HEALTH AND SAFETY
Young Athletes and Concussions
Sports-related concussions and their effects on the developing brains of young people have become a significant public health concern in recent years. Approximately 250,000 sports- and recreation-related concussions and other traumatic brain injuries (TBIs) among youths ages 19 and under were treated in U.S. emergency departments in 2009. However, estimates of the overall incidence of sports-related concussions are likely to be conservative, in part because many young athletes encounter a "culture of resistance" to reporting when they might have a concussion or to following treatment plans, says Sports-Related Concussions in Youth: Improving the Science, Changing the Culture.
The committee that wrote the report found that research about youth concussions is limited and identified several areas for further research, including establishing a national surveillance system to accurately determine the number of sports-related concussions, identifying changes in the brain following concussions in youth, conducting studies to assess the consequences and effects of concussions over a life span, and evaluating the effectiveness of sports rules and playing practices in reducing concussions.
Once a concussion is recognized and diagnosed, its management is of vital importance, but a standard level and duration of rest needed does not exist. Researchers should establish specific metrics and markers of concussion diagnosis, prognosis, and recovery for youths and create age-specific, evidence-based guidelines for managing short- and long-term consequences of concussions.
There is little evidence that current sports helmet designs reduce concussion risk, the committee found. Nevertheless, it recommended properly fitted helmets, face masks, and mouth guards still be worn because they reduce the risk of other injuries, such as skull fractures and facial and dental injuries.
Since the report was released, the Concussion Awareness and Education Act of 2014 was introduced in the U.S. House of Representatives, and the National Athletic Trainers' Association is convening a task force of representatives from many groups involved in youth sports -- such as the National Collegiate Athletic Association, National Federation of State High School Associations, and U.S. Department of Education -- to examine options for changing the culture around concussions.
This study by the Institute of Medicine and National Research Council was funded by Centers for Disease Control and Prevention, U.S. Department of Defense, U.S. Department of Education, Health Resources and Services Administration, National Athletic Trainers' Association Research and Education Foundation, National Institutes of Health, and the CDC Foundation with support from the National Football League.
The Childhood Vaccine Schedule
Roughly 90 percent of American children receive most of the childhood vaccines advised by the federal immunization schedule by the time they enter kindergarten. However, some parents have concerns about the number of doses that children receive or object to having their children immunized at all. The U.S. Department of Health and Human Services asked the Institute of Medicine to review the available evidence on the safety of the schedule.
The Childhood Immunization Schedule and Safety: Stakeholder Concerns, Scientific Evidence, and Future Studies finds no evidence that the schedule is unsafe. If signals arise that indicate the need to investigate the schedule, the report offers a framework for conducting safety research using existing or new data collection systems.
The current schedule entails 24 immunizations by age 2 given in amounts ranging from one to five injections during a pediatric visit. The schedule is designed to protect children from 14 pathogens by inoculating them at the time in their lives when they are most vulnerable to disease. Studies have repeatedly shown the health benefits associated with the recommended schedule, including fewer illnesses, deaths, and hospital stays, the report notes. Every new vaccine is tested for safety and evaluated in the context of the entire schedule before it is added. And the systems designed to detect possible harmful effects of immunization have worked well at discovering any problems with individual vaccines.
However, the elements of the schedule -- the number, frequency, timing, order, and age at which vaccines are administered -- are not well-defined in existing research and should be improved, the report says. Newer data collection and surveillance systems offer great potential to monitor for rare adverse events that may be associated with the childhood immunization schedule.
The study was funded by the U.S. Department of Health and Human Services.
Physical Activity for Children
Only about half of school-age children meet the current guideline of at least 60 minutes of daily vigorous or moderate-intensity physical activity, as recommended by the U.S. Department of Health and Human Services. However, evidence suggests that increasing physical activity and fitness may improve academic performance -- especially in mathematics and reading -- and that the benefits of engaging in physical activity during the school day outweigh the benefits of exclusive use of classroom time for academic learning.
Given the implications for the overall health, development, and academic success of children, most daily physical activity should occur during regular school hours in physical education classes, recess or breaks, and classroom time dedicated to physical activity, with additional opportunities available through active commutes to and from school, before- and after-school programs, and participation in intramural or varsity sports, says Educating the Student Body: Taking Physical Activity and Physical Education to School.
Moreover, schools should devote 30 minutes per day in elementary school and 45 minutes per day in middle and high schools to physical education, and at least half of that class time should be spent engaged in vigorous or moderate-intensity physical activity.
The Institute of Medicine study was funded by the Robert Wood Johnson Foundation.
A Crisis in Cancer Care
In the United States, more than 1.6 million new cases of cancer are diagnosed each year. By 2030, cancer incidence is expected to rise by 45 percent as the segment of the population that accounts for most cancer diagnoses -- older adults -- rapidly increases.
Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis notes that a combination of factors, including higher demand, a shrinking oncology workforce, rising costs of cancer care, and the complexity of the disease and its treatment, is straining an already overburdened system.
The report recommends strategies for improving cancer care, beginning with a system that supports patients in making informed medical decisions that are consistent with their needs, values, and preferences. New models of team-based care can also promote coordinated care for patients with cancer and respond to existing workforce shortages and demographic changes. And to achieve higher-quality care, the workforce must include enough clinicians with essential core competencies for providing care to patients with cancer.
The report also called for a system that can "learn" by enabling real-time analysis of data from cancer patients in a variety of care settings; tools and initiatives that can help clinicians incorporate new medical knowledge into routine care; and accessible and affordable cancer care, especially for vulnerable and underserved populations, such as those who lack access to health care, are of lower socio-economic status, are older, or are racial or ethnic minorities. Since the report's release, the National Association of Managed Care Physicians is using guidance from the report to create a new program to empower cancer patients, physicians, insurance providers, and employers, and improve transparency regarding cancer care choices.
The study was funded by the National Cancer Institute; Centers for Disease Control and Prevention; AARP; American Cancer Society; American College of Surgeons, Commission on Cancer; American Society of Clinical Oncology; American Society of Hematology; American Society for Radiation Oncology; California HealthCare Foundation; LIVESTRONG; National Coalition for Cancer Survivorship; Oncology Nursing Society; and Susan G. Komen for the Cure.
Variation in Medicare Spending
Although Medicare is a national program, variations in spending among different regions of the country -- unrelated to actual health outcomes -- have been documented for years. The Centers for Medicare and Medicaid Services asked the Institute of Medicine to investigate these variations in spending and quality and to analyze payment policies that could encourage high-value care.
The resulting report, Variation in Health Care Spending: Target Decision Making, Not Geography, says a "geographic value index" that would tie Medicare payment rates to the health benefits and costs of health services in particular regions of the country should not be adopted by Congress. Decisions about health care generally are made at the level of the physician or organization, such as a hospital, not at the regional level. Because individual physician performance varies, sometimes even within a single practice group, an index based on regions is unlikely to encourage more efficient behavior among individual providers or improve the overall value of health care.
To improve care, payment reforms need to create incentives for behavioral change by decision makers, whether they are at the level of individual providers, hospitals, health care systems, or stakeholder collaboratives, the report says. CMS should continue to test Medicare payment reforms that encourage the clinical and financial integration of health care delivery systems and the coordination of care among individual providers. CMS should also evaluate the effects of test payment reforms on health care quality, and if they prove effective Congress should give CMS the flexibility to accelerate the adoption of the new Medicare payment models.
The study was funded by the Centers for Medicare and Medicaid Services.
Adjusting to Life After Deployment
More than 2.2 million troops have served in the wars in Iraq and Afghanistan. Although the majority has readjusted well to post-deployment life, a large minority -- 44 percent -- has reported difficulties since returning home.
Returning Home From Iraq and Afghanistan: Assessment of Readjustment Needs of Veterans, Service Members, and Their Families, a report from the Institute of Medicine, says that the U.S. departments of Defense and Veterans Affairs should ensure that their systems have sufficient capacity to provide timely and adequate care to service members, veterans, and their families. The agencies need to boost efforts to reduce the stigma associated with getting care for mental health and substance abuse problems. More efforts are also needed to support the readjustment needs of military family members.
Significant percentages of personnel deployed to Iraq and Afghanistan have suffered traumatic brain injuries (TBI), and many have shown symptoms of post-traumatic stress disorder, depression, and substance misuse or abuse. In many ways, DOD and VA health care providers are at the forefront of providing evidence-based care for TBI and psychological health problems. But the tool that DOD uses to assess cognitive function after a head injury has no clear scientific evidence basis to assure its effectiveness. In addition, VA includes a depression therapy among its front-line treatments that lacks sufficient evidence. And DOD policy prohibits restricting that individual's access to privately owned weapons even if a service member is at risk for suicide.
The report calls for comprehensive, longitudinal studies that increase the understanding the physical, psychological, and social impact of combat. The departments should also complete work as soon as possible on an interoperable electronic health record that will help service members and veterans more easily navigate the services offered by each department and ease the transition from one to the other.
The study was funded by the U.S. Department of Defense.
A Global Response to HIV/AIDS
Through the President's Emergency Plan for AIDS Relief (PEPFAR), one of the most ambitious global health efforts in history, Congress has authorized over $60 billion to address HIV, malaria, and tuberculosis in more than 100 countries during the past decade.
Evaluation of PEPFAR, a congressionally mandated report from the Institute of Medicine, finds that the initiative's bilateral HIV programs have saved and improved millions of lives, offering proof that HIV/AIDS services can be effectively delivered on a large scale in countries with high rates of disease and resource constraints. Overall, PEPFAR reset the world's expectations for what can be accomplished with ambitious goals, ample funding, and humanitarian commitment to a public health crisis.
Working with a wide range of international and local partners, PEPFAR has expanded HIV testing, increased the number of people receiving clinical care and being treated with antiretroviral drugs, and increased services to prevent mother-to-child HIV transmission during pregnancy and birth. Described as a lifeline across partner countries, the initiative has trained hundreds of thousands of service providers, provided additional nonclinical support services for people living with HIV/AIDS, and made an unprecedented investment in programs for orphans and vulnerable children. PEPFAR has also strengthened health systems and engaged with partner countries to facilitate HIV policy and planning.
Going forward, the report says, greater attention to a range of prevention strategies is needed, in particular preventing sexual transmission of HIV, which is responsible for the majority of new infections. The report also recommends the need to support partner countries in taking on greater responsibility for sustainably managing their own HIV/AIDS programs. PEPFAR's guidance should be reoriented from prescribing specific activities to outlining key outcomes and enabling partner countries to determine how to prioritize their efforts to achieve these outcomes.
The study was funded by the U.S. Department of State.
Health Effects of Inorganic Arsenic
People can be exposed to inorganic arsenic through various foods or drinking water, raising questions about the extent to which such exposure contributes to the development of cancer or other health problems. The U.S. Environmental Protection Agency is planning to address such questions using its Integrated Risk Information System (IRIS), and asked the National Research Council to review its draft plan for the assessment.
Critical Aspects of EPA's IRIS Assessment of Inorganic Arsenic -- Interim Report says that to reach the best evidence-based conclusions, EPA's draft plan should take greater advantage of the extensive data on the naturally occurring element. It also recommends alternative statistical approaches over EPA's current default methods for estimating risk.
The interim report largely agrees with EPA's plan to include a framework for categorizing various health problems according to how strongly the evidence supports or suggests causal relationships with exposure to inorganic arsenic and offers a starting point for prioritizing those health outcomes. Lung, skin, and bladder cancer, ischemic heart disease, and skin lesions should be priority outcomes for EPA to evaluate, followed by prostate and renal cancer, diabetes, non-malignant respiratory disease, pregnancy outcomes, neurodevelopmental toxicity, and immune effects.
In addition, newer studies of exposures in the low to moderate range deserve considerable attention, and a key objective of EPA's assessment should be to better characterize risks at lower exposure levels. The agency should also consider whether separate analyses are merited to determine whether factors such health status, sex, age at exposure, or genetic factors might affect people's susceptibility to health effects from inorganic arsenic.
The study was funded by the U.S. Environmental Protection Agency; a final report is expected in the spring of 2014.