REDEFINING CANCER CLASSIFICATION IN THE AGE OF AI

The classification of cancer traditionally has relied on organ of origin and histological characteristics observable through microscopy. This approach has been foundational to obtaining an understanding of cancer biology and treatment for more than a century, shaping how to diagnose, research, and treat various forms of this disease. As knowledge of cancer biology has advanced, however, it has become increasingly clear that the traditional classification system is at odds with the principles of modern precision oncology, according to an article (Khozin, S.) published in the September 2024 issue of the journal Clinical and Translational Science. The essential tenet of precision medicine postulates that administering the right therapy to the right patient at the right time and dose should theoretically result in 100% response to treatment. The goal is not reached because current disease classification methods frequently fail in matching the right therapy to the right patient. Recent developments in molecular profiling and advanced imaging techniques have revealed a more complex picture of cancer biology. It is understood now that tumors arising in different organs can share key molecular and morphological features, while tumors in the same organ can be strikingly heterogeneous at multiple levels of analysis.  

This heterogeneity has an impact on clinical trials, drug development, and patient care. Recent advances in artificial intelligence (AI), particularly machine learning and deep learning, offer promising avenues for reclassifying cancers through comprehensive integration of molecular, histopathological, imaging, and clinical characteristics. AI-driven approaches have the potential to reveal novel cancer subtypes, identify new prognostic variables, and guide more precise treatment strategies for improving patient outcomes. In recent years, artificial intelligence, particularly machine learning and deep learning, has emerged as an important tool for addressing these challenges. Advanced computational methods can analyze vast amounts of multimodal data, identifying patterns and relationships that may not be apparent through traditional disease classification methods. By embracing the full complexity of tumor biology through AI-enabled multimodal analyses, it is possible to move beyond the historical constraints of organ-based and histological classifications and towards a new era that truly delivers on the promise of personalized medicine for patients with cancer. 

OBTAINABLE RESOURCES

AGING, FUNCTION, AND REHABILITATION: WORKSHOP PROCEEDINGS 

With recent medical, technological, and socioeconomic developments, individuals are living longer. The rising average age of the world’s population presents an opportunity to develop health policy that prioritizes functioning as a goal of healthy aging. In February 2024, the National Academies convened a hybrid workshop at the University of Lucerne in Switzerland to host a discussion focused on the World Health Organization's concept of functioning. Speakers paid particular focus to healthy aging and the future of rehabilitation as a health strategy. Experts emphasized that the need for rehabilitation is increasing due to rapid population aging accompanied by a rise in physical and mental health conditions, limitations, and injuries. The associated economic and practical obstacles of optimizing functioning across the life course also were discussed. A Proceedings of a Workshop summarizes discussions from this event. An accompanying Workshop Highlights provides a concise overview of key messages. The Proceedings are here.

RACE AND ETHNICITY IN HIGHER EDUCATION: 2024 STATUS REPORT

U.S. postsecondary education currently is facing challenges and opportunities presented by a growing and highly diverse population. Between 2002 and 2022, the population of the U.S. grew from about 282 million to approximately 329 million inhabitants. It not only increased, but also became more racially and ethnically diverse. The American Council on Education (ACE)’s Race and Ethnicity in Higher Education project fills the need for a singular source from which policymakers, researchers, higher education practitioners, and others can access these types of data combined in a straightforward and reliable format. Race and Ethnicity in Higher Education: 2024 Status Report examines over 200 indicators to determine who accesses a variety of educational environments and experiences, to explore how student trajectories and outcomes differ by race and ethnicity, and to provide an overview of the racial and ethnic backgrounds of faculty, staff, and college presidents. Many indicators present a snapshot of the most recent publicly available data, while others depict data over time. In addition to the Race and Ethnicity in Higher Education project’s traditional focus on disaggregating data by demographic characteristics, this report includes for the first time information on enrollment, completion, and financing by Carnegie Classification. Additionally, graduate enrollment trends in this report were analyzed by R1 doctoral, other doctoral, and master’s institutions to offer a more nuanced view into graduate school completion. The report is here.  

UNFORESEEN HEALTH CARE BILLS AND COVERAGE DENIALS 

A Commonwealth Fund report published on August 1, 2024 examines how frequently insured, working-age adults are denied care by insurers; how often they are billed for services they believed were covered; and their experiences challenging such bills or care denials. The report shows that 45% of insured, working-age adults reported receiving a medical bill or being charged a copayment in the past year for a service they thought should have been free or covered by their insurance. Among other findings, 17% of respondents said that their insurer denied coverage for care that was recommended by their doctor, and nearly six of 10 adults who experienced a coverage denial said their care was delayed as a result. The report examines whether patients challenged such errors or coverage denials, the reasons why they did not do so, and the implications for their health and well-being. Individuals were grouped by the coverage source they reported at the time of the survey, such as employer or individual market or marketplace, although it should be noted that some may have switched insurance plans during the year. The report is here.

DEVELOPMENTS IN HIGHER EDUCATION

As indicated in the July 24, 2024 issue of the Federal Register (the official journal of the federal government), the Secretary of the U.S. Department of Education proposes to amend the Student Assistance General Provisions regulations governing participation in the student financial assistance programs authorized under Title IV of the Higher Education Act of 1965, as amended (HEA), to promote program integrity and institutional quality. These regulations would clarify, update, and consolidate certain provisions that apply to distance education; the return of Title IV, HEA funds; and the Federal TRIO programs. Comments on the proposed regulations must be submitted via the Federal eRulemaking Portal at regulations.gov on or before August 23, 2024.  

The Department is addressing these areas in an effort to: help ensure students are well served by the institutions of higher education they attend, increase access to postsecondary education for disadvantaged students, and ensure that Federal Student Aid programs work in the best interests of students. As the three distinct topics are structured and addressed independently in this proposed rule, the Department generally intends the rule’s provisions to be severable from each other. 

Title IX Regulations

A publication known as Inside Higher Ed is a valuable source of information regarding federal activities in the higher education sphere involving topics, such as Title IX regulations, which strengthen protections for LGBTQ+ students and change how colleges respond to reports of sexual harassment. Those regulations were supposed to become effective on August 1 of this year, but judicial roadblocks are preventing that from occurring. Thus far, federal judges have issued six injunctions temporarily blocking the Education Department from enforcing the new rule in 26 states and hundreds of colleges in other states in response to lawsuits challenging the protections for LGBTQ+, and especially transgender students. On June 14, the first injunction was handed down and the most recent one was issued on July 31. A consequence is that many college officials are fearful, frustrated, and uncertain about what comes next. 

As described in an analysis by Inside Higher Ed, Title IX legal experts expect colleges in the 24 states not currently under an injunction to implement the 2024 regulations. Institutions located in the states under an injunction likely will adhere to the rules put in place by the Trump administration in 2020, particularly if their state leaders, e.g., the governors of Florida and Texas, have directed their public higher education institutions not to comply. Some colleges operating under an injunction will fall into a third group, opting for a mix of the 2024 and 2020 rules. Institutions that do not comply could face a civil rights investigation or lose their federal funding, although both threats are not in effect while there are injunctions. Nonetheless, they could face lawsuits from students who view their Title IX rights as being violated, or from groups taking issue with how the new regulations are being implemented.

Additional Student Loan Relief Implemented

The Biden-Harris Administration announced on July 18, 2024 the approval of roughly $1.2 billion in additional student loan relief for 35,000 borrowers across the nation who work in public service. These approvals are the result of significant fixes that the Administration has made to the Public Service Loan Forgiveness (PSLF) Program. This relief builds on President Biden and his Administration’s efforts to provide relief to as many borrowers as possible in the U.S. The announcement brings the total loan forgiveness approved by the Administration to $168.5 billion for 4.76 million Americans, which includes $69.2 billion for 946,000 borrowers through PSLF. Before President Biden took office, only 7,000 public servants had received debt relief through PSLF. The newly announced debt relief includes borrowers who have benefitted from a limited PSLF waiver, a temporary opportunity that ended in October 2022, as well as from regulatory improvements made to the program. Accompanying improvements to PSLF, the Administration also has made it easier for borrowers to participate in the program.

HEALTH REFORM DEVELOPMENTS

For several recent decades, health policy developments continue to reflect three major concerns: extent of health insurance coverage of the population, efforts to restrain rising costs of health care services, and attempts to improve health care quality. Based on new data that became available in July 2024 from the U.S. Centers for Disease Control and Prevention (CDC), the national uninsured rate rose from 7.7% to 8.2% earlier this year. The increase from that record low rate of 7.7% at the time is the result of states removing enrollees from their Medicaid programs who initially became eligible to obtain coverage during the COVID pandemic. A result is that an estimated 25 million individuals are uninsured today. The cost element of health care services often is affected by advances in technology. New drugs enter the marketplace at regular intervals. A concern is that some products are quite expensive, making insurance companies reluctant to provide coverage. CRISPR (clustered regularly interspaced short palindromic repeats) is making it possible to produce selective modifications of the DNA of living organisms, while related advances in gene technology represent additional ways of creating effective, but highly unaffordable interventions. Meanwhile, health care quality can be influenced by societal changes involving government initiatives that have an impact on individual behavior and health outcomes as shown immediately below. 

Changes In Self-Reported Cannabis Use In The United States From 1979 To 2022

Long-term trends in cannabis use in the U.S. parallel corresponding changes in cannabis policy, with declines during periods of greater restriction and growth during periods of policy liberalization. As described (Caulkins, J.P.) in the September 2024 issue of the periodical Addiction, rates of use reported to the U.S. National Survey on Drug Use and Health and its predecessors are described, as are trends in days of use reported. Four milepost years are contrasted: 1979 (first available data and end of relatively liberal policies of the 1970s), 1992 (end of 12 years of conservative Reagan-Bush era policies), 2008 (last year before the Justice Department signaled explicit federal non-interference with state-level legalizations) and 2022 (most recent data available).  

Whereas the 1992 survey recorded 10 times as many daily or near daily alcohol use as cannabis usage (8.9 vs. 0.9 M), the 2022 survey, for the first time, recorded more daily and near daily users of cannabis than alcohol (17.7 vs. 14.7 M). Far more individuals drink, but high-frequency drinking is less common. In 2022, the median drinker reported drinking on 4–5 days in the past month, versus 15–16 days in the past month for cannabis. In 2022, past-month cannabis consumers were almost four times as likely to report daily or near daily use (42.3% vs. 10.9%) and 7.4 times more likely to report daily use (28.2% vs. 3.8%). Apart from this particular study, worth pondering are possible ramifications of increased cannabis usage. An upside is that legalizing the substance for medicinal and recreational use means that possession of small amounts no longer places users at risk of being incarcerated. A potential downside is that just as consumers of alcohol products may be prone to being involved in motor vehicle accidents, the same may be true for drivers under the influence of cannabis.

Caregiving: Providers And Recipients

A new result from the University of Michigan National Poll released on August 6, 2024 reveals who is providing care and who are the recipients. An estimated 30% of all individuals in their 50s and early 60s provide care to at least one person with a health issue or disability, compared with 23% of caregivers over age 65. One in 10 caregivers in their 50s and early 60s are juggling taking care of three or more persons. Apart from age, there is a gender divide: 32% of women age 50 and over act as caregivers to someone with a health issue or a disability, compared with 22% of men in this age group. Overall, 23% of caregivers are caring for an adult or child with an intellectual or developmental disability, and 66% are caring for someone age 65 or older. The most common health issue or disability that caregivers help their friends or family with was a physical disability or mobility problem, at 59%. The next most common was memory or thinking issues, at 42%, followed by vision or hearing          impairments at 28%, and mental health concerns at 22%. When it comes to covering the cost of caregiving for individuals over age 65, 45% of  those who are 50 and older feel the government should take the lead, 27% believe it should be the person receiving care, 18% think it should be family or friends, and 10% said it should be other sources.  

FY 2025 APPROPRIATIONS UPDATE

The Senate Appropriations Committee on August 1, 2024 approved its Fiscal Year (2025) Labor, Health and Human Services (HHS), Education, and Related Agencies spending bill on a bipartisan vote of 25-3. If eventually signed into law, it would provide $122.8 billion for the HHS, $5.1 billion (4.3%) above the FY 2024 enacted level, and $14.9 billion (13.8%) more than the FY 2025 House bill. Additional features include the provision of $310 million for Title VIII Nursing Workforce Development programs, a total increase of $31 million (3.8%) compared to FY 2024. The legislation would furnish $9.3 billion in total funding for the Centers of Disease Control and Prevention, a $173 million (1.8%) increase compared to FY 2024. While the House bill, would eliminate the Agency for Healthcare Research and Quality (AHRQ), the Senate bill would spend $376 million for this entity in FY 2025, a $7 million (9%) increase compared to FY 2024.  

Congress has responsibility for passing legislation that enables the federal government to function. Executive branch agencies use these laws to produce the rules and regulations necessary to implement the functions and activities Congress originally intended. Since 2024 is an election year, it is worth noting that during the final months of presidential Administrations, federal agencies often have increased the pace of their regulatory activities, a phenomenon known as “midnight rulemaking.” According to a report from the Congressional Research Service (CRS) that was released on July 30 of this year, because it can be a challenge to change or eliminate rules after they have been finalized, issuing midnight rules can help ensure a legacy for an outgoing President.  

Some concerns that have been raised over midnight rulemaking include the decreased political accountability for an outgoing Administration, the potential for rules that are rushed through at the end of an Administration not to have the same opportunity for public input, and the potential for the quality of regulations to suffer during the midnight period because the departing Administration may issue rules quickly and without subjecting them to rigorous review or analysis. A new Administration has various options for reviewing, amending, or repealing midnight regulations and it has fairly wide authority to do so, provided the new policies are consistent with procedural and other legal requirements.  

Congress also has general control over agencies through a variety of means, including general legislative power over agencies’ rulemaking authority and individual regulations. Agencies are bound first and foremost by whatever Congress has established or required in statute. An example is that Congress may use the Congressional Review Act (CRA; 5 U.S.C. §§801-808) to disapprove final rules. The CRA contains fast-track procedures—particularly in the Senate—for considering a joint resolution of disapproval to overturn a rule. If both houses of Congress pass that resolution of disapproval, it is sent to the President for signature. If the President signs it, the rule cannot take effect and will be treated as though it had never been in effect.

SDOH, AGING. AND DEMENTIA CHALLENGES

Advancements in improving personal and community health status in the U.S. depend on successfully addressing various kinds of social determinants of health (SDOH). Demography plays an essential role not only in defining health and health-related social problems, but also in formulating satisfactory remedies. Factors pertaining to race and ethnicity have a major impact on the highly pertinent challenge of reducing health disparities among members of minority population sub-groups. A portion of the population worthy of increased attention consists of older individuals with dementia who live alone. 

Based on an etiological perspective, living alone is associated with increased risk of developing dementia and lower likelihood of timely diagnosis, according to the results of a study (Clare, L. et al) published in the American Journal of Geriatric Psychiatry on June 6, 2024. Estimates range from under one in every five persons to half. Even if the correct figure is at the lower end of the spectrum, it still represents a substantial number of individuals managing life with dementia while living alone.  

Results of a study published on August 18, 2023 in JAMA Network Open (Portacolone, E. et al) shed additional light. In the U.S., it is estimated that 4.3 million older adults (≥55 years) live alone with cognitive impairment (ranging from mild impairment to dementia), which represents 25% of older adults living with this mental health malady. They are likely to be female, poorer, widowed, or divorced and to have never been married. They also have an elevated risk for untreated medical conditions, self-neglect, malnutrition, and falls. Evidence suggests that negative health outcomes are associated with a lack of long-term services and supports from family members, friends, or formal caregivers (e.g., home-care aides). Additionally, older adults living alone with cognitive impairment often have limited access to long-term services and supports because they have less access to unpaid informal help from spouses and children, who provide most of these forms of assistance to such patients.

Moreover, only an estimated 21% of older adults living alone with cognitive impairment are covered by Medicaid, which leaves most of this group ineligible for publicly subsidized home-care aides and other services covered by that federal-state program. Providers have raised many concerns regarding this group of patients. Examples are: missing medical appointments, failing to respond to follow-up telephone calls, and even forgetting why appointments were made, thus leaving them vulnerable to disappearing from the radar. Related concerns are that these individuals were more likely to miss visits because they either forgot or preferred avoiding professionals. Also, serving patients with mental health impairments via telehealth often proved to be difficult owing to trouble navigating video conferencing without technical supports. Other multifactorial challenges include professional concerns about patient safety, such as “not eating,” “not taking care of personal hygiene,” “leaving gas stove on,” “mixing up medications,” “wandering off,” “driving motor vehicles,” and “financial abuse.”

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Health Insurance Coverage

Since 2001, the National Center for Health Statistics (NCHS) National Health Interview Survey (NHIS) Early Release Program has furnished selected estimates of health and health care for the civilian noninstitutionalized U.S. population. A NCHS report released in May 2024 provides quarterly estimates of health insurance coverage disaggregated by age group and family income as a percentage of the federal poverty level (FPL) for the civilian noninstitutionalized U.S. population based on data from the July–September 2023 NHIS. Quarterly population estimates are presented of health insurance coverage disaggregated by age group, along with quarterly estimates of health insurance coverage for adults aged 18–64 disaggregated by race and ethnicity. Quarterly estimates of health insurance coverage for adults aged 18–64 are disaggregated by region. Quarterly estimates for October– December 2022 through July–September 2023 also are presented for comparison.  

Epidemiology Of Parkinson Disease

Recent decades have shown that epidemiological understanding of Parkinson disease (PD) has evolved significantly. Major discoveries in genetics and large epidemiological investigations have enabled a better understanding of the genetic, behavioral, and environmental factors that play a role in the pathogenesis and progression of this disease. A review appearing in the June 2024 issue of the journal Current Neurology and Neuroscience Reports has an epidemiological update of PD with a particular focus on advances in the last five years of published literature.  Included are an overview of PD pathophysiology, followed by a detailed discussion of the known distribution of disease and varied determinants of disease. Investigations of risk factors for PD are described and a critical summary of current knowledge, knowledge gaps, and both clinical and research implications is provided. Recent paradigm shifts in the conceptualization of PD as a biological entity will have an impact on research moving forward and will guide further work in this field. 

HEALTH TECHNOLOGY CORNER 

Predicting First Time Depression Onset In Pregnancy

Approximately 15% of individuals report depressive symptoms at some point in their pregnancy, with instances of major depression occurring among roughly 12% of pregnancies. A simple survey delivered during the first trimester through digital pregnancy support app MyHealthyPregnancy predicted which mothers went on to develop moderate to severe depression with a high level of accuracy. As reported in a study by University of Pittsburgh investigators published on May 22, 2024 in the Archives of Women’s Health, the approach is considered to be unique because it predicts who is likely to develop depression in the future. A conclusion from the study is that a relatively small amount of self-report data produced a highly predictive model of first time depression among pregnant individuals. The researchers analyzed data from 944 patients who used the app as part of a larger study and did not have a history of depression.

Accuracy Of Online Artificial Intelligence Models In Primary Care Settings

As patients increasingly turn to online resources for supplementary advice, the role of artificial intelligence (AI) in providing accurate and reliable information has emerged. A study described in the June 2024 issue of the American Journal of Preventive Medicine aimed to assess ChatGPT-4’s and Google Bard's capacity to deliver accurate recommendations in preventive medicine and primary care. After reaching a consensus, 28.6% of ChatGPT-4-generated answers were deemed accurate, 28.6% inaccurate, and 42.8% accurate with missing information. In comparison, 53.6% of Bard-generated answers were deemed accurate, 17.8% inaccurate, and 28.6% accurate with missing information. Responses to CDC and immunization-related questions showed notable inaccuracies (80%) in both models, while they also demonstrated potential in offering accurate information in preventive care. Additionally, they brought to light the critical need for regular updates, particularly in the rapidly evolving areas of medicine.

DEVELOPMENTS IN HIGHER EDUCATION

A fact of academic life at many higher education institutions is that decisions regarding promotions and tenure relate to research productivity and publication in respected peer review periodicals. As noted in a manuscript published in the April 2024 issue of the journal Scientometrics, collaboration among scholars has emerged as a significant characteristic of contemporary science. Consequently, the number of authors listed in publications continues to rise steadily. Unfortunately, determining the authors to be included in the byline and their respective order entails multiple difficulties which often lead to conflicts.

Sole authorship (one publication-one author), which was a common practice until the 20th century, has transformed over time to co-authorship (one publication-multiple authors), with an ever-increasing number of authors listed on papers. Unfortunately, determining which authors should be listed in the byline and their respective order encompasses multiple challenges. To address this gap, an international, cross-disciplinary survey was conducted that involved 752 academics from 41 fields of research and 93 countries. The findings show that nearly one out of four participants have reported at least one conflict with an advisor either during work for Masters or PhD degrees. The results also suggest that roughly one-half of the study participants have experienced a conflict with their peers, which seems to escalate with age and experience.  

Simply from a numerical perspective, a manuscript that stands out over the years is entitled, “Combined Measurement of the Higgs Boson Mass in pp Collisions at √s =7 and 8 TeV with the ATLAS and CMS Experiments.” The article was published in the May 15, 2015 issue of the journal Physical Review Letters. Consisting of a total of  33-pages, it took 24 and-one-half pages to list the names of 5,154 authors and their academic affiliations. The Journal of Allied Health, a publication of the Association of Schools Advancing Health Professions (ASAHP), may appear somewhat miserly in contrast because it limits authorship to six individuals who can demonstrate they played a constructive role in the preparation of a paper. 

Condition of Education 2024

The latest version of the Condition of Edition 2024, a publication released on May 30, 2024 by the National Center for Education Statistics (NCES), is an annual report mandated by the U.S. Congress and is designed to help policymakers and the public monitor the condition and progress of education in the United States. Some key findings from the section on postsecondary education indicate that the overall   immediate college enrollment rate in 2022 was not measurably different from the rate a decade earlier in 2012, or from the rate in 2021,but the total number of undergraduates enrolled decreased by 13% over this period. In 2022, some 45% of high school completers immediately enrolled in four-year institutions and 17% immediately enrolled in two-year institutions. In academic year 2021–22, postsecondary institutions conferred about 5.1 million awards. The number of bachelor’s, master’s, and doctor’s degrees conferred increased between 2011–12 and 2021–22, while the number of certificates and associate’s degrees conferred was about 1.0 million each in both years. Of the degrees conferred by postsecondary institutions in 2021–22, science, technology, engineering, and mathematics (STEM) fields made up 8% of associate’s degrees, 22% of bachelor’s degrees, 16% of master’s degrees, and 16% of doctor’s degrees.

Congressional Action Proposed To Improving Ihe FAFSA

A troubled rollout of revisions to the Free Application for Federal Student Aid (FAFSA) has resulted in major delays in the transmission of data from the federal government to colleges and universities. Because of these delays, many institutions have been unable to deliver financial aid offers to admitted students in a timely manner. As noted in another section of this newsletter regarding events unfolding in Congress, many legislators are considering the necessity of making changes to ensure that the FAFSA process is more efficient and effective, particularly for the upcoming 2025-26 cycle. An example would be to mandate that the FAFSA be made available by October 1 of each year instead of the current deadline, which is January 1.

HEALTH REFORM DEVELOPMENTS

The health care sector can be characterized as a complex set of mutual interactions between patients and consumers seeking to enhance personal health status through disease prevention initiatives or by obtaining care for health problems and the professional caregivers who furnish these services. The interactions occur in the wider context of a culture that undergoes steady alterations in ways that contribute to the onset of new health problems. An example of an emerging trend involves cannabis. It was not so long ago that individuals who either used marijuana or distributed it to other users could be incarcerated. Presently, cannabis products are available legally for recreational purposes at commercial dispensaries around the nation. Simultaneously, research findings illustrate some dangers associated with the use of these substances. As reported in the March 5, 2024 issue of the Journal of the American Heart Association, cannabis use has strong, statistically significant associations with adverse cardiovascular outcomes independent of tobacco use. The data suggest that cannabis use may be a risk factor for experiencing cardiovascular disease and premature cardiovascular disease, such as a heart attack and stroke.  

Displays by beach goers and athletes on television currently provide evidence that wearing bodily tattoos has entered the mainstream of American life. Tattoo ink often contains carcinogenic chemicals, e.g., primary aromatic amines, polycyclic aromatic hydrocarbons, and metals. The tattooing process invokes an immunologic response that causes translocation of tattoo ink from the injection site. Deposition of tattoo pigment in lymph nodes has been confirmed. In a study reported in the June 2024 issue of the journal cClinical Medicine, tattooed individuals had a higher adjusted risk of overall lymphoma. The results suggest they have a 21% increased risk of overall lymphoma relative to non-tattooed individuals. The authors note that causality cannot be conferred from a single epidemiologic study and acknowledge that more research is needed.

Rural Hospital Closures

According to the May 2024 issue of the Journal of Health Care for the Poor and Underserved, between 1990 and 2020, 334 rural hospitals closed in the United States. Since 2011 hospital closures have outnumbered new hospital openings. A scoping review in that publication evaluates peer-reviewed studies published since 1990 with a focus on rural hospital closures, synthesizing studies across six themes: 1) health care policy environment, 2) precursors to rural hospital closures, 3) economic impacts, 4) effects of rural hospital closures on access to care, 5) health and community impacts, and 6) definitions of rural hospitals and communities. In the 1990s, rural hospitals that closed were smaller, while rural hospitals that closed in the 2010s tended to have more beds. An observation is that given the accelerated rate of hospital closures, more attention should be paid to hospitals that serve rural communities of color and low-income communities. Approximately 46 million individuals live in rural places across the U.S., accounting for nearly 14% of the nation’s population. Rural communities account for two-thirds of primary care health professional shortage areas (HPSAs), a situation exacerbated by their disproportionate risk of hospital closure. Given that rural communities generally are older with higher multi-morbidity and higher preventable mortality, the disparate impact of hospital closures is of great concern.

Politics And Health Spending

Section 508 of Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 raised certain hospitals’ regulated payments. A paper in the May 2024 issue of the Journal of Health Economics analyzes the interplay between congressional politics, the actions of the executive branch, and hospitals’ regulated Medicare payments. It shows that Medicare payments are malleable and can be influenced by political dynamics. In the cross-section, hospitals represented by members of Congress who voted “yea” on the MMA were more likely to receive Section 508 payment increases. These increases were designed to win support for the law. They also raised hospitals’ activity and spending. Members of Congress representing recipient hospitals received increased campaign contributions after the increases were extended. Ultimately, the analysis highlights how Medicare payment increases can serve as an appealing tool for legislative leaders working to win votes for wider pieces of legislation. 

FY 2025 APPROPRIATIONS PROCESS

Each calendar year, it is customary to complete legislation on appropriations that should have been finished by the previous October 1 deadline when a new fiscal year when into effect. Almost immediately, however, work must begin to produce a new set of spending bills to meet the next October 1 deadline. The year 2024 is proving to be no exception to this process. 

House Republicans have announced a plan to complete all 12 appropriation bills by the start of the August 2024 recess. If history serves as a reliable guide, it may be quite challenging to fulfill that aim. A possible obstacle is that these individuals have just a paltry two-vote margin over Democrats. A GOP subgroup called the Freedom Caucus is no advocate of increasing the amount of spending and contributing to an  ever growing amount of federal debt. Although it never is assured, it always is possible that a handful of Democrats could support particular spending bills that they like, which could help to offset any defections by Freedom Caucus members. The overall political context also has potential to complicate what happens in the appropriations arena. For example, as a response to the conviction of former President Donald Trump at the end of May in a New York City courtroom, in retaliation, 10 Republican Senators expressed an intention to block certain appropriation measures from being passed in their chamber.  

An uncomfortable reality is that interest payments on the national debt are beginning to surpass spending on major initiatives, such as defense and Medicare. The Congressional Budget Office (CBO) on May 21, 2024 released a report indicating that if current laws governing revenues and spending generally remained unchanged, the federal budget deficit would increase significantly in relation to gross domestic product (GDP) over the next 30 years, driving up federal debt. The amount of debt held by the public would soar from 99% of GDP in 2024 to 166% of GDP in 2054—exceeding any previously recorded level and on track to increase further. While these projections are not predictions of budgetary outcomes, they provide lawmakers a benchmark for measuring the effects of policy options or proposed legislation. 

Meanwhile, tumult associated with the rollout of revisions to the Free Application to Federal Student Aid (FAFSA) form has prevented many higher education institutions from delivering financial aid offers to students and their families in a timely manner. A result is that some members of Congress are interested in making legislative changes to ensure that the FAFSA process is more efficient and effective. Nonetheless, despite the wrangling that often characterizes what transpires on Capitol Hill, an example was provided in the May 2024 issue of this newsletter of the many occasions when bipartisan harmony is achieved. The purpose of S. 2016, CONNECT for Health Act of 2023, is to expand coverage of telehealth services through Medicare, make permanent telehealth flexibilities that were enacted during COVID, make it easier for patients to connect with their doctors, and help improve health outcomes. The bill had 65 Senate co-sponsors in May. That number remains unchanged.

HIGHER EDUCATION REDUX

The Spring 2024 issue of Daedalus, Journal of the American Academy of Arts & Sciences, is devoted to the topic of higher education. A series of articles indicates  that American leadership in higher education—as in other areas—is under great stress, particularly in its public universities, but also in its distinguished private universities, which have become lightning rods in current political and culture wars. In this nation, 43 of all 50 states have disinvested in higher education since 2008. Because public universities educate the majority of American students, these states have disinvested in their own future and the nation's future. The University of California, Berkeley, is the flagship of what has been the greatest system of public higher education in the world. California would not be the well-known state that it is without its signature network of public universities. Today, Berkeley is a bellwether for the future of American universities, nearly brought to its knees by a series of massive budget cuts, a poster child of the enduring unwillingness of the American public to support public higher education. 

The “mission” of a sector of society can encompass a range of possibilities. Missions serve as guideposts that articulate a central purpose or goal, which should help to structure decisions and actions: who should be served, exactly what should be done, how the work is carried out, which measures can determine whether the mission actually is being realized, and, if not, how a course can and should be corrected. As expressed in one paper in Daedalus, the concept of mission becomes more vexed in the higher education sector. 

Tertiary institutions all over the globe exist for a range of purposes, i.e., to provide professional training; teach and conduct research in an ever-expanding array of disciplines; educate underserved populations; focus explicitly on globalization, climate change, the arts, and cultivate specific political viewpoints and orientations. Many institutions have different stated missions. Extensive research focused on liberal arts and sciences at universities in the U.S. provides a troubling perspective. A disturbing lack of consensus exists among key individuals about the purpose(s) of higher education, both within single institutions and across the sector. Most notable, while students, parents, alumni, and trustees view a university primarily as the necessary path toward a future job, most faculty and administrators believe that the university experience is an opportunity for intellectual transformation, the time and place to prepare students for lifelong learning and citizenship.  

Two reasons underlie this major misalignment. One explanation is mission sprawl, the promotion of multiple missions on a single campus. Rather than a set of focused goals, institutions attempt to pursue a myriad of goals for too many disparate groups in the population, thus obscuring their own primary reason(s) for existing. A second explanation involves universities that not only try to do too much, but also appear to be conflicted about what they are trying to do. Sometimes, single institutions promote explicit missions, clear and accessible statements of intent often found on their website and in their brochures, alongside implicit missions, underlying messages that all too often conflict with what is stated publicly.

HEALTH REFORM DEVELOPMENTS

Health care policy in the United States is dominated by three major concerns: reducing the number of individuals who lack insurance coverage, improving quality of health services, and reducing health costs. Considerations about the health workforce relate to the latter two of these concerns, but the   topic does not always receive the attention it deserves. While the federal government has some jurisdiction over workforce issues, the nation’s 50 states represent battlegrounds where organizations in the health professions compete over scope of practice issues. Members of some professions argue that they are capable of independently providing high quality care at lower cost, but they are opposed by claims that patient safety would be compromised if the scope of practice is broadened to include other groups. 

Meanwhile, the U.S. population continues to grow larger and much of that growth occurs among the oldest cohorts. Advancing age often is accompanied by increases in chronic disease and disability,   placing greater demands on the necessity of having a sufficient cadre of competently-prepared health care practitioners. Occasionally, studies are done that shed valuable light on what is occurring within the health professions. For example, a cross-sectional study published on April 9, 2024 in JAMA Network Open involved 7,887 nurses who were employed in a non–health care job, not currently employed, or retired, the top contributing factors for leaving health care employment were planned retirement (39% of nurses), burnout or emotional exhaustion (26%), insufficient staffing (21%), and family obligations (18%). Age distributions of nurses not employed in health care were similar to nurses currently employed in health care. Although the increase in new registered nurses is expected to outpace retirements, health care systems continue to struggle with recruiting and retaining these individuals.  It certainly would be of immense value to have similar investigations undertaken in order to develop clearer profiles of other groups, such as physical therapists, occupational therapists, and medical laboratory personnel. 

U.S. Dementia Care Spending By State: 2010–2019

A separate item in this issue of the newsletter is about dementia from the standpoint of biomarker     testing. According to a paper appearing in the April 2024 issue of the journal Alzheimer’s and           Dementia, the fourth largest cause of death for individuals 70 years of age and older in the United States is dementia. It is tremendously costly, leading to $80 billion per year in direct medical spending attributable to this disorder. Given the progressive nature of cognitive and functional impairment that accompanies dementia and the associated caregiving needs, the cost of informal care can elevate these cost estimates.

Still, a concern is that existing estimates of the indirect costs of dementia are dated and do not report on differences across the nation. Researchers used data from multiple surveys to create cost estimates and projections for informal dementia caregiving at the state level from 2010 through 2050. In 2019, the annual replacement cost of informal caregiving was $42,422 per prevalent case, and the forgone wage cost was $10,677 per prevalent case ($58 billion overall). In 2019, it would have cost $230 billion to hire home health aides to provide all this care. If past trends persist, this cost is expected to grow to $404 billion per year in 2050.

Vaccination For Healthy Aging

As noted above, the population is aging. In a paper in the May 2024 issue of the periodical Science    Translational Medicine, the WHO estimates that the number of individuals 65 years of age and older will grow to 2.1 billion during the next three decades, nearly doubling as a proportion of the global  population that is 65 and older and tripling the number of persons 80 and older. Also, as the world’s population ages, vaccination is becoming a key strategy for promoting healthy aging. Despite scientific progress in adult vaccine development, obstacles such as immune-senescence and vaccine hesitancy remain. In order to unlock the potential of adult vaccines fully, immunization programs must be enhanced, misinformation dispelled, and investments made in research that deepens an understanding of aging and immunity. A strategy for harnessing the full potential contribution of vaccination to healthy aging entails key actions, e.g. expanding the knowledge base and allowing for timely development of new vaccines.

REDEFINING HOW TO DEFINE AND DESCRIBE DEMENTIA

Progress is being made in moving away from diagnosing dementia solely based on symptoms and going toward a new era of molecular-based diagnosis and disease-modifying treatment. As described in a manuscript published on May 2, 2024 in the periodical Neurology Today, clinicians indicate that advances provide them with new tools to discuss the underlying pathology driving their patients’ cognitive complaints and potential symptoms. It is a time of transition in dementia-related care as the increasing availability of biomarker testing allows for more precise diagnosis and the identification of patients who may benefit from a newly available disease-modifying therapy for Alzheimer’s disease (AD). Clinicians are able to converse with greater clarity with patients about the underlying pathology driving their cognitive complaints and about the expected symptoms patients may see in the future. For example, regarding the question of what is going on in the patient’s brain at the microscopic level, one expert noted that with the availability of anti-amyloid therapies, there is now much more reason to use biomarker proof to answer that query.  

The medication Lecanemab, designed to clear amyloid-beta plaque from the brain, received full U.S. Food and Drug Administration (FDA) approval last year for patients with mild cognitive impairment (MCI) or mild dementia with a biomarker-confirmed diagnosis of AD. Another expert asserted that a key question that will have to be resolved is how to define, and in turn explain to patients, biomarker-positive presymptomatic AD, which will likely become a more common scenario as biomarker testing expands—through imaging, cerebrospinal fluid, or blood sampling. Underscoring this perspective is that in a paper published on October 16, 2024 in JAMA Neurology, a team of experts proposed a “new framework for dementia nomenclature.” The authors stated that their recommendations could help guide communication about cognitive impairment among older adults and lead to consistency in the language used in both clinical practice and research. Another salient observation is that the use of biomarker testing and disease-modifying therapy will have to expand to include primary care providers and other community-based doctors because specialty centers will not be able to accommodate the demand for services.

VALUE STRUCTURE UNDERLYING SHARED DECISION MAKING

Shared decision making (SDM) is a treatment decision model that has been incorporated in many nations. It is viewed as a collaborative process between patients and clinicians in which medical evidence, providers’  expertise, and the values, preferences, and context of patients are used to develop tailored treatment decisions for an individual patient. Despite the increased importance attached to SDM, no unified definition exists according to investigators in an article published in the July 2024 issue of the journal Patient Education and Counseling. Nonetheless, multiple SDM models have been developed for various health care settings, describing in successive steps how the approach should be performed in clinical practice. SDM can be considered a service, with underlying values facilitating a particular type of communication regarding treatment decision making between clinicians and patients and their relatives. References to explicit values underlying SDM are seldom made. Yet, these researchers note that the identification of SDM’s underlying values would enable a comparison with the values of its users and can therefore contribute to the alignment of both. 

Schwartz’s value theory was employed in this study because it is well grounded in empirical research, comprehensive in included value types, and used in numerous studies, including more recently in studying patients’ and health professionals’ values in decision making. The theory has not been applied to SDM yet to the best of their knowledge. They aimed to construct a value structure characterizing SDM that may be used to compare it with those of specific groups using SDM, and to incorporate patients’ values into treatment decision making. They sought to identify how values manifest in scientific articles that describe SDM models and provide an overview of how the identified values of SDM models interrelate. They concluded that the study unraveled the value structure underlying SDM and shows that SDM can be realized through an interplay of various values. The value structure shows that besides knowledge and skills, support, and a good relationship with health professionals. it also enables patients’ Achievement and Self-Direction and facilitates Universalism.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Cigarette Smoking Among Pregnant Women During the Perinatal Period

Cigarette smoking has wide-ranging adverse health consequences. When it occurs during pregnancy, there are increased risks of pregnancy complications and adverse outcomes for infants. According to the May 2, 2024 issue of Morbidity and Mortality Weekly Report, in 2021, among women with a recent live birth, 12.1% reported smoking before pregnancy, 5.4% reported smoking during pregnancy, and 7.2% reported doing so during the postpartum period. Smoking behaviors varied by demographic characteristics and jurisdiction. Overall, 73.7%, 93.7%, and 57.3% of women reported being asked about smoking by a health care provider at any health care visit before pregnancy, at any prenatal visit, and at a postpartum checkup, respectively. An implication is that routine assessment of smoking behaviors among pregnant and postpartum women can guide the development and implementation of evidence-based tobacco control measures.  

The Re-emerging Suicide Crisis In The U.S.: Patterns, Causes And Solutions

The suicide rate in the U.S. has risen nearly 40% since 2000, which is puzzling because rates had been falling for decades at the end of the 20th century. A paper in the Spring 2024 issue of the Journal of Policy Analysis and Management  has a review of important facts about the changing rate. General trends do not tell the story of important differences across groups. Suicide rates rose substantially among middle-aged persons between 2005 and 2015, but have fallen since. Among youth, rates began a rapid rise after 2010 that has not abated. The economic hardship caused by the Great Recession played an important role in rising suicide among prime-aged Americans. Among those under 25, nearly all the increase in suicide mortality during the 2010s can be explained by an increase in the prevalence of depression. Bullying victimization of LGBTQ youth also could account for part of the rise in suicide. The evidence that access to firearms or opioids are major drivers of recent suicide trends is less clear.  

HEALTH TECHNOLOGY CORNER 

A Machine-Learning-Enabled Smart Neckband For Monitoring Dietary Intake

The increasing need for precise dietary monitoring across various health scenarios has led to innovations in wearable sensing technologies, however, continuously tracking food and fluid intake during daily activities can be complex. These devices must be able to distinguish eating and drinking from similar movements, such as speaking and walking. A machine-learning-powered smart neckband that features wireless connectivity and a comfortable, foldable design is described in a study that was published on May 7, 2024 in PNAS Nexus. Initially considered beneficial for managing conditions, such as diabetes and obesity by facilitating dietary control, the device's utility extends beyond these applications. Initially considered beneficial for managing those conditions by facilitating dietary control, utility extends beyond these applications. Smart neckbands have proved to be valuable for sports enthusiasts, individuals focused on diet control, and general health monitoring.  

Nitrogen Dioxide Exposure And Health Outcomes Due To Combustion By U.S. Stoves

Gas and propane stoves emit nitrogen dioxide (NO2) pollution indoors, but the exposures of different U.S. demographic groups are unknown. These household implements increase long-term NO2 exposure 4.0 parts per billion volume on average across the United States, which is 75% of the World Health Organization’s exposure guideline. According to an article published on May 3, 2024 in the journal Science Advances, this increased exposure likely causes ~50,000 cases of current pediatric asthma from long-term NO2 exposure alone. Short-term NO2 exposure from typical gas stove use frequently exceeds both WHO and U.S. Environmental Protection Agency benchmarks. Individuals living in residences <800 ft2 in size incur four times more long-term NO2 exposure than inhabitants of residences >3000 ft2 in size. American Indian/Alaska Native and Black and Hispanic/Latino households incur 60% and 20% more NO2 exposure, respectively, than the national average.

A TYPICAL DAY ON CAPITOL HILL

It should come as no surprise that having 535 federal legislators representing a wide range of political beliefs and opinions on any given day would provide a vibrant scene for the exchange of opposing ideas on how best to address the wide ranging needs of the U.S. citizenry. Adding to the zest is the fact that the House of Representatives currently is ruled by Republicans, but only by the slimmest of majorities. All it takes is for just one or two of them to stray from political party colleagues and mayhem quickly is ensued. Already in recent months, Speaker Kevin McCarthy (R-CA) was deposed from that position for failing to satisfy a small group of other Republicans. Meanwhile, his successor Michael Johnson (R-LA) recently is being threatened with a similar ouster by another small group of dissidents. 

An important function for members of Congress is to enact 12 major spending bills ech year to keep federal machinery afloat. As in past years, they were not successful in doing so until six months after fiscal year 2024 began on October 1, 2023. Domestic issues, such as abortion and initiatives in foreign affairs, involving military aid for Ukraine, Israel, and Taiwan are sufficiently powerful for matters pertaining to appropriations legislation to grind to an immediate halt. Another key function for federal legislators is to furnish oversight of activities of the executive branch of government. Congressional hearings always have the potential to turn into a vast playground where invited witnesses are badgered by indignant legislators. Also, a threat of impeachment can hang in the air over some contentious deliberations. 

Often lost in the fog of various controversies, however, are the many occasions when bipartisan harmony is achieved. During COVID-19, social lockdowns required patients to remain at home where they were unable to leave to obtain health services. Telehealth made it possible for them to receive care in a different manner. Another group that has benefited from this technology consists of rural residents who may reside many miles from clinicians and health facilities. Presently, S. 2016, CONNECT for Health Act of 2023, has 65 co-sponsors in the Senate. The purpose is to expand coverage of telehealth services through Medicare, make permanent telehealth flexibilities that were enacted during COVID, make it easier for patients to connect with their doctors, and help improve health outcomes. Some features are: 

· Permanently removing all geographic restrictions on telehealth services and expand originating sites to include the home and other sites

· Permanently allowing health centers and rural health clinics to provide telehealth services

· Allowing more eligible health care professionals to utilize telehealth services

· Removing unnecessary in-person visit requirement for telemental health services

· Allowing for the waiver of telehealth restrictions during public health emergencies

· Requiring more published data to learn more about how telehealth is being used, impacts of quality of care, and how it can be improved to support patients and health care providers.

TECHNOLOGY AND HEALTH CARE

Similar to what is occurring in other sectors of the U.S. economy, developments in technology already play a role in transforming the health care sphere. Artificial intelligence and virtual reality are expected to continue making significant inroads in health professions education and patient care. Another facet of technology that also attracts increased attention is patient wearables. The New England Journal of Medicine is one of many periodicals that has had a focus on this topic. A final review of a series on wearable digital health technologies (DHTs) appeared in the March 21, 2024 issue. 

It highlights important challenges that must be met to integrate these devices into clinical guidelines and practice. The narrative deliberately is grounded in what is possible today, but speculations also are made about specific uses of wearable DHTs in the future. Six interlocking and vexing issues are identified as being at the foundation of delivering DHT-informed care. They are:  

Data Ownership

Who owns the raw and derivative data obtained from wearable DHTs? Ownership can be unclear, since data collection involves multiple stakeholders, including patients, device manufacturers, app providers, and data aggregators.

Patient Trust, Literacy, and Access

Fear that personal health data may be compromised or misused, especially with the increasing use of AI, is one of the most important trust issues. 

Standards and Interoperability

Although the broad field of DHTs, which includes electronic health records and telemedicine, has adopted data standards, the field of wearable DHTs, which is characterized by ongoing development, lacks such standards.

Integration into Clinical Environments

Integrating wearable DHTs into clinical care presents several workflow challenges that can affect both health care professionals and patients. One of the biggest challenges is the sheer volume of data generated by wearable DHTs, which can be overwhelming.

Patient Empowerment and Agency

For patients to have agency and empowerment in using data from their wearable DHTs, the challenges of control over the data, an understanding of how the data can be used effectively, and trust in the systems managing the data will need to be addressed.

Reimbursement and Return on Investment for Health Care Systems

A set of Current Procedural Terminology (CPT) codes exists for remote patient monitoring with wearables. Devices and procedures that do not meet existing CPT definitions still present serious challenges in securing reimbursement. 

HEALTH REFORM DEVELOPMENTS

Health care policy in the United States is dominated by three major concerns: reducing the number of individuals who lack insurance coverage, improving quality of health services, and reducing health costs. Considerations about the health workforce relate to the latter two of these concerns, but the   topic does not always receive the attention it deserves. While the federal government has some jurisdiction over workforce issues, the nation’s 50 states represent battlegrounds where organizations in the health professions compete over scope of practice issues. Members of some professions argue that they are capable of independently providing high quality care at lower cost, but they are opposed by claims that patient safety would be compromised if the scope of practice is broadened to include other groups. 

Meanwhile, the U.S. population continues to grow larger and much of that growth occurs among the oldest cohorts. Advancing age often is accompanied by increases in chronic disease and disability,   placing greater demands on the necessity of having a sufficient cadre of competently-prepared health care practitioners. Occasionally, studies are done that shed valuable light on what is occurring within the health professions. For example, a cross-sectional study published on April 9, 2024 in JAMA      Network Open involved 7,887 nurses who were employed in a non–health care job, not currently      employed, or retired, the top contributing factors for leaving health care employment were planned    retirement (39% of nurses), burnout or emotional exhaustion (26%), insufficient staffing (21%), and family obligations (18%). Age distributions of nurses not employed in health care were similar to     nurses currently employed in health care. Although the increase in new registered nurses is expected to outpace retirements, health care systems continue to struggle with recruiting and retaining these        individuals.  It certainly would be of immense value to have similar investigations undertaken in order to develop clearer profiles of other groups, such as physical therapists, occupational therapists, and      medical laboratory personnel. 

U.S. Dementia Care Spending By State: 2010–2019

A separate item in this issue of the newsletter is about dementia from the standpoint of biomarker     testing. According to a paper appearing in the April 2024 issue of the journal Alzheimer’s and           Dementia, the fourth largest cause of death for individuals 70 years of age and older in the United States is dementia. It is tremendously costly, leading to $80 billion per year in direct medical spending attributable to this disorder. Given the progressive nature of cognitive and functional impairment that accompanies dementia and the associated caregiving needs, the cost of informal care can elevate these cost estimates. 

Still, a concern is that existing estimates of the indirect costs of dementia are dated and do not report on differences across the nation. Researchers used data from multiple surveys to create cost estimates and projections for informal dementia caregiving at the state level from 2010 through 2050. In 2019, the annual replacement cost of informal caregiving was $42,422 per prevalent case, and the forgone wage cost was $10,677 per prevalent case ($58 billion overall). In 2019, it would have cost $230 billion to hire home health aides to provide all this care. If past trends persist, this cost is expected to grow to $404 billion per year in 2050. 

Vaccination For Healthy Aging

As noted above, the population is aging. In a paper in the May 2024 issue of the periodical Science    Translational Medicine, the WHO estimates that the number of individuals 65 years of age and older will grow to 2.1 billion during the next three decades, nearly doubling as a proportion of the global  population that is 65 and older and tripling the number of persons 80 and older. Also, as the world’s population ages, vaccination is becoming a key strategy for promoting healthy aging. Despite scientific progress in adult vaccine development, obstacles such as immune-senescence and vaccine hesitancy remain. In order to unlock the potential of adult vaccines fully, immunization programs must be        enhanced, misinformation dispelled, and investments made in research that deepens an understanding of aging and immunity. A strategy for harnessing the full potential contribution of vaccination to healthy aging entails key actions, e.g. expanding the knowledge base and allowing for timely development of new vaccines.

TRANSLATING CLINICAL RESEARCH INTO PRACTICE

A well-characterized gap exists between establishing scientific evidence and integrating it into routine clinical practice. It often is noted that only a small proportion of scientific innovation is translated into routine clinical practice and that even then, the process can take more than a decade, according to a manuscript in the April 2024 issue of the journal Mayo Clinic Proceedings. Whereas this lag may vary by measurement approach, funding mechanism, and other factors, more recently published estimates indicate that it takes an average of 14 years and $2 billion to bring a new drug or medical device from conception to market. This research-to-practice gap has not historically been an important consideration in academic clinical research. The clinical research enterprise typically rewards the conduct of descriptive or mechanistic studies that are highly controlled. Although growing attention has focused on the need to accelerate translation of knowledge into clinical practice, protocolized intervention trials for evidence generation are often designed without appreciable attention paid to evidence translation and therefore do not lend themselves to integration of innovation into feasible and sustainable health care programs and policies in real-world settings. Integration of translational and implementation science principles and practices into clinical research can advance the translation of scientific innovation into improved patient care and population health.  

The authors aim to prioritize and guide efforts to create greater efficiency and speed of scientific innovation across the translational science continuum to improve patient and population health. Key principles and practices rooted in translational and implementation science may be incorporated into clinical trials research, particularly pragmatic trials, to improve the relevance and impact of scientific innovation. Their thematic review intends to raise awareness on the value of translational and implementation science in clinical research and to encourage its use in designing and implementing clinical trials across the translational research continuum. These investigators describe the gap in translating research findings into clinical practice, introduce translational and implementation science, and describe the principles and practices from implementation science that can be used in clinical trial research across the translational continuum to inform clinical practice, improve population health impact, and address health care inequities.  

ROBOTS AND THE ART OF HUMAN SYNCHRONY

Currently a global multibillion-dollar industry, the increasing demand for robots with human-like social intelligence marks a significant milestone in technological history. Once primarily confined to dull, dirty, and dangerous work, such as stocking shelves, cleaning floors, and deactivating bombs—robots presently are elevated to join the human social world, with immense transformative potential for society. A good example is the provision of health and social assistance services to patients who live alone and are confined to their homes. According to the March 2024 issue of the journal Science Robotics, although their physical appearance is impressive, interactions with robots often are clunky, stilted, and awkward. One critical limitation is that current social robots lack the art of social synchrony, where nods, smiles, gestures, and speech are orchestrated carefully across conversation partners. For social robots to engage in human social interactions, social synchrony skills are essential. A paper in that issue of this periodical addressed the art of social synchrony by endowing one such humanoid social robot, Emo, with it.  

The device is a soft-skinned anthropomorphic facial robot that can display a wide range of nuanced facial expressions using 26 magnet-controlled facial actuators. It also has high-resolution cameras in its eye sockets to detect different types of facial expressions. Although Emo can mimic the human facial expressions that it detects, engaging in social synchrony involves a more refined planning and execution of responses. To achieve this outcome, Emo was trained using neural networks to predict the facial expressions of its human interlocutors based on their early facial movements. Emo’s predictive ability enables it to plan and execute its own facial expressions in response, achieving a more human-like social synchrony. Researchers also upgraded Emo’s processing capacity to run on lightweight computing facilities, freeing up processing power for the development of other functions, such as speech and listening. Using this simple and elegant approach, Emo’s social interaction skills have been upgraded from mere mimicry to the art of social synchrony. Such a development has profound implications for the future of social robots.