Health and Safety
Compensation and Treatment for Disabled Vets
 Since the Revolutionary War, the United States has recognized the sacrifices of its military personnel by compensating veterans for disabilities suffered as a result of service, such as loss of limbs, chronic disorders, and in recent years, mental conditions including posttraumatic stress disorder (PTSD). As the conflicts in Iraq and Afghanistan produce a new generation of war veterans, the Veterans' Disability Benefits Commission and the U.S. Department of Veterans Affairs each asked the Institute of Medicine to examine aspects of its systems for evaluating and rating disabilities to ensure that veterans are being appropriately compensated for permanent injuries and disabilities incurred during service. Three recent IOM reports examine the overall disability rating system and methods for evaluating PTSD and its treatment.
A 21st Century System for Evaluating Veterans for Disability Benefits calls for an overhaul of the VA's tool for determining the degree of disability suffered during military service, known as the Schedule for Rating Disabilities, and a process for keeping it up to date. Some of its elements have not changed since 1945 and do not adequately reflect current understanding of certain conditions that now occur more frequently, such as traumatic brain injury.
Veterans with service-connected disabilities can receive monthly payments tied to their disability ratings, currently ranging from $115 a month for a 10 percent rating to $2,471 per month for a 100 percent rating, or more if there are dependents. Clinical professionals medically evaluate claimants and provide their assessments to another group of nonclinical professionals who use this information and the rating schedule to determine the applicants' degree of disability. According to federal statutes, the veterans' disability benefits program is supposed to compensate for average loss of earning capacity, although Congress and the VA also have recognized and compensated veterans for other, noneconomic losses since the disability program was codified in the 1920s.
VA's revision of the rating schedule should begin with those conditions that have gone the longest without being updated. This step should remove ambiguous criteria and obsolete conditions and introduce current medical knowledge of the effects of injuries and diseases such as brain injury, diabetes, and hearing loss, the report says. The rating schedule should be reassessed every decade and revised as needed to ensure that recently identified conditions are included, and new diagnostic codes that are widely used by other health care providers and systems should be adopted.
VA should also regularly assess whether the rating schedule accurately predicts loss of potential earnings and adjust it as needed. Such assessments would ensure that earnings at each rating level are the same for all disabling conditions. However, work disability alone is an unduly restrictive rationale for the disability program. Veterans who can work may still be disabled in other aspects of their lives, such as their ability to maintain their family and other personal relationships or to engage in activities they formerly pursued. The agency should develop a scale to determine whether the revised rating schedule adequately compensates for these negative consequences and either modify criteria or develop a separate compensation mechanism if needed.
Every veteran applying for disability compensation should be thoroughly evaluated for medical, psychosocial, and vocational abilities and needs at the time of separation from service, rather than the current method of conducting evaluations piecemeal. Veterans may be eligible for additional benefits such as job training meant to help them achieve their full potential in civilian life, but under the current system, it can take months or years to establish their disability and determine eligibility for the services.
 PTSD in particular is a condition that requires special attention from the VA. Surveys indicate relatively high rates of PTSD among soldiers who have served in Iraq and Afghanistan. At the same time, veterans of previous conflicts have been filing PTSD claims in greater numbers. As a result, the VA recorded an almost 80 percent jump in claims between 1999 and 2004, forcing the agency to reassess how it evaluates, treats, and compensates veterans with PTSD.
PTSD Compensation and Military Service says that the VA needs to develop new evaluation methods and rating criteria specific to the condition and replace the overly general, "one-size-fits-all" standard it currently uses. While some disabilities like physical trauma or high blood pressure are easily recognized, evaluation of PTSD entails greater subjectivity. Therefore, there is more of a need for detailed evaluation criteria. At present, the VA rates the severity of all mental disorders using criteria based on symptoms of schizophrenia and mood and anxiety disorders, but mental disorders vary in their characteristics and effects.
In addition, all claimants should receive a complete and thorough evaluation for PTSD by an experienced clinical professional, the report says. These examinations should provide a detailed picture of each veteran's condition so that disability raters can make more consistent and better informed decisions about the level of compensation each veteran should receive. More thorough clinical evaluations also would enhance the VA's ability to detect inappropriate claims; currently, the time devoted to the evaluations varies widely, as does the amount of information gathered.
Compensation for PTSD should be based on how greatly the disorder affects all aspects of a veteran's daily life, not just his or her ability to be gainfully employed. While beneficiaries with mental disorders may be able to hold full-time jobs even as their symptoms negatively affect other aspects of their lives, current rating criteria only award maximum compensation to those who do not work. In contrast, veterans with physical impairments can receive maximum disability benefits even if they are employed full time.
The VA, Congress, and the medical research community also urgently need to repair the problems that often plague studies of psychiatric therapies for PTSD, says Treatment of Posttraumatic Stress Disorder: An Assessment of the Evidence. While several drugs and psychotherapies are used to treat PTSD, the research examining their effectiveness does not provide a clear picture of what works and what doesn't.
The committee that wrote the report reviewed 53 studies of pharmaceuticals and 37 studies of psychotherapies used in PTSD treatment. Because of shortcomings in many of the studies, there is not enough reliable evidence to draw conclusions about the effectiveness of most treatments. Sufficient data are available to conclude that exposure therapies, which involve exposing individuals to a real or surrogate threat in a safe environment to help them overcome their fears -- are effective in treating PTSD. However, these findings should not be misinterpreted to suggest that only exposure therapies should be used to treat PTSD and that other types of therapy should be discontinued.
Several problems and limitations characterize much of the research on PTSD treatments, making the data less informative than desired. Many of the studies were poorly designed or conducted, and high dropout rates -- from 20 percent to 50 percent of participants -- reduced the certainty of several studies' results. The available research also is not informative in regard to the effectiveness of treatments of veterans compared with civilians, and for subgroups often excluded in research studies, such as those with traumatic brain injury, depression, or substance abuse.
VA and other government agencies that fund clinical research should ensure that studies of PTSD therapies take necessary steps and employ methods that would handle problems that affect their quality and usefulness. In addition, Congress should ensure that resources are available for VA and other federal agencies to fund quality research on treatment of PTSD and that all stakeholders, including veterans, are involved in research planning.
The studies were funded by the U.S. Department of Veterans Affairs.
New Era for Chemical Testing
 Americans have long been concerned about the safety of pharmaceuticals and food additives, and as early as the 1930s, legislation such as the landmark Food, Drug, and Cosmetic Act has been enacted to ensure that public health was protected. Concerns about exposure to chemical contaminants also led to the establishment of the U.S. Environmental Protection Agency to protect human health and safeguard the environment. Today, laws and regulations require that pesticides, pharmaceuticals, and other chemicals be tested for safety, usually by administering large doses to groups of animals and observing them for symptoms of disease. But it can be difficult to determine whether outcomes in animals are relevant to humans, who are usually exposed to much lower doses. In addition, the approach is time-consuming and costly, resulting in an overburdened system that leaves many chemicals untested.
Toxicity Testing in the 21st Century: A Vision and a Strategy, a report from the National Research Council, says that recent advances in scientific fields such as molecular biology, genomics, and bioinformatics have the potential to fundamentally improve the way chemicals are tested for risks they may pose to humans. The report identifies a new approach that would rely less heavily on animal studies and instead focus on in vitro methods that evaluate a chemical's effect on biological processes using cells, cell lines, or cellular components, preferably of human origin. Not only could this generate potentially more relevant data to evaluate risks people face, but it also could expand the number of chemicals that could be scrutinized and reduce the time, money, and animals involved in testing.
Although the need for animal testing could be greatly reduced over time and possibly even eliminated, targeted tests in animals will need to be used for the foreseeable future to complement the in vitro tests, because current methods cannot yet adequately mirror the metabolism of a whole animal. Studies observing human populations also will be needed to provide information on human susceptibility and "background" exposures to chemicals that people face every day, so that results of the in vitro tests can be properly interpreted. These studies may also reveal health risks not previously identified through toxicity testing.
Implementing the new testing strategy will require a substantial research effort to develop and validate all of the components. To ensure success, an institution should be created that fosters multidisciplinary research. If the research is scattered among different locations and organizations without a core organizing body, there is less chance of proceeding in a reasonable time frame.
Current toxicity testing practices have been practiced for decades and are entrenched in some institutions, so the new approach might encounter some resistance, the report says. Federal agencies' risk-assessment methods and guidelines will need to evolve as the new tests are developed and used. However, the proposed changes should generate better data to evaluate the risks humans face from chemicals, which should improve regulatory decisions to mitigate the risks.
Since the report was released, a memorandum of understanding was issued stating that EPA, the National Institute of Environmental Health Sciences' National Toxicology Program, and the National Institutes of Health Chemical Genomics Center will share leadership for implementing the report's recommendations.
The study was funded by the U.S. Environmental Protection Agency.
Fighting AIDS Globally
 HIV/AIDS has become one of the world's greatest public health crises, with more than 33 million people estimated to be living with HIV/AIDS worldwide, and over two-thirds of them in sub-Saharan Africa. As a result, life expectancy in this region has decreased, causing long-lasting demographic, social, and economic consequences. To foster a global response to the crisis and combat the spread of AIDS in some of the hardest-hit countries, the President's Emergency Plan for AIDS Relief, or PEPFAR, was derived from novel legislation in 2003 that allocated the distribution of $15 billion for HIV/AIDS-related relief over a five-year period in a strategy authorized by the president.
A congressionally mandated report by the Institute of Medicine says that to build on these contributions and achieve a lasting impact against the disease, PEPFAR needs continued U.S. leadership and increased flexibility. The report, PEPFAR Implementation: Progress and Promise, says that the program should shift its primary focus from providing emergency relief to building the capacity of affected nations to sustain their fight against HIV/AIDS over future decades. In particular, prevention efforts should be intensified to help keep rising levels of infection from overwhelming the capacity of the program's partner nations to provide treatment and care.
The 2003 PEPFAR legislation called for at least 33 percent of funds allocated to prevention to be directed to programs that promote abstinence until marriage. But HIV infection patterns vary among countries, with some having high rates of mother-to-child transmission, and others having more infections occurring because of injection drug use. The report calls on Congress to remove funding restrictions and allow countries greater flexibility in directing resources while also ensuring that they meet performance targets for prevention, treatment, and care.
The Office of the U.S. Global AIDS Coordinator, which oversees PEPFAR, should continue to focus on building capacity for sustainable, effective, widespread HIV/AIDS responses in these countries for the next decade, the report says. To better align with partner countries' initiatives, the program should work to support World Health Organization standards for ensuring quality of antiretroviral drugs. Currently, all medications purchased with PEPFAR funds must be approved by the U.S. Food and Drug Administration, but most of the focus countries and key donors use the WHO Prequalification of Medications Project to assure the quality of the drugs they purchase. Many of the generic antiretroviral drugs used in recipient countries have since been FDA-approved for purchase through PEPFAR.
PEPFAR's strategy has addressed the particular vulnerability of women and girls to HIV/AIDS, as Congress intended, the report says. The program should keep gender issues at the core of its efforts as PEPFAR switches from emergency relief to a sustained commitment, especially in improving the legal, economic, education, and social status of women and girls.
The study was funded by the U.S. Department of State.
More Efficient, Effective Health Care
 Despite per capita health expenditures that are much higher than any other nation, the United States ranks far down the list of international comparisons on many basic measures of health. Domestically, studies document inconsistent delivery of recommended services as well as wide geographic variations in the intensity of services and spending with no demonstrated health benefit. This poor return on our health care investment is in part the result of a fragmented health care delivery system and payment incentives unrelated to health outcomes. Increasingly, however, the inability to keep pace is connected with the need for better information to guide clinical decision making. Evidence on what is effective, and under what circumstances, is often lacking, poorly communicated, or inadequately applied.
To address these issues, the Institute of Medicine convened the Roundtable on Evidence-Based Medicine as a neutral venue for key stakeholders to engage and cooperate on issues important to transforming how evidence is generated and applied to improve health and health care. The roundtable has set a goal that by the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information, and will reflect the best available evidence. The Learning Healthcare System -- Workshop Summary, the roundtable's first product, identifies the features of health care delivery naturally driven by the best evidence, capable of responding quickly to innovations in care, and continuously capturing the results to improve both evidence and practice. It also identifies several issues that must be addressed before such a system can become a reality.
Missed opportunities, preventable illness, and injury are too often features in today's health care system, and deficiencies in the quantity, quality, and application of evidence are important contributors to these problems, the summary says. To move beyond these obstacles, the workshop participants identified several pressing changes, including more adaptable clinical research, better use of clinical data, and more automated approaches to the update and delivery of evidence at the point of care. The current research paradigm, focused on randomized controlled trials is impractical -- with respect to time, cost, and applicability -- to address many of the issues faced in clinical practice. This issue takes on added urgency in light of the increasing complexity of disease management, rapid scientific advances in areas such as genomics, and new medical technologies. New data sources such as electronic medical records and clinical registries offer opportunities to generate longitudinal health data that can be used to better assess the effectiveness of care for a broader spectrum of patients. Universal electronic health records and tools for linking and mining databases are needed both to develop new types of evidence and to identify patterns and clinical insights.
Adapting tools and research methods to the practice environment will draw research closer to the circumstances where care is delivered, the summary says. But efforts are also needed to ensure that evidence is provided -- to health professionals and patients alike -- in a way that helps inform collaborative health care decisions. Physicians already are facing an overload of factors to consider during the course of an average clinical encounter; and while professional judgment remains vital to shaping care, clinical decision support systems will be needed to allow health professionals to access and manage relevant information more quickly. In addition, the reimbursement system will need to be better aligned to reward all health care stakeholders for supporting evidence-based care.
The roundtable is funded by the Agency for Healthcare Research and Quality, America's Health Insurance Plans, AstraZeneca, Blue Shield of California Foundation, Burroughs Wellcome Fund, California HealthCare Foundation, Centers for Medicare and Medicaid Services, Charina Endowment Fund, U.S. Department of Veterans Affairs, U.S. Food and Drug Administration, Johnson & Johnson, sanofi-aventis, and Stryker.
School Foods That Pass the Test
 Gone are the days when kids either ate the lunch provided by their school cafeteria or brought a lunchbox from home. Today's students often have an array of options available on school grounds, from pizza and other fast foods to chips and soda sold in vending machines. Foods that compete with federally funded meals can be found at nearly 90 percent of American schools, according to one study.
But as any parent knows, giving kids too many choices can backfire. Unlike federally funded school meals, "competitive" foods are not required to meet nutrition standards, and many are low in important nutrients and high in calories or sodium. Research suggests that when these foods are available at school, students may opt for them instead of healthier choices. At a time when childhood obesity has reached epidemic proportions in the United States, concerns have been raised about all the types of foods available to children at school.
Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth proposes a set of guidelines for competitive foods and drinks available in schools that would promote consumption of fruits, vegetables, whole grains, and nonfat or low-fat dairy products and limit the amount of saturated fat, salt, and sugars.
The Institute of Medicine report proposes two tiers of competitive foods and beverages based on varying needs and responsibility levels of children. Tier 1 products should be allowed at all grade levels during the regular school day and during after-school activities involving students. The most important criterion for this category is that foods and drinks provide at least one serving of fruits, vegetables, whole grains, or nonfat or low-fat dairy. Tier 1 snacks should have no more than 200 calories per portion, and entrée items that could be sold a la carte should not exceed calorie limits on comparable school lunch program items. These items should also meet limits on saturated fat, trans fats, sodium, and sugars. Examples of snacks that would satisfy these requirements include whole fruit, fruit purees, carrot sticks, low-salt vegetable juice, whole wheat bagels, and low-fat yogurt; an entrée item could be a fruit salad with yogurt or a turkey sandwich.
Tier 2 foods should be allowed only in high schools after classes are over for the day, the report says. These foods don't need to provide a serving of fruits, vegetables, whole grains, or dairy, but they still must meet limits for calories, fat, sodium, and sugar. Snacks such as baked potato chips, graham crackers, certain granola bars, and pretzels would fit within these requirements. Promotion of these snacks should be minimized, however.
Caffeinated beverages should not be allowed at schools because headaches, shakiness, and other symptoms of caffeine dependency and withdrawal could interfere with students' learning, the report says. And beverages with artificial sweeteners such as diet sodas should only be available in high schools at the end of the regular school day. Plain water should be available at no cost throughout the day.
Making the standards work will require cooperation from legislators, health professionals, school boards, parents, and others, the report says. If they are enacted, it may spur food and beverage manufacturers to develop healthier products for kids. And federal agencies should work with these industries to develop a system for identifying products that meet the Tier 1 and 2 criteria to help food service personnel more readily evaluate competitive food items.
The study was funded by the Centers for Disease Control and Prevention.
Toward a Smoke-Free America
 Since 1964, the number of adult smokers has fallen by 50 percent in this country, an achievement that the Centers for Disease Control and Prevention ranks among the 10 greatest in public health during the 20th century. But other statistics indicate that the fight to end smoking in the United States is far from over. Tobacco use still causes 440,000 deaths in the United States each year, with secondhand smoke the cause of 50,000 of those deaths.
To put the nation on a course toward ending tobacco use, a report from the Institute of Medicine calls for a two-pronged strategy of strengthening current tobacco control measures while fundamentally transforming the regulatory environment for tobacco products. Ending the Tobacco Problem: A Blueprint for the Nation says that such an approach would reduce demand for tobacco products, address addiction, and limit manufacturers' attempts to attract more smokers.
Measures such as substantially increasing the federal excise taxes on cigarettes, instituting indoor smoking bans nationwide, and licensing retail outlets that sell tobacco products would significantly lower the U.S. smoking rate, which hovers at around 21 percent of the adult population, the report says. Overwhelming evidence shows that these strategies work, and if fully supported, control and prevention strategies could help bring smoking rates down to 10 percent by 2025, which would equate to 11 million fewer smokers.
However, without more regulatory oversight, tobacco prevention efforts will always struggle, especially given the $15 billion annually spent on marketing efforts that seek to downplay the products' risks, the report says. Moreover, smoking rates need to be brought down well below 10 percent before the health care costs -- estimated at more than $89 billion annually -- and deaths from tobacco no longer present a significant public health burden.
Therefore, Congress also should empower the U.S. Food and Drug Administration or another suitable agency to regulate the manufacture, marketing, and distribution of tobacco products. The report says that graphic warnings should be required on product packages, advertising should be limited to a text-only, black-and-white format, any activities by tobacco companies to market to youths should be banned, and retail outlets should be regulated more aggressively. These measures would further efforts to limit young people's access to tobacco products, which is critical since a vast majority of smokers pick up the habit during adolescence, a time when they fail to appreciate the addictive aspects of smoking and health consequences.
The study was funded by the American Legacy Foundation.
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