National Academy Of Medicine Research Articles

Programmed Death Ligand-1 and Tumor Mutation Burden Testing of Patients With Lung Cancer for Selection of Immune Checkpoint Inhibitor Therapies: Guideline From the College of American Pathologists, Association for Molecular Pathology, International Association for the Study of Lung Cancer, Pulmonary Pathology Society, and LUNGevity Foundation.

Rapid advancements in the understanding and manipulation of tumor-immune interactions have led to the approval of immune therapies for patients with non-small cell lung cancer. Certain immune checkpoint inhibitor therapies require the use of companion diagnostics, but methodologic variability has led to uncertainty around test selection and implementation in practice. To develop evidence-based guideline recommendations for the testing of immunotherapy/immunomodulatory biomarkers, including programmed death ligand-1 (PD-L1) and tumor mutation burden (TMB), in patients with lung cancer. The College of American Pathologists convened a panel of experts in non-small cell lung cancer and biomarker testing to develop evidence-based recommendations in accordance with the standards for trustworthy clinical practice guidelines established by the National Academy of Medicine. A systematic literature review was conducted to address 8 key questions. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach, recommendations were created from the available evidence, certainty of that evidence, and key judgments as defined in the GRADE Evidence to Decision framework. Six recommendation statements were developed. This guideline summarizes the current understanding and hurdles associated with the use of PD-L1 expression and TMB testing for immune checkpoint inhibitor therapy selection in patients with advanced non-small cell lung cancer and presents evidence-based recommendations for PD-L1 and TMB testing in the clinical setting.

An Overview of the Methodology Used to Develop Clinical Practice Guidelines for the Management of Acute and Intraoperative Spinal Cord Injury.

An overview of the methods used to develop clinical practice guidelines (CPGs). Acute spinal cord injury (SCI) and intraoperative SCI (ISCI) can have devastating physical and psychological consequences for patients and their families. To date, there are several studies that have discussed the diagnostic and management strategies for both SCI and ISCI. CPGs in SCI help to distill and translate the current evidence into actionable recommendations, standardize care across centers, optimize patient outcomes, and reduce costs and unnecessary interventions. Furthermore, they can be used by patients to assist in making decisions about certain treatments and by policy makers to inform allocation of resources. The objective of this article is to summarize the methods used to develop CPGs for the timing of surgery and hemodynamic management of acute SCI, as well as the identification and treatment of ISCI. The CPGs were developed using standards established by the Institute of Medicine (now the National Academy of Medicine), the Guideline International Network and several other organizations. Systematic reviews were conducted according to accepted methodological standards (eg, Institute of Medicine, Agency for Healthcare Research and Quality and Patient-Centered Outcomes Research Institute) in order to summarize the current body of evidence and inform the guideline development process. Protocols for each guideline were created. A multidisciplinary guideline development group (GDG) was formed that included individuals living with SCI as well as clinicians from the broad range of specialties that encounter patients with SCI: spine or trauma surgeons, critical care physicians, rehabilitation specialists, neurologists, anesthesiologists and other healthcare professionals. Individuals living with SCI were also included in the GDG. The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used to rate the certainty of the evidence for each critical outcome. The "evidence to recommendation" framework was then used to translate the evidence obtained from the systematic review to an actionable recommendation. This framework provides structure when assessing the body of evidence and considers several additional factors when rating the strength of the recommendation, including the magnitude of benefits and harms, patient preferences, resource use, health equities, acceptability and feasibility. Finally, the CPGs were appraised both internally and externally. The results of the CPGs for SCI are provided in separate articles in this focus issue. Development of these CPGs for SCI followed the methodology proposed by the Institute of Medicine the Guideline International Network and the GRADE Working Group. It is anticipated that these CPGs will assist clinicians implement the best evidence into practice and facilitate shared-decision making with patients.

Writing for Personal and Professional Wellness.

Writing is a part of every academic career in medicine, yet many busy clinicians have difficulty finding time to write and may see it as extra work during their time off. This professional development perspective offers a reframing of writing, not as extra work, but as a wellness activity. The National Academy of Medicine's (NAM) National Plan for Health Workforce Well-being identified seven priority areas where action should be taken to increase wellness in the workforce. Professional writing can "support mental health and reduce stigma" (an explicit NAM priority area) by allowing workers to express gratitude, practice reflection, and write without a deadline. Writing also addresses the NAM priority area of "create and sustain positive work and learning environments and culture" by giving opportunities to support your colleagues, invest in your team, celebrate success, find satisfaction in the sciences, and seek and find healing. By intentionally writing to process emotion and manage work stress, we shift the paradigm for busy clinicians to improve their well-being while simultaneously contributing to academic success.

Multi-professional perspectives to reduce moral distress: A qualitative investigation.

Encounters of moral distress have long-term consequences on healthcare workers' physical and mental health, leading to job dissatisfaction, reduced patient care, and high levels of burnout, exhaustion, and intentions to quit. Yet, research on approaches to ameliorate moral distress across the health workforce is limited. The aim of our study was to qualitatively explore multi-professional perspectives of healthcare social workers, chaplains, and patient liaisons on ways to reduce moral distress and heighten well-being at a southern U.S. academic medical center. Purposive sampling and chain-referral methods assisted with recruitment through hospital listservs, staff meetings, and newsletters. Interested participants contacted the principal investigator and all interviews were conducted in-person. Consent was attained prior to interviews. All interviews were recorded and transcribed verbatim. Directed content analysis was used to deductively organize codes and to develop themes in conjunction with the National Academy of Medicine's National Plan for Health Workforce Well-Being. Rigor was attained through peer-debriefing, data triangulation methods, and frequent research team meetings. Ethics approval was obtained from the university and medical center institutional review boards. Themes demonstrate that rather than offering interventions in the aftermath of moral distress, multilevel daily practices ought to be considered that pre-emptively identify and reduce morally distressing encounters through (1) the care team, (2) management and leadership, and (3) the health care industry. Strategies include interdisciplinary decision-making, trusting managerial relationships, and organizational policies and practices that explicitly invest in mental health promotion and diverse leadership opportunities. Moral distress interventions ought to target short-term stress reactions while also addressing the long-term impacts of moral residue. Health systems must financially commit to an ethical workplace culture that explicitly values mental health and well-being.

Processes and the Electronic Health Record: Challenges and Difficulties Faced when Creating an OB Quality Dashboard.

Healthcare quality as defined by the National Academy of Medicine is "the degree to which health care services for individuals and populations increase the likelihood of desired health outcomes [1]". While building QI dashboard data quality to improve the maternal health of our patient population issues were discovered that hindered that the progress of the project. This paper will discuss the challenges and difficulties faced while creating an OB quality dashboard at a regional perinatal.

Identifying High-Cost, High-Need Patients in a Network of Community Hospitals.

We examined healthcare costs at HonorHealth, a community-based academic health center comprised of 5 hospitals and numerous ambulatory care facilities. Patient encounters that resulted in admission in 2019 were included in the study. Mean costs in 2019 for high costs and high needs (HCHN) patients were compared with all remaining patients using a framework developed by the National Academy of Medicine. HCHN patients were older (71 vs 52 years), with a lower percentage of females (41.7% vs 59.8%), more frequently White (90.1% vs 87.5%), less frequently married (52.4% vs 54.5%), with a longer length of stay (6.5 vs 3.0 days) and higher mean charges ($134 743 vs $16 414). The mean cost per patient in the HCHN group decreased by age group ($192, 963, $165 200, $144 584, $134 795, and $108 356) for 0 to 18, 19 to 44, 45 to 64, 65 to 84, and 85+ years, respectively. HCHN patients were more publicly insured (49% vs 38%). Targeted interventions to treat HCHN may lead to lower healthcare costs and improved health outcomes within this system.

Critical Appraisal of Content Quality of YouTube Videos on the Whipple Pancreaticoduodenectomy

IntroductionThe coronavirus pandemic has demonstrated profound issues with using the Internet to research health information. For patients recommended a complex operation, such as the Whipple pancreaticoduodenectomy, the quality of health information online has not been appraised. The objective of this study was to define the readability and content quality of YouTube search results for the Whipple pancreaticoduodenectomy. MethodsThe first 100 search results for “whipple procedure” less than 10 min long in English with audio and or text were transcribed. The Flesch-Kincaid Grade defined the reading grade level. High content quality videos were accredited by YouTube in accordance with principles specified by the National Academy of Medicine or mentioned the standard components for a surgical consent. The Anderson-Lau score is a composite of these consent criteria out of a maximum of 8/8. The simplicity of videos for patient education was defined by the DISCERN tool. ResultsThe reading level of 23% of the top 100 search results met the American average (8th grade). Accreditation was present for 45% and associated with an earlier median search ranking (36 versus 68, P = 0.002) and more 5th-8th grade level material (70% versus 38%, P = 0.014). The median Anderson-Lau score was 3/8 (range = 0/8-7/8) with only 5% achieving 7/8. Only 4% were high quality per DISCERN. ConclusionsAlthough accredited videos were more readable, most videos, especially those targeting patients, were beyond the comprehension of the average American. Simpler and higher quality educational materials are needed to inform patients on Whipple pancreaticoduodenectomy beyond their date of clinical diagnosis or surgical consenting.

OTC SENIOR STATION: CONSUMER-FACING TECHNOLOGY TO PROMOTE MEDICATION SAFETY

Abstract Over-the-counter (OTC) medications with anticholinergic effects (e.g. doxylamine, diphenhydramine) are widely used by older adults, despite their association with an increased risk of Alzheimer’s disease and related dementias (ADRD). Authoritative bodies, such as the American Geriatrics Society and National Academy of Medicine, recommend discouraging the use of both prescription and OTC anticholinergics. However, most interventions previously developed and tested have targeted only prescription anticholinergics despite the use rate of OTC anticholinergics being higher in older adult populations. Consumer-facing technology may be ideal for addressing OTC anticholinergic use as it is cost effective, scalable, and can address the constraints of relying on busy pharmacists to intervene during older adult OTC medication purchases; this has become especially relevant as pharmacies face staffing shortages, increasing pharmacist workload and requiring pharmacies adjust their hours of operation. Our interdisciplinary team of pharmacists, engineers, and designers engaged both older adults and pharmacy staff in the co-design of “OTC Senior Station”: a user-centered, consumer-facing kiosk to be placed in community pharmacies to promote reduced anticholinergic use by older adults. Kiosk users are prompted to input brief information, which is used to present safer alternatives to OTC anticholinergics (e.g., for insomnia management). This poster will present OTC Senior Station--what we believe to be the first consumer-facing technology to target OTC anticholinergic use—the participatory design methods used to create it, and the results of studies to assess its usability with older adults.

Servant-Leadership in Nursing Education

Recent changes in healthcare policy including the sentinel paper from the Institutes of Medicine, now known as the National Academy of Medicine, 2010 report, The Future of Nursing: Leading Change, Advancing Health and the most recent, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity reports have demonstrated the changing role of nurses creating a growing need for nurse leaders. The healthcare industry is seeking to find a leadership style that will facilitate the goals of providing quality care in a collaborative environment. With its natural focus on service, the style of the servant-leader is one option. A literature critique of servant-leadership, nursing and nursing education revealed a lack of research in this area. The authors wrote this article to elucidate existing literature on the topic and discus why further research into the need to incorporate servant-leadership into nursing education is important to facilitate the advancement of the profession.

Nothing About Patients Without Patients: More Than Just a Catchphrase!

Health care is sometimes called a "team sport," yet patients were traditionally not considered to be "on the team" in medicine. In 2001, the Institute of Medicine (now National Academy of Medicine) published its seminal book Crossing the Quality Chasm, in which patient-centered care was identified as 1 of 6 quality aims. Many organizations have since included patient-centered care as an important aspect of quality, including The Joint Commission, Centers for Medicare and Medicaid, and many large employers. In the past 10 years, the focus on patient-centered care has expanded in the Kaiser Permanente, Southern California region to include innovative ways for patients to collaborate with health care teams to codesign improvement efforts that are truly patient-centered. We will describe 3 important approaches that have greatly increased the patient-centeredness of our organization: individual patient approaches; adding patients onto health care teams; and effectively utilizing patient and family advisory councils. We will provide examples of how all health care organizations can better partner with their patients to improve their ability to provide higher quality, safer, more equitable, and affordable health care. The slogan "Nothing About Patients Without Patients" was an early rallying cry of the patient engagement movement. It conveyed the idea that as with everything else in our society, patients now expect to have a say in the design and implementation of their care. We show that this is not only possible, but also highly effective and even necessary to improving care.

Could the National Academy of Medicine’s National Plan for Health Workforce Well-Being work as a framework to improve the well-being of our US clinical veterinary healthcare teams?

Abstract The authors propose using the National Academy of Medicine’s (NAM) National Plan for Health Workforce Well-Being as a framework on which the veterinary profession can re-envision patients and clients being cared for by a veterinary workforce that is thriving, where professionals operate in an environment that fosters their occupational well-being and longevity, strives to improve animal and population health, expands and enhances the care experience, and advances animal health equity. Adapting the NAM’s National Plan is intended to inspire collective action to improve the well-being of all veterinary professionals and focuses on changes needed across the profession at the organizational and systemic levels. The Plan focuses on 7 priority areas, many of which would require needed changes to the training and practice business models with input from all interested parties—including clients and the diverse communities our professionals serve. This collective approach and process would inevitably be complex; however, the authors believe that the veterinary profession as a community is ready for the challenge to advance the profession.

The Relationship between Gestational Weight Gain and Cesarean Delivery among Patients undergoing Induction of Labor.

This study aimed to determine the impact of pregnancy weight gain above National Academy of Medicine (NAM) guidelines on cesarean delivery rates following induction. This is a secondary analysis of a prospective cohort study of patients who underwent induction at a single tertiary care center between July 2017 and July 2019. Included in the primary study were patients undergoing term (≥37 weeks) labor induction with a singleton gestation, intact membranes, and unfavorable cervical examination (Bishop score of ≤6 and cervical dilation ≤ 2 cm). Eligibility for this analysis was limited to patients with a documented prenatal body mass index (BMI) < 20 weeks' gestation. The primary exposure was gestational weight gain greater than NAM guidelines (WGGG) for a patient's initial BMI category. The primary outcome was cesarean delivery for any indication. Of 1,610 patients included in the original cohort, 1,174 (72.9%) met inclusion criteria for this analysis and 517 (44.0%) of these had weight gain above NAM guidelines. Of the entire cohort, 60.0% were Black and 52.7% had private insurance. In total, 160 patients (31%) with WGGG underwent cesarean compared with 127 patients (19.3%) without WGGG (p < 0.001), which equates to a 59% increased odds of cesarean when controlling for initial BMI category, parity, gestational diabetes, and indication for induction (Adjusted Odds Ratio [aOR] 1.58, 95% confidence interval [CI] 1.17-2.12). Among only nulliparous patients, WGGG was associated with an increased odds of cesarean (26.4 vs. 38.2%, aOR 1.50, 95% CI 1.07-2.10). In multiparous patients, however, there was no difference in cesarean between those with and without WGGG (8.8 vs. 14.1%, aOR 1.85, 95% CI 0.96-3.58). This study demonstrates that weight gain above NAM guidelines is associated with more than a 50% increased odds of cesarean. Patients should be informed of this association as gestational weight gain may be a modifiable risk factor for cesarean delivery. · Weight gain above NAM guidelines was associated with a 59% increased odds of cesarean delivery.. · Nulliparous patients with weight gain above NAM guidelines are at higher risk of cesarean delivery.. · No difference in cesarean delivery among multiparous patients regardless of gestational weight gain..

Drug use and spending under a formulary informed by cost-effectiveness.

BACKGROUND: The National Academy of Medicine has called for value-based drug formularies to address health plan prescription drug spending while maintaining access to high-value medicines. Thirty employer-sponsored plans implemented a "Value-Based Formulary-essentials" (VBF-e) program that uses cost-effectiveness evidence to inform cost-sharing and coverage exclusion. OBJECTIVE: To evaluate if the VBF-e was associated with changes in medication use and patient out-of-pocket spending and health plan spending on prescription drugs and other health care. METHODS: This was a cohort study using a difference-in-differences design from 2015 through 2019 with 1 year of follow-up after VBF-e implementation at Premera Blue Cross, the largest nonprofit health plan in the Pacific Northwest. The VBF-e exposure group was composed of all individuals aged younger than 65 years and enrolled at least 12 months prior to their employer group's VBF-e implementation date. The contemporaneous control group was composed of propensity score-matched individuals with the same inclusion criteria but their employer group that did not implement VBF-e. We prespecified the following outcomes: days of medication on hand overall and by VBF-e tier (high-value generic, brand, and specialty drugs were in tiers 1 to 3, respectively, and low-value drugs were in tier 4 or excluded from coverage); prescription drug spending; and other health care use (emergency department visits, hospital days, and outpatient visits). RESULTS: Comparing 12,111 exposed (mean age = 36.0; 49.8% female sex) participants with 24,222 control participants (mean age = 34.7; 49.6% female sex), VBF-e reduced use of low-value drugs by 0.3 days per member per month (PMPM) (95% CI = -0.5 to -0.1; 17% decrease) for tier 4 drugs and 0.4 days PMPM (95% CI = -0.5 to -0.4; 83% decrease) for excluded drugs. High-value specialty drug use increased by 0.1 days PMPM (95% CI = 0.0-0.1; 123% increase). Health plan spending decreased by $14 PMPM (95% CI = -26 to -4) and member out-of-pocket spending increased by $1 PMPM (95% CI = 1-2). Other health care use did not change significantly. CONCLUSIONS: An exclusion formulary informed by cost-effectiveness evidence reduced low-value drug use, increased high-value specialty drug use, reduced health plan spending, and increased member out-of-pocket spending without increasing acute care use. DISCLOSURES: This research was supported by a grant from the Patrick and Catherine Weldon Donaghue Medical Research Foundation's Greater Value Portfolio Program. Study Registration Number: NCT04904055.

Parathyroid hormone-vitamin D dynamics vary according to the definition of vitamin D deficiency in newborn infants.

Parathyroid hormone (PTH) is an indirect functional indicator of vitamin D status. Risk of vitamin D deficiency, assessed using circulating 25-hydroxyvitamin D (25(OH)D), is defined as <30nmol/L by the National Academy of Medicine and alternatively <25nmol/L in the global consensus recommendation on prevention and management of nutritional rickets. To test PTH concentrations and the odds for elevated values according to vitamin D deficiency cut-points (<30nmol/L, or <25nmol/L) in newborn infants. Healthy term-born infants (n=858) were recruited from Montreal, Canada (2016-2019). Obstetric data were obtained from medical records, and demographic factors surveyed. Immunoassays were used to measure newborn (24-36h) serum PTH and 25(OH)D; 25(OH)D was standardized to National Institute of Standards and Technology (NIST) standard reference materials. Serum PTH was log-transformed before comparing serum 25(OH)D groups (<30 vs. ≥30; or <25 vs. ≥25nmol/L) using ANCOVA adjusted for infant sex, type of delivery, parity, race, and family income. The odds of elevated PTH (>71.48pg/mL) were tested using logistic regression, adjusted for the same covariates. Infants (50.2% female) were 39.6±1.0weeks gestational age (mean±SD), and 3.41±0.38kg. Median serum 25(OH)D was 45.4 (IQR 23.2) nmol/L; 20.5% had serum 25(OH)D<30nmol/L, and 12.4% <25nmol/L. Median serum PTH was 30.72 (IQR 33.90) pg/mL, elevated in 12.7% overall, and higher in infants born with serum 25(OH)D<25 vs. ≥25nmol/L (35.96 (IQR 39.20) vs. 30.36 (IQR 32.93) pg/mL, p=0.0158). The odds of elevated PTH were higher when serum 25(OH)D was <25nmol/L (ORadj 2.13, 95% CI: 1.23, 3.69). PTH concentration and the odds of being elevated did not differ according to the 30nmol/L cut-point. Based on this study, the definition of vitamin D deficiency relative to bone health as set by the National Academy of Medicine (<30nmol/L) exceeds the threshold at which PTH is elevated in newborn infants.

Practice Guidelines Development: The APSARD United States Guidelines for the Diagnosis and Treatment of ADHD in Adults

Attention-deficit/hyperactivity disorder (ADHD) is a common neuropsychiatric disorder arising in children that persists in many people for the remainder of their lives. While several diagnostic and treatment guidelines in the United States (US) have been developed for childhood ADHD, no guidelines have been published in the US for adults with ADHD. With the increase of care seeking by adults with ADHD accompanied by increasing ADHD medication prescriptions in the past few years, the American Professional Society for ADHD and Related Disorders Association (APSARD) has recognized the need for diagnostic and treatment guidelines for the US. The development of clinical practice guidelines follows a rigorous scientific process of literature review, conflict of interest management, levels of participation of the working group members, clinical recommendations based on published research, a ranking of the quality of data, and a Delphi process to evaluate the rank order of clinical recommendations with little published research available. The Institute of Medicine (now The National Academy of Medicine) and the American Psychiatric Association have established protocols for each of the aforementioned phases of the manuscript development. This article reviews this process in detail and conveys the complexity of the endeavor. [ Psychiatr Ann . 2023;53(10):449–454.]

Sociotechnical Factors Contributing to Burnout among Radiation Oncology Medical Physicists: Survey and Focus Group Results from a Systems-Analysis Approach

While burnout and contributing factors have been studied among physicians and surgeons, there is limited understanding of the factors contributing to radiation oncology medical physicists' (MPs) burnout. Therefore, this study aims to i) explore factors associated with burnout among MPs using a systems-analysis approach, and ii) identify and prioritize key improvement efforts. We administered a survey to MPs at a US academic medical center between May 19-June 2, 2022. The survey included a 2-item Connor-Davidson Resilience Scale, a 2- item abbreviated Maslach Burnout Inventory (MBI) measuring emotional exhaustion (EE) and depersonalization (DP), and 21 general workplace stressors based on the National Academy of Medicine's systems approach to clinicians' burnout. Participants rated workplace stressor severity on a 5-item Likert scale and priorities for improvement on a 4-item Likert scale. Burnout was categorized using a 2-Question Summative Score totaling >3 for EE and DP. Focus groups were held with ∼3 participants per group via a video conferencing platform on June 8-9, 2022. Survey results from top-rated workplace stressors and priorities were summarized and presented to focus groups. Participants were asked open-ended questions to promote discussion and elicit more contextual information about workplace stressors and to rank their highest priority stressors at the end of the focus group. Of the 12 MPs the survey was sent to, 8 responses (67%) were received. Table 1 summarizes the results. The mean resilience score was 6.88, with a standard deviation (SD) of 0.63. 87.5% (n = 7) of MPs identified themselves as burned out. The key workplace stressors contributing most to MPs' burnout were inadequate staffing (mean [SD] 3.1 [1.2]), work-life integration (3.1 [1.2]), excessive workload (2.8 [1.1]), and time pressure (2.6 [1.2]). Specifically, MPs suggested following improvements: i) hire additional physicists to cover clinic responsibilities, ii) limit or compensate for work done post-work hours, iii) improve scheduling workflow, and iv) retain hybrid work model. Survey data demonstrated moderate resilience but high levels of burnout among MPs. Results indicate inadequate staffing as the most severe workplace stressor and highest priority for improvement efforts and remained the top priority even after focus groups. These results warrant further studies with larger sample sizes, assessing factors contributing to burnout among MPs and systems-focused interventions.

Screening for Financial Hardship: Comparing Patient Survey Responses Using Two Different Screening Tools.

Healthcare delivery organizations are increasingly screening patients for social risks using tools that vary in content and length. To compare two screening tools both containing questions related to financial hardship. Cross-sectional survey. Convenience sample of adult patients (n = 471) in three primary care clinics. Participants randomly assigned to self-complete either: (1) a screening tool developed by the Centers for Medicare & Medicaid Services (CMS) consisting of six questions on financial hardship (housing stability, housing quality, food security, transportation security, utilities security); or (2) social and behavioral risk measures recommended by the National Academy of Medicine (NAM), including one question on financial hardship (financial strain). We compared patient acceptability of screening, positive screening rates for financial hardship, patient interest in assistance, and self-rated health. Ninety-one percent of eligible/interested patients completed the relevant survey questions to be included in the study (N = 471/516). Patient acceptability was high for both tools, though more participants reported screening was appropriate when answering the CMS versus NAM questions (87% vs. 79%, p = 0.02). Of respondents completing the CMS tool, 57% (132/232) reported at least one type of financial hardship; on the NAM survey, 52% (125/239) reported financial hardship (p = 0.36). Nearly twice as many respondents indicated interest in assistance related to financial hardship after completing items on the CMS tool than on the NAM question (39% vs. 21%, p < 0.01). Patients reported high acceptability of both social risk assessment tools. While rates of positive screens for financial hardship were similar across the two measures, more patients indicated interest in assistance after answering questions about financial hardship on the CMS tool. This might be because the screening questions on the CMS tool help patients to appreciate the types of assistance related to financial hardship that may be available after screening. Future research should assess the validity and comparative validity of individual measures and measure sets. Tool selection should be based on setting and population served, screening goals, and resources available.

Systematic review of the association between talc and female reproductive tract cancers.

Talc is a hydrous magnesium sheet silicate used in cosmetic powders, ceramics, paints, rubber, and many other products. We conducted a systematic review of the potential carcinogenicity of genitally applied talc in humans. Our systematic review methods adhere to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and incorporated aspects from the US Institute of Medicine (IOM, now the National Academy of Medicine) and several US EPA frameworks for systematic reviews, evaluating and integrating the epidemiological, animal, and mechanistic literature on talc and cancer. We conducted a comprehensive literature search. Detailed data abstraction and study quality evaluation, adapting the Toxic Substances Control Act (TSCA) framework, were central to our analysis. The literature search and selection process identified 40 primary studies that assessed exposure to talc and female reproductive cancer risks in humans (n = 36) and animals (n = 4). The results of our evaluation emphasize the importance of considering biological plausibility and study quality in systematic review. Integrating all streams of evidence according to the IOM framework yielded classifications of suggestive evidence of no association between perineal application of talcum powders and risk of ovarian cancer at human-relevant exposure levels. We also concluded that there is suggestive evidence of no association between genital talc application and endometrial cancer, and insufficient evidence to determine whether a causal association exists between genital talc application and cervical cancer based on a smaller but largely null body of literature.

Surmounting Barriers to Healthcare Data and Information: International Case Studies

Objective: In this article, the authors review the progress in healthcare interoperability from 2010 to 2023 from an international perspective. Countries covered here include the Republic of China (Taiwan), the Republic of Croatia, the Republic of Estonia, and the Commonwealth of Australia. Interoperability, in the context of this paper, is “the ability to share information across time and space from multiple devices, sources, and organizations,” as defined by the Institute of Electrical and Electronic Engineers (IEEE). This is followed by recommendations for future work toward improving the standardization of heterogeneous data in the healthcare setting. Methodology: A literature review was conducted on established interoperability standards and systems in healthcare based on information obtained from journal publications, government, academy reports, published materials, and publicly available websites. Examples of specific interoperability efforts and an evaluation of their feasibility were conducted at three levels of healthcare interoperability, as defined by the National Academy of Medicine: 1) inter-facility (macro-tier) interoperability, 2) intra-facility (meso-tier) interoperability, and 3) Point-of-Care (micro-tier) interoperability. The authors assessed the adoption levels of each standard by looking at factors that support or limit its systemic adoption. Estimations on the number of users—medical professionals and patients—for each system were made in instances where verifiable data are available. Results: Presented here is an evaluation of four interoperability parameters: 1) device/equipment interoperability, 2) compatibility issues, 3) involved organizations, and 4) migration and conversion issues. Conclusions: Despite many parallel ongoing efforts to improve the standardization of healthcare information in the mobile devices, Internet of Things (IoT), and electronic health records (HER) sectors, there remains space for improvement. The recent development of the Trusted Exchange Framework and Common Agreement (TEFCA)  framework has significantly reduced the friction of data exchange in many healthcare contexts. In addition, funding architectures for mediating data between separate healthcare organizations, or middleware architectures, may also be an effective strategy for consolidating healthcare data and improving information exchange.

Pragmatic Approaches to Interoperability – Surmounting Barriers to Healthcare Data and Information Across Organizations and Political Boundaries

Objective This paper provides a review of the landscape of interoperability efforts in healthcare from 2010 to 2023, in the US and abroad. Interoperability, in the context of this paper, is “the ability to share information across time and space from multiple devices, sources, and organizations”, as defined by the IEEE (Institute of Electrical and Electronic Engineers). This review is followed by recommendations for future work toward improving the standardization of heterogeneous data in the healthcare setting.   Methodology and Results A literature review was conducted on established interoperability standards and systems in healthcare, based on information obtained from journal publications, government, academy reports, published materials, and publicly available websites. The review emphasizes four interoperability parameters: device/equipment interoperability, compatibility issues, involved organizations, and migration and conversion issues. It evaluates adoption levels for each standard, evaluating factors supporting and/or limiting systemic adoption. Estimations on the number of users – both medical professionals and patients – for each system were made in instances where verifiable data were available.    Examples of specific interoperability efforts and an evaluation of their feasibility were conducted at three levels of healthcare interoperability, as defined by the National Academy of Medicine: Inter-facility (macro-tier) interoperability, Intra-facility (meso-tier) interoperability, and Point-of-care (micro-tier) interoperability.   Conclusions Despite many parallel ongoing efforts to improve the standardization of healthcare information, in the mobile devices, IoT, and EHR sectors, there is still more space for improvement. The recent development of the TEFCA framework has greatly reduced the friction of data exchange in many healthcare contexts. In addition, funding architectures for mediating data between separate healthcare organizations, or middleware architectures, may also be an effective strategy for consolidating healthcare data and improving information exchange.