Stormy Seas Ahead: Top Trends On The Horizon For Healthcare In 2024

Arielle Trzcinski , Principal Analyst

Shannon Germain Farraher , Senior Analyst

Tiffany Do, Senior Research Associate

Healthcare organizations (HCOs) are navigating turbulent waters as they confront long-standing industry challenges and broad economic currents. The convergence of these factors tests HCOs’ adaptability and resilience. They face rising medical costs and utilization, dwindling consumer trust, an increasing demand for price transparency, and the weight of an impending election. In two new reports on healthcare trends in 2024, we explore how HCOs can weather the storm and overcome these challenges.

Healthcare Providers: Balance Innovation And Business Realities

The crew is getting restless. Mounting clinician burnout and growing medical deserts are creating an unsustainable new normal in healthcare. Healthcare provider organizations (HPOs) transitioning to value-based care models and exploring generative AI solutions should be cautious about their potential consequences. These ramifications not only affect patients but also impact hospital staff, making it crucial for leaders to address them before workforce dissatisfaction reaches a breaking point. HPOs must stay grounded and vigilant, focusing on critical infrastructure and improving employee experience before venturing into new waters. Check out the full report to delve into the top five trends that healthcare providers need to prepare for in 2024.

Health Insurers: Balance Differentiation And Cost Cutting

Like a new boat owner, health insurers are discovering that the promise of Medicare Advantage is not reality. Instead, they encounter empty sails as disappointing profits and controversial changes to star-rating calculations emerge. To address shrinking margins, health insurers are implementing cost-cutting measures and adopting AI, particularly in prior authorization, where there is increasing pressure to reduce turnaround times. As health insurers strive to regain stability and stand out from the competition, they must prioritize customer trust and loyalty. Check out the full report to explore the full list of the top five trends that health insurers need to prepare for in 2024.

Prepare To Sail The Changing Winds

Interested in plunging deeper into these trends and charting a course to smoother sailing in 2024? Forrester clients have the option to request an inquiry or guidance session . If you are not a Forrester client, you can reach out to the Forrester account team to explore how you can benefit from Forrester Decisions and harness its power.

Related Forrester Content

  • The Top Five Trends For US Healthcare Providers In 2024
  • The Top Five Trends For US Health Insurers In 2024
  • customer experience
  • digital business
  • digital disruption
  • employee experience
  • empowered customers
  • Generative AI
  • healthcare trends

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By Francesca Colombo , Head, Health Division, Organisation for Economic Co-operation and Development (OECD) and Helen E. Clark , Prime Minister of New Zealand (1999-2008), The Helen Clark Foundation

The COVID-19 crisis has affected more than 188 countries and regions worldwide, causing large-scale loss of life and severe human suffering. The crisis poses a major threat to the global economy, with drops in activity, employment, and consumption worse than those seen during the 2008 financial crisis . COVID-19 has also exposed weaknesses in our health systems that must be addressed. How?

For a start, greater investment in population health would make people, particularly vulnerable population groups, more resilient to health risks. The health and socio-economic consequences of the virus are felt more acutely among disadvantaged populations, stretching a social fabric already challenged by high levels of inequalities. The crisis demonstrates the consequences of poor investment in addressing wider social determinants of health, including poverty, low education and unhealthy lifestyles. Despite much talk of the importance of health promotion, even across the richer OECD countries barely 3% of total health spending is devoted to prevention . Building resilience for populations also requires a greater focus on solidarity and redistribution in social protection systems to address underlying structural inequalities and poverty.

Beyond creating greater resilience in populations, health systems must be strengthened.

High-quality universal health coverage (UHC) is paramount. High levels of household out-of-pocket payments for health goods and services deter people from seeking early diagnosis and treatment at the very moment they need it most. Facing the COVID-19 crisis, many countries have strengthened access to health care, including coverage for diagnostic testing. Yet others do not have strong UHC arrangements. The pandemic reinforced the importance of commitments made in international fora, such as the 2019 High-Level Meeting on Universal Health Coverage , that well-functioning health systems require a deliberate focus on high-quality UHC. Such systems protect people from health threats, impoverishing health spending, and unexpected surges in demand for care.

Second, primary and elder care must be reinforced. COVID-19 presents a double threat for people with chronic conditions. Not only are they at greater risk of severe complications and death due to COVID-19; but also the crisis creates unintended health harm if they forgo usual care, whether because of disruption in services, fear of infections, or worries about burdening the health system. Strong primary health care maintains care continuity for these groups. With some 94% of deaths caused by COVID-19 among people aged over 60 in high-income countries, the elder care sector is also particularly vulnerable, calling for efforts to enhance control of infections, support and protect care workers and better coordinate medical and social care for frail elderly.

Third, the crisis demonstrates the importance of equipping health systems with both reserve capacity and agility. There is an historic underinvestment in the health workforce, with estimated global shortages of 18 million health professionals worldwide , mostly in low- and middle-income countries. Beyond sheer numbers, rigid health labour markets make it difficult to respond rapidly to demand and supply shocks. One way to address this is by creating a “reserve army” of health professionals that can be quickly mobilised. Some countries have allowed medical students in their last year of training to start working immediately, fast-tracked licenses and provided exceptional training. Others have mobilised pharmacists and care assistants. Storing a reserve capacity of supplies such as personal protection equipment, and maintaining care beds that can be quickly transformed into critical care beds, is similarly important.

Fourth, stronger health data systems are needed. The crisis has accelerated innovative digital solutions and uses of digital data, smartphone applications to monitor quarantine, robotic devices, and artificial intelligence to track the virus and predict where it may appear next. Access to telemedicine has been made easier. Yet more can be done to leverage standardised national electronic health records to extract routine data for real-time disease surveillance, clinical trials, and health system management. Barriers to full deployment of telemedicine, the lack of real-time data, of interoperable clinical record data, of data linkage capability and sharing within health and with other sectors remain to be addressed.

Fifth, an effective vaccine and successful vaccination of populations around the globe will provide the only real exit strategy. Success is not guaranteed and there are many policy issues yet to be resolved. International cooperation is vital. Multilateral commitments to pay for successful candidates would give manufacturers certainty so that they can scale production and have vaccine doses ready as quickly as possible following marketing authorisation, but could also help ensure that vaccines go first to where they are most effective in ending the pandemic. Whilst leaders face political pressure to put the health of their citizens first, it is more effective to allocate vaccines based on need. More support is needed for multilateral access mechanisms that contain licensing commitments and ensure that intellectual property is no barrier to access, commitments to technology transfer for local production, and allocation of scarce doses based on need.

The pandemic offers huge opportunities to learn lessons for health system preparedness and resilience. Greater focus on anticipating responses, solidarity within and across countries, agility in managing responses, and renewed efforts for collaborative actions will be a better normal for the future.

OECD Economic Outlook 2020 , Volume 2020 Issue 1, No. 107, OECD Publishing, Paris

OECD Employment Outlook 2020 : Worker Security and the COVID-19 Crisis, OECD Publishing, Paris

OECD Health at a Glance 2019, OECD Publishing, Paris

https://www.un.org/pga/73/wp-content/uploads/sites/53/2019/07/FINAL-draft-UHC-Political-Declaration.pdf

OECD (2020), Who Cares? Attracting and Retaining Care Workers for the Elderly, OECD Health Policy Studies, OECD Publishing, Paris

Working for Health and Growth: investing in the health workforce . Report of the High-Level Commission on Health Employment and Economic Growth, Geneva.

Colombo F., Oderkirk J., Slawomirski L. (2020) Health Information Systems, Electronic Medical Records, and Big Data in Global Healthcare: Progress and Challenges in OECD Countries . In: Haring R., Kickbusch I., Ganten D., Moeti M. (eds) Handbook of Global Health. Springer, Cham.

2. Improving population health and building healthy societies in times of COVID-19

By Helena Legido-Quigley , Associate Professor, London School of Hygiene and Tropical Medicine

The COVID-19 pandemic has been a stark reminder of the fragility of population health worldwide; at time of writing, more than 1 million people have died from the disease. The pandemic has already made evident that those suffering most from COVID-19 belong to disadvantaged populations and marginalised communities. Deep-rooted inequalities have contributed adversely to the health status of different populations within and between countries. Besides the direct and indirect health impacts of COVID-19 and the decimation of health systems, restrictions on population movement and lockdowns introduced to combat the pandemic are expected to have economic and social consequences on an unprecedented scale .

Population health – and addressing the consequences of COVID-19 – is about improving the physical and mental health outcomes and wellbeing of populations locally, regionally and nationally, while reducing health inequalities.Âč Moreover, there is an increasing recognition that societal and environmental factors, such as climate change and food insecurity, can also influence population health outcomes.

The experiences of Maria, David, and Ruben – as told by Spanish public broadcaster RTVE – exemplify the real challenges that people living in densely populated urban areas have faced when being exposed to COVID-19.Âč

Maria is a Mexican migrant who has just returned from Connecticut to the Bronx. Her partner Jorge died in Connecticut from COVID-19. She now has no income and is looking for an apartment for herself and her three children. When Jorge became ill, she took him to the hospital, but they would not admit him and he was sent away to be cared for by Maria at home with their children. When an ambulance eventually took him to hospital, it was too late. He died that same night, alone in hospital. She thinks he had diabetes, but he was never diagnosed. They only had enough income to pay the basic bills. Maria is depressed, she is alone, but she knows she must carry on for her children. Her 10-year old child says that if he could help her, he would work. After three months, she finds an apartment.

David works as a hairdresser and takes an overcrowded train every day from LeganĂ©s to Chamberi in the centre of Madrid. He lives in a small flat in San Nicasio, one of the poorest working-class areas of Madrid with one of the largest ageing populations in Spain. The apartments are very small, making it difficult to be in confinement, and all of David’s neighbours know somebody who has been a victim of COVID-19. His father was also a hairdresser. David's father was not feeling well; he was taken to hospital by ambulance, and he died three days later. David was not able to say goodbye to his father. Unemployment has increased in that area; small local shops are losing their customers, and many more people are expecting to lose their jobs.

Ruben lives in Iztapalapa in Mexico City with three children, a daughter-in-law and five grandchildren. Their small apartment has few amenities, and no running water during the evening. At three o’clock every morning, he walks 45 minutes with his mobile stall to sell fruit juices near the hospital. His daily earnings keep the family. He goes to the central market to buy fruit, taking a packed dirty bus. He thinks the city's central market was contaminated at the beginning of the pandemic, but it could not be closed as it is the main source of food in the country. He has no health insurance, and he knows that as a diabetic he is at risk, but medication for his condition is too expensive. He has no alternative but to go to work every day: "We die of hunger or we die of COVID."

These real stories highlight the issues that must be addressed to reduce persistent health inequalities and achieve health outcomes focusing on population health. The examples of Maria, David and Ruben show the terrible outcomes COVID-19 has had for people living in poverty and social deprivation, older people, and those with co-morbidities and/or pre-existing health conditions. All three live in densely populated urban areas with poor housing, and have to travel long distances in overcrowded transport. Maria’s loss of income has had consequences for her housing security and access to healthcare and health insurance, which will most likely lead to worse health conditions for her and her children. Furthermore, all three experienced high levels of stress, which is magnified in the cases of Maria and David who were unable to be present when their loved ones died.

The COVID-19 pandemic has made it evident that to improve the health of the population and build healthy societies, there is a need to shift the focus from illness to health and wellness in order to address the social, political and commercial determinants of health; to promote healthy behaviours and lifestyles; and to foster universal health coverage.ÂČ Citizens all over the world are demanding that health systems be strengthened and for governments to protect the most vulnerable. A better future could be possible with leadership that is able to carefully consider the long-term health, economic and social policies that are needed.

In order to design and implement population health-friendly policies, there are three prerequisites. First, there is a need to improve understanding of the factors that influence health inequalities and the interconnections between the economic, social and health impacts. Second, broader policies should be considered not only within the health sector, but also in other sectors such as education, employment, transport and infrastructure, agriculture, water and sanitation. Third, the proposed policies need to be designed through involving the community, addressing the health of vulnerable groups, and fostering inter-sectoral action and partnerships.

Finally, within the UN's Agenda 2030 , Sustainable Development Goal (SDG) 3 sets out a forward-looking strategy for health whose main goal is to attain healthier lives and wellbeing. The 17 interdependent SDGs offer an opportunity to contribute to healthier, fairer and more equitable societies from which both communities and the environment can benefit.

The stories of Maria, David and Ruben are real stories featured in the Documentary: The impact of COVID19 in urban outskirts, Directed by Jose A Guardiola. Available here. Permission has been granted to narrate these stories.

Buck, D., Baylis, A., Dougall, D. and Robertson, R. (2018). A vision for population health: Towards a healthier future . [online] London: The King's Fund. [Accessed 20 Sept. 2020]

Wilton Park. (2020). Healthy societies, healthy populations (WP1734). Wiston House, Steyning. Retrieved from https://www.wiltonpark.org.uk/event/wp1734/ Cohen B. E. (2006). Population health as a framework for public health practice: a Canadian perspective. American journal of public health , 96 (9), 1574–1576.

3. Imagine a 'well-care' system that invests in keeping people healthy

By Maliha Hashmi , Executive Director, Health and Well-Being and Biotech, NEOM, and Jan Kimpen , Global Chief Medical Officer, Philips

Imagine a patient named Emily. Emily is aged 32 and I’m her doctor.

Emily was 65lb (29kg) above her ideal body weight, pre-diabetic and had high cholesterol. My initial visit with Emily was taken up with counselling on lifestyle changes, mainly diet and exercise; typical advice from one’s doctor in a time-pressured 15-minute visit. I had no other additional resources, incentives or systems to support me or Emily to help her turn her lifestyle around.

I saw Emily eight months later, not in my office, but in the hospital emergency room. Her husband accompanied her – she was vomiting, very weak and confused. She was admitted to the intensive care unit, connected to an insulin drip to lower her blood sugar, and diagnosed with type 2 diabetes. I talked to Emily then, emphasizing that the new medications for diabetes would only control the sugars, but she still had time to reverse things if she changed her lifestyle. She received further counselling from a nutritionist.

Over the years, Emily continued to gain weight, necessitating higher doses of her diabetes medication. More emergency room visits for high blood sugars ensued, she developed infections of her skin and feet, and ultimately, she developed kidney disease because of the uncontrolled diabetes. Ten years after I met Emily, she is 78lb (35kg) above her ideal body weight; she is blind and cannot feel her feet due to nerve damage from the high blood sugars; and she will soon need dialysis for her failing kidneys. Emily’s deteriorating health has carried a high financial cost both for herself and the healthcare system. We have prevented her from dying and extended her life with our interventions, but each interaction with the medical system has come at significant cost – and those costs will only rise. But we have also failed Emily by allowing her diabetes to progress. We know how to prevent this, but neither the right investments nor incentives are in place.

Emily could have been a real patient of mine. Her sad story will be familiar to all doctors caring for chronically ill patients. Unfortunately, patients like Emily are neglected by health systems across the world today. The burden of chronic disease is increasing at alarming rates. Across the OECD nearly 33% of those over 15 years live with one or more chronic condition, rising to 60% for over-65s. Approximately 50% of chronic disease deaths are attributed to cardiovascular disease (CVD). In the coming decades, obesity, will claim 92 million lives in the OECD while obesity-related diseases will cut life expectancy by three years by 2050.

These diseases can be largely prevented by primary prevention, an approach that emphasizes vaccinations, lifestyle behaviour modification and the regulation of unhealthy substances. Preventative interventions have been efficacious. For obesity, countries have effectively employed public awareness campaigns, health professionals training, and encouragement of dietary change (for example, limits on unhealthy foods, taxes and nutrition labelling).⁎,⁔ Other interventions, such as workplace health-promotion programmes, while showing some promise, still need to demonstrate their efficacy.

essay on healthcare trends

The COVID-19 crisis provides the ultimate incentive to double down on the prevention of chronic disease. Most people dying from COVID-19 have one or more chronic disease, including obesity, CVD, diabetes or respiratory problems – diseases that are preventable with a healthy lifestyle. COVID-19 has highlighted structural weaknesses in our health systems such as the neglect of prevention and primary care.

While the utility of primary prevention is understood and supported by a growing evidence base, its implementation has been thwarted by chronic underinvestment, indicating a lack of societal and governmental prioritization. On average, OECD countries only invest 2.8% of health spending on public health and prevention. The underlying drivers include decreased allocation to prevention research, lack of awareness in populations, the belief that long-run prevention may be more costly than treatment, and a lack of commitment by and incentives for healthcare professionals. Furthermore, public health is often viewed in a silo separate from the overall health system rather than a foundational component.

Health benefits aside, increasing investment in primary prevention presents a strong economic imperative. For example, obesity contributes to the treatment costs of many other diseases: 70% of diabetes costs, 23% for CVD and 9% for cancers. Economic losses further extend to absenteeism and decreased productivity.

Fee-for-service models that remunerate physicians based on the number of sick patients they see, regardless the quality and outcome, dominate healthcare systems worldwide. Primary prevention mandates a payment system that reimburses healthcare professionals and patients for preventive actions. Ministries of health and governmental leaders need to challenge skepticism around preventive interventions, realign incentives towards preventive actions and those that promote healthy choices by people. Primary prevention will eventually reduce the burden of chronic diseases on the healthcare system.

As I reflect back on Emily and her life, I wonder what our healthcare system could have done differently. What if our healthcare system was a well-care system instead of a sick-care system? Imagine a different scenario: Emily, a 32 year old pre-diabetic, had access to a nutritionist, an exercise coach or health coach and nurse who followed her closely at the time of her first visit with me. Imagine if Emily joined group exercise classes, learned where to find healthy foods and how to cook them, and had access to spaces in which to exercise and be active. Imagine Emily being better educated about her diabetes and empowered in her healthcare and staying healthy. In reality, it is much more complicated than this, but if our healthcare systems began to incentivize and invest in prevention and even rewarded Emily for weight loss and healthy behavioural changes, the outcome might have been different. Imagine Emily losing weight and continuing to be an active and contributing member of society. Imagine if we invested in keeping people healthy rather than waiting for people to get sick, and then treating them. Imagine a well-care system.

Anderson, G. (2011). Responding to the growing cost and prevalence of people with multiple chronic conditions . Retrieved from OECD.

Institute for Health Metrics and Evaluation. GBD Data Visualizations. Retrieved here.

OECD (2019), The Heavy Burden of Obesity: The Economics of Prevention, OECD Health Policy Studies, OECD Publishing, Paris.

OECD. (2017). Obesity Update . Retrieved here.

Malik, V. S., Willett, W. C., & Hu, F. B. (2013). Global obesity: trends, risk factors and policy implications. Nature Reviews Endocrinology , 9 (1), 13-27.

Lang, J., Cluff, L., Payne, J., Matson-Koffman, D., & Hampton, J. (2017). The centers for disease control and prevention: findings from the national healthy worksite program. Journal of occupational and environmental medicine , 59 (7), 631.

Gmeinder, M., Morgan, D., & Mueller, M. (2017). How much do OECD countries spend on prevention? Retrieved from OECD.

Jordan RE, Adab P, Cheng KK. Covid-19: risk factors for severe disease and death. BMJ. 2020;368:m1198.

Richardson, A. K. (2012). Investing in public health: barriers and possible solutions. Journal of Public Health , 34 (3), 322-327.

Yong, P. L., Saunders, R. S., & Olsen, L. (2010). Missed Prevention Opportunities The healthcare imperative: lowering costs and improving outcomes: workshop series summary (Vol. 852): National Academies Press Washington, DC.

OECD. (2019). The Heavy Burden of Obesity: The Economics of Prevention. Retrieved here .

McDaid, D., F. Sassi and S. Merkur (Eds.) (2015a), “Promoting Health, Preventing Disease: The Economic Case ”, Open University Press, New York.

OECD. (2019). The Heavy Burden of Obesity: The Economics of Prevention. Retrieved from OECD.

4. Why e arly detection and diagnosis is critical

By Paul Murray , Head of Life and Health Products, Swiss Re, and André Goy , Chairman and Executive Director & Chief of Lymphoma, John Theurer Cancer Center, Hackensack University Medical Center

Although healthcare systems around the world follow a common and simple principle and goal – that is, access to affordable high-quality healthcare – they vary significantly, and it is becoming increasingly costly to provide this access, due to ageing populations, the increasing burden of chronic diseases and the price of new innovations.

Governments are challenged by how best to provide care to their populations and make their systems sustainable. Neither universal health, single payer systems, hybrid systems, nor the variety of systems used throughout the US have yet provided a solution. However, systems that are ranked higher in numerous studies, such as a 2017 report by the Commonwealth Fund , typically include strong prevention care and early-detection programmes. This alone does not guarantee a good outcome as measured by either high or healthy life expectancy. But there should be no doubt that prevention and early detection can contribute to a more sustainable system by reducing the risk of serious diseases or disorders, and that investing in and operationalizing earlier detection and diagnosis of key conditions can lead to better patient outcomes and lower long-term costs.

To discuss early detection in a constructive manner it makes sense to describe its activities and scope. Early detection includes pre-symptomatic screening and treatment immediately or shortly after first symptoms are diagnosed. Programmes may include searching for a specific disease (for example, HIV/AIDS or breast cancer), or be more ubiquitous. Prevention, which is not the focus of this blog, can be interpreted as any activities undertaken to avoid diseases, such as information programmes, education, immunization or health monitoring.

Expenditures for prevention and early detection vary by country and typically range between 1-5% of total health expenditures.Âč During the 2008 global financial crisis, many countries reduced preventive spending. In the past few years, however, a number of countries have introduced reforms to strengthen and promote prevention and early detection. Possibly the most prominent example in recent years was the introduction of the Affordable Care Act in the US, which placed a special focus on providing a wide range of preventive and screening services. It lists 63 distinct services that must be covered without any copayment, co-insurance or having to pay a deductible.

essay on healthcare trends

Whilst logic dictates that investment in early detection should be encouraged, there are a few hurdles and challenges that need to be overcome and considered. We set out a few key criteria and requirements for an efficient early detection program:

1. Accessibility The healthcare system needs to provide access to a balanced distribution of physicians, both geographically (such as accessibility in rural areas), and by specialty. Patients should be able to access the system promptly without excessive waiting times for diagnoses or elective treatments. This helps mitigate conditions or diseases that are already quite advanced or have been incubating for months or even years before a clinical diagnosis. Access to physicians varies significantly across the globe from below one to more than 60 physicians per 10,000 people.ÂČ One important innovation for mitigating access deficiencies is telehealth. This should give individuals easier access to health-related services, not only in cases of sickness but also to supplement primary care.

2. Early symptoms and initial diagnosis Inaccurate or delayed initial diagnoses present a risk to the health of patients, can lead to inappropriate or unnecessary testing and treatment, and represents a significant share of total health expenditures. A medical second opinion service, especially for serious medical diagnoses, which can occur remotely, can help improve healthcare outcomes. Moreover, studies show that early and correct diagnosis opens up a greater range of curative treatment options and can reduce costs (e.g. for colon cancer, stage-four treatment costs are a multiple of stage-one treatment costs).Âł

3. New technology New early detection technologies can improve the ability to identify symptoms and diseases early: i. Advances in medical monitoring devices and wearable health technology, such as ECG and blood pressure monitors and biosensors, enable patients to take control of their own health and physical condition. This is an important trend that is expected to positively contribute to early detection, for example in atrial fibrillation and Alzheimers’ disease. ii. Diagnostic tools, using new biomarkers such as liquid biopsies or volatile organic compounds, together with the implementation of machine learning, can play an increasing role in areas such as oncology or infectious diseases.

4. Regulation and Intervention Government regulation and intervention will be necessary to set ranges of normality, to prohibit or discourage overdiagnosis and to reduce incentives for providers to overtreat patients or to follow patients' inappropriate requests. In some countries, such as the US, there has been some success through capitation models and value-based care. Governments might also need to intervene to de-risk the innovation paradigm, such that private providers of capital feel able to invest more in the development of new detection technologies, in addition to proven business models in novel therapeutics.

OECD Health Working Papers No. 101 "How much do OECD countries spend on prevention" , 2017

World Health Organization; Global Health Observatory (GHO) data; https://www.who.int/gho/health_workforce/physicians_density/en/

Saving lives, averting costs; A report for Cancer Research UK, by Incisive Health, September 2014

Liquid Biopsy: Market Drivers And Obstacles; by Divyaa Ravishankar, Frost & Sullivan, January 21, 2019

Liquid Biopsies Become Cheap and Easy with New Microfluidic Device; February 26, 2019

How America’s 5 Top Hospitals are Using Machine Learning Today; by Kumba Sennaar, February 19, 2019

5. The business case for private investment in healthcare for all

Pascal Fröhlicher, Primary Care Innovation Scholar, Harvard Medical School, and Ian Wijaya, Managing Director in Lazard’s Global Healthcare Group

Faith, a mother of two, has just lost another customer. Some households where she is employed to clean, in a small town in South Africa, have little understanding of her medical needs. As a type 2 diabetes patient, this Zimbabwean woman visits the public clinic regularly, sometimes on short notice. At her last visit, after spending hours in a queue, she was finally told that the doctor could not see her. To avoid losing another day of work, she went to the local general practitioner to get her script, paying more than three daily wages for consultation and medication. Sadly, this fictional person reflects a reality for many people in middle-income countries.

Achieving universal health coverage by 2030, a key UN Sustainable Development Goal (SDG), is at risk. The World Bank has identified a $176 billion funding gap , increasing every year due to the growing needs of an ageing population, with the health burden shifting towards non-communicable diseases (NCDs), now the major cause of death in emerging markets . Traditional sources of healthcare funding struggle to increase budgets sufficiently to cover this gap and only about 4% of private health care investments focus on diseases that primarily affect low- and middle-income countries.

In middle-income countries, private investors often focus on extending established businesses, including developing private hospital capacity, targeting consumers already benefiting from quality healthcare. As a result, an insufficient amount of private capital is invested in strengthening healthcare systems for everyone.

essay on healthcare trends

Why is this the case? We discussed with senior health executives investing in Lower and Middle Income Countries (LMIC) and the following reasons emerged:

  • Small market size . Scaling innovations in healthcare requires dealing with country-specific regulatory frameworks and competing interest groups, resulting in high market entry cost.
  • Talent . Several LMICs are losing nurses and doctors but also business and finance professionals to European and North American markets due to the lack of local opportunities and a significant difference in salaries.
  • Untested business models with relatively low gross margins. Providing healthcare requires innovative business models where consumers’ willingness to pay often needs to be demonstrated over a significant period of time. Additionally, relatively low gross margins drive the need for scale to leverage administrative costs, which increases risk.
  • Government Relations. The main buyer of health-related products and services is government; yet the relationship between public and private sectors often lacks trust, creating barriers to successful collaboration. Add to that significant political risk, as contracts can be cancelled by incoming administrations after elections. Many countries also lack comprehensive technology strategies to successfully manage technological innovation.
  • Complexity of donor funding. A significant portion of healthcare is funded by private donors, whose priorities might not always be congruent with the health priorities of the government.

Notwithstanding these barriers, healthcare, specifically in middle-income settings, could present an attractive value proposition for private investors:

  • Economic growth rates . A growing middle class is expanding the potential market for healthcare products and services.
  • Alignment of incentives . A high ratio of out-of-pocket payments for healthcare services is often associated with low quality. However, innovative business models can turn out of pocket payments into the basis for a customer-centric value proposition, as the provider is required to compete for a share of disposable income.
  • Emergence of National Health Insurance Schemes . South Africa, Ghana, Nigeria and others are building national health insurance schemes, increasing a population’s ability to fund healthcare services and products .
  • Increased prevalence of NCDs. Given the increasing incidence of chronic diseases and the potential of using technology to address these diseases, new business opportunities for private investment exist.

Based on the context above, several areas in healthcare delivery can present compelling opportunities for private companies.

  • Aggregation of existing players.
  • Leveraging primary care infrastructure. Retail companies can leverage their real estate, infrastructure and supply chains to deploy primary care services at greater scale than is currently the case.
  • Telemedicine . Telecommunications providers can leverage their existing infrastructure and customer base to provide payment mechanisms and telehealth services at scale. As seen during the COVID-19 pandemic, investment in telemedicine can ensure that patients receive timely and continuous care in spite of restrictions and lockdowns.
  • Cost effective diagnostics . Diagnostic tools operated by frontline workers and combined with the expertise of specialists can provide timely and efficient care.

To fully realize these opportunities, government must incentivise innovation, provide clear regulatory frameworks and, most importantly, ensure that health priorities are adequately addressed.

Venture capital and private equity firms as well as large international corporations can identify the most commercially viable solutions and scale them into new markets. The ubiquity of NCDs and the requirement to reduce costs globally provides innovators with the opportunity to scale their tested solutions from LMICs to higher income environments.

Successful investment exits in LMICs and other private sector success stories will attract more private capital. Governments that enable and support private investment in their healthcare systems would, with appropriate governance and guidance, generate benefits to their populations and economies. The economic value of healthy populations has been proven repeatedly , and in the face of COVID-19, private sector investment can promote innovation and the development of responsible, sustainable solutions.

Faith – the diabetic mother we introduced at the beginning of this article - could keep her client. As a stable patient, she could measure her glucose level at home and enter the results in an app on her phone, part of her monthly diabetes programme with the company that runs the health centre. She visits the nurse-led facility at the local taxi stand on her way to work when her app suggests it. The nurse in charge of the centre treats Faith efficiently, and, if necessary, communicates with a primary care physician or even a specialist through the telemedicine functionality of her electronic health system.

Improving LMIC health systems is not only a business opportunity, but a moral imperative for public and private leaders. With the appropriate technology and political will, this can become a reality.

6. How could COVID-19 change the way we pay for health services?

John E. Ataguba, Associate Professor and Director, University of Cape Town and Matthew Guilford, Co-Founder and Chief Executive Officer, Common Health

The emergence of the new severe acute respiratory syndrome coronavirus (SARS-Cov-2), causing the coronavirus disease 2019 (COVID-19), has challenged both developing and developed countries.

Countries have approached the management of infections differently. Many people are curious to understand their health system’s performance on COVID-19, both at the national level and compared to international peers. Alongside limited resources for health, many developing countries may have weak health systems that can make it challenging to respond adequately to the pandemic.

Even before COVID-19, high rates of out-of-pocket spending on health meant that every year, 800 million people faced catastrophic healthcare costs ,100 million families were pushed into poverty, and millions more simply avoided care for critical conditions because they could not afford to pay for it.

The pandemic and its economic fallout have caused household incomes to decline at the same time as healthcare risks are rising. In some countries with insurance schemes, and especially for private health insurance, the following questions have arisen: How large is the co-payment for a COVID-19 test? If my doctor’s office is closed, will the telemedicine consultation be covered by my insurance? Will my coronavirus care be paid for regardless of how I contracted the virus? These and other doubts can prevent people from seeking medical care in some countries.

In Nigeria, like many other countries in Africa, the government bears the costs associated with testing and treating COVID-19 irrespective of the individual’s insurance status. In the public health sector, where COVID-19 cases are treated, health workers are paid monthly salaries while budgets are allocated to health facilities for other services. Hospitals continue to receive budget allocations to finance all health services including the management and treatment of COVID-19. That implies that funds allocated to address other health needs are reduced and that in turn could affect the availability and quality of health services.

Although health workers providing care for COVID-19 patients in isolation and treatment centres in Nigeria are paid salaries that are augmented with a special incentive package, the degree of impact on the quality improvement of services remains unclear. The traditional and historical allocation of budgets does not always address the needs of the whole population and could result in poor health services and under-provision of health services for COVID-19 patients.

In some countries, the reliance on out-of-pocket funding is hardly better for private providers, who encounter brand risks, operational difficulties, and – in extreme cases – the risk of creating “debtor prisons” as they seek to collect payment from patients. Ironically, despite the huge demand for medical services to diagnose and treat COVID-19, large healthcare institutions and individual healthcare practitioners alike are facing financial distress.

Dependence on a steady stream of fee-for-service payments for outpatient consultations and elective procedures is leading to pay cuts for doctors in India , forfeited Eid bonuses for nurses in Indonesia , and hospital bankruptcies in the United States . In a recent McKinsey & Company survey, 77% of physicians reported that their business would suffer in 2020 , and 46% were concerned about their practice surviving the coronavirus pandemic.

COVID-19 is exposing how fee-for-service, historical budget allocation and out-of-pocket financing methods can hinder the performance of the health system. Some providers and health systems that deployed “value-based” models prior to the pandemic have reported that these approaches have improved financial resilience during COVID-19 and may support better results for patients. Nevertheless, these types of innovations do not represent the dominant payment model in any country.

How health service providers are paid has implications for whether service users can get needed health services in a timely fashion, and at an appropriate quality and an affordable cost. By shifting from fee-for-service reimbursements to fixed "capitation" and performance-based payments, these models incentivize providers to improve quality and coordination while also guaranteeing a baseline income level, even during times of disruption.

Health service providers could be paid either in the form of salaries, a fee for services they provide, by capitation (whether adjusted or straightforward), through global budgets, or by using a case-based payment system (for example, the diagnostics-related groups), among others. Because there are different incentives to consider when adopting any of the methods, they could be combined to achieve a specific goal. For example, in some countries, health workers are paid salaries , and some specific services are paid on a fee-for-service basis.

Ideally, health services could be purchased strategically , incorporating aspects of provider performance in transferring funds to providers and accounting for the health needs of the population they serve.

In this regard, strategic purchasing for health has been advocated and should be highlighted as crucial with the emergence of the COVID-19 pandemic. There is a need to ensure value in the way health providers are paid, inter alia to increase efficiency, ensure equity, and improve access to needed health services. Value-based payment methods, although not new in many countries, provide an avenue to encourage long-term value for money, better quality, and strategic purchasing for health, helping to build a healthier, more resilient world.

7. L essons in integrated care from the COVID-19 pandemic

Sarah Ziegler, Postdoctoral Researcher, Department of Epidemiology and Biostatistics, University of Zurich, and Ninie Wang, Founder & CEO, Pinetree Care Group.

Since the start of the COVID-19 pandemic, people suffering non-communicable diseases (NCDs) have been at higher risk of becoming severely ill or dying. In Italy, 96.2% of people who died of COVID-19 lived with two or more chronic conditions.

Beyond the pandemic, cardiovascular disease, cancer, respiratory disease and diabetes are the leading burden of disease, with 41 million annual deaths. People with multimorbidity - a number of different conditions - often experience difficulties in accessing timely and coordinated healthcare, made worse when health systems are busy fighting against the pandemic.

Here is what happened in China with Lee, aged 62, who has been living with Chronic Obstructive Pulmonary Disease (COPD) for the past five years.

Before the pandemic, Lee’s care manager coordinated a multi-disciplinary team of physicians, nurses, pulmonary rehabilitation therapists, psychologists and social workers to put together a personalized care plan for her. Following the care plan, Lee stopped smoking and paid special attention to her diet, sleep and physical exercises, as well as sticking to her medication and follow-up visits. She participated in a weekly community-based physical activity program to meet other COPD patients, including short walks and exchange experiences. A mobile care team supported her with weekly cleaning and grocery shopping.

Together with her family, Lee had follow-up visits to ensure her care plan reflected her recovery and to modify the plan if needed. These integrated care services brought pieces of care together, centered around Lee’s needs, and provided a continuum of care that helped keep Lee in the community with a good quality of life for as long as possible.

Since the COVID-19 outbreak, such NCD services have been disrupted by lockdowns, the cancellation of elective care and the fear of visiting care service . These factors particularly affected people living with NCDs like Lee. As such, Lee was not able to follow her care plan anymore. The mobile care team was unable to visit her weekly as they were deployed to provide COVID-19 relief. Lee couldn’t participate in her community-based program, follow up on her daily activities, or see her family or psychologists. This negatively affected Lee’s COPD management and led to poor management of her physical activity and healthy diet.

The pandemic highlights the need for a flexible and reliable integrated care system to enable healthcare delivery to all people no matter where they live, uzilizing approaches such as telemedicine and effective triaging to overcome care disruptions.

Lee’s care manager created short videos to assist her family through each step of her care and called daily to check in on the implementation of the plan and answer questions. Lee received tele-consultations, and was invited to the weekly webcast series that supported COPD patient communities. When her uncle passed away because of pneumonia complications from COVID-19 in early April, Lee’s care manager arranged a palliative care provider to support the family through the difficult time of bereavement and provided food and supplies during quarantine. Lee could even continue with her physical activity program with an online training coach. There were a total of 38 exercise videos for strengthening and stretching arms, legs and trunk, which she could complete at different levels of difficulty and with different numbers of repetitions.

Lee’s case demonstrates that early detection, prevention, and management of NCDs play a crucial role in a global pandemic response. It shows how we need to shift away from health systems designed around single diseases towards health systems designed for the multidimensional needs of individuals. As part of the pandemic responses, addressing and managing risks related to NCDs and prevention of their complications are critical to improve outcomes for vulnerable people like Lee.

How to design and deliver successful integrated care

The challenge for the successful transformation of healthcare is to tailor care system-wide to population needs. A 2016 WHO Framework on integrated people-centered health services developed a set of five general strategies for countries to progress towards people-centered and sustainable health systems, calling for a fundamental transformation not only in the way health services are delivered, but also in the way they are financed and managed . These strategies call for countries to:

  • Engage and empower people / communities: an integrated care system must mobilize everyone to work together using all available resources, especially when continuity of essential health and community services for NCDs are at risk of being undermined.
  • Strengthen governance and accountability, so that integration emphasizes rather than weakens leadership in every part of the system, and ensure that NCDs are included in national COVID-19 plans and future essential health services.
  • Reorient the model of care to put the needs and perspectives of each person / family at the center of care planning and outcome measurement, rather than institutions.
  • Coordinate services within and across sectors, for example, integrate inter-disciplinary medical care with social care, addressing wider socio-economic, environmental and behavioral determinants of health.
  • Create an enabling environment, with clear objectives, supportive financing, regulations and insurance coverage for integrated care, including the development and use of systemic digital health care solutions.

Whether due to an unexpected pandemic or a gradual increase in the burden of NCDs, each person could face many health threats across the life-course.

Only systems that dynamically assess each person’s complex health needs and address them through a timely, well-coordinated and tailored mix of health and social care services will be able to deliver desired health outcomes over the longer term, ensuring an uninterrupted good quality of life for Lee and many others like her.

  • Wang B, Li R, Lu Z, Huang Y. Does comorbidity increase the risk of patients with COVID-19: evidence from meta-analysis. Aging (Albany NY) 2020;12: 6049–57.
  • WHO. Noncommunicable diseases in emergencies. Geneva: World Health Organization, 2016.
  • WHO. COVID-19 significantly impacts health services for noncommunicable diseases. June 2020.
  • Kluge HHP, Wickramasinghe K, Rippin HL, et al. Prevention and control of non-communicalbe diseases in the COVID-19 response. The Lancet. 2020. 395:1678-1680
  • WHO. Framework on integrated people-centred health services. Geneva: World Health Organization, 2016.

8 . Why access to healthcare alone will not save lives

Donald Berwick, President Emeritus and Senior Fellow, Institute for Healthcare Improvement; Nicola Bedlington, Special Adviser, European Patient Forum; and David Duong, Director, Program in Global Primary Care and Social Change, Harvard Medical School.

Joyce lies next to 10 other women in bare single beds in the post-partum recovery room at a rural hospital in Uganda. Just an hour ago, Joyce gave birth to a healthy baby boy. She is now struggling with abdominal pain. A nurse walks by, and Joyce tries to call out, but the nurse was too busy to attend to her; she was the only nurse looking after 20 patients.

Another hour passes, and Joyce is shaking and sweating profusely. Joyce’s husband runs into the corridor to find a nurse to come and evaluate her. The nurse notices Joyce’s critical condition - a high fever and a low blood pressure - and she quickly calls the doctor. The medical team rushes Joyce to the intensive care unit. Joyce has a very severe blood stream infection. It takes another hour before antibiotics are started - too late. Joyce dies, leaving behind a newborn son and a husband. Joyce, like many before her, falls victim to a pervasive global threat: poor quality of care.

Adopted by United Nations (UN) in 2015, the Sustainable Development Goals (SDG) are a universal call to action to end poverty, protect the planet and ensure that all enjoy peace and prosperity by 2030. SDG 3 aims to ensure healthy lives and promote wellbeing for all. The 2019 UN General Assembly High Level Meeting on Universal Health Coverage (UHC) reaffirmed the need for the highest level of political commitment to health care for all.

However, progress towards UHC, often measured in terms of access, not outcomes, does not guarantee better health, as we can see from Joyce’s tragedy. This is also evident with the COVID-19 response. The rapidly evolving nature of the COVID-19 pandemic has highlighted long-term structural inefficiencies and inequities in health systems and societies trying to mitigate the contagion and loss of life.

Systems are straining under significant pressure to ensure standards of care for both COVID-19 patients and other patients that run the risk of not receiving timely and appropriate care. Although poor quality of care has been a long-standing issue, it is imperative now more than ever that systems implement high-quality services as part of their efforts toward UHC.

Poor quality healthcare remains a challenge for countries at all levels of economic development: 10% of hospitalized patients acquire an infection during their hospitalization in low-and-middle income countries (LMIC), whereas 7% do in high-income countries. Poor quality healthcare disproportionally affects the poor and those in LMICs. Of the approximately 8.6 million deaths per year in 137 LMICs, 3.6 million are people who did not access the health system, whereas 5 million are people who sought and had access to services but received poor-quality care.

Joyce’s story is all too familiar; poor quality of care results in deaths from treatable diseases and conditions. Although the causes of death are often multifactorial, deaths and increased morbidity from treatable conditions are often a reflection of defects in the quality of care.

The large number of deaths and avoidable complications are also accompanied by substantial economic costs. In 2015 alone, 130 LMICs faced US $6 trillion in economic losses. Although there is concern that implementing quality measures may be a costly endeavor, it is clear that the economic toll associated with a lack of quality of care is far more troublesome and further stunts the socio-economic development of LMICs, made apparent with the COVID-19 pandemic.

Poor-quality care not only leads to adverse outcomes in terms of high morbidity and mortality, but it also impacts patient experience and patient confidence in health systems. Less than one-quarter of people in LMICs and approximately half of people in high-income countries believe that their health systems work well.

A lack of application and availability of evidenced-based guidelines is one key driver of poor-quality care. The rapidly changing landscape of medical knowledge and guidelines requires healthcare workers to have immediate access to current clinical resources. Despite our "information age", health providers are not accessing clinical guidelines or do not have access to the latest practical, lifesaving information.

Getting information to health workers in the places where it is most needed is a delivery challenge. Indeed, adherence to clinical practice guidelines in eight LMICs was below 50%, and in OECD countries, despite being a part of national guidelines, 19-53% of women aged 50-69 years did not receive mammography screening.4 The evidence in LMICs and HICs suggest that application of evidence-based guidelines lead to reduction in mortality and improved health outcomes.

Equally, the failure to change and continually improve the processes in health systems that support the workforce takes a high toll on quality of care. During the initial wave of the COVID-19 pandemic, countries such as Taiwan, Hong Kong, Singapore and Vietnam, which adapted and improved their health systems after the SARS and H1N1 outbreaks, were able to rapidly mobilize a large-scale quarantine and contact tracing strategy, supported with effective and coordinated mass communication.

These countries not only mitigated the economic and mortality damage, but also prevented their health systems and workforce from enduring extreme burden and inability to maintain critical medical supplies. In all nations, investing in healthcare organizations to enable them to become true “learning health care systems,” aiming at continual quality improvement, would yield major population health and health system gains.

The COVID-19 pandemic underscores the importance for health systems to be learning systems. Once the dust settles, we need to focus, collectively, on learning from this experience and adapting our health systems to be more resilient for the next one. This implies a need for commitment to and investment in global health cooperation, improvement in health care leadership, and change management.

With strong political and financial commitment to UHC, and its demonstrable effect in addressing crises such as COVID-19, for the first time, the world has a viable chance of UHC becoming a reality. However, without an equally strong political, managerial, and financial commitment to continually improving, high-quality health services, UHC will remain an empty promise.

1. United Nations General Assembly. Political declaration of the high-level meeting on universal health coverage. New York, NY2019.

2. Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health equity in England: the Marmot review 10 years on. Institute of Health Equity;2020.

3. National Academies of Sciences, Engineering, and Medicine: Committee on Improving the Quality of Health Care Globally. Crossing the global quality chasm: Improving health care worldwide. Washington, DC: National Academies Press;2018.

4. World Health Organization, Organization for Economic Co-operation and Development, World Bank Group. Delivering quality health services: a global imperative for universal health coverage. World Health Organization; 2018.

5. Kruk ME, Gage AD, Arsenault C, et al. High-quality health systems in the Sustainable Development Goals era: time for a revolution. The Lancet Global Health. 2018;6(11):e1196-e1252.

6. Ricci-Cabello I, ViolĂĄn C, Foguet-Boreu Q, Mounce LT, Valderas JM. Impact of multi-morbidity on quality of healthcare and its implications for health policy, research and clinical practice. A scoping review. European Journal of General Practice. 2015;21(3):192-202.

7. Valtis YK, Rosenberg J, Bhandari S, et al. Evidence-based medicine for all: what we can learn from a programme providing free access to an online clinical resource to health workers in resource-limited settings. BMJ global health. 2016;1(1).

8. Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America . Washington, DC: National Academies Press 2012.

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National Research Council (US) Committee on Future Directions for Behavioral and Social Sciences Research at the National Institutes of Health; Singer BH, Ryff CD, editors. New Horizons in Health: An Integrative Approach. Washington (DC): National Academies Press (US); 2001.

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New Horizons in Health: An Integrative Approach.

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8 Population Perspectives: Understanding Health Trends and Evaluating the Health Care System

T he earlier chapters on predisease pathways, positive health, environmentally induced gene expression, and personal ties place strong emphasis on preventing disease, maintaining allostasis, and promoting well-being at levels comparatively proximal to the individual (social, psychological, neurophysiological). The chapters addressing collective properties of communities and inequality focus on more intermediate levels whereby environmental and social structural factors influence health. This chapter focuses explicitly on questions of population health at the macro level. Four primary issues are considered: (1) time trends and spatial variation in population health; (2) accounting for such trends, with particular emphasis given to social and behavioral factors; (3) understanding links between population health and the macroeconomy; and (4) evaluating the health care system. An important crosscutting research priority, among several others delineated below, is to account for population health processes by linking them via multilevel analyses to behavioral, psychosocial, and environmental factors described in earlier chapters.

  • TIME TRENDS AND SPATIAL VARIATION IN POPULATION HEALTH

Brief summaries are provided below of health trends in life expectancy and disability, both within the United States and in other countries. Changing rates of communicable diseases (e.g., sexually transmitted diseases and tuberculosis) are also examined. Finally, various indicators of child health (e.g., infant mortality, birth weight, asthma, and other respiratory conditions) are reviewed. Some of these population trends show health improvements across time; others point to increasing health problems. Behavioral and psychosocial factors are implicated in both. A major international data source on health trends is the set of Demographic and Health Surveys. 1 An overarching theme is that the maintenance and improvement of population health have been and continue to be due as much to changes in broader socioeconomic and environmental forces as to more microscopically based biobehavioral science. Understanding and facilitating improvements in socioeconomic conditions, general public health and sanitation, and private and public policies affecting lifestyle have accounted for the bulk of historical changes in population health and very likely recent advances as well ( Rose, 1992 ).

Life Expectancy

Health varies substantially across and within countries. For example, in 1998 life expectancy in Sierra Leone was 37 years and in Japan it was 80 years. Ninety percent of this range, however, is covered by variation across counties within the United States. The range in life expectancy between females born in Stearns County, Minnesota, and males born in various counties in South Dakota is 22.5 years and extends to 41.3 years when race-specific life expectancy is calculated ( WHO, 1999 ). Over time, life expectancy in the United States has risen from 47 years in 1900 to 78 years in 1995. Table 1 shows the changes in life expectancy at birth between approximately 1910 and 1998 in selected countries.

TABLE 1. Life Expectancy at Birth for Selected Countries.

Life Expectancy at Birth for Selected Countries.

On average, people in richer countries live longer and have higher-quality lives than people in poorer countries. Within countries, at the city, county, and regional levels, people with higher socioeconomic status are on average in better health than those with lower socioeconomic status. As described in Chapter 7 , there is also considerable variation across racial and ethnic categories that interacts with socioeconomic status.

Recent research shows clearly that chronic disease disability rates are falling in the United States. Figure 1 shows the proportion of the elderly who were disabled in 1982, 1984, 1989, and 1994. Disability is measured as impairments in activities of daily living (ADLs, such as bathing, toileting) or instrumental activities of daily living (IADLs, such as the ability to perform light household work, use the telephone). The data, from the National Long-Term Care Survey, are for a representative sample of the elderly in each year. The questions are the same in each survey, so the responses give the most accurate available measure of changes in disability over time.

Changes in chronic disability among the elderly, 1982-1996. SOURCE: Manton et al. (1997).

In 1982 and 1984 nearly 25 percent of the elderly were disabled. By 1994 disability had declined to 21 percent, a reduction of over 1 percent per year. Furthermore, disability decline is more rapid in the second half of the time period (1989-1994) than the first half (1984-1989). These findings have been confirmed in other data as well ( Freedman and Martin, 1998 ), suggesting the trend is not an artifact of this particular sample.

Sketchier evidence suggests that the decline in elderly disability has occurred throughout the developed world. Rates of disability and institutionalization among the elderly in various developed countries, compiled by the Organization for Economic Cooperation and Development ( Jacobzone, 2000 ), have been declining over time in most countries. The decline is only modest in some countries (e.g., the United Kingdom) but is rapid in others (e.g., Japan). The average rate of decline among countries where disability rates are falling is 2.3 percent per year. In only two countries have rates of severe disability increased (Australia and Canada), but even there the rates of institutionalization are falling. Such rates have been falling as well in four of the five countries for which there are time series data, although the decline is generally less rapid than the decline in the rate of severe disability. The exception is France, where institutionalization rates have been increasing, perhaps reflecting a change in the location of care. Rates of severe disability in France, however, are declining rapidly.

Overall, these changes in disability have been sufficiently large for some to argue that health promotion might solve the long-term problems of financing public medical care systems ( Singer and Manton, 1998 ). Behavioral, environmental, and psychosocial factors are, as we argue throughout this report, key routes to such health promotion.

Communicable Diseases

Sexually transmitted diseases (STDs) and tuberculosis are among the most important communicable diseases in the United States. The incidence of reported chlamydial infections and viral STDs has steadily increased in recent years, while the incidence of gonorrhea has generally declined. Levels of syphilis vary among different population subgroups but have reached record lows since 1995. Vaginal infections such as trichomonas and bacterial vaginosis have probably remained high, although surveillance for these conditions is rudimentary. Table 2 shows the estimated incidence and prevalence of STDs in the United States in 1996. 2

TABLE 2. Estimated Incidence and Prevalence of Sexually Transmitted Diseases in the United States, 1996.

Estimated Incidence and Prevalence of Sexually Transmitted Diseases in the United States, 1996.

The number of reported cases of gonorrhea has generally declined, starting in the mid-1970s with the introduction of the national gonorrhea control program. A disproportionate share of the decline occurred among older white populations, with infection rates remaining relatively high among minority groups and adolescents. In 1996 the Centers for Disease Control and Prevention (CDC) reported 325,000 new cases of gonorrhea ( CDC, 1999b ). Because previous investigations have shown that only about half of all diagnosed gonorrhea cases are reported to public health authorities, total gonorrhea infections are estimated to be 650,000 in Table 2 .

HIV infection trends in the United States show that in the mid-1970s HIV was transmitted primarily among homosexual and bisexual men. The virus entered the injection-drug-using populations in the 1980s and rapidly spread during that decade. Limited heterosexual transmission occurred until the 1980s. Since 1989 the greatest proportional increase in reported AIDS cases has been among heterosexuals, with this trend expected to continue ( Rosenberg, 1995 ). New methods of estimating HIV incidence and prevalence ( Holmberg, 1996 ) yielded an estimate of 41,000 new HIV infections annually, with between 700,000 and 800,000 prevalent HIV infections. The introduction of protease inhibitors may increase the number of prevalent infections by extending the life of HIV-infected people. Approximately half of the incident and three-quarters of prevalent infections were estimated to have been sexually transmitted. Globally, the incidence of HIV is much higher than in the United States, with an estimated 5.8 million new infections annually and more than 30 million persons currently living with HIV ( UNAIDS, 1998 ). More than 90 percent of the global total has been spread sexually.

An important priority for future research is to improve the accuracy of these estimates. Most STD incidence and prevalence estimates are derived from multiple populations, few of which are representative national surveys, such as NHANES or the national reporting system for AIDS. Establishing nationally representative surveillance for the full range of STDs would help narrow the uncertainty in current estimates. For example, the true number of STD infections could be as low as 10 million or as high as 20 million. The current point estimate is 15.3 million.

Potential improvement in the U.S. STD epidemic could ensue from full implementation of the national prevention and control program identified by the expert panel assembled by the Institute of Medicine ( Eng and Butler, 1997 ). The program focuses on improving public awareness and education, reaching adolescents and women, and instituting effective culturally appropriate programs to promote healthy behavior by adolescents and adults. Additional targets are integrating public health programs, training health care professionals, and modifying messages from the mass media. Improved surveillance of STD incidence and prevalence rates will be necessary to document the progress of such initiatives.

Turning to global tuberculosis, 6.7 million new cases and 2.4 million deaths were estimated in 1998 ( Murray and Salomon, 1998 ). Based on current tends in implementation of the World Health Organization's strategy of directly observed, short-course treatment, a total of 225 million new cases and 79 million deaths from tuberculosis are expected between 1998 and 2030 ( Murray and Salomon, 1998 ). Active case finding using mass miniature radiography could save 23 million lives over this period, which underscores the importance of prevention. Single-contact treatments for TB could avert 24 million new cases and 11 million deaths. Combined with active screening, single-contact treatments could reduce TB mortality by 40 percent.

In the United States the situation is quite different. Table 3 shows the number of reported cases of TB from 1975 to 1992 ( CDC, 1999d ). The rapid decline in TB cases from 1975 to 1986 was followed by an increase through 1991. However, in 1998 a total of 18,361 TB cases were reported in the 50 states and the District of Columbia, a decrease of 8 percent from 1997 and 31 percent from 1992, the height of the TB resurgence. The 1998 rate of 6.8 per 100,000 population was 35 percent lower than in 1992 (10.5) but remained above the national goal for 2000 of 3.5 per 100,000 ( CDC, 1999a ).

TABLE 3. Tuberculosis Cases, Case Rates, Deaths, and Death Rates per 100,000 Population: United States, 1975-1998.

Tuberculosis Cases, Case Rates, Deaths, and Death Rates per 100,000 Population: United States, 1975-1998.

Considering infectious diseases more generally and on a longer time scale, infectious disease mortality declined during the first eight decades of the twentieth century from 797 deaths per 100,000 people in 1900 to 36 deaths per 100,000 in 1980. The overall general decline was interrupted by a sharp increase in mortality due to the 1918 influenza epidemic. From 1938 to 1952 the decline was particularly rapid, with mortality decreasing by 8.2 percent per year. Pneumonia and influenza were responsible for the largest number of infectious disease deaths throughout the century. Although tuberculosis caused almost as many deaths as pneumonia and influenza early in the century, TB mortality dropped off sharply after 1945. Infectious disease mortality increased in the 1980s and early 1990s in persons aged 25 years and older, due mainly to the emergence of AIDS in 25-to 64-year-olds and to a lesser degree to increases in influenza and pneumonia deaths in persons aged 65 and older. Although most of the twentieth century was marked by declining infectious disease mortality, substantial year-to-year variations and recent increases emphasize the dynamic nature of infectious diseases and the need for preparedness to address them. A considerable effort in this direction was stimulated by a 1992 Institute of Medicine (IOM) report focused on emerging infectious diseases. A wider-ranging multidisciplinary program emphasizing emerging infectious diseases of wildlife, including threats to human health, ( Daszak et al., 2000 ) is notable for its integrative consideration of ecology, pathology, and population biology of host-parasite systems and the emphasis on investigations incorporating individual, population, and environmental perspectives.

Child Health

In the United States the overall infant mortality rate has decreased rapidly since 1960. Between 1960 and 1994 the rate fell from 24.9 to 8.0 infant deaths per 1,000 live births. Between 1960 and 1992 the infant mortality rate decreased by 69 percent among whites, 62 percent among African Americans, 68 percent among Asians, and 77 percent among Native Americans. Nevertheless, as of 1992 there were considerable racial and ethnic disparities in the infant mortality rate (see also Chapter 7 ). The African American infant mortality rate of 16.8 infant deaths per 1,000 live births was 2.4 times higher than the white rate of 6.9. The Native American rate of 9.9 infant deaths per 1,000 live births was second highest, and the Asian rate of 4.8 per 1,000 live births was lowest.

Two other trends of concern in the health of children that are implicated in longer-term negative health consequences are the rate of low-birth-weight babies and the teen birth rate. Nationally, the percent of live births weighing less than 5.5 lbs. (a standard indicator of low birth weight) was 6.8 in 1985 and 7.4 in 1996. The number of births to teenagers between 15 and 17 per 1,000 females in this age category rose from 31 in 1985 to 34 in 1996. There was substantial variation across states in these two statistics. For example, in 1996 the low-birth-weight rate was 4.8 percent in New Hampshire, 9.9 percent in Mississippi, and 14.3 percent in the District of Columbia. The teen birth rate ranged from 15 in New Hampshire to 52 in Mississippi and 79 in the District of Columbia ( Annie E. Casey Foundation, 1999 ).

When assessing the health of children, it is important to examine the prevalence of chronic health conditions. Children with persistent health problems are more likely to miss school and require medical assistance and follow-up. Such chronic problems also pose difficulties for the parents, who may experience emotional stress, often lose days from work, and incur additional medical expenses associated with recurrent medical visits and follow-up care. The circumstances of both children and their parents in this kind of persistent difficult environment contribute to the predisease pathways described in Chapter 2 .

Asthma is the most common chronic disease of childhood, affecting an estimated 4.8 million children. It is one of the leading causes of school absenteeism, accounting for over 10 million missed school days each year ( U.S. DHHS, 1996 ). In addition, managing asthma is expensive and imposes financial burdens on the families of people who have it. In 1990 the cost of asthma to the U.S. economy was estimated to be $6.2 billion, with the majority of the expense attributed to medical care. A 1996 analysis found the annual cost of asthma to be $14 billion ( CECS, 1998 ).

Table 4 shows the number of children per 1,000 children aged 0-17 in 1993 with a diversity of chronic conditions ( NCHS, 1993 ). Over the past 20 years, respiratory conditions have been the most prevalent type of chronic health problem experienced by children aged 0-17. Rates for most of the chronic health problems identified in Table 4 were fairly constant during that time period, with the exception of chronic respiratory conditions, which showed sizable increases from 1982 to 1993. For example, rates of chronic bronchitis rose from 34 per 1,000 children in 1982 to 59 per 1,000 in 1993 (a 76 percent increase). Similarly, rates of asthma rose 79 percent, going from 40 cases per 1,000 in 1982 to 72 cases per 1,000 in 1993 ( NCHS, 1982-1993 ).

TABLE 4. Selected Reported Chronic Conditions, Number per 1,000 Persons, by Age: United States, 1993.

Selected Reported Chronic Conditions, Number per 1,000 Persons, by Age: United States, 1993.

Risk Factors

In a widely cited paper McGinnis and Foege (1993) showed that unhealthy behaviors and environmental exposures were the “actual causes of death” that accounted for 50 percent of all U.S. mortality. Heading the list of causes were tobacco (19 percent), diet/activity patterns (14 percent), and alcohol (5 percent). Smoking has transformed lung cancer from a virtually unknown disease in 1900 to the leading cause of cancer deaths in 1999, accounting with environmental tobacco smoke and interactions with other exposures (e.g., radon) for more than 90 percent of lung cancer deaths each year. Smoking is also the leading cause of chronic obstructive pulmonary disease and chronic bronchitis and emphysema ( Warner, 2000 ). The prevalence of smoking has dropped from 45 percent in 1963, the year prior to publication of the Surgeon General's report on smoking and health ( U.S. DHEW, 1964 ), to 25 percent in 1997 ( CDC, 1999c ). Based on projections of the demographics of smoking, even in the absence of stronger tobacco control education and policy, and assuming no change in youth initiation of smoking, prevalence should continue to fall over the next 20 years, leveling off at approximately 18 percent of adults ( Mendez and Warner, 1998 ; see also).

Of adult Americans, 24.7 percent were smokers in 1997 ( CDC, 1999c ). Although a greater percentage of men smoke than women (27.6 percent and 22.1 percent, respectively), the gap between the two genders has declined gradually over time. Racial and ethnic differences in smoking prevalence are substantial, ranging from 16.9 percent for Asians and Pacific Islanders to 34.1 percent for Native Americans and Native Alaskans. Smoking rates vary substantially by age, with prevalence declining in the fourth and subsequent decades of life. Smoking cessation, the principal determinant of the decline in prevalence with age, rises significantly with age.

An important research challenge for demographers is the development of more effective ways of assessing smoking initiation. In the 1999 Monitoring the Future Survey, 34.6 percent of high school seniors had smoked within the previous 30 days. 3 The comparable figures for tenth and eighth graders were 25.7 percent and 17.5 percent, respectively. The interpretive problem with these figures, from the point of view of health risk, is that, while 30-day prevalence rates were rising during the 1990s, measures of regular and heavy smoking (e.g., half a pack or more per day) were not. While the latter clearly point to increased health risk, it is unclear what risks follow from the 30-day prevalence rates among youth.

Since the inception of the antismoking campaign in 1964, the most notable change in smoking prevalence is by education class. In 1965, the year following the first Surgeon General's report, less than 3 percentage points separated the prevalence of smoking among college graduates (33.7 percent) from that of Americans who did not graduate from high school ( U.S. DHHS, 1989 ). By 1997 prevalence among college graduates had fallen by nearly two-thirds to 11.6 percent. Among people without a high school diploma, in contrast, prevalence had fallen by only one-sixth (to 30.4 percent; CDC, 1999c ; Warner, 2000 ). Although considerable speculation has been put forth about the reasons for this disparity, this is an important future research direction, directly linked to those of and Chapter 7 , where the social and behavioral sciences are particularly prominent.

Dietary factors and sedentary activity patterns together account for at least 300,000 deaths each year ( McGinnis and Foege, 1993 ). Dietary factors have been associated with cardiovascular diseases (coronary artery disease, stroke, and hypertension), cancers (colon, breast, and prostate), and diabetes mellitus ( U.S. DHHS, 1988 ). Physical inactivity has been associated with an increased risk for heart disease ( Manson et al., 1992 ; Paffenberger et al., 1990 ) and colon cancer ( Lee et al., 1991 ). The interdependence of dietary factors and physical activity patterns as risk factors for obesity has received considerable attention ( Mokdad et al., 1999 ; Wickelgren, 1998 ; Hill and Peters, 1998 ; Tauber, 1998 ). Understanding these interactions as part of a more mechanistic characterization of predisease pathways ( Chapter 2 ) to a range of cardiovascular diseases and cancers is an important research direction requiring integrative perspectives (see Chapter ).

Alcohol and illicit drug use are associated with violence, injury (particularly automobile injuries and fatalities), and HIV infection (injecting drugs with contaminated needles). The annual economic costs to the United States from alcohol abuse are estimated to be $167 billion, and the costs from drug abuse are estimated to be $110 billion ( U.S. DHHS, 2000 ). Among adolescents alcohol is the most frequently used substance among the alcohol/illicit drug items. In 1997, 21 percent of adolescents aged 12-17 years reported drinking alcohol in the last month. Such use has remained at about 20 percent since 1992. Eight percent of this age group reported binge drinking and 3 percent were heavy drinkers (five or more drinks on the same occasion on each of five or more days in the last 30 days). Data from 1998 show that 10 percent of adolescents aged 12-17 years reported using illicit drugs in the last 30 days. This rate is significantly lower than in the previous year and remains well below the all-time high of 16 percent in 1979. Current illicit drug use had nearly doubled for those aged 12 to 13 years between 1996 and 1997 but then decreased between 1997 and 1998. Among adults binge drinking has remained at the same approximate level of 16 percent since 1988, with the highest current rate of 32 percent among adults aged 18 to 25 years. Illicit drug use has been near the present rate of 6 percent since 1980. Men continue to have higher rates of illicit drug use than women, and rates are higher in urban than in rural areas ( U.S. DHHS, 2000 ).

The above data summarize population-level profiles of adverse health behaviors (smoking, obesity and physical inactivity, alcohol and illicit drug use). Consistent with the integrative theme guiding this report (see Chapter 1 ), there is a great need for broadening research agendas around these topics. On the one hand, the behavioral and social sciences can help identify precursors (e.g., personality factors, coping styles, socialization processes, work and family stress, peer and community influences) to poor health practices (see Chapter 2 , Chapter 5 , and Chapter 6 ). Understanding the mechanisms through which poor health behaviors translate to chronic disease requires, however, that the above processes be linked to gene expression and multiple pathophysiological systems. It also requires attending to the reality that many of the above risk factors (behavioral and physiological) co-occur and have multiple health consequences (see discussion of co-occurring risk and comorbidity in Chapter 2 ).

From the integrative perspective, it is important to recognize that many of the above behavioral, psychological, social, and environmental factors are driven by broad social structural influences, such as socioeconomic inequality and racial/ethnic discrimination and stigmatization (see Chapter 7 ). Thus, macro-level forces must also be part of the integrative agenda. Finally, from the perspectives of prevention and treatment, the social and behavioral sciences point to diverse venues for avoiding, offsetting, or reversing these poor health practices (see Chapter 3 and Chapter 9 ). This report calls for deeper understanding of these interacting processes and thus requires coming at the question of population health risk from many diverse but related angles.

  • ACCOUNTING FOR MACRO-LEVEL HEALTH PATTERNS

An integrative perspective is required both to understand the antecedents and consequents of behavioral health risks and to account for macrolevel changes in health, such as gains in life expectancy, declining rates of disability, the spread of STDs, and infant mortality and childhood diseases. These topics and needed agendas following from them are described below.

The dramatic increase in life expectancy in the United States during the twentieth century is attributable largely to primary prevention interventions ( Bloom, 1999 ), such as improved sanitation, housing, nutrition, and new technologies for food preservation. The decrease of 6 percent per decade in chronic disease prevalence in males between 1910 and 1985 was achieved with relatively primitive medical and public health technologies and when little was known about the mechanisms of chronic disease processes at relatively advanced ages ( Fogel, 1999 ). Recent data suggest that nutritional factors affecting maternal health and fetal development help explain this chronic disease risk decline ( Fogel, 1999 ). Nutritional deficiencies could have affected maternal pelvic development and increased subsequent risks for cerebrovascular disease in the 1910 elderly Civil War veteran cohorts who were born between 1825 and 1844 ( Costa, 1998 ). Maternal nutritional deficiency during pregnancy also can impact development of the pancreas and liver in the fetus, which may alter risks of diabetes and heart disease as the child ages. These nutritional deficiencies were increasingly alleviated in the post-1840s birth cohorts.

Chronic disease risks were further altered in the early part of the twentieth century. For example, in the 1920s and 1930s changes in food preservation, thermal preparation, and storage affecting microbial food contaminants likely combined with changes in salt intake and water quality (e.g., reducing the prevalence of H. pylori infections) to alter the incidence of a wide range of chronic diseases, including stroke, hypertension, gastric and other cancers, and peptic ulcers ( Fogel, 1999 ; Fogel and Costa, 1997 ). A similar pattern was found in Great Britain. Up to the 1940s the British centenarian population grew 1 percent per year ( Perutz, 1998 ). After the 1940s (i.e., centenarians born after the 1840s) the growth rate was nearer 6 percent. Thus, in both Britain and the United States the major socioeconomic and nutritional changes appear to have affected the health and survival of post-1840 birth cohorts.

The national trends described above are accompanied by enormous variation within countries. County-specific analyses of historical trends in the adoption of primary prevention strategies and shifts in average socioeconomic status levels relative to those for a given state, or for the country at large, could provide a useful baseline for the formulation and targeting of future health promotion and disease prevention strategies.

Several influences on declining rates of disability among the elderly have been proposed. One suggestion is that these health improvements result from changes in the nature of work. Work has become less manually intensive and more cognitive over time, potentially delaying the onset of a range of adverse conditions, including musculoskeletal disorders and cardiovascular complications. In addition, exposure to dust and hazardous chemicals has declined. Preliminary evidence suggests that these changes may explain up to one-quarter of improvements in health for the elderly since the turn of the century ( Costa, 1998 ), although no evidence exists for recent years.

The nature of work may matter in other ways as well. Work that is mentally stressful or not mentally challenging enough may lead to psychological stress that is manifest in physical disorder. For example, musculoskeletal disorders are more common in people with low job satisfaction, elevated psychophysiological stress reactions, and lack of opportunity to unwind, all of which are characteristic of repetitious work with short time cycles ( Melin and Lundberg, 1997 ). Such findings are also reported in the Whitehall studies ( Marmot et al., 1991 ; Marmot, 1994 ).

A second possibility is that health improvements result from improved socioeconomic status (SES). SES has a large effect on individual health. As highlighted in Chapter 7 , people with higher SES exhibit better health in a wide variety of settings and for a number of measures of health ( Marmot, 1994 ). Furthermore, SES has changed substantially in recent years. Between 1970 and 1998, for example, the share of the elderly with more than a high school degree rose from 15 percent to 36 percent. Some evidence suggests that increased educational attainment of the elderly can explain part of the reduction in disability ( Freedman and Martin, 1999 ). The existence of these socioeconomic factors in and of themselves does not constitute full explanations, but rather emphasizes the need to better understand the pathways through which they are linked to behavioral, environmental, and psychosocial variables and underlying neurophysiological mechanisms.

A third idea invokes more macro-level influences, namely, the impact of public health measures either in childhood or earlier in adulthood. Many infectious diseases affect health long after a person has passed the infectious stage ( Costa, 1998 ), and there is recent evidence that nutrition as early as the fetal stage affects health in midlife and later ( Barker, 1997a , b ). Public health advances in the past century thus may have made important contributions to health among the elderly.

Many public health changes may also be linked with macro-level policies, such as the Surgeon General's report on smoking in 1964 ( U.S. DHEW, 1964 ) or prohibitions against smoking in public places. Welfare reform can potentially be associated with health impacts on children. Regulations regarding the geographic placement and protective features of toxic waste dumps can influence the health of entire communities. Analyses of the impact of policies such as these are frequently undertaken by special-interest groups. Monitoring such programs over long periods of time is, however, necessary to establish trends and deviations from them, as illustrated with the case of smoking and its much later disease sequelae (lung cancer, chronic bronchitis and emphysema, cardiovascular diseases; Warner, 2000 ). An important research priority is support for analyses of the health impacts of these policies. Linking them to the health of communities and of individuals is critically needed.

A final hypothesis concerning improvements in health is that medical advances, in the form of new therapies or prescription drugs, have played a major role. There clearly have been impressive medical advances in the past half century. Consider just one example: the treatment of severe coronary artery disease, which a half-century ago consisted largely of rest, hoping that less strain on the heart would reduce damage from the event. Today, therapy includes acute surgical advances such as cardiac catheterization, bypass surgery, and angioplasty; acute medical interventions such as thrombolysis; and less acute pharmaceutical innovations such as oral diuretics, beta blockers, ACE inhibitors, and calcium channel blockers. These advances have certainly contributed to reduced mortality and probably to reduced morbidity as well ( Cutler et al., 1998 ).

Our ability to empirically differentiate among these various explanations of improved health outcomes has been significantly enhanced by recent developments in data sources. The availability of information from medical claims for large numbers of patients is one such advance. A decade ago medical records on representative groups of patients with particular conditions were not available. Today, Medicare and many private medical insurers in the United States keep such information and use it for this type of research. A second advance has been the implementation of longitudinal population surveys collecting information on socioeconomic status, early life resources, work conditions, family stress and support, physical and mental health, and medical care received that are also linked to earnings records from Social Security systems and medical care utilization from health insurers. Longitudinal data are essential because changing disability will be fully understood only by following the same people over time. The National Long-Term Care Survey, Health and Retirement Study (HRS), and Asset and Health Dynamics Survey (AHEAD) are three recent data sets having information that will be enormously important in this research. Other data sets could be designed (or relevant questions appended to existing surveys) to allow even more valuable research.

The spread of STDs is influenced by three factors: (1) the average risk of infection per exposure, (2) the average rate of sexual partner change within the population, (3) and the average duration of the infectious period. The average duration of infection depends largely on availability and use of medical treatments. Medical treatment for STDs is generally poor in the United States ( Holmes, 1994 ), with some evidence suggesting that overall lack of funding limits the ability of people to receive treatment.

Behavioral changes affecting the rate of sexual partner change are a second explanation for rising STD rates. The age of first sexual intercourse has been falling, rates of unsafe sex are rising, and the number of partners is increasing. The behavioral factors underlying these changes are less clear. One factor may be changes in social norms about appropriate sexual behavior. But other factors include economic circumstances such as the proportion of women working, physical circumstances such as the mix of rich and poor within cities, amount of crowding, and social programs such as the size of welfare benefits and the availability of medical treatments.

Understanding these behavioral and social determinants is central to reducing the spread of STDs. As emphasized in Chapter 6 , the relation between community variables and individual behavior is an extremely fruitful area for behavioral and social science research. Work on these areas will be greatly enhanced by ongoing monitoring of STDs and tuberculosis by the CDC. STD and tuberculosis rates can now be measured overall and at the level of particular communities, which will significantly increase our ability to understand the role of community factors in these health outcomes.

Changes in Child Health

Rates of infant mortality and low birth weight are each driven by a confluence of conditions that include low socioeconomic status; poor or no prenatal care; high-risk health behaviors (e.g., smoking, drinking, and drug abuse by pregnant mothers); and chronic exposure to violence, poverty, and nonsupportive social networks. The teen birth rate is strongly correlated with the mother having grown up in an environment in which at least four of the following six conditions held: (1) as a child she was not living with two parents; (2) the household head was a high school dropout; (3) family income was below the poverty line; (4) the parent(s) did not have steady, full-time employment; (5) the family was receiving welfare benefits; and (6) she did not have health insurance ( Annie E. Casey Foundation, 1999 ). All the above conditions vary dramatically by state and by county in the United States. For example, the percentage of children living in families that satisfy four or more of the above high-risk conditions for teen parenthood in 1996 varied from 7 percent in New Hampshire to 21 percent in Mississippi and 39 percent in the District of Columbia.

A more subtle understanding of pathways to low-birth-weight babies, teen parenthood, and infant mortality requires multilevel analyses linking community characteristics with individual histories. Much remains to be done in this area. The recent methodological advances and recommended research priorities for Chapter 6 can be expected to play a central role in future developments.

Turning to asthma, the most common chronic disease of childhood, a deep understanding of its causes still lies in the future. Several current National Institutes of Health (NIH) initiatives are aimed at addressing this knowledge gap. The National Heart, Lung, and Blood Institute (NHLBI) has an initiative aimed at specifying how genetic and environmental factors interact in the developing lung and lead to the onset of asthma. One study sponsored by NHLBI will examine the cellular and molecular mechanisms underlying asthma's relationship with sleep and day-night events. The National Institute of Environmental Health Sciences (NIEHS) has a new Environmental Genome Project that will study different populations in different parts of the country in order to examine how interaction between the environment and certain genes leads to diseases like asthma. The National Institute of Allergy and Infectious Diseases (NIAID) and NIEHS are extending the Inner City Asthma Study, a study of children with asthma in seven U.S. cities that is examining the effects of interventions to reduce children's exposure to indoor allergens and improve communication with their primary care physicians. This investigation also involves collaboration with the Environmental Protection Agency to evaluate the effects of exposure to indoor and outdoor pollutants. Integrating findings from these studies into a unified multilevel explanation of how asthma comes about, together with an assessment of preventive and curative interventions is an important future priority that will require integrative analyses of the sort described throughout this report.

  • HEALTH AND THE MACROECONOMY

The health status of the population may have macroeconomic effects in addition to affecting individual behavior. Empirically, countries that are less healthy are poorer than countries that are more healthy, and their incomes grow less rapidly. Thus, the income gap between more and less healthy countries is increasing over time. Recent research indicates that life expectancy is a powerful predictor of national income levels and subsequent economic growth ( Fogel, 1999 ). Studies consistently find a strong effect of health on growth rates. Economic historians have concluded that perhaps 30 percent of the estimated per capita growth rate in Britain between 1780 and 1979 was a result of improvements in health and nutritional status ( Fogel and Costa, 1997 ). That lies within the range of estimates produced by cross-country studies using data from the last 30-40 years ( Jamison et al., 1998 ).

Health improvements also influence economic growth through their impact on demography. For example, in the 1940s rapid health improvements in East Asia provided a catalyst for demographic transition. An initial decline in infant and child mortality first dramatically increased the number of young people and then somewhat later prompted a fall in fertility rates. These asynchronous changes in mortality and fertility, which comprise the first phase of what is called the “demographic transition,” substantially altered East Asia's age distribution. After a time lag the working-age population began growing much faster than young dependents, temporarily creating a disproportionately high percentage of working-age adults. This bulge in the age structure of the population created an opportunity for increased economic growth ( Bloom, 1999 ).

Over the past several years, the Pan American Health Organization/Inter-American Development Bank and the United Nations Economic Commission for Latin America and the Caribbean carried out a study to eluci date relations between investments in health, economic growth, and household productivity ( WHO, 1999 ). Estimates based on data from Mexico throw some light on the time frame in which health affects economic indicators. High life expectancy at birth for males and females has an economic impact 0-5 years later. The impact of male life expectancy on the economy appears to be greater than that of female life expectancy, possibly because of the higher level of economic activity among males. The data suggest that for each additional year of life expectancy there will be an additional 1 percent increase in gross domestic product 15 years later. Similar findings were found for schooling.

Studies of this kind are in their infancy compared to other studies described in this report. Much remains to be done to link macro-level associations to the community and individual-level dynamics as discussed in Chapter 2 , Chapter 3 , Chapter 5 , and Chapter 6 . Understanding the reciprocal relationships between population health and the macroeconomy and their linkages to micro-level behavioral dynamics and intermediate-level community and social structural influences is a high-priority research direction. Indeed, it is precisely results such as those for Mexico, described above, that have implications for national economic policies leading to sustained commitments to investments in health. Providing clear evidence about linkages to community and individual levels can substantially strengthen the arguments for national commitments.

Health and the economy have long been linked by the practice of having children to ensure being cared for in old age. This is still true in many countries, but with public-sector innovations such as Social Security and medical care, the direct need for children as insurance has declined. In its place are issues of individual behavior (whether people live alone or with their children, whether they work or retire) and social questions about whether society can afford to provide care to an aging population.

The backdrop for much of the concern about changes in health is the strain that increasing length of life places on public programs in industrialized countries. The Social Security system in the United States is forecast to become insolvent around 2030, and Medicare is expected to be insolvent long before then. This situation, repeated throughout the developed world and in many developing countries, is made worse as population growth rates fall. Health improvements have hidden costs if they lead to difficulty financing public-sector programs for the elderly. However, recent evidence of rectangularization of survival curves, not only for mortality but for the age-specific onset of disability and chronic diseases ( Vita et al., 1998 ), suggests that prevention strategies may be having positive countervailing effects.

Health improvements can play a substantial role in solving public-sector problems. People who develop a serious illness late in their working life are more likely to retire early than are people who do not experience a serious illness at that age ( Smith, 1999 ), which reduces their lifetime earnings. Adolescents who are diagnosed with depression are less likely to get a college degree than are those not so diagnosed ( Berndt et al., 2000 ) and thus are likley to earn less over their lifetime. Advances in interventions that alleviate these health burdens could substantially reduce the public-sector financial burden. In any case, a central economic challenge facing the public sector is how to prepare for an aging society.

  • THE HEALTH CARE SYSTEM

The medical system is an important part of health. Indeed, public discussion about health focuses to an overwhelming degree on access to medical care. Understanding how the system operates and how well it works is therefore a central issue for behavioral and social research. We address three issues of concern in current and future evaluations of the health care system: (1) the effects of medical care on improving health, (2) the managed care debate, and (3) growing public interest in alternative medicine.

Effectiveness of Medical Care

Research shows mixed results regarding the value of the medical system. We illustrate these issues with medical care for the elderly, but the same issues apply to those who are not elderly, for example, asthma in children or disease transmission in teens and young adults. Some research highlights the positive effect of medical care on improving health. As noted above, one of the leading theories for reduced disability among the elderly is that such advances result from medical technology improvements. This view is widespread among biomedical researchers: medical advances, they believe, embodied in new technologies lead to significant health gains. Other research, however, highlights the apparently low return from additional medical spending. For example, Medicare spending varies by a factor of two among areas of the country, with no apparent differences in health outcomes ( CECS, 1998 ). Research on heart attack patients shows that intensive procedures are used up to five times more frequently in the United States than in Canada, but mortality rates are the same in the two countries ( Rouleau et al., 1993 ; Mark et al., 1994 ; Tu et al., 1997 ). Indeed, within the United States, people who live close to high-tech hospitals receive intensive services more frequently than people who live farther away from such hospitals, but again health outcomes are essentially the same ( McClellan et al., 1994 ). The value of additional medical spending is therefore unclear and is a needed avenue for future research.

Several explanations have been proposed for the disparate or conflicting findings about whether medical care has high or relatively low returns. One hypothesis is that medical care is valuable but is often applied inappropriately. For example, areas that spend a lot on medical care may simply give the technology to more people than will benefit from it. Much evidence supports the view that medical care is frequently wasted. Studies of medical procedure use in the United States, for example, find that a significant number of patients receiving high-tech services should not receive them on the basis of published clinical studies ( Chassin et al., 1987 ; Winslow et al., 1988a , b ; Greenspan et al., 1988 ). Other evidence is less supportive, however, finding that rates of inappropriate procedure use are no greater in areas with high usage rates compared to areas with lower usage rates. Reconciling conflicting evidence about the value of medical care is an important priority for future research.

It also has been proposed that preventive care is used in inverse proportion to more intensive medical services, so that people not receiving intensive treatment still have good outcomes. This is claimed to explain the lack of outcome differences between the United States and Canada. Canada has more complete coverage for outpatient pharmaceuticals than does the United States. Increased use of pharmaceuticals may allow Canadians to live longer, offsetting the survival advantage that comes from more intensive procedure use in the United States.

The distinction between over-time and point-in-time analysis must also be considered in evaluating the effectiveness of medical care. Many studies that find that medical care has a high rate of return compare treatments at different points in time, that is, before and after a particular technology is available. For example, changes in the treatment of heart attacks during the 1980s are associated with large increases in survival ( Cutler and Sheiner, 1998 ). The same is true for care of low-birth-weight infants between 1950 and 1990 ( Cutler and Meara, 2000 ). In contrast, studies that find that medical care has a low rate of return generally look at the use of the same treatment in different localities at the same point in time. Differences in use at a point in time may be more wasteful than increased use over time.

An increasing number of cost-effectiveness analyses of preventive strategies and alternative therapies are appearing. For example, Trussell et al. (1997) analyzed the economic benefits of adolescent contraceptive use utilizing information from a national private payer data base and from the California Medicaid program. Their study estimated the costs of acquiring and using 11 contraceptive methods appropriate for adolescents, treating associated side effects, providing medical care related to an unintended pregnancy during contraceptive use, and treating sexually transmitted diseases (STDs) and compared them with the costs of not using a contraceptive method. The average annual cost per adolescent at risk of unintended pregnancy who uses no method of contraception is $1,267 ($1,079 for unintended pregnancy and $188 for STDs) in the private sector and $677 ($541 for unintended pregnancy and $137 for STDs) in the public sector. After one year of use private-sector savings from adolescent contraceptive use ranged from $308 for an implant designed to prevent ovulation to $946 for the male condom. Public-sector savings rose from $60 for the implant to $525 for the male condom. Both the use of male condoms with another method and the advance provision of backup emergency contraceptive pills provided additional savings.

Shifting to an example of the cost effectiveness of cholesterol-lowering therapies, Prosser et al. (2000) found that ratios varied according to different risk factors. Specifically, incremental cost effectiveness ratios were found for primary prevention with a low fat, low cholesterol diet (National Cholesterol Education Program step I), ranging from $1,900 per quality-adjusted life-year (QALY) gained to $500,000 per QALY depending on risk subgroup characteristics. Primary prevention with a statin (a cholesterol-lowering drug) compared with diet therapy was $54,000 per QALY to $1.4 million per QALY. Secondary prevention with a statin cost less than $50,000 per QALY for all risk subgroups. Primary prevention with a step I diet seems to be cost effective for most risk subgroups defined by age, sex, and the presence of additional risk factors. It may not be cost effective for otherwise healthy young women. In addition, primary prevention with a statin may not be cost effective for younger men and women with few risk factors, given the option of secondary prevention and of primary prevention in older age groups. Secondary prevention with a statin seems to be cost effective for all risk subgroups and is cost saving for some high-risk subgroups.

As a further illustration, an economic evaluation was conducted alongside a randomized controlled trial of two lifestyle interventions (e.g., education and video to assess risk factors, program plan for risk factor behavior change) and a routine care (control) group to assess cost effectiveness for patients with risk factors for cardiovascular disease ( Salkeld et al., 1997 ). The cost per QALY for males ranged from $152,000 to $204,000. Further analysis suggested that a program targeted at high-risk males would cost $30,000 per QALY. The lifestyle interventions had no significant effect on cardiovascular risk factors when compared to routine patient care. There remains insufficient evidence that lifestyle programs conducted in general practice are effective. Resources for general-practice-based lifestyle programs may be better spent on high-risk patients who are contemplating changes in risk factor behaviors. Alternatively, the extensive literature on the economics of coronary heart disease prevention ( Brown and Garber, 1998 ) suggests that many programs (e.g., exercise, smoking cessation, detection and treatment of hypertension, cholesterol reduction) are highly cost effective.

While these examples are illustrative of the kinds of studies needed on a wider scale, it is important to underscore that such inquiries can have substantial impact on the quality of care provided by a diverse range of practitioners. In addition, errors in specification of therapeutic programs, mistakes made during surgical procedures, improper diagnoses, and faulty laboratory procedures are being documented on an increasingly broad scale. Such lines of inquiry are important for understanding the behavior of health care providers as a function of economic and organizational constraints placed on them. It will be equally important to turn solid research findings into improved practices. This will require effective communication and ongoing dialogue between the research community and practitioners. Cultural factors also play a prominent role here, since patients of different ethnic backgrounds approach—or do not approach—health care providers with very diverse views of health and wellness ( Kleinman, 1981 , 1989 ). Also important for the future will be analyses of data on medical treatments matched to health outcomes. Such data are now becoming widely available through Medicare and large insurers.

The Managed Care Debate

Public concern about managed care is intense, as recent legislative efforts to enact a patients' bill of rights attest. Research about how managed care actually affects medical practice, however, is limited. Changes in insurance coverage for nonelderly Americans between 1980 and 1996 were dramatic. In 1980, 92 percent of the population had traditional indemnity insurance, with 8 percent in health maintenance organizations (HMOs). In 1996 only 3 percent of the population remained in unmanaged fee-for-service plans. An additional 22 percent were in managed fee-for-service plans. The bulk of the population was enrolled in various types of managed care programs, including traditional HMOs, preferred-provider organizations (PPOs), and point-of-service plans (POSs). The spread of managed care is largely responsible for the reduced rate of growth of medical spending in the 1990s ( Cutler and Sheiner, 1998 ).

This trend has provoked fundamental questions. How does managed care save money: by restricting the number of services provided or by cutting payments for services? That is, managed care might affect the delivery of medical care in two ways: by altering the access rules (determining which people have access to medical providers) and the payment rules (determining reimbursement to providers). People with managed care insurance typically have more restrictive access to providers and high-tech care than do people in traditional indemnity insurance. On the other hand, people with managed care insurance generally have lower costs than do those with indemnity insurance.

The central issue is how health outcomes are affected by managed care. A second issue is whether the rise of managed care affects the diffusion of medical technology and whether that will be good or bad. Understanding the full incentives of managed care is difficult and requires the participation of both economic and medical expertise, for example, in understanding exactly how physicians are paid and what services they are able to provide. Sociological and psychological input is necessary as well. For example, physicians treated as employees of a managed care insurer may behave differently than physicians who see themselves as running their own practice. The degree to which managed care affects physician practice may depend on how it changes physicians' perceptions of their role in the medical system as much as it changes their actual ability to provide certain services. Research has yet to explore this issue.

Managed care might also have a direct effect on the extent to which providers acquire and use particular technologies. Several recent papers argue that managed care has reduced the diffusion of hospital-based technologies, including diagnostic scanners and some surgical procedures ( Cutler and Sheiner, 1998 ; Baker and Spetz, 1999 ). If such changes in access translate into change in utilization, it could have important implications for the long-term value of the medical sector. Research on this issue is just beginning as well.

In summary, the phenomenal change in the medical system encompassed by managed care, coupled with the availability of rich sources of data, make this topic a prime candidate for future research. Understanding the economic and health consequences of managed care has great import for informing public policy pertaining to the health care system.

Alternative Medicine Therapies

A large and expanding component of the U.S. health care system involves alternative medicine therapies, functionally defined as interventions neither taught widely in medical schools nor generally available in U.S. hospitals ( Eisenberg et al., 1993 ). In 1990 a national survey of alternative medicine prevalence, costs, and patterns of use demonstrated that alternative medicine has a substantial presence in the U.S. health care system. Since that time, an increasing number of insurers and managed care organizations have offered alternative medicine programs and benefits. Correlatively, the majority of U.S. medical schools now offer courses on alternative medicine ( Wetzel et al., 1998 ; Eisenberg et al., 1998 ).

In a follow-up national survey conducted in 1997 ( Eisenberg et al., 1998 ), data were assembled that allowed for quantitative assessment of trends in alternative medicine use over that time period. Use of at least one of 16 alternative therapies investigated increased from 8 percent in 1990 to 42.1 percent in 1997. The therapies increasing the most included herbal medicine, massage, megavitamins, self-help groups, folk remedies, energy healing, and homeopathy. In both the 1990 and 1997 surveys alternative therapies were used most frequently for chronic conditions, including back problems, anxiety, depression, and headaches. The percentage of users paying entirely out of pocket for services provided by alternative medicine practitioners did not change significantly between 1990 (64.0 percent) and 1997 (58.3 percent). Extrapolations to the U.S. population suggest a 47.3 percent increase in total visits to alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997, thereby exceeding total visits to all U.S. primary care physicians. An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies and/or high-dose vitamins (18.4 percent of all prescription users). Estimated expenditures for alternative medicine professional services increased 45.2 percent between 1990 and 1997 and were conservatively estimated at $21.2 billion in 1997, with at least $12.2 billion paid out of pocket. This exceeds the 1997 out-of-pocket expenditures for all U.S. hospitalizations. Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $27 billion, which is comparable to the projected 1997 out-of-pocket expenditures for all U.S. physician services.

The large economic impact of alternative medicine clearly demands research attention. Specifically, substantial resources should be devoted to clinical and integrated biological and social science research to provide rigorous understanding of the role of these interventions in the health of the U.S. population. This is important for establishing the credibility of claims for alternative medicine therapies. Part of this line of inquiry should include research on why placebos sometimes work and for whom. More generally, the broad area of mind/body relationships and their neurobiological underpinnings represent a vast research opportunity for the future. A useful example of the kind of knowledge development and synthesis that are needed is the elaborate study of meditation and neurobiology by Austin (1998) . The new NIH trans-institute initiative that recently established five mind/body centers around the United States constitutes a further important step in this direction.

  • FUTURE DIRECTIONS IN POPULATION SURVEYS

Several sources of data and methodologies will be essential in addressing the agendas described above. Perhaps the most basic need is for enhanced longitudinal population-level surveys. Such surveys should be enhanced in three ways:

  • They need to be linked to administrative records on the receipt of medical care and on work histories. Such linkage is vital because individuals will not recall all of the medical care they have received nor their earnings records.
  • Surveys need to be supplemented with community-level variables to determine how the social and economic environments affect individual behavior.
  • They need to have basic biological markers. Incorporating indicators of cumulative physiological risk (e.g., allostatic load) as standard components of longitudinal survey protocols would provide a basis for the integrative analyses recommended throughout this report. Augmenting longitudinal surveys with physical health examinations would be of enormous value, as the Framingham Study has shown.

Data from medical systems are also essential. Health insurers in the United States and other countries have access to unparalleled data on medical treatments and outcomes. These data can be used to study the value of the medical system. They can also address questions about behavior and community-level variables because they often contain detailed information on health conditions and medical treatments at the community level. Finally, we stress the role for international comparative work in answering the full range of population health questions discussed in this chapter. Economic, social, and medical systems differ greatly across countries, and thus international work is a natural laboratory for analysis.

  • RECOMMENDATIONS

We urge NIH to invest new resources in research to identify linkages between population health trends and the behavioral, environmental, and psychosocial factors emphasized in preceding chapters. Priority should be given to the following topics:

  • multilevel analyses necessary to advance rigorous explanations for the observed dynamics of the health of populations, giving particular emphasis to behavioral risk and protective factors and to psychosocial and environmental influences on aggregate-level health changes;
  • development of projection methodologies to provide defensible scenarios of how health changes will affect society in the future;
  • continue and expand multi-institute support of research on child health, particularly asthma and its costs, both economic (e.g., parental absence from work) and social (e.g., family burden, child development);
  • increase support for research on the reciprocal relationships between population health and the macroeconomy, together with linkages to community and individual-level dynamics as discussed in prior chapters;
  • develop new initiatives to investigate the conflicting findings about whether medical care has high or low returns for whom, when, and how. Importantly, data on medical treatments must be matched to health outcomes;
  • increase support for research on the economic and health costs or benefits of managed care (of central importance are studies that clarify how health outcomes are affected by managed care);
  • establish new trans-institute priorities to evaluate the effectiveness of alternative medicine therapies as well as to clarify their economic impact.

The data are available electronically: Demographic and Health Surveys: http://www ​.measuredhs.com .

The full report is available online from the Kaiser Family Foundation: http://www ​.kff.org/content ​/archive/1447/std_rep.pdf .

The data are available electronically: http: ​//monitoringthefuture.org/ .

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Health Care Comes Home: The Human Factors (2011)

Chapter: 7 conclusions and recommendations.

7 Conclusions and Recommendations

Health care is moving into the home increasingly often and involving a mixture of people, a variety of tasks, and a broad diversity of devices and technologies; it is also occurring in a range of residential environments. The factors driving this migration include the rising costs of providing health care; the growing numbers of older adults; the increasing prevalence of chronic disease; improved survival rates of various diseases, injuries, and other conditions (including those of fragile newborns); large numbers of veterans returning from war with serious injuries; and a wide range of technological innovations. The health care that results varies considerably in its safety, effectiveness, and efficiency, as well as its quality and cost.

The committee was charged with examining this major trend in health care delivery and resulting challenges from only one of many perspectives: the study of human factors. From the outset it was clear that the dramatic and evolving change in health care practice and policies presents a broad array of opportunities and problems. Consequently the committee endeavored to maintain focus specifically on how using the human factors approach can provide solutions that support maximizing the safety and quality of health care delivered in the home while empowering both care recipients and caregivers in the effort.

The conclusions and recommendations presented below reflect the most critical steps that the committee thinks should be taken to improve the state of health care in the home, based on the literature reviewed in this report examined through a human factors lens. They are organized into four areas: (1) health care technologies, including medical devices and health information technologies involved in health care in the home; (2)

caregivers and care recipients; (3) residential environments for health care; and (4) knowledge gaps that require additional research and development. Although many issues related to home health care could not be addressed, applications of human factors principles, knowledge, and research methods in these areas could make home health care safer and more effective and also contribute to reducing costs. The committee chose not to prioritize the recommendations, as they focus on various aspects of health care in the home and are of comparable importance to the different constituencies affected.

HEALTH CARE TECHNOLOGIES

Health care technologies include medical devices that are used in the home as well as information technologies related to home-based health care. The four recommendations in this area concern (1) regulating technologies for health care consumers, (2) developing guidance on the structure and usability of health information technologies, (3) developing guidance and standards for medical device labeling, and (4) improving adverse event reporting systems for medical devices. The adoption of these recommendations would improve the usability and effectiveness of technology systems and devices, support users in understanding and learning to use them, and improve feedback to government and industry that could be used to further improve technology for home care.

Ensuring the safety of emerging technologies is a challenge, in part because it is not always clear which federal agency has regulatory authority and what regulations must be met. Currently, the U.S. Food and Drug Administration (FDA) has responsibility for devices, and the Office of the National Coordinator for Health Information Technology (ONC) has similar authority with respect to health information technology. However, the dividing line between medical devices and health information technology is blurring, and many new systems and applications are being developed that are a combination of the two, although regulatory oversight has remained divided. Because regulatory responsibility for them is unclear, these products may fall into the gap.

The committee did not find a preponderance of evidence that knowledge is lacking for the design of safe and effective devices and technologies for use in the home. Rather than discovering an inadequate evidence base, we were troubled by the insufficient attention directed at the development of devices that account, necessarily and properly, for users who are inadequately trained or not trained at all. Yet these new users often must

rely on equipment without ready knowledge about limitations, maintenance requirements, and problems with adaptation to their particular home settings.

The increased prominence of the use of technology in the health care arena poses predictable challenges for many lay users, especially people with low health literacy, cognitive impairment, or limited technology experience. For example, remote health care management may be more effective when it is supported by technology, and various electronic health care (“e-health”) applications have been developed for this purpose. With the spectrum of caregivers ranging from individuals caring for themselves or other family members to highly experienced professional caregivers, computer-based care management systems could offer varying levels of guidance, reminding, and alerting, depending on the sophistication of the operator and the criticality of the message. However, if these technologies or applications are difficult to understand or use, they may be ignored or misused, with potentially deleterious effects on care recipient health and safety. Applying existing accessibility and usability guidelines and employing user-centered design and validation methods in the development of health technology products designed for use in the home would help ensure that they are safe and effective for their targeted user populations. In this effort, it is important to recognize how the line between medical devices and health information technologies has become blurred while regulatory oversight has remained distinct, and it is not always clear into which domain a product falls.

Recommendation 1. The U.S. Food and Drug Administration and the Office of the National Coordinator for Health Information Technology should collaborate to regulate, certify, and monitor health care applications and systems that integrate medical devices and health information technologies. As part of the certification process, the agencies should require evidence that manufacturers have followed existing accessibility and usability guidelines and have applied user-centered design and validation methods during development of the product.

Guidance and Standards

Developers of information technologies related to home-based health care, as yet, have inadequate or incomplete guidance regarding product content, structure, accessibility, and usability to inform innovation or evolution of personal health records or of care recipient access to information in electronic health records.

The ONC, in the initial announcement of its health information technology certification program, stated that requirements would be forthcom-

ing with respect both to personal health records and to care recipient access to information in electronic health records (e.g., patient portals). Despite the importance of these requirements, there is still no guidance on the content of information that should be provided to patients or minimum standards for accessibility, functionality, and usability of that information in electronic or nonelectronic formats.

Consequently, some portals have been constructed based on the continuity of care record. However, recent research has shown that records and portals based on this model are neither understandable nor interpretable by laypersons, even by those with a college education. The lack of guidance in this area makes it difficult for developers of personal health records and patient portals to design systems that fully address the needs of consumers.

Recommendation 2. The Office of the National Coordinator for Health Information Technology, in collaboration with the National Institute of Standards and Technology and the Agency for Healthcare Research and Quality, should establish design guidelines and standards, based on existing accessibility and usability guidelines, for content, accessibility, functionality, and usability of consumer health information technologies related to home-based health care.

The committee found a serious lack of adequate standards and guidance for the labeling of medical devices. Furthermore, we found that the approval processes of the FDA for changing these materials are burdensome and inflexible.

Just as many medical devices currently in use by laypersons in the home were originally designed and approved for use only by professionals in formal health care facilities, the instructions for use and training materials were not designed for lay users, either. The committee recognizes that lack of instructional materials for lay users adds to the level of risk involved when devices are used by populations for whom they were not intended.

Ironically, the FDA’s current premarket review and approval processes inadvertently discourage manufacturers from selectively revising or developing supplemental instructional and training materials, when they become aware that instructional and training materials need to be developed or revised for lay users of devices already approved and marketed. Changing the instructions for use (which were approved with the device) requires manufacturers to submit the device along with revised instructions to the FDA for another 510(k) premarket notification review. Since manufacturers can find these reviews complicated, time-consuming, and expensive, this requirement serves as a disincentive to appropriate revisions of instructional or training materials.

Furthermore, little guidance is currently available on design of user

training methods and materials for medical devices. Even the recently released human factors standard on medical device design (Association for the Advancement of Medical Instrumentation, 2009), while reasonably comprehensive, does not cover the topic of training or training materials. Both FDA guidance and existing standards that do specifically address the design of labeling and ensuing instructions for use fail to account for up-to-date findings from research on instructional systems design. In addition, despite recognition that requirements for user training, training materials, and instructions for use are different for lay and professional users of medical equipment, these differences are not reflected in current standards.

Recommendation 3. The U.S. Food and Drug Administration (FDA) should promote development (by standards development organizations, such as the International Electrotechnical Commission, the International Organization for Standardization, the American National Standards Institute, and the Association for the Advancement of Medical Instrumentation) of new standards based on the most recent human factors research for the labeling of and ensuing instructional materials for medical devices designed for home use by lay users. The FDA should also tailor and streamline its approval processes to facilitate and encourage regular improvements of these materials by manufacturers.

Adverse Event Reporting Systems

The committee notes that the FDA’s adverse event reporting systems, used to report problems with medical devices, are not user-friendly, especially for lay users, who generally are not aware of the systems, unaware that they can use them to report problems, and uneducated about how to do so. In order to promote safe use of medical devices in the home and rectify design problems that put care recipients at risk, it is necessary that the FDA conduct more effective postmarket surveillance of medical devices to complement its premarket approval process. The most important elements of their primarily passive surveillance system are the current adverse event reporting mechanisms, including Maude and MedSun. Entry of incident data by health care providers and consumers is not straightforward, and the system does not elicit data that could be useful to designers as they develop updated versions of products or new ones that are similar to existing devices. The reporting systems and their importance need to be widely promoted to a broad range of users, especially lay users.

Recommendation 4. The U.S. Food and Drug Administration should improve its adverse event reporting systems to be easier to use, to collect data that are more useful for identifying the root causes of events

related to interactions with the device operator, and to develop and promote a more convenient way for lay users as well as professionals to report problems with medical devices.

CAREGIVERS IN THE HOME

Health care is provided in the home by formal caregivers (health care professionals), informal caregivers (family and friends), and individuals who self-administer care; each type of caregiver faces unique issues. Properly preparing individuals to provide care at home depends on targeting efforts appropriately to the background, experience, and knowledge of the caregivers. To date, however, home health care services suffer from being organized primarily around regulations and payments designed for inpatient or outpatient acute care settings. Little attention has been given to how different the roles are for formal caregivers when delivering services in the home or to the specific types of training necessary for appropriate, high-quality practice in this environment.

Health care administration in the home commonly involves interaction among formal caregivers and informal caregivers who share daily responsibility for a person receiving care. But few formal caregivers are given adequate training on how to work with informal caregivers and involve them effectively in health decision making, use of medical or adaptive technologies, or best practices to be used for evaluating and supporting the needs of caregivers.

It is also important to recognize that the majority of long-term care provided to older adults and individuals with disabilities relies on family members, friends, or the individual alone. Many informal caregivers take on these responsibilities without necessary education or support. These individuals may be poorly prepared and emotionally overwhelmed and, as a result, experience stress and burden that can lead to their own morbidity. The committee is aware that informational and training materials and tested programs already exist to assist informal caregivers in understanding the many details of providing health care in the home and to ease their burden and enhance the quality of life of both caregiver and care recipient. However, tested materials and education, support, and skill enhancement programs have not been adequately disseminated or integrated into standard care practices.

Recommendation 5. Relevant professional practice and advocacy groups should develop appropriate certification, credentialing, and/or training standards that will prepare formal caregivers to provide care in the home, develop appropriate informational and training materials

for informal caregivers, and provide guidance for all caregivers to work effectively with other people involved.

RESIDENTIAL ENVIRONMENTS FOR HEALTH CARE

Health care is administered in a variety of nonclinical environments, but the most common one, particularly for individuals who need the greatest level and intensity of health care services, is the home. The two recommendations in this area encourage (1) modifications to existing housing and (2) accessible and universal design of new housing. The implementation of these recommendations would be a good start on an effort to improve the safety and ease of practicing health care in the home. It could improve the health and safety of many care recipients and their caregivers and could facilitate adherence to good health maintenance and treatment practices. Ideally, improvements to housing design would take place in the context of communities that provide transportation, social networking and exercise opportunities, and access to health care and other services.

Safety and Modification of Existing Housing

The committee found poor appreciation of the importance of modifying homes to remove health hazards and barriers to self-management and health care practice and, furthermore, that financial support from federal assistance agencies for home modifications is very limited. The general connection between housing characteristics and health is well established. For example, improving housing conditions to enhance basic sanitation has long been part of a public health response to acute illness. But the characteristics of the home can present significant barriers to autonomy or self-care management and present risk factors for poor health, injury, compromised well-being, and greater dependence on others. Conversely, physical characteristics of homes can enhance resident safety and ability to participate in daily self-care and to utilize effectively health care technologies that are designed to enhance health and well-being.

Home modifications based on professional home assessments can increase functioning, contribute to reducing accidents such as falls, assist caregivers, and enable chronically ill persons and people with disabilities to stay in the community. Such changes are also associated with facilitating hospital discharges, decreasing readmissions, reducing hazards in the home, and improving care coordination. Familiar modifications include installation of such items as grab bars, handrails, stair lifts, increased lighting, and health monitoring equipment as well as reduction of such hazards as broken fixtures and others caused by insufficient home maintenance.

Deciding on which home modifications have highest priority in a given

setting depends on an appropriate assessment of circumstances and the environment. A number of home assessment instruments and programs have been validated and proven to be effective to meet this need. But even if needed modifications are properly identified and prioritized, inadequate funding, gaps in services, and lack of coordination between the health and housing service sectors have resulted in a poorly integrated system that is difficult to access. Even when accessed, progress in making home modifications available has been hampered by this lack of coordination and inadequate reimbursement or financial mechanisms, especially for those who cannot afford them.

Recommendation 6. Federal agencies, including the U.S. Department of Health and Human Services and the Centers for Medicare & Medicaid Services, along with the U.S. Department of Housing and Urban Development and the U.S. Department of Energy, should collaborate to facilitate adequate and appropriate access to health- and safety-related home modifications, especially for those who cannot afford them. The goal should be to enable persons whose homes contain obstacles, hazards, or features that pose a home safety concern, limit self-care management, or hinder the delivery of needed services to obtain home assessments, home modifications, and training in their use.

Accessibility and Universal Design of New Housing

Almost all existing housing in the United States presents problems for conducting health-related activities because physical features limit independent functioning, impede caregiving, and contribute to such accidents as falls. In spite of the fact that a large and growing number of persons, including children, adults, veterans, and older adults, have disabilities and chronic conditions, new housing continues to be built that does not account for their needs (current or future). Although existing homes can be modified to some extent to address some of the limitations, a proactive, preventive, and effective approach would be to plan to address potential problems in the design phase of new and renovated housing, before construction.

Some housing is already required to be built with basic accessibility features that facilitate practice of health care in the home as a result of the Fair Housing Act Amendments of 1998. And 17 states and 30 cities have passed what are called “visitability” codes, which currently apply to 30,000 homes. Some localities offer tax credits, such as Pittsburgh through an ordinance, to encourage installing visitability features in new and renovated housing. The policy in Pittsburgh was impetus for the Pennsylvania Residential VisitAbility Design Tax Credit Act signed into law on October 28, 2006, which offers property owners a tax credit for new construction

and rehabilitation. The Act paves the way for municipalities to provide tax credits to citizens by requiring that such governing bodies administer the tax credit (Self-Determination Housing Project of Pennsylvania, Inc., n.d.).

Visitability, rather than full accessibility, is characterized by such limited features as an accessible entry into the home, appropriately wide doorways and one accessible bathroom. Both the International Code Council, which focuses on building codes, and the American National Standards Institute, which establishes technical standards, including ones associated with accessibility, have endorsed voluntary accessibility standards. These standards facilitate more jurisdictions to pass such visitability codes and encourage legislative consistency throughout the country. To date, however, the federal government has not taken leadership to promote compliance with such standards in housing construction, even for housing for which it provides financial support.

Universal design, a broader and more comprehensive approach than visitability, is intended to suit the needs of persons of all ages, sizes, and abilities, including individuals with a wide range of health conditions and activity limitations. Steps toward universal design in renovation could include such features as anti-scald faucet valve devices, nonslip flooring, lever handles on doors, and a bedroom on the main floor. Such features can help persons and their caregivers carry out everyday tasks and reduce the incidence of serious and costly accidents (e.g., falls, burns). In the long run, implementing universal design in more homes will result in housing that suits the long-term needs of more residents, provides more housing choices for persons with chronic conditions and disabilities, and causes less forced relocation of residents to more costly settings, such as nursing homes.

Issues related to housing accessibility have been acknowledged at the federal level. For example, visitability and universal design are in accord with the objectives of the Safety of Seniors Act (Public Law No. 110-202, passed in 2008). In addition, implementation of the Olmstead decision (in which the U.S. Supreme Court ruled that the Americans with Disabilities Act may require states to provide community-based services rather than institutional placements for individuals with disabilities) requires affordable and accessible housing in the community.

Visitability, accessibility, and universal design of housing all are important to support the practice of health care in the home, but they are not broadly implemented and incentives for doing so are few.

Recommendation 7. Federal agencies, such as the U.S. Department of Housing and Urban Development, the U.S. Department of Veterans Affairs, and the Federal Housing Administration, should take a lead role, along with states and local municipalities, to develop strategies that promote and facilitate increased housing visitability, accessibil-

ity, and universal design in all segments of the market. This might include tax and other financial incentives, local zoning ordinances, model building codes, new products and designs, and related policies that are developed as appropriate with standards-setting organizations (e.g., the International Code Council, the International Electrotechnical Commission, the International Organization for Standardization, and the American National Standards Institute).

RESEARCH AND DEVELOPMENT

In our review of the research literature, the committee learned that there is ample foundational knowledge to apply a human factors lens to home health care, particularly as improvements are considered to make health care safe and effective in the home. However, much of what is known is not being translated effectively into practice, neither in design of equipment and information technology or in the effective targeting and provision of services to all those in need. Consequently, the four recommendations that follow support research and development to address knowledge and communication gaps and facilitate provision of high-quality health care in the home. Specifically, the committee recommends (1) research to enhance coordination among all the people who play a role in health care practice in the home, (2) development of a database of medical devices in order to facilitate device prescription, (3) improved surveys of the people involved in health care in the home and their residential environments, and (4) development of tools for assessing the tasks associated with home-based health care.

Health Care Teamwork and Coordination

Frail elders, adults with disabilities, disabled veterans, and children with special health care needs all require coordination of the care services that they receive in the home. Home-based health care often involves a large number of elements, including multiple care providers, support services, agencies, and complex and dynamic benefit regulations, which are rarely coordinated. However, coordinating those elements has a positive effect on care recipient outcomes and costs of care. When successful, care coordination connects caregivers, improves communication among caregivers and care recipients and ensures that receivers of care obtain appropriate services and resources.

To ensure safe, effective, and efficient care, everyone involved must collaborate as a team with shared objectives. Well-trained primary health care teams that execute customized plans of care are a key element of coordinated care; teamwork and communication among all actors are also

essential to successful care coordination and the delivery of high-quality care. Key factors that influence the smooth functioning of a team include a shared understanding of goals, common information (such as a shared medication list), knowledge of available resources, and allocation and coordination of tasks conducted by each team member.

Barriers to coordination include insufficient resources available to (a) help people who need health care at home to identify and establish connections to appropriate sources of care, (b) facilitate communication and coordination among caregivers involved in home-based health care, and (c) facilitate communication among the people receiving and the people providing health care in the home.

The application of systems analysis techniques, such as task analysis, can help identify problems in care coordination systems and identify potential intervention strategies. Human factors research in the areas of communication, cognitive aiding and decision support, high-fidelity simulation training techniques, and the integration of telehealth technologies could also inform improvements in care coordination.

Recommendation 8 . The Agency for Healthcare Research and Quality should support human factors–based research on the identified barriers to coordination of health care services delivered in the home and support user-centered development and evaluation of programs that may overcome these barriers.

Medical Device Database

It is the responsibility of physicians to prescribe medical devices, but in many cases little information is readily available to guide them in determining the best match between the devices available and a particular care recipient. No resource exists for medical devices, in contrast to the analogous situation in the area of assistive and rehabilitation technologies, for which annotated databases (such as AbleData) are available to assist the provider in determining the most appropriate one of several candidate devices for a given care recipient. Although specialists are apt to receive information about devices specific to the area of their practice, this is much less likely in the case of family and general practitioners, who often are responsible for selecting, recommending, or prescribing the most appropriate device for use at home.

Recommendation 9. The U.S. Food and Drug Administration, in collaboration with device manufacturers, should establish a medical device database for physicians and other providers, including pharmacists, to use when selecting appropriate devices to prescribe or recommend

for people receiving or self-administering health care in the home. Using task analysis and other human factors approaches to populate the medical device database will ensure that it contains information on characteristics of the devices and implications for appropriate care recipient and device operator populations.

Characterizing Caregivers, Care Recipients, and Home Environments

As delivery of health care in the home becomes more common, more coherent strategies and effective policies are needed to support the workforce of individuals who provide this care. Developing these will require a comprehensive understanding of the number and attributes of individuals engaged in health care in the home as well as the context in which care is delivered. Data and data analysis are lacking to accomplish this objective.

National data regarding the numbers of individuals engaged in health care delivery in the home—that is, both formal and informal caregivers—are sparse, and the estimates that do exist vary widely. Although the Bureau of Labor Statistics publishes estimates of the number of workers employed in the home setting for some health care classifications, they do not include all relevant health care workers. For example, data on workers employed directly by care recipients and their families are notably absent. Likewise, national estimates of the number of informal caregivers are obtained from surveys that use different methodological approaches and return significantly different results.

Although numerous national surveys have been designed to answer a broad range of questions regarding health care delivery in the home, with rare exceptions such surveys reflect the relatively limited perspective of the sponsoring agency. For example,

  • The Medicare Current Beneficiary Survey (administered by the Centers for Medicare & Medicaid Services) and the Health and Retirement Survey (administered by the National Institute on Aging) are primarily geared toward understanding the health, health services use, and/or economic well-being of older adults and provide no information regarding working-age adults or children or information about home or neighborhood environments.
  • The Behavioral Risk Factors Surveillance Survey (administered by the Centers for Disease Control and Prevention, CDC), the National Health Interview Survey (administered by the CDC), and the National Children’s Study (administered by the U.S. Department of Health and Human Services and the U.S. Environmental Protection Agency) all collect information on health characteristics, with limited or no information about the housing context.
  • The American Housing Survey (administered by the U.S. Department of Housing and Urban Development) collects detailed information regarding housing, but it does not include questions regarding the health status of residents and does not collect adequate information about home modifications and features on an ongoing basis.

Consequently, although multiple federal agencies collect data on the sociodemographic and health characteristics of populations and on the nation’s housing stock, none of these surveys collects data necessary to link the home, its residents, and the presence of any caregivers, thus limiting understanding of health care delivered in the home. Furthermore, information is altogether lacking about health and functioning of populations linked to the physical, social, and cultural environments in which they live. Finally, in regard to individuals providing care, information is lacking regarding their education, training, competencies, and credentialing, as well as appropriate knowledge about their working conditions in the home.

Better coordination across government agencies that sponsor such surveys and more attention to information about health care that occurs in the home could greatly improve the utility of survey findings for understanding the prevalence and nature of health care delivery in the home.

Recommendation 10. Federal health agencies should coordinate data collection efforts to capture comprehensive information on elements relevant to health care in the home, either in a single survey or through effective use of common elements across surveys. The surveys should collect data on the sociodemographic and health characteristics of individuals receiving care in the home, the sociodemographic attributes of formal and informal caregivers and the nature of the caregiving they provide, and the attributes of the residential settings in which the care recipients live.

Tools for Assessing Home Health Care Tasks and Operators

Persons caring for themselves or others at home as well as formal caregivers vary considerably in their skills, abilities, attitudes, experience, and other characteristics, such as age, culture/ethnicity, and health literacy. In turn, designers of health-related devices and technology systems used in the home are often naïve about the diversity of the user population. They need high-quality information and guidance to better understand user capabilities relative to the task demands of the health-related device or technology that they are developing.

In this environment, valid and reliable tools are needed to match users with tasks and technologies. At this time, health care providers lack the

tools needed to assess whether particular individuals would be able to perform specific health care tasks at home, and medical device and system designers lack information on the demands associated with health-related tasks performed at home and the human capabilities needed to perform them successfully.

Whether used to assess the characteristics of formal or informal caregivers or persons engaged in self-care, task analysis can be used to develop point-of-care tools for use by consumers and caregivers alike in locations where such tasks are encouraged or prescribed. The tools could facilitate identification of potential mismatches between the characteristics, abilities, experiences, and attitudes that an individual brings to a task and the demands associated with the task. Used in ambulatory care settings, at hospital discharge or other transitions of care, and in the home by caregivers or individuals and family members themselves, these tools could enable assessment of prospective task performer’s capabilities in relation to the demands of the task. The tools might range in complexity from brief screening checklists for clinicians to comprehensive assessment batteries that permit nuanced study and tracking of home-based health care tasks by administrators and researchers. The results are likely to help identify types of needed interventions and support aids that would enhance the abilities of individuals to perform health care tasks in home settings safely, effectively, and efficiently.

Recommendation 11. The Agency for Healthcare Research and Quality should collaborate, as necessary, with the National Institute for Disability and Rehabilitation Research, the National Institutes of Health, the U.S. Department of Veterans Affairs, the National Science Foundation, the U.S. Department of Defense, and the Centers for Medicare & Medicaid Services to support development of assessment tools customized for home-based health care, designed to analyze the demands of tasks associated with home-based health care, the operator capabilities required to carry them out, and the relevant capabilities of specific individuals.

Association for the Advancement of Medical Instrumentation. (2009). ANSI/AAMI HE75:2009: Human factors engineering: Design of medical devices. Available: http://www.aami.org/publications/standards/HE75_Ch16_Access_Board.pdf [April 2011].

Self-Determination Housing Project of Pennsylvania, Inc. (n.d.) Promoting visitability in Pennsylvania. Available: http://www.sdhp.org/promoting_visitability_in_pennsy.htm [March 30, 2011].

In the United States, health care devices, technologies, and practices are rapidly moving into the home. The factors driving this migration include the costs of health care, the growing numbers of older adults, the increasing prevalence of chronic conditions and diseases and improved survival rates for people with those conditions and diseases, and a wide range of technological innovations. The health care that results varies considerably in its safety, effectiveness, and efficiency, as well as in its quality and cost.

Health Care Comes Home reviews the state of current knowledge and practice about many aspects of health care in residential settings and explores the short- and long-term effects of emerging trends and technologies. By evaluating existing systems, the book identifies design problems and imbalances between technological system demands and the capabilities of users. Health Care Comes Home recommends critical steps to improve health care in the home. The book's recommendations cover the regulation of health care technologies, proper training and preparation for people who provide in-home care, and how existing housing can be modified and new accessible housing can be better designed for residential health care. The book also identifies knowledge gaps in the field and how these can be addressed through research and development initiatives.

Health Care Comes Home lays the foundation for the integration of human health factors with the design and implementation of home health care devices, technologies, and practices. The book describes ways in which the Agency for Healthcare Research and Quality (AHRQ), the U.S. Food and Drug Administration (FDA), and federal housing agencies can collaborate to improve the quality of health care at home. It is also a valuable resource for residential health care providers and caregivers.

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Free Issues and Trends in Healthcare Essay Sample

The fourth stage of healthcare development calls for extensive consumer health reforms. This stage is geared towards ensuring that all citizens have more control on their health. At this stage, the targeted population is the consumers. That is, the consumers (all citizens) of the healthcare are given priority.

A Nazi Theme: Comparison with Current US Policy

In 1939, Adolph Hitler and the Nazi party called a healthcare conference in which the theme “lives unworthy to be lived” came about. This was a scheme to identify and remove people (through a ‘merciful’ death) that were supposedly a burden to the healthcare system. Through this way, the healthcare sector will not have to spend money on “lives or medical procedures that were unworthy.” This theme has been compared with the current United States proposal whereby a list of medical procedures that will be permitted from now henceforth, and those that will not, will be prepared and implemented. The administration believes that this will remove a $2 trillion expenditure burden.

Definition of Unsustainable

Unsustainable means “cannot be maintained”. That is, something that is unsustainable means that it cannot be maintained. Example in a sentence: the large operational costs associated with this machine simply mean that it is unsustainable in this company.

Nuremberg Code of 1946

The Nuremberg Code was meant to protect human subjects that are engaged in any clinical researches and trials. The major requirement is that the human subjects have to voluntarily consent to the clinical studies and trials. Other requirements include: the studies are aimed at benefitting the whole society, the experiments are to be designed and based on the similar animal results, the subjects should not suffer any form of injury, experiments cannot be done when there is a possibility of death, the risks involved in the experiments should be very minimal, preparations and facilities should be almost perfect for the safety of the subjects, the experiments are to be conducted by only highly qualified professionals, the human subjects have the freedom to end their involvement in the experiments at any time and lastly, the researcher has to terminate the experiment if there is a slight hint that it may lead to an injury or death of the human subject.

Government Resources

It is no secret that the United States government rates the proper health of its citizens very highly. The expenditure on health is the largest, at about 18% of the total GDP. In the year 2010, the government spent about $2.6 billion on healthcare. This is expected to be increased to $4.6 billion by 2020. This simply means that it has relatively extensive financial resources to implement and monitor the Healthcare Law of 2010 and EO 13544. To implement and monitor the programs at the lower levels, an advisory group (consisting of about 25 representatives outside the federal government) was appointed that will report to the Council chair. This group will deal with all matters related to health (prevention, promotion, publicity…). A national health prevention and promotion strategy was also developed and will set the goals, implement, monitor and advise on health-related issues. The government has also been using people’s surveys to monitor healthcare issues. These include the American community survey, national health interview survey, current population survey and national survey of children’s health. Feedback from these surveys helps to shape the country health sector at all levels (SHADAC).

US Healthcare Spending: Comparison with other Developed Nations

The spending on healthcare by the United States constantly expanded from about $ 75 billion in 1970 (about 7% of the GDP) to over $2 trillion in the recent past (16% of the GDP). This is more than double the spending rate of other developed nations. This high level of spending may suggest that all Americans should have their healthcare covered. However, this is not the case. There are tens of millions of American citizens that lack health insurance while many more cannot afford proper healthcare. This simply means that there should be reforms in the expenditure politics. More specifically, the spending should prioritize the American citizens above everything else. Such reforms should empower the citizens to decide and control how their healthcare costs are spent, make healthcare coverage affordable to all, make specialty care fully accessible, extend access and coverage for those uninsured or underinsured and do away with unsustainable programs. In this way, spending will be channeled directly towards meeting the health needs of the people (AAOS).

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Sample Essay On Healthcare Trends

Type of paper: Essay

Topic: Health , Disease , Medicine , Nursing , Health Care , Illness , Patient , Life

Published: 2020/11/30

The current trends in healthcare are evolving and bringing about new advancements in the

field of healthcare. The changes are making healthcare better day by day. Innovation in the new technologies and widening horizons of knowledge are bringing about vast improvements. According to an article in an e-newsletter the major trends that will be seen in the upcoming year in the field of healthcare are : further increase in the electronic records, more attention to be paid towards the care of the chronically ills, more and more healthcare coaches to be employed by the people and employees to be paid incentives for showing a healthy behavior (Adamopoulos, 2014) In this article we will talk about management of the chronically ill patient. Nowadays a large number of people are suffering from chronic diseases. It has almost become certain that after a particular age in the middle life everyone suffers from some or the other form of chronic illness. Some get bed ridden and some lucky ones do not. But the ones ho do get bed ridden should not become a burden to the family and the society. They need to ;\learn how to take care of themselves so that they can live a better and a safer life with a happy family environment. The more these patients are dependent on others for their care, the more they have to bear the loneliness, isolation and helplessness. The chronically ill patients need to know about self care. They should be taught how to live a life without being dependent on others. They need to know regarding the self management support. According to some researchers there are three steps that these patients must be thorough about. They are: management of their Illness on their own, which is, they should know regarding the medications, nursing techniques, the extent of their disease, medications to be taken and the timing of the medications and proper care of the disease. Secondly they should be able to carry out their day to day activities, this may be difficult for some patients, but they should try doing the same. This will boost up their confidence level. They will not feel helpless or a burden on others or their near ones. This will give them an emotional stability. Lastly they should know how to manage the emotional impact of the disease. In chronic illness mostly it is not the disease that hampers the patient. But it is the emotional distress that breaks him down. The patient undergoes through lots of trauma and mental agony that makes his life hell (Improvingchroniccare.org, 2015). In other words, it is the patient himself who needs to take of his own. No one else can nurse him better than he can. He needs to be stronger and calmer towards his disease. He needs to build a stronger morale to tackle his illness. Everyone else can be a part of his illness, but no one else can experience it the way he does. It is only him who can help himself. If he is self dependent then he would never become a burden to others. He will receive the love and respect he deserves from the society and this near ones. The stronger he is, the better it is for him. Not just emotionally, but this positive attitude will help him combat his disease in a better manner too.

Adamopoulos, H. (2014). 8 Healthcare Trends to Watch in 2014. Becker's Hospital Review. Retrieved from http://www.beckershospitalreview.com/strategic-planning/8-healthcare-trends-to-watch-in-2014.html Improvingchroniccare.org,. (2015). 7: Self-Management Support :: Improving Chronic Illness Care. Retrieved 28 February 2015, from http://www.improvingchroniccare.org/index.php?p=7:_Self-Management_Support&s=369

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Science News

Social media harms teens’ mental health, mounting evidence shows. what now.

Understanding what is going on in teens’ minds is necessary for targeted policy suggestions

A teen scrolls through social media alone on her phone.

Most teens use social media, often for hours on end. Some social scientists are confident that such use is harming their mental health. Now they want to pinpoint what explains the link.

Carol Yepes/Getty Images

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By Sujata Gupta

February 20, 2024 at 7:30 am

In January, Mark Zuckerberg, CEO of Facebook’s parent company Meta, appeared at a congressional hearing to answer questions about how social media potentially harms children. Zuckerberg opened by saying: “The existing body of scientific work has not shown a causal link between using social media and young people having worse mental health.”

But many social scientists would disagree with that statement. In recent years, studies have started to show a causal link between teen social media use and reduced well-being or mood disorders, chiefly depression and anxiety.

Ironically, one of the most cited studies into this link focused on Facebook.

Researchers delved into whether the platform’s introduction across college campuses in the mid 2000s increased symptoms associated with depression and anxiety. The answer was a clear yes , says MIT economist Alexey Makarin, a coauthor of the study, which appeared in the November 2022 American Economic Review . “There is still a lot to be explored,” Makarin says, but “[to say] there is no causal evidence that social media causes mental health issues, to that I definitely object.”

The concern, and the studies, come from statistics showing that social media use in teens ages 13 to 17 is now almost ubiquitous. Two-thirds of teens report using TikTok, and some 60 percent of teens report using Instagram or Snapchat, a 2022 survey found. (Only 30 percent said they used Facebook.) Another survey showed that girls, on average, allot roughly 3.4 hours per day to TikTok, Instagram and Facebook, compared with roughly 2.1 hours among boys. At the same time, more teens are showing signs of depression than ever, especially girls ( SN: 6/30/23 ).

As more studies show a strong link between these phenomena, some researchers are starting to shift their attention to possible mechanisms. Why does social media use seem to trigger mental health problems? Why are those effects unevenly distributed among different groups, such as girls or young adults? And can the positives of social media be teased out from the negatives to provide more targeted guidance to teens, their caregivers and policymakers?

“You can’t design good public policy if you don’t know why things are happening,” says Scott Cunningham, an economist at Baylor University in Waco, Texas.

Increasing rigor

Concerns over the effects of social media use in children have been circulating for years, resulting in a massive body of scientific literature. But those mostly correlational studies could not show if teen social media use was harming mental health or if teens with mental health problems were using more social media.

Moreover, the findings from such studies were often inconclusive, or the effects on mental health so small as to be inconsequential. In one study that received considerable media attention, psychologists Amy Orben and Andrew Przybylski combined data from three surveys to see if they could find a link between technology use, including social media, and reduced well-being. The duo gauged the well-being of over 355,000 teenagers by focusing on questions around depression, suicidal thinking and self-esteem.

Digital technology use was associated with a slight decrease in adolescent well-being , Orben, now of the University of Cambridge, and Przybylski, of the University of Oxford, reported in 2019 in Nature Human Behaviour . But the duo downplayed that finding, noting that researchers have observed similar drops in adolescent well-being associated with drinking milk, going to the movies or eating potatoes.

Holes have begun to appear in that narrative thanks to newer, more rigorous studies.

In one longitudinal study, researchers — including Orben and Przybylski — used survey data on social media use and well-being from over 17,400 teens and young adults to look at how individuals’ responses to a question gauging life satisfaction changed between 2011 and 2018. And they dug into how the responses varied by gender, age and time spent on social media.

Social media use was associated with a drop in well-being among teens during certain developmental periods, chiefly puberty and young adulthood, the team reported in 2022 in Nature Communications . That translated to lower well-being scores around ages 11 to 13 for girls and ages 14 to 15 for boys. Both groups also reported a drop in well-being around age 19. Moreover, among the older teens, the team found evidence for the Goldilocks Hypothesis: the idea that both too much and too little time spent on social media can harm mental health.

“There’s hardly any effect if you look over everybody. But if you look at specific age groups, at particularly what [Orben] calls ‘windows of sensitivity’ 
 you see these clear effects,” says L.J. Shrum, a consumer psychologist at HEC Paris who was not involved with this research. His review of studies related to teen social media use and mental health is forthcoming in the Journal of the Association for Consumer Research.

Cause and effect

That longitudinal study hints at causation, researchers say. But one of the clearest ways to pin down cause and effect is through natural or quasi-experiments. For these in-the-wild experiments, researchers must identify situations where the rollout of a societal “treatment” is staggered across space and time. They can then compare outcomes among members of the group who received the treatment to those still in the queue — the control group.

That was the approach Makarin and his team used in their study of Facebook. The researchers homed in on the staggered rollout of Facebook across 775 college campuses from 2004 to 2006. They combined that rollout data with student responses to the National College Health Assessment, a widely used survey of college students’ mental and physical health.

The team then sought to understand if those survey questions captured diagnosable mental health problems. Specifically, they had roughly 500 undergraduate students respond to questions both in the National College Health Assessment and in validated screening tools for depression and anxiety. They found that mental health scores on the assessment predicted scores on the screenings. That suggested that a drop in well-being on the college survey was a good proxy for a corresponding increase in diagnosable mental health disorders. 

Compared with campuses that had not yet gained access to Facebook, college campuses with Facebook experienced a 2 percentage point increase in the number of students who met the diagnostic criteria for anxiety or depression, the team found.

When it comes to showing a causal link between social media use in teens and worse mental health, “that study really is the crown jewel right now,” says Cunningham, who was not involved in that research.

A need for nuance

The social media landscape today is vastly different than the landscape of 20 years ago. Facebook is now optimized for maximum addiction, Shrum says, and other newer platforms, such as Snapchat, Instagram and TikTok, have since copied and built on those features. Paired with the ubiquity of social media in general, the negative effects on mental health may well be larger now.

Moreover, social media research tends to focus on young adults — an easier cohort to study than minors. That needs to change, Cunningham says. “Most of us are worried about our high school kids and younger.” 

And so, researchers must pivot accordingly. Crucially, simple comparisons of social media users and nonusers no longer make sense. As Orben and Przybylski’s 2022 work suggested, a teen not on social media might well feel worse than one who briefly logs on. 

Researchers must also dig into why, and under what circumstances, social media use can harm mental health, Cunningham says. Explanations for this link abound. For instance, social media is thought to crowd out other activities or increase people’s likelihood of comparing themselves unfavorably with others. But big data studies, with their reliance on existing surveys and statistical analyses, cannot address those deeper questions. “These kinds of papers, there’s nothing you can really ask 
 to find these plausible mechanisms,” Cunningham says.

One ongoing effort to understand social media use from this more nuanced vantage point is the SMART Schools project out of the University of Birmingham in England. Pedagogical expert Victoria Goodyear and her team are comparing mental and physical health outcomes among children who attend schools that have restricted cell phone use to those attending schools without such a policy. The researchers described the protocol of that study of 30 schools and over 1,000 students in the July BMJ Open.

Goodyear and colleagues are also combining that natural experiment with qualitative research. They met with 36 five-person focus groups each consisting of all students, all parents or all educators at six of those schools. The team hopes to learn how students use their phones during the day, how usage practices make students feel, and what the various parties think of restrictions on cell phone use during the school day.

Talking to teens and those in their orbit is the best way to get at the mechanisms by which social media influences well-being — for better or worse, Goodyear says. Moving beyond big data to this more personal approach, however, takes considerable time and effort. “Social media has increased in pace and momentum very, very quickly,” she says. “And research takes a long time to catch up with that process.”

Until that catch-up occurs, though, researchers cannot dole out much advice. “What guidance could we provide to young people, parents and schools to help maintain the positives of social media use?” Goodyear asks. “There’s not concrete evidence yet.”

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Working from home can bring big health benefits, study finds

A review of 1,930 papers into home working found major pluses, but also downsides such as antisocial hours and being overlooked for promotion

Working from home allows people to eat more healthily, feel less stressed and have lower blood pressure, according to a large-scale review of academic literature on post-pandemic workplaces.

Yet remote workers are also more likely to eat snacks, drink more, smoke more and put on weight, the study found. And employers who believe that people working from home are lazy should think again – they are less likely to take time off sick, tend to work longer hours and to work evenings and weekends.

The review , funded by the National Institute for Health and Care Research Health Protection Research Unit in Emergency Preparedness and Response – a partnership between the UK Health Security Agency, King’s College London, and the University of East Anglia – considered 1,930 academic papers on home working, teleworking and other types of hybrid and home working in an effort to distil the often contradictory research.

Prof Neil Greenberg, a psychiatrist at King’s College London and one of the study’s authors, said the study showed that workers and employers needed to start considering home working with the same seriousness as they did office working.

“In the old days of office working, people realised that if you put everyone in the same room with no sound-proofing, it was all unpleasant and you didn’t have a very productive workforce,” he said.

“Now that we’ve shifted to a home working culture, it makes sense for organisations and the government to make sure that people who are home working are doing it in as effective a way as possible.”

The review, published in the Journal of Occupational Health , identified three themes – the working environment at home, the effect on workers’ lives and careers, and the effect on their health. Greenberg said the research showed that there were winners and losers in many areas of home working. The working environment depended on how much space there was at home, the available equipment and on how much control workers had over their day.

People on higher incomes often enjoyed home working more, but those with more responsibilities at home such as childcare or housework – often women and those living alone – tended to be more stressed.

“Overall, people felt more productive at home,” Greenberg said. “It was particularly good for creative things, but much more difficult dealing with tedious matters. A lot of people worried about career prospects – this feeling that if you’re not present in the office, you’re going to get overlooked.”

Effects on health were clearer. The transition to home working during Covid was linked “with an increase in intake of vegetables, fruit, dairy, snacks, and self-made meals; younger workers and females benefited the most in terms of healthier eating,” the paper said.

One of the studies reviewed found that 46.9% of employees working from home had gained weight, and another put the figure at 41%. Most of the papers reviewed showed that homeworkers were more sedentary.

Greenberg said: “Managers needed to think about finding ways to support their homeworkers and help create their working environment.

“There’s a great adage in science that at some point, we need to stop admiring the problem and actually think about solutions,” he said. “We know quite a lot now. So we need to ask ‘what is the best training for an individual who’s going to become a partial homeworker?’ What we don’t need to do is to ask ‘would it be helpful to train someone to homework?’ The answer is clearly yes.”

Since the end of Covid restrictions in 2022, some companies have insisted that employees return to the office full-time, with firms such as JP Morgan requiring managers to be in five days a week.

“If companies like JP Morgan are afraid that people at home will be slacking, or won’t be doing a good job, and they can’t keep an eye on them, then I think that is an outdated concept,” Greenberg said.

Refusing WFH options will mean that talented employees may find other jobs, and makes companies less flexible in the event of future crises, such as another health emergency or strikes or severe weather conditions that prevent people from reaching their offices, he added.

“If they are doing it merely out of fear, then they risk being left behind,” he said. “We looked at a huge amount of evidence of the years and what our review shows is that there are ways to make the home working approach actually work well for the organisation and also for the employee.”

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Healthcare Information Technology Trends in Nursing Practice

  • Rachel R.N. R.N.
  • September 28, 2023
  • MSN Nursing Papers Examples

Healthcare Information Technology Trends in Nursing Practice Essay Example

Advances in technology and biomedicine knowledge discovery have broadened the concept of patient empowerment, where patients get both tools and resources to play an active role in health care services delivery. Since the publication of the original Institute of Medicine (IOM), healthcare organizations have accelerated the development and adoption of healthcare information technology (HIT), resulting in a positive impact of HIT on patient safety. According to Alotaibi & Federico (2017), patient safety refers to avoiding, preventing, and ameliorating injuries or adverse outcomes from healthcare processes. One of these trends in healthcare technology of the 21st century is healthcare informatics, defined as the intersection of healthcare, computer science, and information science. Through patient-centered care, varied resources, devices, and methods are optimized to acquire, store, retrieve, and utilize information in health and biomedicine—consequently, this essay targets to describe healthcare informatics as a healthcare trend that impacts patient safety.(Healthcare Information Technology Trends in Nursing Practice Essay Example)

Healthcare Information Technology Trends in Nursing Practice Essay Example

Potential Challenges or Risks Inherent in Selected Health Informatics Tools

Health care informatics tools that significantly improve patient safety but are also laden with potential risks and challenges include patient data management systems (PDMS), automated medication dispensing cabinets (AMDC), and computerized physician’s orders (CPOE)(Healthcare Information Technology Trends in Nursing Practice Essay Example). Additional tools are clinical decision support (CDS), electronic medication administration record (eMAR), and bar code medication administration (BCMA). However, the limited scope of this essay necessitates that only two of the tools (CDS and CPOE) highlighted will be described in the context of the potential challenges and risks.(Healthcare Information Technology Trends in Nursing Practice Essay Example)

Clinical decision support is a system that seeks to improve medical decision-making around diagnosis or clinical predication rules, prevention and management of diseases through routine care reminders to clinicians or patients, and treatment sing electronic medication prescribing (Demiris & Kneale, 2015). Despite the many benefits of using CDS, one of its drawbacks is that, like EHRs, they mainly rely on external data, leading to deficiencies at times (Sutton et al., 2020). A typical example is that a CDS module may encourage ordering even when the healthcare facility lacks sufficient supplies. CDS users also risk developing workarounds that compromise data by entering incorrect or generic data, mainly in poorly designed CDS systems. The third and last of CDS challenges is that these systems encounter interoperability issues because most of them exist as stand-alone systems or exist in a system that cannot communicate with other systems.(Healthcare Information Technology Trends in Nursing Practice Essay Example)

Similarly, CPOE technology enables physicians to order drugs and tests and consultations, and other medical services or products electronically, thus avoiding the issuance of handwritten prescriptions. Wears (2016) posits that while it has been heralded as the Holy Grail for patient safety, CPOE presents the challenge of poor usability where a computer-user interface may contain embedded traps causing users to make mistakes(Healthcare Information Technology Trends in Nursing Practice Essay Example). The human mind by nature is exquisitely tailored to make sense of its environment, given the slightest clue. However, poorly designed artifacts compromise this mental faculty by offering few or, worse, misleading indications, thus translating old problems into new ones. As such, while eliminating the problem of illegible handwriting, they introduce the problem of picking the wrong item in a drop-down list leading to prescribing the wrong medication. Other pick list errors could result in the wrong dose, route of administration, selecting the wrong diagnostic test, or prescribing to the wrong patient. Be that as it may, the organization in context can employ mechanisms to identify the most common pick list errors and resolve them.(Healthcare Information Technology Trends in Nursing Practice Essay Example)

Most Promising Healthcare Technology Trends- BCMA and PDMS and the Promise Each Holds

According to Mulac et al. (2021), proper use of BCMA can prevent medication errors and promote patient safety. Nurses can confirm the five rights of medication administration: the right patient, proper medication, right dose, right route, and right time by scanning the bar code on the medication and the patient identification wristband. Suffice it to say that BCMA raises the bar of patient safety as medication administration reduces medication errors. While at the patient’s bedside, the nursing professional retrieves the product and scans its barcode with the patient identification bracelet. Every medication is scanned with the system telling the nurse everything is right or triggers a warning if something is wrong.

Moreover, in this closed-loop system, the medication order is electronically tracked across all the steps of the medication process. There exist enough checks and balances during the ordering, dispensing, and administration of the medications(Healthcare Information Technology Trends in Nursing Practice Essay Example). The bedside happens to be the tail end of medication administration and thus comprises a critical place to prevent medical errors from occurring. With the automated scanning process offered by BCMA, the result is a significant improvement on the patient, better patient outcomes due to appropriate treatment, and improved patient satisfaction.(Healthcare Information Technology Trends in Nursing Practice Essay Example)

The author’s considered opinion is that the introduction of patient data management system, like BCMA, has excellent potential in the future as it improves patient outcomes and financial situation in a hospital (Lemma et al., 2020). The cited researchers’ further note that PDMS facilitate clinical documentation at the patient’s bedside and have demonstrated their efficacy on completeness of patient charting and the time taken to document. It is essential to acknowledge that more studies need to be conducted on the economic validation of PDMS in hospitals. Most importantly, existing literature indicates that a combination of interventions focusing on technical and behavioral factors does improve the quality of patient data and its use.(Healthcare Information Technology Trends in Nursing Practice Essay Example)

This essay has determined that healthcare technology trends in the 21st century are many, with health informatics tools comprising a significant component. They include CDS, CPOE, BCMA, and PDMS, amongst others. Each HIT trend has its benefits and a fair share of its drawbacks, hence the need for healthcare organization management to implement their preferred technology diligently(Healthcare Information Technology Trends in Nursing Practice Essay Example). BCMA demonstrates the excellent potential to improve both patient safety and better patient outcomes through reduced medication errors. Likewise, PDMS has shown its promise in improving data management, although its initial cost of implementation is relatively high. Proper utilization of healthcare technology trends will enhance patient safety by reducing medication errors, lowering adverse drug reactions, and improving practice guidelines compliance.(Healthcare Information Technology Trends in Nursing Practice Essay Example)

Healthcare Information Technology Trends in Nursing Practice Essay Example

Alotaibi, Y. K., & Federico, F. (2017). The impact of health information technology on patient safety.  Saudi medical journal ,  38 (12), 1173.  URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5787626/

Demiris, G., & Kneale, L. (2015). Informatics systems and tools to facilitate patient-centered care coordination.  Yearbook of medical informatics ,  24 (01), 15-21. URL: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4587048/

Lemma, S., Janson, A., Persson, L. Å., Wickremasinghe, D., & KĂ€llestĂ„l, C. (2020). Improving quality and use of routine health information system data in low-and middle-income countries: A scoping review.  PloS one ,  15 (10), e0239683. URL: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0239683

Mulac, A., Mathiesen, L., Taxis, K., & GranÄs, A. G. (2021). Barcode medication administration technology used in hospital practice: a mixed-methods observational study of policy deviations.  BMJ quality & safety . URL: https://qualitysafety.bmj.com/content/early/2021/07/19/bmjqs-2021-013223

Sutton, R. T., Pincock, D., Baumgart, D. C., Sadowski, D. C., Fedorak, R. N., & Kroeker, K. I. (2020). An overview of clinical decision support systems: benefits, risks, and strategies for success.  NPJ digital medicine ,  3 (1), 1-10. URL: https://www.nature.com/articles/s41746-020-0221-y

Wears, R.L(2016), Unintended Consequences of CPOE  URL: https://psnet.ahrq.gov/web-mm/unintended-consequences-cpoe

Healthcare Information Technology Trends in Nursing Practice Essay Example

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Ten Healthcare Trends, Essay Example

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Introduction

The top healthcare trends represent the majority of the most prevalent opportunities that exist in today’s organizations. They provide support for the development of new strategies to accommodate the type of work that is performed and the value of that healthcare organizations bring to their patients. Trends such as patient safety and security/privacy matters are instrumental in shaping how patients are treated and the how the scope of practice impacts their wellbeing.

In the healthcare setting, the manager is responsible for facilitating the rollout of different activities that impact patient care. In addition, the manager must rally employees together in order to support the use of technologies in order to support patient care needs on a continuous basis. This process also encourages the development of new strategies to facilitate the rollout of specific programs as necessary to maximize quality of care. At the same time, it is important to identify specific factors that will enable managers to respond to current trends effectively and to make these matters a key priority as best as possible. Trends such as evidence-based practice objectives are here to stay; therefore, it is important to determine how managers might best contribute to this process in order to achieve effective outcomes for patient care.

The trends under discussion are appropriate and timely, given the many challenges of healthcare that exist today. These frameworks support the continued growth and development of practice settings that employ managerial feedback and ongoing support by employees for these endeavors. It is expected that these objectives will continue to support the growth of healthcare practice and the overall improvement of patient care quality by addressing these trends in a timely and efficient manner at all times, using the resources that are available within the surrounding environment.

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Your First Step Toward a Better Mood

Poor sleep can make anxiety, depression and other mental health issues worse. Here’s what to do about it.

An illustration of a person lying on their back in a bed with eyes open. The bedroom walls and floor tiles are deteriorating, breaking off and floating away.

By Christina Caron

It started with mild anxiety.

Emily, who asked to be identified only by her first name because she was discussing her mental health, had just moved to New York City after graduate school, to start a marketing job at a big law firm.

She knew it was normal to feel a little on edge. But she wasn’t prepared for what came next: chronic insomnia.

Operating on only three or four hours of sleep, it didn’t take long for her anxiety to ramp up: At 25, she was “freaking nervous all the time. A wreck.”

When a lawyer at her firm yelled at her one day, she experienced the first of many panic attacks. At a doctor’s suggestion, she tried taking a sleeping pill, in the hopes that it might “reset” her sleep cycle and improve her mood. It didn’t work.

Americans are chronically sleep deprived: one-third of adults in the United States say they get less than 7 hours a night. Teenagers fare even worse: About 70 percent of high school students don’t get enough sleep on school nights.

And it is having a profound effect on mental health.

An analysis of 19 studies found that while sleep deprivation worsened a person’s ability to think clearly or perform certain tasks, it had a greater negative effect on mood. And when the National Sleep Foundation conducted a survey in 2022, half of those who said they slept less than 7 hours each weekday also reported having depressive symptoms. Some research even indicates that addressing insomnia may help prevent postpartum depression and anxiety .

Clearly, sleep is important. But despite the evidence, there continues to be a shortage of psychiatrists or other doctors trained in sleep medicine, leaving many to educate themselves. So what happens to our mental health if we aren’t getting enough sleep, and what can be done about it?

How does poor sleep affect your mood?

When people have trouble sleeping, it changes how they experience stress and negative emotions, said Aric Prather, a sleep researcher at the University of California, San Francisco, who treats patients with insomnia. “And for some, this can have a feed-forward effect — feeling bad, ruminating, feeling stressed can bleed into our nights,” he said.

Carly Demler, 40, a stay-at-home mother in North Carolina, said she went to bed one night and never fell asleep . From that point onward, she would be up at least once a week until 3 or 4 a.m. It continued for more than a year.

She became irritable, less patient and far more anxious.

Hormone blood work and a sleep study in a university lab offered her no answers. Even after taking Ambien, she stayed up most of the night. “It was like my anxiety was a fire that somehow jumped the fence and somehow ended up expanding into my nights,” she said. “I just felt I had no control.”

In the end, it was cognitive behavioral therapy for insomnia , or C.B.T.-I., that brought Ms. Demler the most relief. Studies have found that C.B.T.-I. is more effective than sleep medications are over the long term: As many as 80 percent of the people who try it see improvements in their sleep.

Ms. Demler learned not to “lay in bed and freak out.” Instead, she gets up and reads so as not to associate her bedroom with anxiety, then returns to bed when she’s tired.

“The feeling of gratitude that I have every morning, when I wake up and feel well rested, I don’t think will ever go away,” she said. “That’s been an unexpected silver lining.”

Adults need between 7 and 9 hours of sleep a night, according to the Centers for Disease Control and Prevention . Teenagers and young children need even more.

It’s not just about quantity. The quality of your sleep is also important. If it takes more than 30 minutes to fall asleep, for example, or if you regularly wake up in the middle of the night, it is harder to feel rested, regardless of the number of hours you spend in bed.

But some people “have a tendency to think they’re functioning well even if they’re sleepy during the day or having a harder time focusing,” said Lynn Bufka, a clinical psychologist and spokeswoman for the American Psychological Association.

Ask yourself how you feel during the day: Do you find that you’re more impatient or quick to anger? Are you having more negative thoughts or do you feel more anxious or depressed? Do you find it harder to cope with stress? Do you find it difficult to do your work efficiently?

If so, it’s time to take action.

How to stop the cycle.

We’ve all heard how important it is to practice good sleep hygiene , employing the daily habits that promote healthy sleep. And it’s important to speak with your doctor, in order to rule out any physical problems that need to be addressed, like a thyroid disorder or restless legs syndrome.

But this is only part of the solution.

Conditions like anxiety, post-traumatic stress disorder and bipolar disorder can make it harder to sleep, which can then exacerbate the symptoms of mental illness, which in turn makes it harder to sleep well.

“It becomes this very difficult to break cycle,” Dr. Bufka said.

Certain medications, including psychiatric drugs like antidepressants, can also cause insomnia. If a medication is to blame, talk to your doctor about switching to a different one, taking it earlier in the day or lowering the dose, said Dr. Ramaswamy Viswanathan, a professor of psychiatry and behavioral sciences at State University of New York Downstate Health Sciences University and the incoming president of the American Psychiatric Association.

The cycle can afflict those without mental health disorders too, when worries worsen sleep and a lack of sleep worsens mood.

Emily, who worked in the big law firm, would become so concerned about her inability to sleep that she didn’t even want to get into bed.

“You really start to believe ‘I’m never going to sleep,’” she said. “The adrenaline is running so high that you can’t possibly do it.”

Eventually she came across “Say Goodnight to Insomnia” by Gregg D. Jacobs. The book, which uses C.B.T.-I. techniques, helped Emily to reframe the way she thought about sleep. She began writing down her negative thoughts in a journal and then changing them to positive ones. For example: “What if I’m never able to fall asleep again?” would become “Your body is made to sleep. If you don’t get enough rest one night, you will eventually.” These exercises helped her stop catastrophizing.

Once she started sleeping again, she felt “way happier.”

Now, at 43, nearly 20 years after she moved to New York, she is still relying on the techniques she learned, and brings the book along whenever she travels. If she doesn’t sleep well away from home, “I catch up on sleep for a few days if necessary,” she said. “I’m way more relaxed about it.”

Christina Caron is a Times reporter covering mental health. More about Christina Caron

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First, bring calm and clarity into your life with these 10 tips . Next, identify what you are dealing with: Is it worry, anxiety or stress ?

Persistent depressive disorder is underdiagnosed, and many who suffer from it have never heard of it. Here is what to know .

If you notice drastic shifts in your mood during certain times of the year, you could have seasonal affective disorder. Here are answers to your top questions about the condition .

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Drawing, music and writing can elevate your mood and benefit your mental health. Here are some easy ways to welcome them into your life .

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National Healthcare Trends Case Study

Introduction, trends description: the cause of changes, healthcare delivery: the impact of changes, possible legislation to remedy the issues: the effect of changes.

Contemporary trends and policies emerging in healthcare transform this industry and, as a rule, aim to optimize its fields. The activities of Trinity Community Hospital with its professional specialists and high development prospects are dynamic. However, in the context of digitalization and the introduction of information technology in all areas, including medicine, new trends may be useful approaches to enhance the quality of work. In particular, in the hospital, a new service line is planned to be launched – a cardiovascular center that will provide screening and treatment services to targeted patients. To ensure the sustainable operation of the center and follow modern standards of medical care, the introduction of specific modern trends is a valuable prospect. The work of the future cardiovascular center will be evaluated in terms of the use of remote interaction with patients by using 5G technology and artificial intelligence (AI) computing as innovative approaches to diagnostics and treatment.

One of the trends that may be applied to the development of a new cardiology service line at Trinity Community Hospital is the use of remote interaction with patients through the introduction of 5G technology. Zhang et al. (2020) describe the specifics of this trend and explain how it works. According to the authors, interaction with the target audience is carried out remotely, and due to the innovative generation of mobile services, communication is stable (Zhang et al., 2020). Patients’ cardiovascular data are stored in the cloud, and physicians can access the necessary information when needed. Treatment planning can also take place remotely, which is particularly essential during the COVID-19 pandemic when the principles of social distancing have become a mandatory aspect of interpersonal communication.

Establishing remote access via a 5G network can go in different ways. Elgendi et al. (2018) propose a connection scheme in which users’ and providers’ devices are connected through the same channel, and any information transmitted by either party is stored in a single cloud. Moreover, as the researchers argue, due to innovative technology, special programs allow setting specific parameters, for instance, the heart rate level (Elgendi et al., 2018). In case of deviations from the norm, the program notifies a provider about the deterioration of a patient’s condition. By creating a new service line, Trinity Community Hospital specialists can develop the basic principles of the program specifics themselves. To establish communication and notification algorithms, the involvement of IT specialists is essential. Such a trend is modern and can be implemented as a tool to optimize the interaction between physicians and patients.

Another trend that has also developed recently and can be used at Trinity Community Hospital to introduce a new cardiovascular center is AI computing. According to Romiti et al. (2020), this technology allows diagnosing abnormalities in screening tests, for instance, electrocardiograms, and informing about deviations from the norm. In the context of the transition to digital screening instruments, this algorithm is useful and can be utilized in a normal clinical environment along with traditional diagnostic and treatment methods. Ouyang et al. (2020) also consider AI computing with the use of video testing and provide an algorithm that detects cardiac abnormalities in conditions of real-time observation. Both these trends can change the traditional principles of diagnosis and treatment of cardiovascular diseases.

Bringing these healthcare trends into Trinity Community Hospital’s clinical environment and, in particular, its new cardiovascular center could have an impact on the delivery of care. First, there may be too many people willing to participate in digital diagnostics and communication programs. The employees of the center will have to work in an enhanced mode or set a limit on these services. These measures, however, contradict the principles of free access to healthcare services and are not objective solutions to the problem. Remote screening and AI computing technologies are designed to simplify and, at the same time, improve the quality of treatment and care for cardiovascular patients. Nevertheless, the lack of proper monitoring over the use of these algorithms can slow down the communication process and make remote interaction meaningless. Therefore, adequate control over the mode of implementation and patient access to these technologies requires scheduling the use of these computer tools.

Secondly, the introduction of technological healthcare trends in the cardiovascular center may require the training of personnel for qualified delivery of care. Working with high-precision computer equipment requires preliminary preparation. Therefore, Trinity Community Hospital management may need to arrange special training courses for the staff of the new service center. This measure, in turn, entails additional financial and time costs. Despite the potential convenience of remote interaction with patients via 5G and video broadcasting with AI computing, not all employees may have the necessary skills to operate with digital devices. Therefore, organizing educational sessions is one of the inevitable impacts of the implementation of the considered trends in the cardiovascular center.

To remedy the aforementioned challenges with the introduction of computer technology into the operation of the cardiovascular center at Trinity Community Hospital, the institution can expect possible changes in the legislation. According to Albahri et al. (2018), today, “telemedicine is hardly included in legislation” (p. 80). However, with the development of the digital sphere, denying innovation is pointless, and the need to regulate issues related to the control of remote care is imperative to ensure safe care delivery. In this regard, one of the initiatives may be the development of a draft law defining the categories of citizens in need of remote interaction and AI computing services. This may be in addition to the existing Medicare act, but the regulation will be individual. Such an initiative will help coordinate the number of people who want to undergo screening tests remotely and allow those in need to receive help timely.

Another future law is the introduction of training courses for medical personnel through federal funding. The trend of introducing digital methods of treatment and care is increasing in healthcare, and as an incentive for clinics and individual centers, financial assistance from the state can be allocated to train specialists in working with computer equipment. Administrators will need to coordinate the timing of these sessions, with the government covering all equipment costs and overtime pay. This step will be relevant to addressing the issue of high costs on the part of healthcare providers and stimulate the implementation of innovative treatment and care algorithms.

Remote communication via the 5G network and AI computing are contemporary healthcare trends, but their implementation in the cardiovascular center of Trinity Community Hospital may be accompanied by some challenges. To overcome the surplus of those wishing to undergo screening tests on new equipment and the high costs of training personnel, the adoption of future relevant laws may be relevant. Adjusting the number of patients following their needs and federal funding are valuable initiatives that will enable innovative trends in the cardiovascular center.

Albahri, O. S., Albahri, A. S., Mohammed, K. I., Zaidan, A. A., Zaidan, B. B., Hashim, M., & Salman, O. H. (2018). Systematic review of real-time remote health monitoring system in triage and priority-based sensor technology: Taxonomy, open challenges, motivation and recommendations. Journal of Medical Systems , 42 (5), 80. Web.

Elgendi, M., Al-Ali, A., Mohamed, A., & Ward, R. (2018). Improving remote health monitoring: A low-complexity ECG compression approach. Diagnostics , 8 (1), 10. Web.

Ouyang, D., He, B., Ghorbani, A., Yuan, N., Ebinger, J., Langlotz, C. P., Heidenreich, P. A., Harrington, R. A., Liang, D. H., Ashley, E. A., & Zou, J. Y. (2020). Video-based AI for beat-to-beat assessment of cardiac function. Nature , 580 (7802), 252-256. Web.

Romiti, S., Vinciguerra, M., Saade, W., Anso Cortajarena, I., & Greco, E. (2020). Artificial intelligence (AI) and cardiovascular diseases: An unexpected alliance. Cardiology Research and Practice , 2020 (4972346), 1-8. Web.

Zhang, Y., Chen, G., Du, H., Yuan, X., Kadoch, M., & Cheriet, M. (2020). Real-time remote health monitoring system driven by 5G MEC-IoT. Electronics , 9 (11), 1753. Web.

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High levels of niacin linked to heart disease, new research suggests

High levels of niacin, an essential B vitamin, may raise the risk of heart disease by triggering inflammation and damaging blood vessels, according to new research.

The report, published Monday in Nature Medicine, revealed a previously unknown risk from excessive amounts of the vitamin, which is found in many foods, including meat, fish, nuts, and fortified cereals and breads.

The recommended daily allowance of niacin for men is 16 milligrams per day and for women who are not pregnant is 14 milligrams per day.

About 1 in 4 Americans has higher than the recommended level of niacin , said the study’s senior author, Dr. Stanley Hazen, chair of cardiovascular and metabolic sciences at the Cleveland Clinic’s Lerner Research Institute and co-section head of preventive cardiology at the Heart, Vascular and Thoracic Institute.

The researchers currently don’t know where to draw the line between healthy and unhealthy amounts of niacin, although that may be determined with future research.

"The average person should avoid niacin supplements now that we have reason to believe that taking too much niacin can potentially lead to an increased risk of developing cardiovascular disease,” Hazen said.

Currently, Americans get plenty of niacin from their diet since flour, grains and cereals have been fortified with niacin since the 1940s after scientists discovered that very low levels of the nutrient could lead to a potentially fatal condition called pellagra, Hazen said.

Prior to the development of cholesterol-lowering statins , niacin supplements were once even prescribed by doctors to improve cholesterol levels.

To search for unknown risk factors for cardiovascular disease, Hazen and his colleagues designed a multipart study that included an analysis of fasting blood samples from 1,162 patients who had come into a cardiology center to be evaluated for heart disease. The researchers were looking for common markers, or signs, in the patients’ blood that might reveal new risk factors. 

The research resulted in the discovery of a substance in some of the blood samples that is only made when there is excess niacin. 

Meat in grocery store

That finding led to two additional “validation” studies, which included data from a total of 3,163 adults who either had heart disease or were suspected of having it. The two investigations, one in the U.S. and one in Europe, showed that the niacin breakdown product, 4PY, predicted participants’ future risk of heart attack, stroke and death.

The final part of the study involved experiments in mice. When the rodents were injected with 4PY, inflammation increased in their blood vessels. 

The results are “fascinating” and “important,” said Dr. Robert Rosenson, director of metabolism and lipids for the Mount Sinai Health System in New York City.

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The newly detected pathway to heart disease might lead to the discovery of a medication that could reduce blood vessel inflammation and decrease the likelihood of major cardiovascular events, he added.

Rosenson hopes that the food industry will take note and “stop using so much niacin in products like bread. This is a case where too much of a good thing can be a bad thing.”

The new information could influence dietary recommendations for niacin, said Rosenson, who was not involved with the Cleveland Clinic research.

Scientists have known for decades that a person’s cholesterol level could be a major driver of heart disease, said Dr. Amanda Doran, an assistant professor of medicine in the division of cardiovascular medicine at the Vanderbilt University Medical Center.

Even when patients’ cholesterol levels were brought down, some continued to have a high risk of heart attacks and stroke, Doran said, adding that a 2017 trial suggested that the increased risk might be related to blood vessel inflammation.

Doran was surprised to learn that niacin could be involved in driving up the risk of heart disease.

“I don’t think anyone would have predicted that niacin would have been pro-inflammatory,” she said. “This is a powerful study because it combines a variety of techniques: clinical data, genetic data and mouse data.”

Finding the new pathway may allow future researchers to discover ways to reduce blood vessel inflammation, Doran said.

“It’s very exciting and promising,” she said.

Linda Carroll is a regular health contributor to NBC News. She is coauthor of "The Concussion Crisis: Anatomy of a Silent Epidemic" and "Out of the Clouds: The Unlikely Horseman and the Unwanted Colt Who Conquered the Sport of Kings." 

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