HEALTH AND SAFETY
Making Cardiac Arrest Less Deadly
Cardiac arrest strikes close to 600,000 people each year in the U.S. and is the nation’s third leading cause of death behind cancer and heart disease, according to estimates. More than half of cardiac arrests occur outside of hospitals, where the survival rate is less than 6 percent. And for those that do occur in hospitals, the survival rate is just 24 percent.
Cardiac arrest treatment is a community issue, requiring a wide range of people to be prepared to help, says Strategies to Improve Cardiac Arrest Survival: A Time to Act. The report identifies several actions that first responders, emergency medical personnel, health care providers, and communities should take to improve responses and boost survival rates.
Effective treatment demands an immediate response from an individual who can recognize cardiac arrest, call 911, start CPR, and use an automated external defibrillator (AED), the report says. Decreasing the time between cardiac arrest onset and the first chest compression is critical. The likelihood of surviving decreases by 10 percent with every passing minute between collapse and return of spontaneous circulation, although new research offers hope in extending this time.
Although evidence indicates that receiving CPR and defibrillation from a bystander can significantly improve survival and outcomes from cardiac arrest, each year less than 3 percent of the U.S. population receives CPR and AED training. The report calls for wider education and training on recognizing cardiac arrest, administering CPR, and using AEDs.
EMS systems vary in capacities and resources to respond to complex medical needs such as cardiac arrest. Educating and training EMS providers to administer “high-performance CPR” -- which emphasizes team-related factors such as communication and collaboration to attain high-quality CPR -- and providing dispatcher-assisted CPR can help increase the likelihood of positive outcomes. The report also calls for strategies to improve systems of care within hospital settings, efforts to improve accountability for survival rates, increased surveillance and research, and enhanced collaboration within the resuscitation field.
The Academies’ study was funded by the American Heart Association, American Red Cross, American College of Cardiology, Centers for Disease Control and Prevention, National Institutes of Health, and the U.S. Department of Veterans Affairs.
Better Diagnosis of a Serious Illness
Between 836,000 and 2.5 million Americans suffer from myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Characterized by profound fatigue, cognitive dysfunction, sleep abnormalities, and other symptoms that are made worse by exertion of any sort, ME/CFS can severely impair one’s ability to carry on a normal life. Some individuals struggle with symptoms for years before receiving a diagnosis, and many health care providers misunderstand the disease or lack knowledge about diagnosis and treatment.
Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness recommends new diagnostic criteria to improve timely diagnosis and care and enhance understanding among health care providers and the public.
Diagnosis of ME/CFS requires that a patient have three core symptoms: a substantial reduction or impairment in the ability to engage in pre-illness levels of activities that persists for more than six months and is accompanied by fatigue -- which is often profound -- of new or definite onset, not the result of ongoing excessive exertion and not substantially alleviated by rest; worsening of patients’ symptoms after any type of exertion -- such as physical, cognitive, or emotional stress -- known as post-exertional malaise; and unrefreshing sleep. To receive a diagnosis, the report says that patients should also have cognitive impairment or the inability to remain upright with symptoms that improve when lying down.
The report also calls for the name of the disease to be changed to systemic exertion intolerance disease (SEID) to more accurately capture the central characteristic of the illness -- that exertion of any sort can adversely affect the patient’s health, often seriously and for long periods. The terms “chronic fatigue syndrome” and “myalgic encephalomyelitis” perpetuate misunderstanding of the illness.
After the report’s release, NIH announced efforts to advance research on the disease, including launching a research protocol at the NIH Clinical Center to study individuals with ME/CFS following a probable infection and renewing a multi-institute research effort.
The Academies’ study was funded by the Office on Women’s Health within the U.S. Department of Health and Human Services, National Institutes of Health, Centers for Disease Control and Prevention, U.S. Food and Drug Administration, Agency for Healthcare Research and Quality, and U.S. Social Security Administration.
Access to Timely Health Care
Tremendous variability in wait times for health care appointments exists throughout the U.S., ranging from same-day service to several months. Delays in access to health care have negative effects on health outcomes, patient satisfaction, health care utilization, and organizational reputation.
Transforming Health Care Scheduling and Access: Getting to Now calls for health care providers to develop “systems-based approaches” -- similar to systems-based engineering approaches applied successfully in industries beyond health care -- that would to provide immediate engagement of a patient’s concern at the point of initial contact. Such approaches could be used at in-person appointments as well as in alternatives such as team-based care; electronic, telephone, or video consultations; and surge capacity agreements with other caregivers and facilities.
The report notes that same-day options have been successfully employed through a variety of strategies, and to improve access to health care, continuous assessment, monitoring, and realigning of supply and demand are required. In addition, alternatives to in-office physician visits, including the use of non-physician clinicians and telephone consultants, can often meet patients’ needs.
Different clinical circumstances and patient preferences will compel different approaches, the report says. However, certain basic access principles should apply across all settings, such as ongoing evaluation; immediate engagement of patient concerns at the time of inquiry; and patient choice of timing and nature of care invited at the time of inquiry. National leaders should help spread and implement these basic access principles; instigate coordinated federal initiatives across multiple departments; broadly promote systems-based strategies in health care; and propose, test, and apply standards development. Also, professional societies should help lead in the application of these system approaches, and public and private payers should provide financial and other tools.
The Academies’ study was funded by the U.S. Department of Veterans Affairs.
Implications of Raising the Minimum Age for Tobacco Purchase
Over the past 50 years, tobacco control efforts in the U.S. have led to an estimated 8 million fewer premature deaths. However, tobacco use continues to significantly affect public health, and more than 40 million Americans still smoke. Although the Family Smoking Prevention and Tobacco Control Act of 2009 granted the U.S. Food and Drug Administration broad authorities over tobacco products, it prohibited FDA from establishing a nationwide minimum age of legal access (MLA) to tobacco products above 18 years of age. In response to congressional direction, FDA asked the Academies to assess the potential public health implications of raising the MLA.
The resulting report, Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products, says increasing the MLA to tobacco products would prevent or delay initiation of tobacco use by adolescents and young adults, particularly those ages 15 to 17, and improve the health of Americans across the lifespan. The report estimated the likely reductions in tobacco-use initiation that would be achieved by raising the MLA to 19, 21, and 25, and used two tobacco-use simulation models to quantify the accompanying public health outcomes. says that the overarching lesson learned is that nuclear plant licensees and their regulators must actively seek out and act on new information about hazards that have the potential to affect nuclear safety.
Raising the MLA to 21 would likely have a substantially greater impact on reducing the initiation of tobacco use -- defined as having smoked 100 cigarettes -- than raising it to 19 would. Between ages 15 and 17, social networks and potential sources of tobacco start to increase as mobility increases with driving privileges and as adolescents take on part-time jobs with co-workers who may be over the MLA. Therefore, increasing the MLA to 19 may not change access to tobacco products through friends and other social sources substantially for this age group, but raising the MLA to 21 is likely to have a considerable impact on initiation. However, the added effect of raising the minimum age beyond age 21 to age 25 would probably be less substantial.
Since the report was released, several states and many localities have raised the minimum age to 21 for purchase of tobacco products. The Academies’ study was funded by the U.S. Food and Drug Administration.
Keeping Older Brains Sharp
The aging process affects the brain just like any other part of the body. Known as “cognitive aging,” the type and rate of change can vary widely among individuals: Some will experience very few, if any, effects, while others may experience changes in their memory, speed of processing information, problem solving, learning, or decision-making abilities.
Cognitive Aging: Progress in Understanding and Opportunities for Action identifies three top actions that individuals can take to help maintain optimal cognitive abilities as they grow older:
- Be physically active.
- Reduce and manage cardiovascular disease risk factors, including high blood pressure, diabetes, and smoking.
- Regularly discuss and review health conditions and medications that might influence cognitive health with a health care professional.
Other actions that may promote cognitive health include being socially and intellectually active, getting adequate sleep, and carefully evaluating products that claim to improve consumers’ cognitive health. For example, despite widespread publicity about the benefits of vitamins and supplements for brain health, the medical literature does not convincingly support any vitamin supplement as effective for preventing cognitive decline, the report says. Similarly, claims about cognitive aging related products such as computer games or brain training techniques require careful evaluation by consumers and in regulatory review. Review of relevant policies, regulations, and guidelines by the Food and Drug Administration and Federal Trade Commission is needed.
Noting that older adults lose an estimated $2.9 billion a year to financial fraud, the report also calls for the development of cognitive aging information resources and tools from financial and other institutions that can help individuals and families. Increased research on risk and protective factors and interventions to promote cognitive health and prevent or reduced cognitive decline is also needed.
The Academies’ study was funded by the McKnight Brain Research Foundation, National Institutes of Health (National Institute of Neurological Disorders and Stroke and National Institute on Aging), Centers for Disease Control and Prevention, Retirement Research Foundation, and AARP.
Updates for WIC Program
WIC -- shorthand for the Special Supplemental Nutrition Program for Women, Infants, and Children -- is one of the largest nutrition programs in the United States. Part of the U.S. Department of Agriculture’s Food and Nutrition Service, WIC provides nutrition education and health and social service referrals for low-income infants; children up to age 5; and women who are pregnant, breast-feeding, or postpartum. The program’s food “packages” are designed to help participants meet specific nutrient shortfalls in their diets.
Five percent or more of WIC participants ages 19 to 50 have inadequate intakes of several nutrients that could be addressed with changes to the program’s food packages. Review of WIC Food Packages: Proposed Framework for Revisions -- Interim Report, the first phase of a two-phase study reviewing the current food packages in the WIC program, presents findings and establishes a set of criteria and a framework to guide the second phase of the study.
The inadequate nutritional intakes may be linked to under-consumption of certain recommended food groups, the report says. In particular, intakes of vegetables, whole grains, and seafood were lowest for children between 2 and 5 years old and for women. In addition, although the WIC food packages aim to reduce added salt, saturated fat, and added sugars, intakes of all three were excessive across subgroups of WIC participants, as is the case for the general U.S. population.
Recommended changes to WIC food packages will be presented in the final report, due to be issued 12 months after the release of the 2015 Dietary Guidelines for Americans. The Academies’ study was funded by the U.S. Department of Agriculture.
Vital Signs for Health
Thousands of measures are in use today to assess health and health care in the United States. Although many provide useful information, the sheer number of these measures, as well as their lack of focus, consistency, and organization, limits their overall effectiveness in improving performance of the health system.
To achieve better health at lower cost, all stakeholders -- including health professionals, payers, policymakers, and members of the public -- should be alert to which measures matter most, says Vital Signs: Core Metrics for Health and Health Care Progress. The report identifies a streamlined set of 15 standardized measures that could provide consistent benchmarks for health progress across the nation and improve system performance in the highest-priority areas.
The core measures are:
- Life expectancy
- Overweight and obesity
- Addictive behavior
- Unintended pregnancy
- Healthy communities
- Preventive services
- Access to care
- Patient safety
- Evidence-based care
- Care that matches patient goals
- Personal spending burden
- Population spending burden
- Individual engagement
- Community engagement
Each of the report’s recommended measurements was evaluated according to its importance for health, likelihood to contribute to progress, understandability, technical integrity, potential to have broader system impact, and utility at multiple levels. Not intended to replace the full range of measures in use today, these 15 “vital signs” are expected to evolve over time, keeping pace with the needs and capabilities of the health system.
The report calls for specific actions for different stakeholder groups to help ensure the adoption and implementation of the core measures. In particular, the secretary of the U.S. Department of Health and Human Services should use them to increase focus and consistency and reduce the number and burden of measure reporting in HHS programs.
The Academies’ study was funded by the Robert Wood Johnson Foundation, Blue Shield of California Foundation, and California HealthCare Foundation.
Airport Screening and Radiation Exposure
Machines that use advanced X-ray imaging technology to screen airport passengers -- known as X-ray backscatter imaging machines -- were deployed in U.S. airports between 2008 and 2013 but were then removed by the Transportation Security Administration due to privacy concerns. However, second-generation machines equipped with congressionally mandated privacy software are under evaluation by TSA.
Airport Passenger Screening Using Backscatter X-Ray Machines: Compliance With Standards assesses both the previously used and next-generation machines for compliance with radiation exposure standards, and finds that the machines comply with radiation exposure limits set by the American National Standards Institute/Health Physics Society. The report also estimates the radiation dose per scan for individuals being screened, for operators and bystanders outside the machines, and for special populations including children and pregnant women, which are not considered separately in the ANSI/HPS standard.
Radiation measurements on both first- and second-generation machines and extensive modeling simulations, both performed by subcontractors of the committee that wrote the report, confirmed that radiation doses delivered to individuals being screened are at least a factor of 10 below the recommended standard. Using appropriately calibrated detectors, they found that radiation levels outside the screening area are so low as to be statistically indistinguishable from background radiation. The report says that per scan, no individual, regardless of age or weight, would receive a dose that exceeds the currently recommended limit.
After inspections and testing of both generations of machines, the committee was unable to identify any circumstance where an accidental failure or malicious tampering could result in the person being screened or the operator receiving a larger X-ray exposure than the effective dose for a normal screening.
The Academies’ study was funded by the U.S. Department of Homeland Security.