October 21, 2020

HISPANIC GENDER DIFFERENCES IN HOSPITALIZED HEART PATIENTS

October 21, 2020

More than 3,000,000 women in the U.S. die of heart failure (HF) annually. Women significantly are underrepresented in studies that inform practice guidelines, especially women hospitalized for HF despite associated negative outcomes. HF is common in Hispanic individuals, the largest ethnic minority group in this nation, who are mostly of Mexican origin. Since there were no studies of gender differences in Mexican-Hispanic persons hospitalized for HF, as reported in the September-October 2020 issue of the periodical Women’s Health Issues, researchers sought to describe gender differences in demographic and clinical characteristics, clinical presentation, treatment, in-hospital outcomes, and discharge status in Mexican-Hispanic patients hospitalized for HF.

Compared with men, women were equally affected by obesity, on average six years older (p < .01), and more likely to be widowed (31% vs 6%; p < .001). Women had significantly higher ejection fractions, more total comorbid conditions, more hyperlipidemia, more arthritis, more anxiety, and were less likely to be treated with digoxin and more likely to be treated with calcium channel blockers. At discharge, women were significantly less likely to receive an angiotensin-converting enzyme inhibitor or an aldosterone receptor blocker and had a higher systolic blood pressure. A conclusion reached from this investigation is that key gender differences in chronic illness burden, treatment, and discharge status were found, highlighting the heterogeneity of women with HF and the need for further gender-specific research to develop care strategies specific to women of all races and ethnicities.

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BIG DATA, RESEARCH, AND ETHICS CHALLENGES FOR IRBs

Kristen Truong

October 21, 2020

Trends Archives

The increased use of big data has shifted the way in which biomedical research is designed and implemented. This kind of research has begun to pursue opportunities afforded by big data by relying on large‐scale databases, multiplication of data sources, advanced storage capacity, and novel computational tools that allow for high‐velocity data analytics. Big data also enable researchers to draw health insights from data sources that are not strictly medical, such as data from wearable trackers, social media, and Internet searches that open new prospects to accelerate health‐related research and potentially elicit breakthroughs that will benefit patients. Currently, a large portion of health‐related research depends on big data, while the novelty of techniques and methods brought by big data research brings new challenges to institutional review boards (IRBs). It is unclear, however, if those entities should be the responsible oversight bodies for big data research and, if so, which criteria they should use.

According to a manuscript published in the September-October 2020 issue of the journal Ethics & Human Research, big data investigations shift the way biomedical researchers design and carry out their studies because their work departs from the traditional research model since it is largely exploratory rather than hypothesis driven. The methodological novelty of big data research models brings new challenges and questions to IRBs, including whether they are the bodies responsible for assessing these projects. Given current technologies, analytic methods, and regulations, IRBs cannot take their traditional review frameworks as given since big data research models might not fit within the traditional national review policies for the protection of human subjects. Health-related big data research also challenges IRBs in referring to existing safeguards for ethics research, such as informed consent, privacy, confidentiality, and minimal risk. A threefold consideration is involved. First, individuals whose data are used in research often are not sufficiently informed concerning the use of their data. Second, breaches in data privacy and confidentiality represent a major source of risk stemming from the informational richness of large data repositories, which makes them a primary target for actors outside the research domain. Third, correlations arising from health‐related big data analytics can be abused by various actors for unethical purposes, such as discriminating against applicants to health insurance services or jobs based on health risk indicators.

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AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

Kristen Truong

October 21, 2020

Trends Archives

U.S. Women Living In Areas Devoid Of Proper Maternity Care

Maternity care deserts are characterized as being areas without hospitals that offer obstetric care, birth centers, or a specialized provider. According to a new report from the March of Dimes, these areas continue to be a problem in the U.S. as women die of pregnancy complications at rates higher than women in other high-income nations. More than 2.2 million women of childbearing age live in such deserts and an additional 4.8 million live in areas with limited access to maternity care. Women in the rural U.S. are especially at risk of giving birth without proper access to care. Also, there are more than four times as many rural counties that are maternity care deserts than urban counties, and only 8% of obstetrics providers report working in rural areas. At the same time, 1 in 3 women of childbearing age in a maternity care desert lives in an urban setting. The report can be obtained here.

Mental Health Of U.S. Adults

Three new data briefs from the CDC outline the state of mental health among U.S. adults in 2019. More than 1 in 7 of these individuals experienced some level of anxiety during 2019, before the pandemic, while nearly 1 in 5 reported depression. Additional information is as follows:

Anxiety: When asked about their anxiety symptoms in the two weeks prior to being surveyed, nearly 10% of adults reported mild anxiety, while around 3% reported severe forms of anxiety. Women and those aged 18-29 were most likely to report being anxious. The data brief can be obtained here.

Depression: Nearly 12% of respondents reported mild depression symptoms in the two weeks prior to being surveyed, while nearly 3% reported severe depression. White and Black adults were most likely to report depression than other racial groups. The data brief can be obtained here.

Treatment: Around 1 in 5 U.S. adults reported having any mental health treatment last year. Around 16% said they had taken some medication, while around 10% reported obtaining counseling. The data brief can be obtained here.

Integrating Systems And Sectors Toward Obesity Solutions

The Roundtable on Obesity Solutions of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine held a virtual public workshop, Integrating Systems and Sectors Toward Obesity Solutions, on April 6, 2020 (Part I), and June 30, 2020 (Part II). The event explored complex systems and contributing factors that can influence obesity, and shared real-life examples of applying systems thinking and systems science approaches to addressing obesity and population health and well-being. In Part I, speakers provided an overview of systems science theories and approaches and their application. In Part II, speakers discussed complex systems in society that have the potential to shape the public’s health and considered opportunities for systems change with regard to obesity solutions. Specifically, the workshop explored how factors such as power dynamics, structural racism, relationships, resources, place-based issues, policy, and political will affect systems that can influence obesity, as well as how these factors can have an impact on communications and cross-sector collaboration to address obesity. The Proceedings of the Workshop can obtained here.

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QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Kristen Truong

October 21, 2020

Trends Archives

American Adolescents And Mental Illness Treatment Variation

A new national investigation finds that many youth do not receive appropriate follow-up care soon after an initial insurance claim for a mental health condition. The study included data from more than two million children covered by Blue Cross Blue Shield. Of the more than 200,000 children in the study with at least one mental health claim, nearly 30% did not obtain any follow-up treatment in the three months after an initial claim. Published on September 29, 2020 in Proceedings of the National Academy of Sciences of the USA, the study examined insurance claims from children between the ages of 10 and 17 covered by Blue Cross Blue Shield. Of the more than two million children included in the study, nearly one in 10 had a claim related to mental illness between 2012 and 2018. Of those who were prescribed medication, 45% were given drugs that could be addictive or that were not FDA-approved for use in children. Having more psychiatrists in each child’s zip code increased the likelihood of medication treatment, while more therapists in the area increased the chances of therapy alone.

Alcohol-Induced Deaths Among Adults Aged 25 And Over: United States, 2000–2018

As reported in an October 2020 Data Brief from the National Center for Health Statistics, excessive alcohol consumption is a well-known risk factor for mortality and has been causally linked to many diseases, conditions, and injuries, including alcohol-attributable cancer, liver cirrhosis, and alcohol poisonings. Age-adjusted rates of alcohol-induced deaths among adults aged 25 and over were stable from 2000 to 2006, then increased 43% from 10.7 per 100,000 in 2006 to 15.3 in 2018. For both males and females, alcohol-induced death rates increased at a greater rate between 2000 and 2018 in rural compared with urban areas. Among males, the rate of alcohol-induced deaths was highest in large central metro areas in 2000 (21.3); by 2018, rates in medium (25.1) and small metro (25.9), micropolitan (26.7), and noncore (25.3) areas were highest. Among females, the rate of alcohol-induced deaths in noncore areas (4.4) was among the lowest in 2000; by 2018, rates in noncore areas had more than doubled (9.9).

HEALTH TECHNOLOGY CORNER

Use Of Holographic Imaging To Detect Viruses And Antibodies

A team of New York University scientists has developed a method using holographic imaging to detect both viruses and antibodies. This approach has the potential to aid in medical diagnoses and, specifically, those related to the COVID-19 pandemic. Holographic immunassays can be targeted for specific diseases by replacing protein A as a surface binding group with appropriate specific antigens, including peptides, proteins, or other biomolecules. Holographic analysis yields results faster and at lower cost by eliminating reagents, processing steps, and expertise needed to apply fluorescent labels while yielding quantitative results for antibody concentration without requiring extensive calibration. According to an article published on October 8, 2020 in the journal Soft Matter, if fully realized, this proposed test could be done in under 30 minutes, is highly accurate, and can be performed by minimally trained personnel. Moreover, the method can test for either the virus (current infection) or antibodies (immunity).

Cell Revival Following A Heart Attack

Extracellular vesicles (EVs), small membrane-bound particles released from cells, have been shown to have cardioprotective effects and are promising tools for the next generation of therapies for everything from autoimmune and neurodegenerative diseases to cancer and tissue injury. EVs derived from stem cells help heart cells recover after a heart attack. Exactly how they help and whether the beneficial effect is specific to EVs derived from stem cells has remained a mystery. Now, according to a study reported in the October 14, 2020 issue of the journal Science Translational Medicine, investigators from Harvard University have unraveled potential mechanisms behind the healing power of EVs and demonstrated their capacity not only to revive cells after a heart attack, but keep them functioning while deprived of oxygen during a heart attack. This functionality in human tissue was demonstrated using a heart-on-a-chip with embedded sensors that continuously tracked tissue contractions.

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DEVELOPMENTS IN HIGHER EDUCATION

Kristen Truong

October 21, 2020

Trends Archives

The beginning of the fall semester each year is highlighted by the return of college football. Due to COVID-19, many teams have decided to play fewer games this season compared to previous years. Some major conferences originally decided to postpone competition until 2021, but subsequently agreed to play a limited number of games later this year. Depending on the team, some players, coaches, and other personnel have tested positive for the virus, which led to decisions to postpone some contests to later dates. A common feature has been either to have no fans present in stadiums or to reduce the usual attendance drastically. Meanwhile, the non-football side of academic institution life also displays a considerable amount of variation regarding the volume of disease testing that occurs and whether to send students home who test positive or just quarantine them for different periods of time. Schools also vary on the proportion of students who decided to enroll for the fall semester. Each college and university is affected differently by reductions in revenue derived from tuition, housing, meals provision, and activity fees.

Fostering Research Integrity And The Responsible Conduct Of Research

As posted on October 19, 2020 in the Federal Register on pages 66341-66342, the Department of Health and Human Services (HHS), Office of Research Integrity (ORI) seeks information and comments from entities and individuals regarding activities that foster research integrity and promote the responsible conduct of research. In particular, ORI is interested in learning about best practices, challenges, and needs related to teaching the responsible conduct of research, promoting research integrity, and preventing research misconduct. ORI will use this information to support the goal of conducting outreach and developing educational resources that best support the Public Health Service (PHS) funded research community. Responses to the RFI must be received electronically no later than 5:00 p.m. ET on the 60th day following the date of publication of this announcement in the Federal Register.

The following three categories are of interest:

Using Training and Education To Foster Research Integrity (ORI seeks to understand key challenges to using training and educational efforts to foster a climate that encourages research integrity and the responsible conduct of research.)

Research Integrity/Responsible Conduct of Research Program Administration and Facilitation of Training (ORI requests answers to 10 questions.)

Research Integrity/Responsible Conduct of Research Training Sessions (ORI seeks information on institutional experiences, practices, and needs.)

U.S. Department Of Education Launches 2021-2022 FAFSA Cycle

The U.S. Department of Education on October 1, 2020 released the 2021–2022 Free Application for Federal Student Aid (FAFSA) form as a means of providing information, tools, and resources to help students make informed decisions about their education options. This year, enhanced help topics provide even more guidance through the form. As a result of user feedback, many financial help topics on fafsa.gov feature images of the forms with relevant line numbers visually highlighted to help applicants navigate the FAFSA form. Additionally, skip-logic functionality means applicants see only the questions that pertain to them. The Department also furnishes other tools and resources designed to help students complete and submit the FAFSA form and make informed choices.

The Annual Student Loan Acknowledgment provides links to College Scoreboard where students can estimate their post-completion starting salary based on the school they plan to attend and the program in which they will enroll. For borrowers with existing loans, the Annual Student Loan Acknowledgment outlines how much they owe and how much more they can borrow, and grant recipients can see how much they have received and their remaining eligibility. Starting with the 2021–2022 award year, the Annual Student Loan Acknowledgment will be required before borrowers can receive a financial aid disbursement.

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HEALTH REFORM DEVELOPMENTS

Kristen Truong

October 21, 2020

Trends Archives

A decade has passed since the Patient Protection and Affordable Care Act (ACA) became law. This legislation continues to be controversial, however, as evidenced by a series of exchanges between members of the U.S. Senate Judiciary Committee and Judge Amy Coney Barrett, a nominee to the Supreme Court to fill a vacancy resulting from the death of Judge Ruth Bader Ginsburg. Democrats on the committee pressed her on her views regarding how she might vote on the case California v. Texas, which is scheduled for oral argument at the Supreme Court on November 10. These individuals are expected to vote against her confirmation because of a fear that she will be instrumental in overturning the ACA.

Apart from several attempts by Congressional Republicans over the past 10 years to repeal the ACA, this latest manifestation of opposition stems from a case, NFIB v. Sebelius, in which the deciding vote cast by Chief Justice John Roberts found that the individual mandate could not be justified under the constitution’s Commerce or Necessary and Proper clauses, but it could be upheld as an exercise of Congress’ taxing power. Since then, the 2017 Tax Cuts and Jobs Act set the mandate penalty at zero beginning in 2019. Subsequently, Attorneys General in 17 states argued in court that since the mandate no longer produces revenue and is not a tax, not only the mandate, but the entire law is unconstitutional. A district court agreed, indicating that the mandate was an essential part of the law, was not severable, thereby rendering the entire law as being unconstitutional. Next, the Fifth U.S. Circuit Court of Appeals allowed the Democrat-controlled House of Representatives to intervene to defend the ACA on appeal. That step led to a decision by the Supreme Court to accept a petition to conduct an immediate review.

Policies To Achieve Near-Universal Health Insurance Coverage

A report from the Congressional Budget Office (CBO) in October 2020 examines policy approaches to achieve near-universal health insurance coverage using some form of automatic coverage through a default plan. As defined by CBO, a proposal would achieve near-universal coverage if close to 99% of citizens and noncitizens who are lawfully present in this country were insured either by enrolling in a comprehensive major medical plan or government program or by receiving automatic coverage through a default plan. Proposals to achieve near-universal coverage would have two primary features. At a minimum, if they required premiums, those premiums would be subsidized for low- and moderate-income individuals, and would include a mandatory component that would not allow them to forgo coverage or that would provide such coverage automatically.

CBO organized existing proposals into four general approaches, ranging from one that would retain existing sources of coverage to one that would almost entirely replace the current system with a government-run program. All four approaches would provide automatic coverage to individuals who did not enroll in a plan on their own. Two approaches would fully subsidize coverage for lower-income people and partially subsidize coverage for middle-income and some higher-income people while retaining employment-based coverage. Another two approaches would fully subsidize coverage for individuals at all income levels.

Nationwide Evaluation Of Health Care Prices Paid By Private Health Plans

A new analysis from the RAND Corporation indicates that private health plans in the U.S. pay hospitals an average of 247% percent of what Medicare would pay for the same services at the same facilities. Wide variation exists in pricing among states (e.g., Michigan under 200% and Florida more than 325%). Addressing prices paid by employer-sponsored and other private insurance plans represents a tangible way to reduce health care spending. Where quality and convenience are comparable, employers can use network and benefit design approaches to move patient volume away from higher-priced, lower-value hospitals and hospital systems and toward lower-priced, higher-value providers. Employers also can use this information to reformulate how contracts are negotiated on their behalf. Various changes are not possible without price transparency information. Price transparency by itself will not be sufficient, however, if employers do not act on price information. In some cases, employers may need state or federal policy interventions to rebalance negotiating leverage between hospitals and their health plans.

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DUELING COVID-19 AID PACKAGES

Kristen Truong

October 21, 2020

Trends Archives

Prior to reaching agreement on the size of another package of financial aid in response to COVID-19, a more immediate test for Congress was to agree on legislation to provide funding to prevent a federal government shutdown at the start of a new fiscal year on October 1, 2020. Legislators were able to pass that test by producing a $1.4 trillion stopgap spending measure to fund the federal government at current levels through December 11 of this year. Still pending is the necessity of completing work on the 12 annual appropriations bills for fiscal year 2021 during the lame duck session of Congress that will follow the elections on November 3.

An effort to agree on the size of an aid package to address a wide range of problems stemming from the coronavirus has proved, however, to be much more challenging and nettlesome. Last May, the House of Representatives passed a $3.4 trillion stimulus bill (H.R.6800, the Health and Economic Recovery Omnibus Emergency Solutions Act or the HEROES Act) that included aid for state and local governments; rent and mortgage relief; expanded unemployment benefits and food assistance; another round of direct cash payments of up to $1,200 to individuals; and a two-year federal backstop of subsidies to support health plans and coverage of job-based insurance premiums between March and next January for workers who have been laid off or furloughed. Senate Republicans responded by indicating that among many other objections, they would not approve an extension and were in no hurry to pass more relief. Instead, they were in favor of gauging the impact of previously passed stimulus packages before considering additional legislation.

By early July, Republicans expressed interest in having coronavirus legislation that would prioritize COVID-19 testing and vaccine research, and address expanded unemployment benefits that were scheduled to expire at the end of July. By the middle of that month, White House officials and Senate Republicans agreed that relief legislation should cost $1 trillion or less. By the end of July, GOP members favored having another round of loans for the Paycheck Protection Program (PPP), stimulus checks for individual Americans, and provisions to protect seniors from a potential increase in their health insurance premiums. White House officials were less enthusiastic about including stimulus check eligibility and a possible payroll tax cut. By early August, congressional Republicans favored a $1.1 trillion stimulus package. Unable to overcome an impasse on Capitol Hill, as reported in the July/August 2020 issue of this newsletter, President Trump released a series of executive orders in August to address several current needs.

By the start of October, House Democrats were willing to trim their aid package to $2.2 trillion, but Senate Republicans showed little interest in providing funds at that level. House Speaker Nancy Pelosi (D-CA) and Treasury Secretary Steven Mnuchin met to negotiate on several occasions, but could not finalize an agreement. Next, Republicans agreed to increase their proposal to $1.6 trillion, but Democrats insisted a larger amount is needed. By October 9, President Trump was willing to go as high as $1.88 trillion, but as of the time this issue of the newsletter is being distributed, final results still are pending.

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IN SEARCH OF CONNECTIONS

Kristen Truong

October 21, 2020

Trends Archives

Epidemiologists serve as detectives in rooting out the causes of disease. Not only are they often successful in identifying the multifactorial origins of specific causes of morbidity and mortality, they also can show how all aspects of a given condition are connected. A death certificate may contain the singular label cardiovascular disease, but a more accurate descriptor involves connections among several factors in the form of social determinants, such as inadequate nutrition, residence in unsafe neighborhoods, unemployment/underemployment, and exposure to pollution.

A vivid illustration from the public health realm of the importance of establishing connections is an epidemiological study of a deadly cholera outbreak in London in 1854. John Snow was convinced that the disease was caused by a contagious agent. He conducted interviews with residents of the area about their water sources, while meticulously recording the time, person, and place of disease events. He integrated the interview data with disease-event information and concluded that cholera was occurring mostly in victims who were drawing their water from the Broad Street water pump. He convinced skeptical authorities to remove the pump handle and the outbreak was brought to a halt.

As described in a paper appearing in the October 5, 2020 issue of the journal Current Biology, it wasn’t until 30 years later when the renowned microbe hunter, Robert Koch, independently discovered V. cholerae that its responsibility for cholera became common knowledge. Koch and his contemporaries were part of the golden age of microbe hunting during which microscopes were trained onto many disease states and linked with their causative pathogens, leading to the widespread acceptance of the germ theory of disease underpinned by his famous four postulates. Snow’s pioneering epidemiological methods for tracing disease now could be coupled with microbiological methods that identify causative pathogens. Connecting disease and infection proved to be pivotal for the management of infectious agents.

Rolling ahead to the current pandemic, weekly reports from the CDC indicate that for only 6% of deaths, COVID-19 is the only cause mentioned. Other underlying conditions or comorbidities, such as influenza/pneumonia, respiratory failure, hypertension, diabetes, and cardiac arrest account for the remaining 94% of mortality. Another important connection pertains to perceived collateral damage from social lockdown policies that are associated with lower childhood vaccination rates, fewer cancer screenings, and deteriorating mental health that can lead to greater excess mortality.

Moreover, a steady growth in the size of the human population has led to increased encroachment on forests that previously were inhabited only by animals. Greater exposure to zoonotic diseases that jump from other species (e.g., bats) to humans can result in more infectious disease epidemics and pandemics. Successful virus mutations in humans then can be transmitted from human to human. Hence, it is likely our species is in it for the long haul regarding infectious disease outbreaks.

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QUANTIFYING HEALTH SYSTEMS’ INVESTMENTS IN SOCIAL DETERMINANTS OF HEALTH

John Colbert

February 25, 2020

Trends Archives

Social determinants (e.g., conditions in which individuals are born, grow, work, live, and age) are seen as accounting for substantially more of the variation in health outcomes than medical care does while interest in addressing these determinants has increased markedly in recent years. According to a study reported in the February 2020 issue of the journal Health Affairs, the past decade has involved a growing recognition of the importance of social determinants of health for health outcomes. Meanwhile, the degree to which health systems in the U.S. are investing directly in community programs to address social determinants of health as opposed to screening and referral is uncertain.

Researchers conducting this investigation searched for all public announcements of new programs involving direct financial investments in social determinants of health by U.S. health systems from January 1, 2017, to November 30, 2019. They identified 78 unique programs involving 57 health systems that collectively included 917 hospitals. The programs involved at least $2.5 billion of health system funds, of which $1.6 billion in 52 programs was committed specifically to housing-focused interventions. Additional focus areas were employment (28 programs, $1.1 billion), education (14 programs, $476.4 million), food security (25 programs, $294.2 million), social and community context (13 programs, $253.1 million), and transportation (six programs, $32 million). These figures demonstrate that health systems are making sizable investments in social determinants of health. To cite one example, housing-related programs included strategies, such as direct building of affordable housing, often with a fraction set aside for homeless patients or those with high use of health care; funding for health system employees to purchase local homes to revitalize neighborhoods; and eviction prevention and housing stabilization programs.

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THE ROAD TO IMMORTALITY IS PAVED WITH EPONYMS

John Colbert

February 25, 2020

Trends Archives

The health sphere represents fertile ground for the production of eponyms. Prominent examples are Salk vaccine, Alzheimer’s disease, Parkinson’s disease, and Obamacare. Perpetual glory appears to be associated with having one’s name used in such ways and the website Whonamedit.com provides thousands of examples of medical eponyms. Is the practice of employing them a constructive use of nomenclature or has it become more timeworn than beneficial? This kind of question is addressed in a manuscript that appeared in the February 11, 2020 issue of the journal Neurology in which a study is described that assesses historical trends of medical eponym use in neurology literature, and knowledge and attitudes among current trainees related to eponyms. The yearly prevalence of eponyms among neurologist-authored publications ranged from 15% and 25%, with a mean of 21%. The total number of unique eponyms appearing in titles and abstracts increased from 693 in 1988 to 1,076 in 2013, representing 1.8% average annual growth.

Worth noting is that medical eponyms represent a polarizing issue among clinicians, including neurologists. Impassioned calls for the abandonment of eponyms in the published literature and in clinical use have appeared regularly in the literature for decades. Supporters explain that eponyms are concise and memorable, providing an effective shorthand to communicate precisely in clinical settings. Eponyms also may represent an essential thread of medical history, an oral tradition transmitted to successive generations of students through teaching rounds. An opposing perspective is that eponyms can be viewed as lacking accuracy and being characterized by inconsistent usage, frequent misattribution of credit, and occasional recognition of individuals with unethical research practices, such as Nazi-affiliated physicians. Study findings indicate that residents with at least one year of neurology training reported familiarity with significantly more eponyms than those before neurology training (p < 0.001). For familiar eponyms, most residents either were unaware of an alternative descriptor or preferred using the eponym. Despite recognizing both the benefits and drawbacks of eponyms, the vast majority of trainees stated that historical precedent, pervasiveness, and ease of use would drive the continued use of eponyms in neurology. For the nonce, it seems reasonable to predict that this path to immortality will remain open.

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AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

John Colbert

February 25, 2020

Trends Archives

Clinical Prevention and Population Health Curriculum Framework

The Association for Prevention Teaching and Research (APTR) announced the release of the newly revised Clinical Prevention and Population Health Curriculum Framework, which undergoes revision and public comment every five years, and is the result of almost two years of review and deliberation by the Healthy People Curriculum Task Force (HPCTF). This group’s mission is to achieve Healthy People objectives of increasing health promotion, disease prevention, population health, and interprofessional learning experiences for students in health professions education programs. Kenneth Johnson, Associate Dean of the Dumke College of Health Professions at Weber State University, represented the Association of Schools Advancing Health Professions (ASAHP) in this important endeavor. The Clinical Prevention and Population Health Curriculum Framework provides a common core of knowledge for clinical health professions about individual and population‐oriented prevention and health promotion efforts. The Framework can support interprofessional prevention education and practice. The 4th revision of the Framework features: a new domain addressing mental and behavioral health; greater emphasis on Social Determinants of Health (SDOH) and health equity; improved, updated illustrative examples; and 14 new or revised topic areas. The Framework can be obtained here.

Precarious Work Schedules And Population Health

According to a new brief from the journal Health Affairs, work has become more precarious in America over the past half century as employers have transferred more of the risks and uncertainties of doing business onto workers and households. As part of this shift, many workers have experienced an erosion of job quality—reductions in the real value of their wages; a loss or cutback of fringe benefits such as retirement plans and health insurance; and an increase in job insecurity. Policymaking responses to the rise in precarious employment have commonly focused on the economic dimensions, exemplified by appeals for a living wage. Yet, alongside changes in the economic dimension, the temporal dimension of work also has undergone seismic shifts. Unstable and unpredictable work schedules have become the new normal for many workers as the U.S. economy has shifted from manufacturing to service-sector jobs—and from steady Monday through Friday, 9–5 work hours—to a 24/7 economy. The brief synthesizes research findings that allow dots to be connected between precarious work schedules and health, and gaps are identified that remain to be filled. The brief can be obtained here.

Quantification Of U.S. Neighborhood-Level Social Determinants Of Health

The consequences of social determinants of health (SDOH) increasingly dominate public health discussions in the U.S. as population health outcomes have not kept pace with those of other developed nations despite higher per-person spending for medical services. A report in the journal JAMA Network Open on January 29, 2019 looks at geographic variation in social determinants of health in the continental U.S. Fifteen variables, measured as a five-year mean, were selected to characterize SDOH as small-area variations for demographic characteristics of vulnerable groups, economic status, social and neighborhood characteristics, and housing and transportation availability at the census-tract level. This data matrix was reduced to four indices reflecting advantage, isolation, opportunity, and mixed immigrant cohesion and accessibility, which then were clustered into seven distinct multidimensional neighborhood typologies. The report can be obtained here

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QUICK STAT (SHORT, TIMELY, AND TOPICAL)

John Colbert

February 25, 2020

Trends Archives

2020 Patient Data Breach Barometer

In 2019, the healthcare industry continued to be plagued by data breaches involving sensitive patient information, with public reports of hacking jumping a staggering 48.6% from 2018. This number of reported hacking incidents is a reminder of how vulnerable patient data remain. An analysis by Protenus is based on 572 health data breaches reported to the U.S. Department of Health and Human Services (HHS), the media, or some other source during 2019. For the 481 incidents where data exist, breaches had an impact on 41,404,022 patients, which is likely to be a huge underestimate. Two incidents for which there were no data affected 500 dental practices and clinics and could affect significant volumes of patient records. The number of breaches went from 503 in 2018 to 572 in 2019, along with a substantial increase in the number of affected records. In 2019, the total number of affected records almost tripled when compared to 2018 data (i.e., 15,085,302 affected records).

Self-reported Marijuana Use In Electronic Cigarettes Among U.S. Youth

The National Youth Tobacco Survey (NYTS) is a cross-sectional, school-based study conducted annually using a stratified, three-stage cluster sampling design to produce a nationally representative sample of middle school (grades 6-8) and high school (grades 9-12) students in the U.S. They were asked about whether they ever have used marijuana in an e-cigarette. As reported in the February 4, 2020 issue of the Journal of the American Medical Association, the study identified a significant increase in self-reported ever marijuana use in e-cigarettes from 2017 to 2018 among U.S. students. Prevalence estimates reported for all students (14.7%) and current e-cigarette users (53.5%) in 2018 also were much higher than those reported in 2016 (8.9% and 39.5%, respectively). The increase in marijuana use in e-cigarettes could be attributable to the increase of sales of pod-mod–style e-cigarette products, access to marijuana through informal sources (e.g., friends, family members, illicit dealers), and reduced perception among adolescents of the harms of marijuana use.

HEALTH TECHNOLOGY CORNER

Light-Adapted Electroretinogram Differences In Autism Spectrum Disorder

A new eye scan could help identify autism in children years earlier than currently possible. This non-invasive device uses a hand-held instrument to locate a pattern of subtle electrical signals in the retina that are different in children on the autism spectrum. According to a manuscript published on February 7, 2020 in the Journal of Autism and Developmental Disorders, the retina is an accessible model of neural connectivity in the brain where specific retinal signaling pathways can be probed and measured with an electroretinogram (ERG). Light-adapted (LA) electroretinograms (ERGs) of individuals with autism spectrum disorder (ASD) were compared to control subjects in a multicenter study of children. The results show that the LA-ERG is a potential marker for neurodevelopmental conditions, such as ASD in children. These potential biomarkers for ASD also could allow for early detection of other disorders, such as attention deficit hyperactivity disorder (ADHD).

Evolving Magnetically Levitated Plasma Proteins Detect Opioid Use Disorder As A Model Disease

As reported on January 29, 2020 in the journal Advanced Healthcare Materials, new research from the University of British Columbia, Harvard Medical School, and Michigan State University suggests that levitating human plasma may lead to faster, more reliable, portable, and simpler disease detection. The researchers used a stream of electricity that acted like a magnet and separated protein from blood plasma, which is the clear, liquid portion that remains after red blood cells, white blood cells, platelets, and other cellular components are removed. The basic notion is that as plasma proteins are different densities, when separated the proteins levitate at different heights, and therefore become identifiable. An evaluation of these types of proteins and how they group together can produce a picture that identifies whether a patient has the possibility of contracting a disease or becoming addicted to drugs, such as opioids.

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DEVELOPMENTS IN HIGHER EDUCATION

John Colbert

February 25, 2020

Trends Archives

It is a tossup on any given day in the nation’s capital whether health care or education can result in the most congressional perturbations. Education definitely can holds its own when it comes to demonstrating a proclivity for generating partisan-oriented activity. February 2020 was marked by groups representing the nation's colleges and universities in the act of rebuking a Trump administration proposal aimed at punishing institutions for violating students' free speech rights. Proposed regulations would allow the U.S. Department of Education to cut off some federal grants to public colleges that don't comply with the First Amendment or private universities that don't follow their own campus speech policies. Under the proposal, department officials would rely on the “final judgement” of a court in determining whether a school violated the First Amendment and should lose access to funding.

The American Council on Education (ACE), along with several other national education organizations, responded by indicating that the proposed rule would encourage excessive and frivolous litigation in ways that undermine the Department’s and academia’s shared goal to maintain broad protections for campus speech. Another concern is that courts will reach different conclusions as to whether an institution violated the First Amendment or its stated policies, even when looking at the same or similar set of facts. Also, unique considerations in the freedom of speech context call for greater clarity in defining when the Department may terminate federal grant funding.

If the Department proceeds with its proposed rule, the education groups offer the following recommendations to minimize some of the more problematic aspects: (1) Modify the trigger for when an institution is deemed to be out of compliance with the First Amendment or its stated policies, (2) Provide clearer criteria under which the Department will attempt to terminate or suspend a federal grant, (3) Strike from the text of the regulation references to “academic freedom” as well as the clause that attempts to enumerate specific rights under the First Amendment, (4) Extend the window for submitting notice of a final judgment to the Department, and (5) Remove language from the preamble that would require private institutions to certify to the Secretary compliance with institutional policies on free inquiry as a material condition of an award.

A Bipartisan Proposal For Reauthorization Of The Higher Education Act (HEA)

A task force convened by the Bipartisan Policy Center over an 18-month period examined a variety of issues and conducted modeling, where relevant data were available, to inform decision-making. Recommendations in a report issued in January 2020 are aimed at advancing multiple objectives: promoting college affordability and reducing equity gaps; strengthening institutional accountability while also ensuring that low-capacity institutions have the resources needed to succeed; simplifying the federal student loan program and reducing unsustainable borrowing; and providing better information and data to policymakers, researchers, and, most importantly, students and families. Specific challenges that must be addressed to ensure the U.S. higher education system meets the needs of students and the economy are: Access and Affordability; Outcomes and Accountability; and Data and Information.

Access and Affordability: Twenty-three recommendations were identified to address the need for improvement and reform in areas, such as (1) Renewing the federal-state partnership in higher education, (2) Strengthening the federal Pell Grant program, and (3) Reforming the federal student loan program.

Outcomes and Accountability: Ten recommendations were identified to promote quality assurance, increase schools’ capacity to support students and deliver better student outcomes, and give postsecondary institutions stronger incentives for improvement.

Data and Information: Twelve recommendations were identified to address a lack of high-quality data on student outcomes and institutional behavior; prepare students to understand and make informed decisions regarding federal financial aid; and aid in comparing financial implications of one institution over another.

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HEALTH REFORM DEVELOPMENTS

John Colbert

February 25, 2020

Trends Archives

Debates by candidates seeking to be the Democratic party’s nominee to run against President Donald Trump in the upcoming election indicate that health care is a major policy issue that cries out for significant improvement. Proposals range from eliminating private forms of insurance coverage available through employers to protection offered solely by the federal government to a single-payer government operated program that also includes options for other forms of coverage. The latter choice recognizes that some beneficiaries may prefer having insurance provided by an employer rather than being compelled to participate in a governmental program.

Recent findings from the National Health Interview Survey help to highlight why some form of remediation is considered desirable. An estimated 14.2% of U.S. residents said they or a family member had problems paying medical bills in 2018, down from 19.7% in 2011, according to a report issued in February 2020 from the Centers for Disease Control and Prevention. The percentage of individuals in families having problems paying medical bills was higher among females (14.7%), children (16.2%), and non-Hispanic black persons (20.6%) compared with males, adults, and other racial and ethnic groups, respectively. Among persons under age 65, those who were uninsured were more likely than those with Medicaid or private coverage to have problems paying medical bills.

The Challenge Of Financing The Costs Of Health Care

National spending on healthcare is projected to grow 5.5% between 2018 and 2027, according to the Centers for Medicare & Medicaid Services (CMS) Office of the Actuary's annual report that was issued in February last year. This growth would outpace average projected GDP growth by 0.8%. The forecast means the healthcare segment of the U.S. economy would climb to 19.4% by 2027, up from 17.9% in just two years. Medicare for All is one proposal being touted as a way of addressing the challenge of financing the cost of health care. Differences exist among advocates of this approach regarding whether it will be necessary to impose additional taxes. Individuals in favor of higher taxation believe that the amount beneficiaries must pay will be offset by eliminating other expenses associated with deductibles, co-payments and co-insurance.

A concern is that even if Medicare for All ever becomes the law of the land, there is no guarantee that it will be implemented and sustained as originally planned. The Affordable Care Act furnishes compelling evidence of the kinds of unintended alterations that can occur once a significantly large national endeavor leaves the launching pad. An original element of the ACA pertained to Community Living Services and Supports (CLASS) as a means of meeting the costs of long-term care. Seventeen months after the law was enacted, however, the HHS Secretary announced that CLASS would be abandoned because it was unsound financially. Reforming the federal tax code in 2017 resulted in repeal of the individual mandate to purchase health insurance or pay a penalty for failing to do so. In December 2019, legislation was enacted to eliminate three mechanisms designed to pay for the ACA: the so-called “Cadillac Tax”, the “Health Insurer Tax”, and the “Medical Device Tax.”

Curbing Waste In The Provision Of Health Care Services

A review of 54 unique peer-reviewed publications, government-based reports, and reports from the gray literature described in the October 15, 2019 issue of the Journal of the American Medical Association yielded the following estimated ranges of total annual cost of waste: (1) failure of care delivery, $102.4 billion to $165.7 billion, (2) pricing failure, $230.7 billion to $240.5 billion, (3) fraud and abuse, $58.5 billion to $83.9 billion, and (4) administrative complexity, $265.6 billion. The estimated annual savings from measures to eliminate waste were as follows: (1) failure of care delivery, $44.4 billion to $97.3 billion, (2) pricing failure, $81.4 billion to $91.2 billion, and (3) fraud and abuse, $22.8 billion to $30.8 billion. No studies were identified that focused on interventions targeting administrative complexity. The estimated total annual costs of waste, including items not listed here, were $760 billion to $935 billion and savings from interventions that address waste were $191 billion to $286 billion.

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PULLING BACK THE CURTAIN

John Colbert

February 25, 2020

Trends Archives

Two events that are prominent in the nation’s annual political pageant enable voters to obtain a glimpse of the kinds of policies that may be concealed behind the curtain. One is the President’s State of the Union Address, which makes it possible to boast of past achievements and describe in broad terms anticipated future legislative initiatives. While members of the President’s party cheer vigorously at each utterance, Congressional members of the opposition party typically are more reticent. The second noteworthy event is the release by the Administration of its federal budget for the next fiscal year. Stock full of details on how money should be allocated, it’s relatively easy to determine which budgetary elements are destined to undergo some exceptionally rough legislative sledding based on who cheered wildly at the State of the Union address and who remained silent.

Lobbyists and leaders of special interest groups pay close attention to the proposed federal budget. Each year, the plot lines in the drama are reasonably clear. Many liberals tend to fret that important discretionary social programs involving health care and education will be seriously underfunded, while proclaiming that some military programs are too bloated and either should be eliminated outright or undergo significant reductions in spending. Many conservatives view matters differently and it is rare for them to fail to acknowledge what they perceive as redundant and wasteful amounts of money allocated for ineffective social programs.

The budget sent to Congress on February 10, 2020 contained some of the following items:

The administration proposes funding $38.7 billion for the National Institutes of Health (NIH) in FY 2021, which amounts to $3 billion less money or more than a 7% cut below the FY 2020 enacted program level.
The Agency for Healthcare Research and Quality (AHRQ) would be funded as a new institute within the NIH in the amount of $257 million, representing an $82 million (24%) reduction below AHRQ’s current funding level.
On the plus side, the budget proposes a nearly $900 million increase in career and technical education funding.
The Food and Drug Administration (FDA) would obtain a small budget increase in FY 2021 ($25 million, for a total of $3.29 billion).

Apart from legislation that involves spending, bipartisan cooperation has aided in producing efforts aimed at protecting patients from surprise medical billing. House Ways and Means Committee Chairman Richard Neal (D-MA) and Ranking Member Kevin Brady (R-TX) on February 7, 2020 announced the Consumer Protections Against Surprise Medical Bills Act of 2020 while Education and Labor Committee Chairman Robert “Bobby” Scott (D-VA) and Ranking Member Virginia Foxx (R-NC) revealed their surprise billing legislation, the Ban Surprise Billing Act.

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PRESIDENT’S CORNER

John Colbert

February 25, 2020

Trends Archives

BY ASAHP PRESIDENT PHYLLIS KING

A Blueprint for the Future (2020 – 2024) of the Association of Schools Advancing Health Professions

I am pleased to announce a new Strategic Plan is in place that articulates ASAHP’s priorities and will focus our energy and resources to best serve the organization in accomplishing its mission of advancing health through interprofessional collaboration. This plan includes a shared vision of ASAHP being THE source for interprofessional collaboration to improve health.

Values driving our actions include quality education, interprofessional collaboration, connecting education and health, innovation, leadership and diversity. Five strategic areas of activity have been identified, each led by a board member with a committee structure, to achieve ASAHP’s mission and vision:

Communications, public relations and marketing – Andrew Butler
Leadership development – Deborah Larsen
Education – Ces Thompson
Partnerships, alliances and advocacy – Teresa Conner-Kerr
Research, member services and programs – Brian Shulman

Over the coming months you will receive more detailed information on the activities and metrics each committee is employing and how you can be involved. Member benefits of networking, professional development, research and development, the institutional profile survey, the leadership development program, representation on the Federal level and in other health organizations, and publications are retained with an eye toward adding even more value for members. Rest assured you have a dedicated leadership team excited to shape the future of ASAHP and adapt to ever changing environments with you.

TEAM ABOUT TO BREAK THE HUDDLE TO REVISE STRATEGIC PLAN

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GEOGRAPHIC INFLUENCE ON HEALTH DISPARITIES

John Colbert

February 25, 2020

Trends Archives

Individuals possess distinguishing characteristics, such as age, education, level of income, extent of health insurance coverage, and degree of health literacy that contribute to the likelihood they will experience health disparities. Where they live and work also will play an important role due to a rural-urban divide that exists. For example, an article in the January 2020 issue of the American Journal of Preventive Medicine discusses how in the U.S., rural residents have poorer health than urban residents and this disadvantage is growing. Compared with metropolitan county residents, inhabitants of the most rural counties were seven percentage points more likely to have a usual source of care (81% vs 74%), but their providers were 13 percentage points less likely to be physicians (22% vs 35%). Despite having to travel longer to reach their usual source of care providers, residents of the most rural counties were 12 percentage points less likely than metropolitan residents to have usual source of care providers with office hours on nights and weekends (27% vs 39%).

Rural counties make up approximately 80% of the land area of this nation, but they contain less than 20% of the U.S. population. The relative sparseness of the population in rural areas is one of many factors that influence the health and well- being of the inhabitants of these places. An important difference pertaining to the health workforce is that some rural counties may lack the presence of a single member of a particular health profession, such as dentistry or psychiatry. Older patients with chronic ailments often require rehabilitation care, which typically requires a team consisting at a minimum of physicians, nurses, dietitians, occupational therapists, physical therapists, and speech therapists.

Hospitals often serve as the main type of venue where such teams are located, but as Seema Verma, Administrator of the Centers for Medicare & Medicaid Services, pointed out in a presentation she made on February 12, 2020 at the National Rural Health Association’s policy institute, more than 120 rural hospitals have closed since 2010, which does not appear to be a step in the right direction of ensuring the presence of a sufficient network of health providers. Unlike students who live in big cities that have access to several academic institutions with health professions programs reachable by subway and bus, rural students lack this luxury and may live hundreds of miles from educational resources. Fortunately, telehealth services can benefit patients and online degree programs may be available to enable the pursuit of academic degrees necessary to become health professionals, but it is not the same as having face-to-face kinds of opportunities that exist in urban areas.

Health policy is in a state of flux. Some presidential candidates propose new approaches, such as Medicare for All, but it is not entirely clear what impacts possibly could materialize that affect the delivery of health care services. Changes in reimbursement patterns, for example, either could slow the pace of hospital closings in rural areas or accelerate their disappearance if financing levels prove to be less than what is necessary to enable these facilities to remain afloat financially.

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GEOGRAPHY DETERMINES WHEN A DEATH CAN BE DECLARED

John Colbert

January 24, 2020

Trends Archives

Apart from decision fatigue, there is the issue of decision confusion. An example is that it is possible for an individual to be pronounced dead in one state, but not dead in a neighboring jurisdiction. As described in an article appearing on December 24, 2019 in the Annals of Internal Medicine, this situation exists because only 36 states have incorporated the complete language of the Uniform Determination of Death Act (UDDA) into their respective definitions of death. An original goal was for all states to adopt the UDDA as the legal standard for death by neurologic criteria (DNC). Instead, there is ongoing confusion about DNC since medical standards of determination vary, public acceptance is inconsistent, and responses to family objections have ranged from continuation of organ support indefinitely to unilateral discontinuation. Unresolved problems pertain to: (1) lack of uniformity in the medical standards used to determine DNC, (2) uncertainty about whether “all functions of the entire brain, including the brainstem” entail hormonal functions, (3) the UDDA does not address whether consent is needed before a determination of DNC, and (4) the UDDA does not address religious objections to discontinuation of organ support after DNC.

In a related vein, a debate is underway in the field of Alzheimer’s disease (AD) research over the definition of the disease itself. As described in the December 11, 2019 issue of the journal Science Translational Medicine, a problem is that the terms dementia and AD have become interchangeable. Arguments in favor of using a biological versus a clinical diagnosis for AD are that: the latter is not specific for any etiology; a biological definition of AD will lead to a better understanding of the sequence of events that leads to cognitive impairment and dementia; biological markers will improve efficiency of clinical trials; and a biological definition of AD enables study of the disease from the preclinical stage through all symptomatic stages and of all disease phenotypes, not only the memory loss phenotype.

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A CONCEPTUAL ANALYSIS OF DECISION FATIGUE

John Colbert

January 24, 2020

Trends Archives

The Lovesong of J. Alfred Prufrock by T.S. Eliot contains the following verse:

Time for you and time for me,
And time yet for a hundred indecisions,
And for a hundred visions and revisions,
Before the taking of a toast and tea.

The memory of the TRENDS newsletter’s editor of this portion of the poem was triggered while perusing an article on the topic of decision fatigue that appeared in the January 2020 issue of the Journal of Health Psychology, in which it is estimated that an American adult makes 35,000 decisions each day. While some of them seemingly are benign, an emerging body of science indicates that making decisions may possess negative ramifications for controlling one’s behavior and the quality of subsequent decisions. The phenomenon is known as “decision fatigue,” an impaired ability to make decisions and control behavior as a consequence of repeated acts of decision-making that often lead to choices that seem impulsive or irrational. Decision-making is a central component of modern health care, with each decision possessing some level of influence on patient outcomes. With a substantial proportion of all adults possessing at least one chronic condition, decision-making may be considered a central facet of day-to-day chronic disease self-management.

Decision fatigue as a concept has been applied scantily to health care disciplines, despite its potential relevance to inform the decision-making behaviors of patients and clinicians. If health professionals are working to the point where they are in severe states of ego depletion (manifesting as decision fatigue) and are not in an ideal cognitive state to make logical and safe decisions for patients, an exploration of decision fatigue may serve as a highly relevant and necessary endeavor. Hence, decision fatigue analysis may possess significance to inform regulatory policies related to health care employee workload.

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AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

John Colbert

January 24, 2020

Trends Archives

U.S. Investments In Medical And Health Research And Development 2013 - 2018

A new report from the advocacy group Research!America finds that the total spending on health and medical research was more than $194 billion in 2018. Since 2013, medical and health R&D spending has increased by $51 billion. Industry and academia funding have increased by nearly 40% over this time. Industry was responsible for two-thirds of the 2018 R&D funding, while federal agencies invested about 22%. Academic institutions and foundations made up the rest. Spending on health care far outweighs spending on health research. In 2018, $3.6 trillion was spent on care, which means research funding accounts for only five cents of every health sector dollar. The report can be obtained here.

More Americans Delaying Medical Treatment Due To Cost

Approximately one out of four Americans say the cost of treatment caused them to delay care for a serious medical condition, according to Gallup’s annual Health and Healthcare poll in 2019. An additional 8% of respondents indicated that costs played a factor in deciding to delay seeking care for less serious conditions. In 2018, 19% of Americans claimed that treatment costs led to a delay in treatment for a serious condition. The poll tracked a few trends within this data, including the following: On the basis of household income, 36% percent of adults with household income of less than $40,000 reported delaying treatment for a serious condition, a jump in 13 percentage points since last year. Rates stayed relatively flat for middle-and high-income households. Americans who reported having a pre-existing condition, or living with someone who has, were more likely to delay medical care for a serious condition this year compared to 2018. According to Gallup, these trends could have broad implications for both the health care system and the economy. The report can be obtained here.

Do Advanced Driver Assistance And Semi-Automated Vehicle Systems Lead To Improper Driving Behavior?

According to a report from the AAA Foundation for Traffic Safety, the ultimate goal of advanced driver assistance systems (ADAS) is to increase traffic safety and driving comfort. Despite their potential safety benefits, there are concerns about unintended consequences associated with intermediate levels of automation. In these scenarios, speed control and/or steering are automated, but the driver still is required to monitor traffic and be ready to resume control. A key concern is that drivers may become inattentive due to engagement in non-driving-related tasks or become drowsy while driving using these systems. As drivers gain experience using advanced driver assistance systems (ADAS), such as adaptive cruise control and lane-keeping assist, they also are more likely to drive distracted while using the systems, according to research from AAA Foundation for Traffic Safety. Conducted in collaboration with the Virginia Tech Transportation Institute, the study found that drivers with experience using ADAS were nearly twice as likely to engage in distracted driving while using the systems compared to when they were driving without the systems. Researchers noted the opposite effect in drivers with less familiarity using the technology. Those drivers were less likely to drive distracted with the systems engaged compared to when the systems were not in use. The report can be obtained here.

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More October 2020 TRENDS Articles

IN SEARCH OF CONNECTIONS

DUELING COVID-19 AID PACKAGES

HEALTH REFORM DEVELOPMENTS

DEVELOPMENTS IN HIGHER EDUCATION

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

BIG DATA, RESEARCH, AND ETHICS CHALLENGES FOR IRBs