QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Muscle-Building Exercise, Weapon Carrying, And Physical Fighting

Since the COVID pandemic began, gun violence and school violence have been on the rise while there has been an emphasis on muscularity as today’s body ideal for many boys. A new study published on May 12, 2022 in the Journal of Interpersonal Violence has revealed a link between the two. Cross-sectional data from the 2019 Youth Risk Behavior Survey (U.S.) were analyzed (N = 4120). Three forms of weapon carrying (general, on school grounds, gun carrying) and two forms of physical fighting (general, on school grounds) were assessed. Over 75% of participants reported engaging in muscle-building exercise. One in five (19.8%) participants reported any general weapon carrying in the past 30 days, 3.3% reported any weapon carrying at school in the past 30 days, 6.5% reported any gun carrying in the past 12 months, 28% reported any general physical fighting in the past 12 months, and 10.7% reported any physical fighting at school in the past 12 months.

Evaluation Of Age Patterns Of COVID-19 Mortality By Race And Ethnicity In The U.S.

As reported on May 17, 2022 in JAMA Network Open, reductions in COVID-19 mortality among older populations are remarkable. From March 2020 to October 2021, declines in death rates for the various racial and ethnic and sex combinations were especially large among those aged 80 to 84 years and those 85 years or older. Despite the availability of effective vaccines, COVID-19 mortality rose among younger adults. Possible factors underpinning these changing patterns are higher vaccination prevalence and less exposure to infection among older individuals. This advantage may have increased over time as younger individuals returned to work and other activities and the Delta variant emerged. Limitations included the use of provisional mortality data and the exclusion of other racial and ethnic groups owing to data quality issues. The rise in mortality rates among young adults underscores the value of increasing the lagging vaccination rate in this population.

HEALTH TECHNOLOGY CORNER

Machine Learning-Based In-Hospital COVID-19 Disease Outcome Predictor (CODOP)

Scientists have developed and validated CODOP, an algorithm to help identify who is most at risk of dying from COVID-19 when admitted to a hospital, according to a report of a study published on May 17, 2022 in eLife. This machine learning-based tool was trained, tested, and validated with six cohorts encompassing 29,223 COVID patients from more than 150 hospitals in Spain, the USA, and Latin America during 2020-22. CODOP uses 12 clinical parameters commonly measured at hospital admission for reaching high discriminative ability up to nine days before clinical resolution, it is well calibrated, and it enables an effective dynamic risk stratification during hospitalization. Furthermore, CODOP maintains its predictive ability independently of the virus variant and the vaccination status. The performance of this tool in heterogeneous and geographically disperse patient cohorts and the easiness of use strongly suggest its clinical utility, particularly in resource-limited countries.

Scent Dogs Detect Coronavirus Reliably From Skin Swabs

Results of a study published in May 2022 in BMJ Global Health involve estimating scent dogs’ diagnostic accuracy in identification of individuals infected with SARS-CoV-2 in comparison with reverse transcriptase polymerase chain reaction (RT-PCR). Researchers conducted a randomised triple-blinded validation trial, and a real-life study at the Helsinki-Vantaa International Airport, Finland. This controlled investigation comprised four identical sets of 420 parallel samples (from 114 individuals tested positive and 306 negative by RT-PCR), randomly presented to each dog over seven trial sessions. The validation experiments had an overall accuracy of 92% (95% CI 90% to 93%), a sensitivity of 92% (95% CI 89% to 94%) and a specificity of 91% (95% CI 89% to 93%) compared with RT-PCR. One finding highlights the importance of continuous retraining as new variants emerge. Using scent dogs may present a valuable approach for rapid screening of large numbers of individuals.

HEALTH REFORM DEVELOPMENTS

Individual health status can be enhanced by having adequate insurance coverage and ready availability of health care services. A new report from the National Center for Health Statistics (NCHS) presents coverage estimates of health for the civilian noninstitutionalized U.S. population based on data from the 2021 National Health Interview Survey (NHIS). These estimates are being published before final editing and final weighting so that access to the most recent information can be provided. Estimates are disaggregated by age group, sex, family income (as a percentage of the federal poverty level [FPL]), race and ethnicity, and state Medicaid expansion status. With three years of comparable data available starting with the redesigned NHIS in 2019, this report is able to provide data on trends, similar to reports using 2018 and earlier data. Estimates of health insurance coverage based on data from 2021 are provided, along with selected trends from 2019–2021.

In 2021, 30.0 million individuals of all ages (9.2%) were uninsured at the time of interview. This amount was lower than, but not significantly different from 2020, when 31.6 million persons of all ages (9.7%) were uninsured. In 2021, among adults aged 18–64, 13.5% were uninsured at the time of interview, 21.7% had public coverage, and 66.6% had private health insurance coverage. Among children aged 0–17 years, 4.1% were uninsured, 44.3% had public coverage, and 53.8% had private health insurance coverage. Among non-Hispanic White adults aged 18–64, the percentage who were uninsured decreased from 10.5% in 2019 to 8.7% in 2021. The percentage of individuals under age 65 with exchange-based coverage increased from 3.7% in 2019 to 4.3% in 2021.

Adverse Events In Hospitals

A separate item in this issue of the newsletter discusses the topic of health care quality. A Report in Brief that became available in May 2022 from the Office of Inspector General of the U.S. Department of Health and Human Services (HHS) indicates that 25% of Medicare patients experienced patient harm during their hospital stays in October 2018. Patient harm includes adverse events and temporary harm events. Among that group of patients, 12% experienced adverse events, which are events that led to longer hospital stays, permanent harm, life-saving intervention, or death. Also, 13% of patients experienced temporary harm events, which required intervention, but did not cause lasting harm, prolong hospital stays, or require life-sustaining measures. Temporary harm events sometimes were serious and could have caused further harm if providers had not treated patients promptly.

The most common type of harm event was related to medication (43%), such as patients experiencing delirium or other changes in mental status. The remaining events related to patient care (23%), such as pressure injuries; to procedures and surgeries (22%), such as intraoperative hypotension; and to infections (11%), such as hospital-acquired respiratory infections. Physician-reviewers determined that 43% of harm events were preventable, with preventable events commonly linked to substandard or inadequate care provided to the patient. Reviewers determined that 56% of harm events were not preventable and occurred even though providers followed proper procedures. Events were determined not preventable for several reasons, including that the patients were found to be highly susceptible to the events because of their poor health status.

Prices Paid To Hospitals By Private Health Plans

Findings from a new report by the RAND Corporation show that in 2020, across all hospital inpatient and outpatient services (including both facility and related professional charges), employers and private insurers paid 224% of what Medicare would have paid for the same services at the same facilities. That percentage is a reduction from the 247% figure reported for 2018 in the previous study owing to an increase in the volume of claims from states with prices below the previous mean price. Prices for common outpatient services performed in ambulatory surgery centers (ASCs) averaged 162% of Medicare payments, but if paid using Medicare, payment rates for hospital outpatient departments (HOPDs) would have averaged 117%. Although relative prices are lower for ASC claims priced according to HOPD rules, HOPD prices are higher than ASC prices. Little variation in prices is explained by each hospital’s share of patients covered by Medicare or Medicaid. A larger portion of price variation is explained by hospital market power. Prices for COVID-19 hospitalization were similar to prices for overall inpatient admissions and averaged 241% of Medicare.

FEDERAL REGULATION AND MORTALITY IN THE 50 STATES

As long as U.S. mortality rates continue to be an object of interest, it is worth considering the extent to which activities of the federal government have the potential to influence such rates. Congress regularly passes laws pertaining to health care that are enacted, while federal agencies have the responsibility of specifying in detailed language exactly how such laws should be implemented. An excellent source for discovering what unfolds in the sphere of regulations is the Federal Register, the official journal of the federal government. Published every weekday, except on federal holidays, it contains government agency rules, proposed rules, and public notices. Previous research speculates that some regulations are counterproductive in the sense that they increase (rather than decrease) mortality risk, but few empirical studies have measured the extent to which this phenomenon holds across the regulatory system as a whole. A study described in the March 2022 issue of the journal Risk Analysis was intended to estimate the effect of U.S. federal regulation on state-level mortality.

Investigators found that a 1% increase in federal regulation of state economies is associated with an increase in an index of state mortality of between 0.53% and 1.35%. The findings are robust to the form of mortality measure, choice of covariates, and the inclusion/exclusion of various regions, states, and industries. They also provided an update of the “cost-per-life saved cutoff,” which is the counterproductive risk threshold for expenditures. Financial outlays in excess of $38.6 million (2019 dollars) per life saved can be expected to increase mortality risk. Examples are provided of how unintended consequences of regulations can increase mortality in some cases. Fuel efficiency regulations have resulted in some automakers producing smaller cars, which can be more dangerous in an accident. The increased cost of flying as a result of Department of Homeland Security regulations may have induced individuals to drive instead, thereby increasing traffic accidents. Also, if individual expenditures on health are at all effective at reducing mortality risk and if regulatory costs are sizeable, it follows that regulatory costs induce some deaths. By extension, even regulations with a primary aim of reducing mortality can have the opposite effect if costs are excessive relative to benefits.

SPECIES OF ARTIFICIAL INTELLIGENCE (AI)

Charles Darwin in 1859 set the stage for the emergence of artificial intelligence (AI) when stating in the final sentence of his book Origin of Species, “from so simple a beginning endless forms most beautiful and most wonderful have been, and are being, evolved.” According to an article with the title, “From So Simple a Beginning:” Species of Artificial Intelligence that was published in the Spring 2022 issue of the journal Daedalus, artificial intelligence has a decades-long history exhibiting alternating enthusiasm and disillusionment for the field’s scientific insights, technical accomplishments, and socioeconomic impact. Recent achievements involve renewed claims for the transformative and disruptive effects of AI. Exponential increases in computing power, open-source software, available data, and embedded services have been crucial to this success. Yet, there is growing unease around whether the behavior of these systems can be rendered transparent, explainable, unbiased, and accountable. The author argues that artificial general intelligence (AGI)—able to range across widely differing tasks and contexts—is unlikely to be developed, or emerge, any time soon.

From driving cars to controlling critical infrastructure, from diagnosing illnesses to recommending content for entertainment, AI is ubiquitous. When in 2011 IBM announced a new age of cognitive computing with Watson, it was asked, why not turn Watson into a physician, but task transfer and generalization have turned out to be quite difficult. A physician’s general problem-solving is full of task and context changes. Rather than replicating accomplished physicians, IBM’s Watson Health has turned out AI assistants that can perform routine tasks. Recent possession of symbolic language and discovery of mathematics and formal systems of computation have provided tools to build and explore new AI systems, a broad repertoire of approaches and methods that remains essential. AI systems with their ability to represent and discover patterns in high dimensional data have as yet low dimensional embedding in the physical and digital worlds they inhabit. This thin tissue of grounding, of being in the world, represents the single largest challenge to realizing AGI, systems able to range across widely differing tasks and contexts reflectively.

AESCHYLUS AND HEALTH CARE QUALITY

An essay on the topic of death by Michel de Montaigne serves as a reminder about the manner in which the famous ancient Greek playwright Aeschylus met his fateful demise. Warned in a prophesy that he would die after being struck by a falling object, he took to the great outdoors to reduce the likelihood of such an outcome. While he was sitting by the sea, an eagle soaring aloft that had just captured a tortoise committed the error of mistaking the tragedian’s shiny bald pate for a rock. In order to crack the shell of its quarry, the bird unfortunately dropped it on the playwright’s head.

Similarly, health care is a sphere where many examples can be found of actions resulting in outcomes that differ from what originally was anticipated. Long-term efforts to achieve health reform have focused on access, cost, and quality. Three articles published in the April 29, May 5, and May 12, 2022 issues of the New England Journal of Medicine represent a scorecard for assessing how successful various initiatives have been in enhancing health care quality.

A premise is that to improve quality, the system must be fixed. As attractive as that notion may appear, the author indicates that some 30 years later, the fix itself is a massive system. As reimbursement models shift toward value-based payment, quality improvement (QI) no longer is just about being better, but also about documenting improvement to maximize payment. An entire industry has arisen to support the optimization and demonstration of performance. For example, CMS’s Merit-Based Incentive Payment System (MIPS) for ambulatory care settings found that clinicians and administrators invested about 200 hours per year to meet each physician’s MIPS requirements. That these hours could be spent in countless other ways, especially caring for patients, raises an obvious question: Is the system created to fix the system even working? Moreover, despite innumerable metrics and vast research assessing their worth, it still is not clear that what matters is being measured nor whether the tools to do so exist.

Another example involves CMS’s Hospital Readmissions Reduction Program (HRRP). In 2019, hospitals caring for a high percentage of Black patients were disproportionately likely to incur financial penalties. Hospitals serving the highest-risk patients incurred the largest penalties under the HRRP, independent of quality of care. Ironically, billions of dollars thus are being transferred from poorly resourced hospitals or those serving the sickest patients to well-resourced facilities, thereby worsening the disparities policymakers claim to be trying to fix.

Furthermore, a perception that practice variation signals quality deficiencies remains foundational to the pursuit of “high value” care. If value is defined as quality divided by cost, then measuring value faces all the same problems as measuring quality—flawed risk adjustment, metric gaming, and omission of the many aspects of quality that defy measurement. A good question is why continue to embrace these flawed constructs, particularly when it is not clear that the current regulatory approach effectively serves patients or clinicians?

MENTAL HEALTH FOCAL POINT

Glaring problems, such as an unacceptably high mortality rate stemming from drug overdoses, growing evidence of increased suicide ideation among some U.S. population subgroups, along with increases in gun violence and eating disorders have stimulated a bipartisan effort on Capitol Hill to have mental health legislation passed that addresses such problems effectively. For example, the rate of overdose deaths among U.S. teenagers nearly doubled in 2020, the first year of the COVID pandemic, and rose another 20% in the first half of 2021 compared with the 10 years before the pandemic, even as drug use remained generally stable during the same period. It is the first time in recorded history that the teen drug death rate has seen an exponential rise, according to new UCLA research that was published in April 2022 in the Journal of American Medical Association, even though rates of illicit drug use among teens are at all-time lows. The month of May 2022 featured the introduction of H.R. 7666, the Restoring Hope for Mental Health and Well-Being Act of 2022. The bill went from the Subcommittee on Health of the Committee on Energy and Commerce to the full committee on a vote of 32-0 and was passed as amended on a vote of 55-0 on May 18, 2022. This comprehensive legislative approach includes provisions to: • Have the Secretary of the Department of Health and Human Services (HHS) establish an office to coordinate work relating to behavioral health crisis care across the operating divisions and agencies of the Department, including the Substance Abuse and Mental Health Services Administration, the Centers for Medicare & Medicaid Services, and the Health Resources and Services Administration • Establish a behavioral health crisis coordinating office within the Substance Abuse and Mental Health Services Administration (SAMHSA) • Reauthorize the Garrett Lee Smith Memorial Act Suicide Prevention Program; the Maternal Mental Health Screening and Treatment Grant Program; grants to support American Indian and Alaska Native communities with mental health and substance use disorder prevention, treatment, and recovery services; and the Behavioral Health Workforce Education and Training Program • Require self-funded, non-federal governmental plans to comply with mental health parity laws In the Senate, a bipartisan effort also is underway to reauthorize a bill focusing on mental health care. Initially, the Mental Health Reform Act of 2015 was incorporated into the 21st Century Cures Act, which passed Congress in 2016. That 2016 law, P.L. 114-255, needs to be updated. An aim is to report out a comprehensive reauthorization bill in this session of Congress that establishes an Office of the Assistant Secretary for Mental Health; improves children’s access to mental health care by providing grants to integrate behavioral health care into primary care offices; promotes coordination of mental health benefits, increases recruitment of a diverse mental health workforce by expanding SAMHSA’s Minority Fellowship Program; and promotes access to mental health services by authorizing $25 million to support states' ability to enforce existing mental health parity laws.

AESCHYLUS AND HEALTH CARE QUALITY

An essay on the topic of death by Michel de Montaigne serves as a reminder about the manner in which the famous ancient Greek playwright Aeschylus met his fateful demise. Warned in a prophesy that he would die after being struck by a falling object, he took to the great outdoors to reduce the likelihood of such an outcome. While he was sitting by the sea, an eagle soaring aloft that had just captured a tortoise committed the error of mistaking the tragedian’s shiny bald pate for a rock. In order to crack the shell of its quarry, the bird unfortunately dropped it on the playwright’s head.

Similarly, health care is a sphere where many examples can be found of actions resulting in outcomes that differ from what originally was anticipated. Long-term efforts to achieve health reform have focused on access, cost, and quality. Three articles published in the April 29, May 5, and May 12, 2022 issues of the New England Journal of Medicine represent a scorecard for assessing how successful various initiatives have been in enhancing health care quality.

A premise is that to improve quality, the system must be fixed. As attractive as that notion may appear, the author indicates that some 30 years later, the fix itself is a massive system. As reimbursement models shift toward value-based payment, quality improvement (QI) no longer is just about being better, but also about documenting improvement to maximize payment. An entire industry has arisen to support the optimization and demonstration of performance. For example, CMS’s Merit-Based Incentive Payment System (MIPS) for ambulatory care settings found that clinicians and administrators invested about 200 hours per year to meet each physician’s MIPS requirements. That these hours could be spent in countless other ways, especially caring for patients, raises an obvious question: Is the system created to fix the system even working? Moreover, despite innumerable metrics and vast research assessing their worth, it still is not clear that what matters is being measured nor whether the tools to do so exist.
Another example involves CMS’s Hospital Readmissions Reduction Program (HRRP). In 2019, hospitals caring for a high percentage of Black patients were disproportionately likely to incur financial penalties. Hospitals serving the highest risk patients incurred the largest penalties under the HRRP, independent of quality of care. Ironically, billions of dollars thus are being transferred from poorly resourced hospitals or those serving the sickest patients to well-resourced facilities, thereby worsening the disparities policymakers claim to be trying to fix.

Furthermore, a perception that practice variation signals quality deficiencies remains foundational to the pursuit of “high value” care. If value is defined as quality divided by cost, then measuring value faces all the same problems as measuring quality—flawed risk adjustment, metric gaming, and omission of the many aspects of quality that defy measurement. A good question is why continue to embrace these flawed constructs, particularly when it is not clear that the current regulatory approach effectively serves patients or clinicians?

NON-REFLECTIVE PROCESSES AND HEALTH CARE QUALITY

One viewpoint is that translating research evidence into clinical practice to improve care involves having health care professionals adopting new behaviors and changing or stopping their existing behaviors. As noted in a paper appearing in the April 2022 issue of the journal Social Science & Medicine, however, changing professional behavior can be difficult, particularly when it involves altering repetitive, ingrained ways of providing care. Consequently, an increasing focus is being made on understanding health professionals’ behavior from the perspective of non-reflective processes, such as habits and routines, along with more often studied deliberative processes. Theories of habit and routine provide two complementary lenses for understanding professional behavior, but to date, each perspective has only been applied in isolation.

The objective of a study that was undertaken by investigators was to combine theories of habit and routine to generate a broader understanding of health care professional behavior and how it might be changed. The study involved having a group of experts meet for a two-day multidisciplinary workshop on how to advance implementation science by developing a greater understanding of non-reflective processes. From a psychological perspective, ‘habit’ is understood as a process that maintains ingrained behavior through a learned link between contextual cues and behaviors that have become associated with those cues. Theories of habit are useful for understanding an individual's role in developing and maintaining specific ways of working. Theories of “routine” add to this perspective by describing how clinical practices are formed, adapted, reinforced and discontinued in and through interactions with colleagues, systems, and organizational procedures. The researchers concluded that combining theories of habit and routines has the potential to advance implementation science by providing a fuller understanding of the range of factors operating at multiple levels of analysis, which can have an impact on the behaviors of health care professionals and on the provision of quality care.

IMPACT OF AGE STEREOTYPES ON OLDER INDIVIDUALS’ MENTAL HEALTH

The COVID-19 pandemic that began in the United States early in 2020 has produced many dramatic effects, including fatalities resulting from becoming infected. Another consequence that is attracting some attention is how stigmatization of older individuals has increased as exemplified by extensive press coverage of government officials that appear to devalue older individuals by suggesting they are unworthy of adequate medical care. According to an article published in the April 2022 issue of the The Journals of Gerontology: Series B, recent analyses of Twitter data found that the pandemic has sparked a proliferation of negative-age-stereotype-based comments. These incidents led to an effort to determine whether prevalent negative messaging about aging had a detrimental impact on older individuals’ mental health. The study also considered whether the relatively uncommon positive messaging about aging during the pandemic, such as news reports of older health-care workers who came out of retirement to help sectors overwhelmed by COVID-19, benefited older individuals’ mental health.

Data collection took place between April 23 and May 5, 2020, when stay-at-home pandemic policies were implemented throughout the United States. According to the investigators, this study is the first to demonstrate experimentally that structural ageism, by which societal institutions promote bias against older individuals, can have an impact on their mental health. Specifically, among older individuals, the negative-age stereotype messaging led to more anxiety and less peacefulness than among those exposed to neutral messaging. In contrast, among older individuals, the positive-age stereotype messaging led to less anxiety and more peacefulness than among those exposed to neutral messaging. Interventions in both the negative- and positive-age-stereotype conditions were drawn from actual media reporting about older persons during the COVID-19 pandemic. Study participants exposed to the negative-age-stereotype interventions were twice as likely to report moderate or severe levels of anxiety, compared to those exposed to the neutral conditions. Whereas, those exposed to the positive-age-stereotype interventions were twice as likely to report moderate or greater levels of peacefulness, compared to those individuals exposed to the neutral conditions.

DEVELOPMENTS IN HIGHER EDUCATION

The U.S. Department of Education on April 6, 2022 announced an extension of the pause on student loan repayment, interest, and collections through August 31 of this year. Although the economy continues to improve and COVID cases continue to decline, President Biden has made clear the ongoing need to respond to the pandemic and its economic consequences, as well as to allow for the responsible phase-down of pandemic relief. The extension will provide additional time for borrowers to plan for the resumption of payments, reducing the risk of delinquency and defaults after restart. During the extension, the Department will continue to assess the financial impacts of the pandemic on student loan borrowers and to prepare to transition borrowers smoothly back into repayment. Efforts include allowing all borrowers with paused loans to receive a “fresh start” on repayment by eliminating the impact of delinquency and default and allowing them to reenter repayment in good standing.

Payments and interest accrual have been paused for borrowers with federal student loans since March 13, 2020, at the beginning of the pandemic. The previous pause was scheduled to expire on May 1, following a 90-day extension that was announced as cases of the Omicron variant of Covid-19 surged in December 2021. Approximately 40 million individuals owe about $1.7 trillion in federal student debt, an amount larger than credit card or auto debt. Federal loans make up more than 90% of outstanding student debt. Borrowers with private loans are not eligible for the pause in payments, although some lenders and servicers have offered flexibility.

FY 2023 Budget Proposal Contents Involving Higher Education
The Biden Administration on March 28, 2022 submitted to Congress the President's Budget for fiscal year 2023 that begins on October 1 of this year. As a means of increasing equitable and affordable access to an education beyond high school, the budget would increase the maximum Pell Grant by $2,175 over the 2021-2022 award year, through a combination of discretionary and mandatory funding, helping an estimated 6.7 million students from low- and middle-income backgrounds overcome financial barriers. The proposed increase is a significant step in the budget's comprehensive proposal to double the maximum Pell Grant by 2029. Additionally, the Administration continues to support expanding federal student aid, including Pell Grant eligibility, to Deferred Action for Childhood Arrivals (DACA) recipients, commonly known as DREAMers.

The budget proposal also calls for enhancing institutional capacity at Historically Black Colleges and Universities (HBCUs), Tribally Controlled Colleges and Universities (TCCUs), Minority Serving Institutions (MSIs), and low-resourced institutions, including community colleges, by providing an increase of $752 million over the 2021 enacted level. This funding includes a $450 million initiative to expand research and development infrastructure at four-year HBCUs, TCCUs, and MSIs.

Growth In The Number of Master’s-Degree Programs In Less Than A Decade
Readers of the Chronicle of Higher Education had an opportunity on March 24, 2022 to learn about the rapid growth in the number of master’s-degree programs in the period 2011-12. According to data from the U.S. Department of Education, colleges and universities have added more than 9,000 of these programs. A Chronicle analysis of more than 2,200 public, private nonprofit, and private for-profit colleges from 2011-12 to 2019-20 found that about 60% of those institutions experienced growth in the number of master’s programs they offered. Growth spanned institutions of all types and sizes, including bachelor’s, master’s, doctoral, and four-year special-focus institutions.

Yale University increased its master’s programs by 1.2%, while Gordon College, a small private institution in Massachusetts, went from having two such programs in 2011-12 to 25 in 2019-20, a 1,150% increase. Approximately 160 colleges, nearly all institutions with fewer than 5,000 students, did not have a single master’s program in 2011-12, but had at least one by 2019-20. One institution, the online arm of Johnson & Wales University, ended up with 18 such programs.

HEALTH REFORM DEVELOPMENTS

Access, quality, and cost are the equivalent of a three-legged stool in health care policy. A steady increase in the overall size of the overall U.S. population and dramatic growth in the number and proportion of individuals age 65 and older, a group characterized by increased morbidity, point to a steady escalation of spending on health care. The Centers for Medicare & Medicaid Services (CMS) on March 28 of this year released the 2021-2030 National Health Expenditure (NHE) report, prepared by the CMS Office of the Actuary. It presents health spending and enrollment projections for the coming decade. The report notably shows that despite the increased demand for patient care in 2021, the growth in national health spending is estimated to have slowed to 4.2%, from 9.7% in 2020, as supplemental funding for public health activity and other federal programs, specifically those associated with the COVID-19 pandemic declined significantly.

The NHE has been published annually since 1960. It often is referred to as the “official” estimates of U.S. health spending. These historical and projected estimates of NHE measure total annual U.S. spending for the delivery of health care goods and services by type of good or service (e.g., hospital, physician, prescription drugs), type of payer (e.g., private health insurance, Medicare, Medicaid), and type of sponsor (e.g., businesses, households and federal/state governments). The NHE report also includes spending on government public health; investment in structures and equipment; and non-commercial research, as well as information on insurance enrollment and uninsured estimates.

The report finds that annual growth in national health spending is expected to average 5.1% over 2021-2030, and to reach nearly $6.8 trillion by 2030. Growth in the nation’s Gross Domestic Product (GDP) also is projected to be 5.1% annually over the same period. As a result of the comparable projected rates of growth, the health share of GDP is expected to be 19.6% in 2030, nearly the same as the 2020 share of 19.7%. Selected highlights in national health expenditures by major payer include:

Medicare

Spending growth is projected to average 7.2% over 2021-2030, the fastest rate among the major payers, and also is projected to exceed $1 trillion for the first time in 2023. By 2030, Medicare spending growth is expected to slow to 4.3% as Baby Boomers are no longer enrolling.

Medicaid

Average annual growth of 5.6% is projected for Medicaid spending for 2021-2030. Medicaid spending growth is expected to have accelerated to 10.4% in 2021, associated with rapid gains in enrollment. Spending is projected to exceed $1 trillion for the first time in 2028.

Private Health Insurance And Out-of-Pocket Expenditures

For 2021-2030, private health insurance spending growth is projected to average 5.7%. Out-of-pocket expenditures are projected to grow at an average rate of 4.6% over 2021-2030 and to represent 9% of total spending by 2030 (ultimately falling from its current historic low of 9.4% in 2020).

Impact Of COVID-19 On Employer-Sponsored Health Insurance Coverage

When the COVID-19 pandemic began, there was a concern that millions of Americans could lose employer-sponsored health insurance coverage and become uninsured. Researchers from the Urban Institute released a report in March 2022 based on an analysis of data from the National Health Interview Survey (NHIS), the Current Population Survey (CPS), and the Health Reform Monitoring Survey (HRMS). Among their findings are the following:

• The uninsurance rate among nonelderly adults (ages 18 to 64) remained flat between early 2019 and early 2021, according to all three surveys.

• Gains in public coverage offset estimated private coverage losses on all three surveys, but the CPS showed much smaller public and private coverage changes than the HRMS and the NHIS.

• Administrative data on Medicaid enrollment show substantial changes consistent with the estimates reported on the NHIS and the HRMS.

AVALANCHE OF PUBLIC POLICY ACRONYMS

Official Washington, DC constitutes a paradise for the generation of acronyms that involve public policy initiatives. For example, U.S. involvement in outer space exploration gave rise to the highly recognizable acronym NASA. Public figures, such as the nation’s chief executive have their own designations, e.g., POTUS. The health domain also has its fair share of visible acronyms as evidenced by the existence of COVID, NIH, CDC, FDA, and the ACA, with the latter serving as a shorthand version of the Patient Protection and Affordable Care Act of 2010.

It is not difficult to imagine the average length of time for eyes to glaze over completely when listeners to an oral presentation or readers of a document repeatedly are exposed to an item along lines of an apocryphal Society of Newsletter Editors Who Love Acronyms (SNEWLA). Generally, many periodicals in the health professions prove to be a rich source of additions to a steadily growing verbal mountain of acronyms. A noteworthy example is the Journal of Medical Entomology. An article in the March 2022 issue has a focus on achieving public policy goals to prevent and control the spread of infectious diseases.

Included among this smorgasbord of acronyms are the following: Vector-borne diseases (VBD); West Nile virus (WNV); CDC Epidemiology and Laboratory Capacity (ELC); Mosquito Abatement for Safety and Health (MASH); Pandemic and All-Hazards Preparedness and Advancing Innovation (PAHPAI) Act; Centers of Excellence (COEs); and CDC Southeastern regional center of excellence in vector-borne diseases (SERCOEVBD). These items appear in the article in ways that highlight the importance of sustained efforts needed to achieve legislative goals by collectively identifying specific areas for (1) improvement, and (2) solutions to address national inadequacies in vector-borne disease policy and infrastructure.

An effective vector-borne disease response in the U.S. is a task that requires national policy to fund research and control efforts against both endemic and epidemic diseases. One major opportunity to influence policy authorized to protect against VBD threats is balancing short-term versus long-term goals (i.e., fixing versus preventing a problem). Whereas the story of federal funding in the last 18 years is reactive to emerging VBDs, in recent years there have been efforts to create a proactive system. Emergency funds acquired during the 2016 Zika virus outbreak were used to establish five Regional Centers of Excellence (COEs) in Vector-Borne Diseases with the goal of preventing and responding to emerging vector-borne disease across the United States.

These COEs work to train public health entomologists, vector biologists, and medical providers in VBD-related skills and knowledge; develop and validate effective prediction, prevention, and control methods and tools; and strengthen and expand communities of practice. Conventional wisdom is that there will be additional vector-borne disease threats in the near future, whether in the form of the vectors themselves or pathogens crossing borders. The only way to address future threats responsibly will be through stable, consistent funding. As with many other worthwhile public policy endeavors, such as efforts to enhance the allied health workforce, persistence will be required from one year to the next.

CROSS-FERTILIZATION OF HEALTH CARE INNOVATIONS

Innovative developments that occur in one type of health domain are capable of being transported successfully to related areas. The horrors of war provide a major impetus for the ability to create and implement fast, effective means of treating battlefield casualties. Skills learned and applied in that arena often prove to be highly welcome in the civilian sector. Similarly, capabilities produced in civilian institutions have proven of immense benefit in the military setting.

Beginning in the 1960s with the Mercury Space Program, astronaut Alan Shepard was the first American to participate in a suborbital flight of short duration. Today, the average amount of time for a team of astronauts to be aboard the International Space Station (ISS) is six months. According to an article published in the February 2022 issue of the journal Nature Medicine, spending that amount of time high above the earth can exert an impressive toll on the human body. Bones lose density and their arteries thicken and stiffen the equivalent of a normal decade of terrestrial aging. Over a six-month period, an astronaut’s internal temperature can rise by one degree Celsius upon being exposed to the equivalent of 375 chest X- rays’ worth of radiation. These space travelers also become more susceptible to kidney stones, allergies, and infectious diseases. Even an astronaut’s height changes in space.

Thus, it has become mandatory to consider how to deal with these kinds of ill effects. Fortunately, there have been some successes. Already, technologies have been developed to help astronauts survive, including telehealth, portable ultrasounds, air purifiers, and gravity-compensating bodysuits, to name a few examples of innovations that have made their way down to terrestrial health care settings. Meanwhile, technology developed to help astronauts conduct basic medicine with limited tools and knowledge already has aided in the delivery of health care to remote places, such as Antarctica, ships at sea, or home care settings, which are hard to access and face a shortage of health care workers and supplies.

The all-civilian, four-person crew of SpaceX’s Inspiration4 mission in September 2021 tested out the Butterfly iQ, a handheld ultrasound, taking images of their hearts, lungs, and urinary systems without any ground support. That same pocket-sized device already has been deployed in rural communities around the world where X-ray, CT, and MRI machines are at distances many hours away. Other remote monitoring innovations, such as miniature and body-worn scanning devices can collect and track biomedical data

Moving forward, researchers are investigating ways to equip astronauts so they can serve as their own medical providers: monitoring their own health, diagnosing any issues, and treating them with whatever is onboard. Some researchers have focused on how to augment a spacecraft’s stores by using genetically modified plants as chemical factories so that astronauts someday could grow the medicine they need in space. All these advances offer the prospect of enhancing life for more earthbound inhabitants of this planet.

COLLECTIVE PERCEPTIONS OF AGING AND OLDER INDIVIDUALS

According to an article in the March 2022 issue of the Journal of Applied Gerontology, by 2060 the number of older adults (age 65+) in the U.S. is projected to be more than 98 million, up from 37.2 million in 2006. The American Geriatric Society reports a 45% rise in the demand for geriatricians through 2025 without an adequate workforce supply. Hence, the number of health care professions students entering the geriatric workforce must be increased to meet the imminent and complex needs of this growing population. To attract them, an understanding of the factors influencing career preference and what may prevent students from pursuing geriatric careers is necessary. A mixed methods study design of 864 students from eight healthcare professions (dietetics, medicine, nursing, pharmacy, physician assistant, physical therapy, social work, and speech-language pathology) is described that characterizes social factors that ultimately may influence career choice. The mean age of respondents was 24.0 ± 3.7 years. The majority were female (70.3%), White (63.5%), and represented graduate-level studies (80.3%). Over two-thirds of respondents reported prior experience with older adults through paid work (37.0%) or volunteer work (32.4%). Over half (56.9%) agreed or strongly agreed that they had a close relationship with their parents or grandparents.

Altogether, the results of this study demonstrated students’ variable and paradoxical views of aging and older persons. It may be that students are unable to process and resolve the contradiction on their own, suggesting that earlier intervention with exposure, mentoring, and modeling via positive educator and preceptor attitudes may be necessary to generate positive attitudes. Geriatric training and education programs are critical avenues to correct misperceptions, quell ageism, and address the current shortage in the geriatrician workforce. This investigation provides rich narrative examples of students’ perceptions and understanding of the aging process, as well as myths and misconceptions of aging and older individuals that can be used to inform geriatric curricula across multiple health professions training and education programs.

INTERSECTING VULNERABILITIES AND CASCADING CONSEQUENCES

A separate article in the current issue of this newsletter discusses how the health care sphere in the U.S. can be characterized as consisting of dynamic multiscale systems. Tackling problems effectively in diverse areas will require not only linking vast datasets that encompass numerous components and spatio-temporal scales, but also bringing together multiple disciplines, institutions, departments, and programs. A related way of viewing how to move forward is described in a paper appearing in the March/April 2022 issue of the MIT Technology Review. A case is made for meeting the biggest challenges of today and the future by mobilizing leadership roles across the technology industry, academia, and government so that they act in concert in an innovation ecosystem. A good example demonstrating the power of such a system when mobilized in a crisis is the speed with which vaccines against COVID-19 were developed and deployed.

Vaccines alone have not overcome this pandemic because this disease has revealed weaknesses in the health care system, supply chains, labor markets, social safety net, and even the political system as a way to mount coherent responses to a complex problem. The pandemic also exposed a deeper truth, i.e., that certain triggering events leave the U.S. population subject to intersecting vulnerabilities, with cascading consequences. The appearance and spread of COVID is such a triggering event. In a deeply interconnected world with inherent instabilities that include climate change, inadequate cybersecurity, non-state bad actors, and geopolitical tensions of all kinds, such triggering events are likely to become more frequent if work is not undertaken to forestall them. The risks are not merely economic that hurt both knowledge and a technology-intensive economy, they also are strategic that threaten national and global security. A powerful innovation ecosystem needs to become both more agile and more robust in the face of these risks. Moreover, risk assessments at the federal level must become more holistic and integrated, examining the effect of one danger on another. In conjunction with universities and industry, a government coordinating body should be planning for hazards that could compound other hazards, and offering strategic focus and funding for discoveries and innovations designed to respond to and mitigate them as part of an overall innovation policy.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Structural Racism As A Mediator Of Disparities In Acute Myeloid Leukemia

Black and Hispanic individuals with acute myeloid leukemia (AML) in greater Chicago were more likely to die from the disease than their non-Hispanic white counterparts, with a 59% and 25% greater risk, respectively, according to a new study led by University of Illinois Chicago researchers that was published online January 21, 2022 in the journal Blood. Researchers examined how structural violence, neighborhood disadvantage, perpetuated by social, economic and political systems, can set the stage for poorer outcomes in patients with AML. Strikingly, census tract measures accounted for nearly all of the disparity in leukemia death. Treatment patterns, including induction intensity and allogeneic transplant, as well as treatment complications, as assessed by ICU admission during induction chemotherapy, were additional mediators of survival disparities. The study highlights the need to investigate mechanisms by which structural racism (e.g., segregation) interacts with known prognostic and treatment factors to influence leukemia outcomes.

Suicide Mortality In The United States, 2000–2020

In 2020, suicide was the 12th leading cause of death for all ages in the United States, changing from the 10th leading cause in 2019 due to the emergence of COVID-19 deaths and increases in deaths from chronic liver disease and cirrhosis. As the second leading cause of death for individuals aged 10–34 and the fifth leading cause in the age group 35–54, suicide is a major contributor to premature mortality according to a March 2022 data brief from the National Center for Health Statistics (NCHS). Suicide rates increased from 2000 to 2018, but recent data have shown declines between 2018 and 2020. The leading means of suicide for females in 2020 was firearm-related, a change from previous years, while rates for males have continued to increase. This report presents final suicide rates from 2000 through 2020, in total and by sex, age group, and means of suicide, using mortality data from the National Vital Statistics System (NVSS). This report updates a provisional 2020 report and a previous report with final data through 2019.

HEALTH TECHNOLOGY CORNER

Exposure To Adverse Lead Levels In Early Childhood

Lead is a developmental neurotoxicant in wide industrial use that once was broadly distributed in the environment. The extent of the US population exposed in early life to high levels of lead is unknown, as are the consequences for population IQ. Little evidence is available on the harms past lead exposures continue to hold for yesterday’s children, who are victims of what is termed legacy lead exposures, according to an article published on March 7, 2022 in Proceedings of the National Academy of Sciences of the USA. Investigators estimate that more than 170 million Americans alive today were exposed to high-lead levels in early childhood, several million of whom were exposed to five-plus times the current reference level. These estimates allow future work to plan for the health needs of these Americans and to inform estimation of the true contributions of lead exposure to population health. The researchers estimate population-level effects on IQ loss and find that lead is responsible for the loss of 824,097,690 IQ points as of 2015.

Ants Can Detect Cancer Cells Through Volatile Organic Compounds

Cancer detection is a major public health challenge. Methods, such as MRIs and mammograms available to achieve it often are expensive and invasive, which limits large-scale use. An alternative method being explored by scientists from the CNRS, Université Sorbonne Paris Nord, Institut Curie involves the sense of smell of the species of ants, Formica fusca. As described in a paper appearing in the March 18, 2022 issue of the journal iScience, after a few minutes of training, these insects, which use smell for daily tasks, were able to differentiate healthy human cells from cancerous human cells. Cancer cells are characterized by an altered metabolism, producing unique patterns of volatile organic compounds (VOCs) that can be used as biomarkers. Each cell line had its own smell that could be used by the ants to detect them. The efficacy of this method must now be assessed using clinical trials on a human being, but this first study shows that ants have high potential, are capable of learning quickly, at lower cost, and are efficient.

DEVELOPMENTS IN HIGHER EDUCATION

Another section of this issue of the newsletter describes how omnibus appropriations legislation will increase funding for various government agencies in the health domain. The field of education also will benefit from the availability of added money. The enactment of Consolidated Appropriations Act, 2022 (H.R. 2471) will provide $3 billion for higher education to fund increases for most Title IV programs at the U.S. Department of Education. The maximum Pell Grant will undergo a $400 increase that raises it to $6,895. Although the boost is a welcome development, an aim is to double the grant, an objective that was advocated by some Democrats during the campaign for the presidency in 2020. Compared to funding in FY 2021, Federal Work-Study, Federal Supplemental Educational Opportunity Grants, TRIO, and GEAR UP are among the other programs benefiting from modest increases for FY 2022.

Historically Black colleges and universities (HBCUs), tribal colleges and universities, and other primarily minority serving institutions (MSIs) are highly important entities that will experience an increase of $96 million compared to the previous fiscal year. The overall amount of funding is $885 for these institutions. A related consideration is that HBCUs and MSIs will have more flexibility regarding how COVID-19 relief aid is spent. Another noteworthy feature pertains to the acquisition of real property or construction directly related to preventing, preparing for, and responding to the coronavirus.

While acknowledging these gains, within the education community there is a concern that other unresolved issues warrant additional government action. An example is the necessity of addressing the student debt crisis. Thus far, the Biden administration has approved approximately $16 billion in targeted forgiveness, according to the Education Department. Students who qualify for the total and permanent discharge program due to disability, who qualify for the Public Service Loan Forgiveness program with nonprofit or government work, or who were misled by fraudulent schools have been the beneficiaries of this forgiveness. A partial remedy is that payments on student loans have been paused by the federal government since March 2020 because of the COVID-19 pandemic. Unless further action is taken, payments will resume in May of this year.

The Changing Face Of Federal Regulations

The Higher Education Act (HCE) is a vital piece of legislation that undergirds a great many key governmental activities. Initially passed in 1965, it has been rewritten on eight separate occasions since that year. In its most current version, although originally destined to expire at the end of 2013, the law has been extended by Congress. It remains unclear when the next reauthorization will take place. Until then, however, agencies achieve their respective agendas by using regulations to do so. A concern is that some regulations can be guaranteed to be reversed whenever a new occupant resides in the White House. It used to be more the case that once regulations were formulated, they tended to remain in place for lengthy periods of time. The current pattern is for rules to come and go in cycles that reflect which political party is in control of the executive branch. The result affecting colleges and universities can be somewhat chaotic when they attempt to implement official guidance that experiences constant revisions.

The Negotiated Rulemaking Process

Typically, the Department of Education develops its proposed regulations without public input and then publishes them in the Federal Register for comment by the public. The published document is known as a Notice of Proposed Rulemaking, or NPRM. Under negotiated rulemaking, the Department works to develop an NPRM in collaboration with representatives of the parties who will be affected significantly by the regulations. A series of meetings is conducted during which these representatives, referred to as negotiators, work with the Department to reach consensus on the Department’s proposed regulations. The Institutional and Programmatic Eligibility Committee had its 1st session on January 18-21, its 2nd session on February 14-18, and the 3rd session on March 14-18. Gainful employment is an example of a topic discussed at these sessions. Registration links closer to the start of negotiations are posted at www2.ed.gov/ policy/highered/reg/hearulemaking/2021/index.html, along with recordings and transcripts of the meetings on that site.

OMNIBUS SPENDING PACKAGE APPROVED

Once again, the clock was ticking and a continuing resolution (CR) that provided funds for the federal government to continue operating was about to expire on March 11. With only a single day to go before another CR might have to be created, legislators in both chambers rose to the occasion by producing an omnibus bill, the Consolidated Appropriations Act, 2022 (H.R. 2471), for President Biden to sign into law to furnish money for the remainder of FY 2022. Although the achievement required nearly six months of effort after the current fiscal year began last October, a collective sigh of relief throughout the government accompanied this outcome.

Despite being at loggerheads on many issues in a Congress almost evenly divided between Democrats and Republicans serving in both House and Senate, the results were greeted with general satisfaction by both groups. Weighing in at a colossal 2,700 pages, 1.5 trillion dollars now can be divided in varying amounts among all 12 fiscal year 2022 spending categories. Division H of the bill pertains to the Labor-HHS-Education section. For example, $45 billion is designated for the National Institutes of Health (NIH), representing a $2.5 billion (4.7%) increase over the comparable FY 2021 funding level, the seventh consecutive increase since FY 2016. The CDC has been awarded $8.4 billion, an increase of $582.4 million (7.4%) above the FY 2021 program level. The Agency for Healthcare Research and Quality (AHRQ) will receive $350 million, an increase of $12.4 million (3.7%) above the FY 2021 spending level. The Health Resources and Services Agency (HRSA), an entity that has a major focus on the health workforce, will benefit from obtaining $799 million for Title VII Health Professions and Title VIII Nursing Workforce Development Programs, a $45.1 million (5%) increase above FY 2021 comparable levels.

Disagreements over how much funding to provide for defense and non-defense purposes account for some of the delay that occurs each year in the appropriations process. Democrats tend to place more emphasis on supporting various social programs rather than defense activities, while Republicans generally are more inclined to do the opposite. For FY 2022, the omnibus legislation allows for almost equal increases in defense and nondefense spending from FY 2021 levels, with a $42 billion ( 5.6%) increase in defense accounts and $46 billion or a 6.7% boost for nondefense programs. Democrats originally hoped to double that amount. Another factor that helps to slow down the speed of legislation is an attempt by Democrats each year since 1976 to override the Hyde Amendment, a provision barring the use of federal funds to pay for abortion, except to save the life of a woman, or if her pregnancy arises from incest or rape. That component remains intact.

Appropriations legislation from previous years was famous for including “earmarks” for special endeavors favored by members from each party in both chambers. Senator William Proxmire (D-WI) became famous for creating what he called the “Golden Fleece Award.” From 1975 to 1988, he issued on a monthly basis 168 such honors. His purpose was to expose to public view the somewhat less than noble ways in which the federal government wastes the hard-earned money of taxpayers. Banned 11 years ago, the new round of spending includes some 5,000 separate earmarks at a cost of $9.7 billion.

DYNAMIC MULTISCALE SYSTEMS

The health care sphere can be characterized as consisting of dynamic multiscale systems. Typically, it is viewed as comprising silos that often function independently of one another in ways that lessen the likelihood of achieving effective outcomes. A positive intervention constructed in recognition of this problem is the ongoing creation of activities that place a much greater focus on interprofessional cooperation. One form occurs at educational institutions where students from different professions are given opportunities to learn more about what other disciplines have to offer in the provision of clinical services. The workplace is a related venue where many kinds of clinicians must work together seamlessly to deliver optimal patient care.

Occasionally, this newsletter has apprised readers of other developments that are not viewed necessarily as pertaining exclusively to the health domain, but still have considerable relevance. As an illustration of this wider viewpoint involving the Anthropocene (the current geological period during which human activity has been the dominant influence on climate and the environment), the May 2021 issue of TRENDS featured a discussion of how the insect world is influenced adversely by human activity, such as habitat loss occurring when humans move to previously uninhabited locales and use of pesticides. Insects play a vital role in a terrestrial food web that affects many species of birds, bats, reptiles, amphibians and fish, while also performing essential functions involving pollination, pest control, and nutrient recycling.

Along similar lines, it is worth noting that biological challenges facing the world are complex, multi-factorial, and intimately tied to the future of human health, welfare, and stewardship of the earth. Tackling problems constructively in diverse areas, such as agriculture, ecology, and health care will require linking vast datasets that encompass numerous components and spatio-temporal scales. The December 2021 issue of the journal Integrative and Comparative Biology became available earlier this month. An article in it on the “Axes of Life,” provides a new framework and a road map for using experiments and computation to understand dynamic biological systems that span multiple scales. Theories are offered that can help understand complex systems and highlight the limitations of existing methodologies.

Meanwhile, there are barriers to bringing together all disciplines, institutions, departments, and programs successfully because of disciplinary variations, such as language, terminology, and definition. It also could be due to self-imposed barriers that limit interactions among disciplines. A tendency to gravitate toward like-minded individuals reduces cross-pollination that could bolster advances in interdisciplinary science. Different disciplines may approach similar problems from different perspectives, which causes a separation in focus when disparate groups try to answer similar questions. One remedy might be to produce more journals that are interdisciplinary. ASAHP’s Journal of Allied Health furnishes a positive example of the wisdom of implementing such an approach.

DISABILITY TRAINING FOR HEALTH WORKERS

Steady growth in the portion of the population age 65 and older in the U.S. and other nations is associated with an increase in the onset of various disabilities. As noted in an article published in January 2022 in the Disability and Health Journal, individuals with disabilities often face significant barriers to health care, including lack of accessible transport and facilities; limited financial protection; poor health worker attitudes that result in worse outcomes; or limited health worker training on disability. Moreover, even in countries where there is guaranteed universal access and financial protection, health workers’ unfamiliarity with disability, or negative attitudes toward patients with disabilities, not only could foster an unwelcoming environment, but also contribute to high rates of patient safety issues and lower quality care. A principal aim described in this journal article was to understand the published literature on training health workers about disability.

The investigators searched five databases for relevant peer-reviewed articles published between January 2012 and January 2021. Studies that focused on training health care workers to improve knowledge, confidence, self-efficacy, and competence to support individuals with physical, sensory, or intellectual impairments were included. Data about the details of the intervention (setting, participants, format, impact assessments, etc.) and its effects were extracted. They found that there is an array of highly local tools to train health workers across stages of their training and careers (preservice, in-service, and continuing professional development). Studies involving patients with disabilities in the training, community placements, simulations, or interactive sessions were found to be most effective in improving knowledge, confidence, competency, and self-efficacy. These researchers concluded that as part of initiatives to build inclusive health systems and improve health outcomes, health workers around the world need to receive appropriate and evidence-based training that combines multiple methods and involves people with disabilities. To monitor progress on the impact of training, there also should be a standardized measure of impact on core outcomes. Additionally, while focusing on training by impairment is useful, there also is a need to have holistic disability training. Improving the standardization of core competencies that training on disability should address and measures of impact for disability training can further improve progress in this area.