DEVELOPMENTS IN HIGHER EDUCATION

Nothing tends to remain static in the realm of post-secondary education. Recent months have shown that many institutions have experienced large-scale growth in the number of new master’s degree program offerings. Depending on the institution, a shrinking pool of students applying for admission to college poses a hazard if tuition income is heavily relied upon to stay in existence. Any decline in endowments and donations also may result in various unwelcome outcomes, such as terminating academic programs that do not attract sufficient numbers of students and decreasing the size of faculty and staff. Financial pressures have made it necessary to convert to a greater reliance of adjunct faculty who do not need to occupy office space on campus, are not provided with health and retirement benefits, and whose salary may be limited to teaching a single course instead of being remunerated as a full-time faculty member.

Many smaller, private institutions around the United States may be faced with such challenges. As an alternative to shutting their doors, the only viable option may be to merge with another college or university. A recent example occurred earlier this month when the University of the Sciences in Philadelphia merged with Saint Joseph’s University, a Jesuit school, in that city. This new single institution will bear Saint Joseph’s name. Such mergers also may lead to the possibility that some academic offerings will no longer be available and both faculty and staff positions may have to be eliminated in order to create a leaner set of operations that will be less expensive to maintain.

Condition Of Education Report 2022

The Condition of Education is an annual report mandated by the U.S. Congress that summarizes the latest data on education in this nation. The report uses data from the National Center for Education Statistics and from other sources and is designed to help policymakers and the public monitor the condition and progression of education. For example, in fall 2020, some 69% (10.9 million students) of the total under-graduate population were enrolled at four-year institutions. The remaining 31% (4.9 million students) were enrolled in two-year institutions. At the postsecondary level, total undergraduate enrollment decreased by 9% from fall 2009 to fall 2020 (from 17.5 million to 15.9 million students). For male and female students, enrollment patterns exhibited similar trends between 2009 and 2019 (both decreasing by 5%. From 2019 to 2020, however, female enrollment fell 2%, while male enrollment fell 7%. Additionally, between 2019 and 2020, undergraduate enrollment dropped 5% at public institutions and 2% at private nonprofit institutions. In contrast, undergraduate enrollment at for-profit institutions was 4% higher in fall 2020 than in fall 2019, marking the first positive single year change in enrollments at these institutions since 2010. Meanwhile, at the postbaccalaureate level, enrollment in master’s and doctoral programs increased by 10% between fall 2009 and fall 2020 (from 2.8 million to 3.1 million students).

Gainful Employment And For-Profit Educational Institutions

A new study from The Institute for College Access and Success (TICAS) indicates that the U.S. Department of Education (ED) designed the Gainful Employment (GE) rule as a baseline accountability metric to ensure that career education programs leave their graduates with debts that are affordable relative to their eventual earnings. The rule worked on multiple fronts, from improving institutional quality, lowering costs, and saving taxpayer money to advancing racial equity in how career education programs served historically marginalized students. The GE rule also worked to mitigate the large number of students at for-profit colleges, disproportionately Black and Latino students, from ending up in student loan default. In 2019, ED officials rescinded the rule at an estimated cost to taxpayers of more than $6 billion. Since then, ED has lacked this baseline accountability measure to hold low-performing career education programs accountable for low earnings and saddling their students with unmanageable student loan debt. In early 2022, the Department presented a proposal to create an earnings threshold metric that would complement the 2014 rule’s debt-to-earnings (D/E) metric to constitute a new GE rule. TICAS has modeled how the proposed threshold potentially would have an impact on GE programs. Under the proposed earnings measure, more than 40% of GE programs at for-profit institutions would fail, risking the ability to qualify for federal student aid.

HEALTH REFORM DEVELOPMENTS

An aspect of the troika known as health care access, cost, and quality that does not often receive the attention it warrants is scope of practice laws in the states. Substantial amounts of time and money are spent throughout the U.S. by members of certain professions to enhance their scope of practice. Their efforts are opposed by members of other professions who devote similar amounts of energy to preventing these groups from succeeding. The main rationale for this staunch resistance is to protect the safety of patients. Nonetheless, once additional states loosen restrictions and allow other professions to expand their scope of practice, eventually hundred of thousands of patients will have been treated by the newcomers. If the outcome is that none or a neglible amount of them were endangered in any way, then an argument that the public is at a serious risk of injury as a result of changing practice laws begins to lose some of its power to persuade legislators.

For example, Colorado Governor Jared Polis on June 7, 2022 signed into law HB 22-1233, making that state the 10th one to allow optometrists to perform laser procedures. The legislation, which goes into effect on August 10 of this year, also will allow the practice of optometry to include several interventions that include eyelid injections and use of local anesthetic. Despite opposition from the American Academy of Pediatrics, Colorado Medical Society, Colorado Society of Eye Physicians & Surgeons, and the American Society of Plastic Surgeons, the optometrists were successful in convincing legislators that experience in nine other states has shown that patient safety concerns should not be a factor in preventing optometrists from enhancing their scope of practice. Moreover, since care by ophthalmologists is not readily available throughout the state, access by patients to vision care will be improved. Similarly, other professions that engage in efforts to enhance their scope of practice on the basis of being able to provide safe care and address the problem of underserved areas include: nurse practitioners v. physicians; dental hygienists/therapists v. dentists; psychologists v. psychiatrists; and nurse anesthetists v. anesthesiologists.

Medicare Prospective Payment Systems And Proposed Policy Changes

Medicare is a highly important federal health program that is instrumental in meeting the needs of millions of beneficiaries. As it continues to increase in size over the decades, it also undergoes constant change. A recent example of how modifications tend to occur can be found in the May 10, 2022 issue of the Federal Register, the official journal of the federal government of the U.S. This particular edition contains a proposed rule that would affect several different functions, including the Hospital Inpatient Quality Reporting (IQR) Program and Hospital-Acquired Condition (HAC) Reduction Program. Detailed in small print at three columns per page, the proposed rule covers 639 pages and is drenched in a torrent of acronyms, e.g., Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Interested parties were invited to comment on the proposed rule and the deadline for doing so was no later than 5 p.m. EDT on June 17, 2022. Hundreds of respondents have expressed their views.

Examples of some concerns are that if the rule is implemented, the Centers for Medicare & Medicaid Services (CMS) will be able to suppress hospital data and measures of preventable hospital-cause harm, such as falls resulting in serious injuries. A related issue is that the 10-measure Patient Safety and Adverse Events Composite (PSI 90) would be hidden from public data files and would not appear on the CMS Hospital Compare website. Also, worst-performing hospitals no longer would be subject to a reduction in Medicare reimbursement. An overall concern is that the ability to identify providers with patient safety problems will be compromised seriously.

Public’s Confidence In Federal Government Employees

As exemplified by a recent proposed Medicare rule on May 10, 2022 that required 639 pages of triple-columned pages to describe, at some juncture program staff will have to synthesize all the public comments that arrive and decide the extent to which these views will affect the contents of that rule. Clearly, federal agencies have a significant impact on the lives of U.S. inhabitants. Meanwhile, according to a report on June 6 of this year from the Pew Research Center, the share of Americans who have a great deal or fair amount of confidence in career employees at federal agencies has declined among Democrats and Republicans since 2018. A decline in appreciation for the work these employees do probably will not act as a major disincentive to finding some joy in carrying out their daily tasks.

APPROPRIATIONS PROCESS IS UNDERWAY

The major federal legislative task of crafting a series of spending bills that can be enacted into law has begun. Similar to previous years, the prospect of completing work by the end of the present fiscal year on September 30 does not appear to be especially promising. A more likely outcome is that a continuing resolution (CR) will be necessary to fund the federal government beyond the end of the fiscal year this coming September 30. Given that 2022 involves conducting a national election, all House members and one-third of Senate members will be campaigning with a hope of staying in office. The result could be that reaching agreement on the 12 annual spending bills will have to be postponed until a lame-duck session after the November elections.

No budget is in place this year because a budget resolution that sets overall limits in spending has not been adopted. That step should have been completed in April. Instead, a shortcut budget in the form of a deeming resolution was produced recently in the House of Representatives that provides for a spending cap of $1.6 trillion to be enforced when bills reach the House floor. That amount is enough to begin work on the one dozen separate pieces of legislation. The House Appropriations Committee then can use this overall number, known as a “302(a)” after its section in the 1974 budget law to divide it into a dozen “302(b)” subcommittee allocations. Apart from disagreements over defense and non-defense spending amounts, controversy also can be anticipated regarding how much the spending bills will contribute to increasing the federal budget deficit.

Typical battles occur annually regarding efforts to achieve parity between defense and non-defense expenditures, which led to many lengthy delays in finalizing legislation for the current fiscal year. The result was that comparable increases were provided in both the defense and non-defense accounts. It usually proves to be quite difficult to resolve such differences.

The House Appropriations Committee has updated its markup schedule with an aim of acting on each of the 12 spending bills before the end of June 2022. A plan is to bring plans to the House floor in July. Senate appropriators seem less inclined to proceed on a similar timetable. Members of that chamber can be expected to focus on total defense versus non-defense spending levels, with Republicans advocating for an increase in defense spending that exceeds the rate of inflation. Now that inflation is at its highest peak in several decades, it should prove highly challenging to reach an agreement on a spending package that aligns with that elevated level.

ASAHP belongs to the Health Professions and Nursing Education Coalition (HPNEC), which submitted outside witness testimony on May 26, 2022 to reiterate fiscal year 2023 funding priorities to the House Labor, Health and Human Services, Education, and Related Agencies (Labor-HHS) Appropriations Subcommittee. The Coalition advocates adequate and continued support for authorized health professions and nursing workforce development programs. The subcommittee is encouraged to adopt at least $1.51 billion for Titles VII and VIII programs of the Health Resources & Services Administration (HRSA).

REIFICATION OF A HEALTH BEDROCK

Demography is a useful tool for projecting social challenges that must be addressed in the future. Whether through steady increases in the number of births that occur in the U.S. or through immigration, this country’s population will continue to grow. Perhaps more importantly, both numerically and proportionately, increased growth will occur among individuals ages 65 and older. This cohort also will be distinguished by the disproportionate existence of various chronic co-morbidities that will strain the nation’s ability to address health and health-related social needs pertaining to problems, such as dementia. Three major sectors in the health sphere can play important roles in undertaking improvements in the years that lie ahead.

Higher Education Institutions in the health professions must continue to place an emphasis on ensuring that education programs will enable students to work cooperatively and effectively in team-based care with members of other professions. These schools play a fundamental role in the production of adequate numbers of graduates to serve as faculty, researchers, and clinicians. The latter group should be equipped with the ability to furnish high quality care to a broad spectrum of patients with dementia that differ according to key factors, including age, gender, race/ethnicity, culture, health literacy, and digital competency. A necessary set of skills will involve the provision of person-centered care that includes taking into account patient preferences, their life history, and opportunities to advise them about ways of achieving dementia risk reduction.

Clinical Settings will entail service delivery by health care providers working in conjunction with informal caregivers in the home environment. Both as part of their formal educational preparation and in providing patient care, a necessary skill will be an ability to offer education for the informal group to become competent in providing care to in-home patients. These individuals should be able to support medication management within the home setting, especially since improper pharmaceutical use is associated with an increase in fall risks among individuals living with dementia. Caring for this kind of patient is distinctive insofar as they may experience progressive declines in physical, cognitive, and emotional functioning. Because some caregivers themselves are in advanced age brackets, they may be at risk of stress-related declines in physical and mental health status.

Policymakers work in government programs, such as Medicare and Medicaid, and health insurance companies in the private sector. Recognizing the burdens placed on informal caregivers in the home setting, there needs to be increased opportunities for these individuals to benefit from respite services. The WHO in 2019 published its first evidence-based guideline on dementia risk reduction, which currently must be implemented into policy and practice. Direct and indirect costs of dementia will continue to soar unless changes are made in the way care is delivered. A greater understanding is needed of how cognitive impairment affects care delivery costs in the context of the Medicare home health benefit. Health insurance coverage options are complicated and confusing. Additional efforts are required to make this information more understandable for all concerned parties.

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.

OBTAINABLE RESOURCES

How Black Women Experience Student Debt

A new Brief from The Education Trust is the first in a four-part series using qualitative data from the National Black Student Debt Study. The forthcoming briefs will be released over the next few months and will cover income-driven repayment plans, the impact of student debt on mental health, and Parent PLUS loans. Forty-five million Americans collectively owe student loan debt. Women hold nearly two-thirds of that debt, and because of the gender pay gap, are more likely than men to have trouble paying off their debt. Black borrowers are the group most negatively affected by student loans. Black women enroll in college at higher rates than Black men, but because they exist at the intersection of two marginalized identities and experience sexism and racism at the same time, they make less money and often need to borrow more to cover the cost of attendance, and struggle significantly with repayment. Financial aid hasn’t kept pace with college costs, which are now unaffordable for most Americans. In 1980, the maximum Pell Grant, the nation’s most important need-based grant, covered more than 50% of the full cost of a public four-year college; in the 2020-21 academic year, it covered only 28%, driving many students to borrow to make up the difference. A year after completing a bachelor’s degree, Black women hold more student debt than any other group, with an average of $38,800 in federal undergraduate loans. Black female borrowers who attended graduate school hold an average of $58,252 in graduate loans. The Brief can be obtained here.

National Imperative To Improve Nursing Home Care Quality

Nursing homes play a unique dual role in the long-term care continuum, serving as a place where patients receive needed health care and a place they call home. Ineffective responses to the complex challenges of nursing home care have resulted in a system that often fails to ensure the well-being and safety of nursing home residents. The devastating impact of the COVID-19 pandemic on nursing home residents and staff has renewed attention to the long-standing weaknesses that impede the provision of high-quality nursing home care. With support from a coalition of sponsors, the National Academies of Sciences, Engineering, and Medicine formed the Committee on the Quality of Care in Nursing Homes to examine how the United States delivers, finances, regulates, and measures the quality of nursing home care. The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff identifies seven broad goals and supporting recommendations which provide the overarching framework for a comprehensive approach to improving the quality of care in nursing homes. The report can be obtained here.

Fair Share Spending By NonProfit Hospitals For Their Communities

Nonprofit hospital systems are expected to return to their communities in amounts that justify their massive tax breaks. A new report from the health care think tank, the Lown Institute, indicates that this result is rarely the case. A determination shows that 227 of the 275 systems studied had fair share deficits, meaning they spent less on charity care and community investment than the value of their tax exemption. Adding the fair share deficits of all hospital systems together reveals $18.4 billion in stranded dollars that could have been used to advance health equity, housing, food insecurity, and other local needs. The 10 private nonprofit hospital systems with the largest fair share deficits (FY 2019) account for $5.6 billion of the $18.4 billion total fair share deficit. Many of these systems also received hundreds of millions from the CARES Act in 2020 and ended the year with high net incomes. In seven states, the total fair share deficit for all hospitals exceeded $1 billion (CA, PA, NY, OH, IL, MI, MA). Data sources were hospital tax filings from fiscal year ending 2019, the most recent year available for most hospitals. Information on hospital systems’ CARES Act grant funding and excess revenue were obtained through hospitals’ public audited financial statements. The report can be obtained here.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Sexually Transmitted Diseases (STDs) Remain Too High

Reported cases of sexually transmitted diseases (STDs) in the United States decreased during the early months of the COVID-19 pandemic in 2020, but most resurged by the end of that year. Ultimately, reported cases of gonorrhea, syphilis, and congenital syphilis surpassed 2019 levels, while chlamydia declined, according to new data published on April 12, 2022 by the Centers for Disease Control and Prevention (CDC). The data provide the clearest picture yet of COVID-19’s impact on this nation’s STD epidemic. Reported cases of gonorrhea and primary & secondary (P&S) syphilis were up 10% and 7%, respectively, compared to 2019. Syphilis among newborns (i.e., congenital syphilis) also increased, with reported
cases up nearly 15% from 2019, and 235% from 2016. Early data indicate primary and secondary syphilis and congenital syphilis cases continued to increase in 2021 as well. Reported cases of chlamydia declined 13% from 2019.

Trends in Drug Overdose Deaths Among US Adolescents, January 2010 to June 2021

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, according to new UCLA research. It is the first time in recorded history that the teen drug death rate has seen an exponential rise, even though rates of illicit drug use among teens are at all-time lows. Published on April 12, 2022 in JAMA, this study indicates that beginning in 2020, adolescents experienced a greater relative increase in overdose mortality than the overall population, attributable in large part to fatalities involving fentanyls. In the context of decreasing adolescent drug use rates nationally, these shifts suggest heightened risk from illicit fentanyls, which have variable and high potency. The highest rates of overdose deaths were among American Indian and Alaska Native adolescents.

HEALTH TECHNOLOGY CORNER

Use Of Smart Sensors To Ensure Vaccine Safety

A new study from Tel Aviv University enables developers, for the first time in the world, to determine vaccine safety via smart sensors that measure objective physiological parameters. According to the researchers in an article published on March 14, 2022 in Communications Medicine (part of the Nature family of journals), most clinical trials testing the safety of new vaccines. including COVID-19 vaccines, rely on participants' subjective reports, which can lead to biased results. In contrast, objective physiological data, obtained through sensors attached to the body, are clear and unambiguous. The study was conducted when many Israelis received their second dose of the COVID-19 vaccine. The investigators believe that there is no reason to rely on self-reports or wait for the occurrence of rare side effects like myocarditis, an inflammation of the heart muscle, which occurs in one of 10,000 patients. Innovative sensors monitored 13 physiological parameters, such as: heart rate, breathing rate, cardiac output, and blood pressure.

Ancestral Diversity And Genetic Loci For Anthropometric Traits

Researchers in genomic studies examine the DNA of a population to understand the influence of genetics on health and disease. Although genomic studies have been common for more than a decade, most participants in these studies have been of European descent. Hispanic/Latinos have been underrepresented in genome-wide association studies (GWAS) for anthropometric traits despite their notable anthropometric variability, ancestry proportions, and high burden of growth stunting and overweight/obesity. Results of a study published on April 14, 2022 in the journal Human Genetics and Genomic Advances show that increasing the diversity of genomic samples can improve researchers’ ability to identify important genetic markers for health conditions. A goal of conducting genomic studies is to develop precision medicine, which is the delivery of the exact treatment or medication that individuals need exactly when they need it. To date, the article is the largest published genomic study of body measures in Hispanic/Latino individuals.

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.