities. Hospitals face increasing risk of periods of scarcity of life-sustaining resources such as ventilators for mechanical respiratory support, as has been the case in Italy as of March, 2020. The National Academy of Medicine has provided guidance on crisis standards of care, which call for the reallocation of scarce medical resources to those who will benefit most during extreme situations. Given that this will require a departure from the usual fiduciary duty of the bedside clinician, we determined and mapped potential barriers to the implementation of the guidelines from stakeholders using an implementation science framework. Methods: A protocol was created to operationalize national and state guidelines for triaging ventilators during crisis conditions. Focus groups and key informant interviews were conducted from July-September 2018 with clinicians at three acute care hospitals of an urban academic medical center. Respiratory therapists, intensivists, nursing leadership and the palliative care interdisciplinary team participated in focus groups. Key informant interviews were conducted with emergency management, respiratory therapy and emergency medicine. Subjects were presented the protocol and their reflections were elicited using a semi-structured interview guide. Data from transcripts and notes were categorized using a coding strategy based on the Theoretical Domains Framework. Results: Participants anticipated that implementing this protocol would challenge their roles and identities as clinicians including both their fiduciary duty to the patient and their decision-making autonomy. Despite this, many participants acknowledged the need for such a protocol to standardize care and minimize bias as well as to mitigate potential consequences for individual clinicians. Participants identified the question of considering patient quality of life in triage decisions as an important and unresolved ethical issue in disaster triage. Conclusion: Clinicians’ discomfort with shifting roles and obligations could pose implementation barriers for crisis standards of care.

Vital Directions for Health & Health Care: The North Carolina Experience.

In 2019, the National Academy of Medicine (NAM) turned to the all-important state level to draw insights on the status of health and health care within the context of the NAM Vital Directions for Health and Health Care initiative. The NAM held a two-day symposium in the Research Triangle to bring together various stakeholders to better understand actions that states and localities are taking to achieve-and the barriers they face in pursuing-more affordable, value-driven quality care and health outcomes. The NAM purposefully chose to pivot to the state level with North Carolina given that it has been at the forefront of health care transformation and illustrates the promise but also the challenges facing US health and health care nationally. A 19-member planning committee, cochaired by NAM President Victor Dzau and Secretary Mandy Cohen of the North Carolina Department of Health and Human Services, selected topics that resonate with the state's activities within the context of the Vital Directions framework, ranging from empowering people and connecting care through the integration of social, physical, and behavioral health to payer alignment though the advancement of new payment models (Figure 1). The priorities discussed during the symposium continue to be central to health reform in North Carolina and are further explored in the commentaries in this issue.

Disability Rights as a Necessary Framework for Crisis Standards of Care and the Future of Health Care

In this essay, we suggest practical ways to shift the framing of crisis standards of care toward disability justice. We elaborate on the vision statement provided in the 2010 Institute of Medicine (National Academy of Medicine) "Summary of Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations," which emphasizes fairness; equitable processes; community and provider engagement, education, and communication; and the rule of law. We argue that interpreting these elements through disability justice entails a commitment to both distributive and recognitive justice. The disability rights movement's demand "Nothing about us, without us" requires substantive inclusion of disabled people in decision-making related to their interests, including in crisis planning before, during, and after a pandemic like Covid-19.

AGA Rapid Recommendations for Gastrointestinal Procedures During the COVID-19 Pandemic

Abbreviations used in this paper AGAAmerican Gastroenterological AssociationCDCCenters for Disease Control and PreventionCIconfidence intervalCOVID-19coronavirus disease 2019GIgastrointestinalGRADEGrading of Recommendations Assessment, Development and EvaluationMERS-CoVMiddle East respiratory syndrome–related coronavirusORodds ratioPAPRpowered air-purifying respiratorPPEpersonal protective equipmentRRrisk ratioSARS-CoV-2severe acute respiratory syndrome coronavirus 2WHOWorld Health Organization

In memory of Bruce McEwen: a gentle giant of neuroscience

On 2 January 2020, the neuroscience community lost not only a pioneering figure, but also a generous and influential thought leader. Bruce Sherman McEwen, head of the Harold and Margaret Milliken Hatch Laboratory of Neuroendocrinology at the Rockefeller University, passed away at age 81, following a short illness. A member of the National Academy of Sciences, National Academy of Medicine and American Academy of Arts & Sciences, and former president of the Society for Neuroscience, Bruce will be remembered for his profound scientific impact, measured not only by output of papers, but also by the large family of neuroscientists he trained over a career spanning nearly six decades. Above all, Bruce will be remembered for his generosity, kindness, gentleness of soul, and for being an extraordinary mentor.

Report advises system-level approach to clinician burnout.

Healthcare organizations must adopt a system-level approach to creating positive work and learning environments to reduce the risk of burnout among clinical staff, according to a report released in October by the National Academy of Medicine (NAM). “Our nation is facing an epidemic of clinician burnout,” NAM President Victor Dzau said during the unveiling of the consensus report Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Despite the urgency of the problem, he said “the public remains largely unaware of it.” The consensus report, produced through the work of NAM’s Action Collaborative on Clinician Well-Being and Resilience—of which ASHP is a sponsoring member—includes 6 system-level goals and several recommendations to help healthcare organizations achieve the goals. The first goal calls for transforming healthcare workplaces through initiatives that support positive work environments and foster well-being. Recommendations associated with the goal urge organizational leaders to incorporate values such as “respect, justice, ethical practice, compassion, and diversity” into interventions that address burnout and to use validated tools to monitor burnout.

Late-Life Depression: A Narrative Review on Risk Factors and Prevention.

After participating in this activity, learners should be better able to:• Identify risk factors for late-life depression• Evaluate strategies to prevent late-life depression ABSTRACT: Late-life depression (LLD) is one of the major sources of morbidity and mortality in the world. Because LLD is related to increased public health burden, excess health care costs and utilization, reduced quality of life, and increased mortality, prevention is a priority. Older adults differ from younger adults with respect to key features, such as their chronicity and lifetime burden of depression and their constellation of comorbidities and risk factors. LLD likely arises from a complex interplay of risk factors, including medical, physiologic, psychosocial, behavioral, and environmental factors. Thus, a comprehensive understanding of LLD risk factors is necessary to inform prevention strategies. In this narrative literature review, we address both the risk architecture of LLD and several potential strategies for prevention. Our description of LLD risk factors and prevention approaches is informed by the framework developed by the National Academy of Medicine (formerly, Institute of Medicine), which includes indicated, selective, and universal approaches to prevention.

Commemorating Frances Arnold

Frances H. Arnold is the Linus Pauling Professor of Chemical Engineering, Bioengineering, and Biochemistry at the California Institute of Technology, and Director of Caltech’s Rosen Bioengineering Center. Anyone reading this Retrospective probably knows that Frances was awarded the Nobel Prize in Chemistry in 2018 for the directed evolution of enzymes. She is also only the fifth woman to ever win this prize, and the First American woman to win it. The list of Frances’ prior honors and awards is extensive and astounding, and includes elections to the National Academy of Engineering (2000), the National Academy of Medicine (2004), and the National Academy of Sciences (2008) (the first woman to be elected to all three), the 2011 NAE Draper Prize (the first woman to receive it), and the 2016 Millennium Technology Prize (first woman to win). At the time of this writing, Google Scholar reports her co-authored publications receiving over 50,000 citations, with an h-index of 122. She is co-founder of Gevo, Inc. (producing carbon-neutral biofuels) and Provivi (producing environmentally safe biopesticides), and was recently appointed to the board of directors for Alphabet, Inc. (the parent company of Google).

Ignacio Chávez Rivera. A paradigm in Medicine.

This article summarizes the life of Ignacio Chávez Rivera, one of the six most valuable directors that the National Institute of Cardiology has had “Ignacio Chávez Sánchez,” founder of the same and father of the aforementioned. His time in life left a clear example to emulate both in the scientific, academic and teaching as well as in the human, family, social and friendly, which make him in the most outstanding student of Master Chávez. His time in life at the National Academy of Medicine, the National Autonomous University of Mexico, the Interamerican Society of Cardiology, the Mexican Society of Cardiology and the Institute itself, has left an indelible mark on these Institutions. The National Institute of Cardiology bows reverently to the figure of Ignacio Chávez Rivera.

In Memoriam: James T. Willerson, MD (1939-2020).

In Memoriam: James T. Willerson, MD (1939-2020).

Survivorship objectives in comprehensive cancer control plans: a systematic review.

Over a decade ago, the National Academy of Medicine (NAM) recommended that states develop, implement, and evaluate plans that include consideration of survivorship care. The purpose of this study was to review comprehensive cancer control plans in the USA, specifically to identify the inclusion of cancer survivorship-focused goals and objectives and examine alignment of survivorship-focused objectives with the NAM recommendations. Plans from 50 states, 7 territories, 5 tribal organizations, and the District of Columbia were reviewed to assess inclusion of survivorship goals and objectives. One territory plan was excluded because it did not include a survivorship-focused goal or objective (final n = 62). Objectives were assigned to domains based on NAM survivorship recommendations. Plans included between 1 and 19 survivorship-related objectives. Of the 345 survivorship objectives extracted and analyzed, the most prevalent domains addressed were raising awareness, survivorship care plans, healthcare professional capacity, and models of coordinated care. Employment-related concerns, developing and implementing quality measures, and investments in research were not frequently included in objectives. Comprehensive cancer control plans represent an important strategy that may reduce the impact of cancer and its treatment. State, territorial, and tribal coalitions can use these results to systematically focus future survivorship efforts on areas relevant to their region and population. The growing number of survivors requires broad-ranging policy strategies. Future efforts are needed to assess the implementation and impact of plan strategies to improve the overall wellness of cancer survivors.

Future of Nursing 2020-2030 Philadelphia Town Hall: Lessons Shared From a Relentless School Nurse.

The Robert Wood Johnson Foundation in partnership with the National Academy of Medicine held Town Meeting discussions the summer of 2019 at three sites across the country on the Future of Nursing 2030. Included in the testimony were both invited presentation and public testimony. This article is the transcript of the invited testimony of Robin Cogan, a school nurse who has established a voice for advocacy and the creator of the blog titled The Relentless School Nurse and is one of four presentations featured in this issue of the NASN School Nurse. In her January 2020 letter, NASN's President Laurie Combe discussed the Future of Nursing 2030 and the importance of school nurse advocacy.

The Impact of Covid-19 on the Mental Health of Health Care Providers

Isabelle Davis, dean of the School of Nursing at Mountain View University, must develop a plan to support the mental health and well-being of the clinical workforce. She has spent the last three years working with the National Academy of Medicine on clinician well-being and burnout, and now the COVID-19 pandemic is adding a new stressor to the lives of clinicians, including doctors and nurses. Ensuring that clinicians would seek the support and care they needed could be elusive and was often fraught with stigma, especially if the care was psychiatric and even when the help was confidential. Left untreated, severe stress, emotional, and behavioral health issues affecting clinicians led to burnout, which could have very serious consequences on both patients and clinicians. This case, which has been taught successfully online at Darden, addresses financial issues caused by the pandemic, cultural stigma around mental health, and performance indicators to monitor to evaluate mental health care in the health system. Excerpt UVA-E-0457 Rev. Jan. 26, 2021 The Impact of COVID on the Mental Health of Health Care Providers Introduction Isabelle Davis sat at her desk in June of 2020 and reflected on a critical issue: the mental health and well-being of the clinical workforce at Mountain View University (MVU) Health. Since becoming the dean of the School of Nursing at MVU Health in the fall of 2019, she had been trying to get her arms around efforts to support clinician well-being at MVU. Davis had spent the last three years working on a focus group at the National Academy of Medicine on clinician well-being and burnout, and she was a member of its task force dedicated to this issue. The COVID-19 pandemic added a new stressor to the lives of clinicians, including doctors and nurses, so Davis had been charged by MVU Health leadership to develop a plan for the health system. Background . . .

LA PAZ DECLARATION 2018 ON PERSON-CENTERED PRIMARY CARE: POPULAR AND SCIENTIFIC KNOWLEDGE, ECOLOGY, AND COMMUNITY PARTICIPATION

Resulting from the Fourth Latin American Conference of Person-Centered Medicine held in La Paz, Bolivia on September 7 and 8, 2018, organized by the Latin American Network of Person-Centered Medicine and the National Academy of Medicine of Bolivia under the auspices of the Latin American Association of National Academies of Medicine, the Peruvian Association of Person-Centered Medicine, the Representation in Bolivia of the Pan American Health Organization/WHO, the University of San Andrés (Bolivia), the Franz Tamayo University (Bolivia), San Marcos National University (Peru), and the International College of Person Centered Medicine.

We are living in the geologic age when human activities have dramatically affected our planet and its environment.

Dr Barry is incoming Board Chair of the Consortium of Universities for Global Health (CUGH) and past President of the American Society of Tropical Medicine and Hygiene. She is a member of the National Academies of Sciences, Engi-neering, and Medicine, and serves on the National Academy of Medicine's Board of Global Health. She has received the Elizabeth Blackwell Medal for outstand-ing contributions to women in the fi eld of medicine, and is founder of WomenLift Health, a global initiative to transform global health outcomes by unleashing and elevating talented mid-career women to become global health leaders.

Reappraisal of Gestational Weight Gain Recommendations in Obese Pregnant Women: A Population-Based Study of 337,590 Births

Background and Objective: Maternal obesity is an epidemic health problem that is aggravated by excessive gestational weight gain (GWG) and postpartum weight retention. Current US Institute of Medicine (now US National Academy of Medicine) guidelines (2009) for GWG need to be evaluated against the current rise in obesity in the general and pregnant population. We wanted to study the relation between GWG and pregnancy and birth outcomes and to relate this to the current recommendations for GWG. Methods: Population-based study. We performed an epidemiological analysis in a cohort of Belgian pregnant women with singleton live births at term (≥37 weeks) between 2009 and 2014 (n = 337,590). Logistic regression was used to determine the optimal GWG in relation to relevant pregnancy and birth outcomes. Results: The prevalence of maternal obesity significantly increased from 10.3% in 2009 to 11.4% in 2014. The mean (SD) body mass index at the start of the pregnancy significantly increased from 23.9 (4.5) in 2009 to 24.2 (4.6) in 2014. Excessive GWG was frequent, especially in overweight (56.8%) and obese (52.9%) pregnant women. In the logistic regression model, the amount of GWG associated with the lowest incidence of both large-for-gestational-age and small-for-gestational-age infants was 21 kg in underweight women, 14 kg in normal weight, 8 kg in overweight, 0 kg in obese class I, –4 kg in obese class II and –5 kg in obese class III. Conclusion: The prevalence of maternal obesity has risen in Belgium between 2009 and 2014. Current GWG guidelines, based on historic observational data, are probably too liberal for class II and III obese women in which better outcomes are being predicted for lower weight gain than recommended.

The Family Tree Grows Tall: A Salute to Family Physicians Inducted Into the National Academy of Medicine

The Family Tree Grows Tall: A Salute to Family Physicians Inducted Into the National Academy of Medicine

EHR audit logs: A new goldmine for health services research?

A byproduct of the transition to electronic health records (EHRs) is the associated observational data that capture EHR users' granular interactions with the medical record. Often referred to as audit log data or event log data, these datasets capture and timestamp user activity while they are logged in to the EHR. These data - alone and in combination with other datasets - offer a new source of insights, which cannot be gleaned from claims data or clinical data, to support health services research and those studying healthcare processes and outcomes. In this commentary, we seek to promote broader awareness of EHR audit log data and to stimulate their use in many contexts. We do so by describing EHR audit log data and offering a framework for their potential uses in quality domains (as defined by the National Academy of Medicine). The framework is illustrated with select examples in the safety and efficiency domains, along with their accompanying methodologies, which serve as a proof of concept. This article also discusses insights and challenges from working with EHR audit log data. Ensuring that researchers are aware of such data, and the new opportunities they offer, is one way to assure that our healthcare system benefits from the digital revolution.