Development and Evaluation of a Risk-Adjusted Measure of Intraoperative Hypotension in Patients Having Nonemergent, Noncardiac Surgery.

BACKGROUND: Intraoperative hypotension is common and associated with organ injury and death, although randomized data showing a causal relationship remain sparse. A risk-adjusted measure of intraoperative hypotension may therefore contribute to quality improvement efforts. METHODS: The measure we developed defines hypotension as a mean arterial pressure <65 mm Hg sustained for at least 15 cumulative minutes. Comparisons are based on whether clinicians have more or fewer cases of hypotension than expected over 12 months, given their patient mix. The measure was developed and evaluated with data from 225,389 surgeries in 5 hospitals. We assessed discrimination and calibration of the risk adjustment model, then calculated the distribution of clinician-level measure scores, and finally estimated the signal-to-noise reliability and predictive validity of the measure. RESULTS: The risk adjustment model showed acceptable calibration and discrimination (area under the curve was 0.72 and 0.73 in different validation samples). Clinician-level, risk-adjusted scores varied widely, and 36% of clinicians had significantly more cases of intraoperative hypotension than predicted. Clinician-level score distributions differed across hospitals, indicating substantial hospital-level variation. The mean signal-to-noise reliability estimate was 0.87 among all clinicians and 0.94 among clinicians with >30 cases during the 12-month measurement period. Kidney injury and in-hospital mortality were most common in patients whose anesthesia providers had worse scores. However, a sensitivity analysis in 1 hospital showed that score distributions differed markedly between anesthesiology fellows and attending anesthesiologists or certified registered nurse anesthetists; score distributions also varied as a function of the fraction of cases that were inpatients. CONCLUSIONS: Intraoperative hypotension was common and was associated with acute kidney injury and in-hospital mortality. There were substantial variations in clinician-level scores, and the measure score distribution suggests that there may be opportunity to reduce hypotension which may improve patient safety and outcomes. However, sensitivity analyses suggest that some portion of the variation results from limitations of risk adjustment. Future versions of the measure should risk adjust for important patient and procedural factors including comorbidities and surgical complexity, although this will require more consistent structured data capture in anesthesia information management systems. Including structured data on additional risk factors may improve hypotension risk prediction which is integral to the measure's validity.

Financial Toll of Untreated Perinatal Mood and Anxiety Disorders Among 2017 Births in the United States.

Objectives. To estimate the economic burden of untreated perinatal mood and anxiety disorders (PMADs) among 2017 births in the United States.Methods. We developed a mathematical model based on a cost-of-illness approach to estimate the impacts of exposure to untreated PMADs on mothers and children. Our model estimated the costs incurred by mothers and their babies born in 2017, projected from conception through the first 5 years of the birth cohort's lives. We determined model inputs from secondary data sources and a literature review.Results. We estimated PMADs to cost $14 billion for the 2017 birth cohort from conception to 5 years postpartum. The average cost per affected mother-child dyad was about $31 800. Mothers incurred 65% of the costs; children incurred 35%. The largest costs were attributable to reduced economic productivity among affected mothers, more preterm births, and increases in other maternal health expenditures.Conclusions. The US economic burden of PMADs is high. Efforts to lower the prevalence of untreated PMADs could lead to substantial economic savings for employers, insurers, the government, and society.

Continuing conversations about abortion and deprivation.

In 'Abortion and deprivation: a reply to Marquis', I argued that Marquis' argument about abortion encounters the Epicurean Challenge. In this essay, I continue the conversation begun there. I aim to motivate the Challenge further by examining Marquis' argument on his own terms and responding to objections about whom death deprives, whether we should focus on the action of killing or the result of death, and how harms suffered before existence compare to harms suffered after death. Finally, I suggest that perhaps the solution to the ethics of killing lies in considering another account of harm entirely-one that does not rely on deprivation.

Structural validity and reliability of the Danish self-report Strengths and Difficulties Questionnaire among male and female students in vocational education and training.

Objective: The Strengths and Difficulties Questionnaire (SDQ) is a widely used mental health screening instrument among children and adolescents and increasingly used by welfare professionals in Denmark. However, the psychometric properties of the SDQ-self report (SDQ-S) among vocational education and training (VET) students are unknown. We assess the structural validity, internal consistency reliability, and test-retest reliability of the Danish SDQ-S among these students. Method: The SDQ-S was tested twice in a sample of VET students (sample N = 486; mean age = 17 years) with 10 to 14 days in-between. Using separate analyses for men (n = 371) and women (n = 115), structural validity was assessed using confirmatory factor analysis; internal consistency was assessed using composite reliability (CR); and test-retest reliability using Pearson's correlation. Results: Overall, the results provide inconsistent support for the five-factor first-order model, especially among males. CR was acceptable for all five scales except for Peer problems (among females and males) and Conduct (among males only). Test-retest reliability was satisfactory for all scales among females but for only two of the five scales (Conduct, Hyperactivity) among men. Conclusion: Overall, the SDQ-S is a more valid and reliable instrument among females. Results suggest caution in using the SDQ-S among VET students, in particular males.

Implementing Electronic Health Record Default Settings to Reduce Opioid Overprescribing: A Pilot Study.

Objective: To pilot test the effectiveness, feasibility, and acceptability of instituting a 15-pill quantity default in the electronic health record for new Schedule II opioid prescriptions. Design: A mixed-methods pilot study in two health systems, including pre-post analysis of prescribed opioid quantity and focus groups or interviews with prescribers and health system administrators. Methods: We implemented a 15-pill electronic health record default for new Schedule II opioids and assessed opioid quantity before and after implementation using electronic health record data on 6,390 opioid prescriptions from 448 prescribers. We then analyzed themes from focus groups and interviews with four staff members and six prescribers. Results: The proportion of opioid prescriptions for 15 pills increased at both sites after adding an electronic health record default, with one reaching statistical significance (from 4.1% to 7.2% at CHC, P = 0.280, and 15.9% to 37.2% at WVU, P < 0.001). The proportion of 15-pill prescriptions increased among high-prescribing departments and among most high- and low-frequency prescribers, except for low-frequency prescribers at CHC. Sites reported limited challenges in instituting the default, although ease of implementation varied by electronic health record vendor. Most prescribers were not aware of the default change and stated that they made prescribing decisions based on patient clinical characteristics rather than defaults. Conclusions: This pilot provides initial evidence that changing default settings can increase the number of prescriptions at the default level. This low-cost and relatively simple intervention could have an impact on opioid overprescribing. However, default settings should be selected carefully to avoid unintended consequences.

Abortion and deprivation: a reply to Marquis.

In 'Why Abortion is Immoral', Don Marquis argues that abortion is wrong for the same reason that murder is wrong, namely, that it deprives a human being of an FLO, a 'future like ours,' which is a future full of value and the experience of life. Marquis' argument rests on the assumption that the human being is somehow deprived by suffering an early death. I argue that Marquis' argument faces the 'Epicurean Challenge'. The concept of 'deprivation' requires that some discernible individual exists who can be deprived. But if death involves total annihilation, then no discernible individual exists to be so deprived. I argue that the Epicurean Challenge must be addressed before it can be proven that Marquis is correct to claim that abortion and murder are wrong because they deprive someone of an FLO.

Diagnosis and Management of Borrelia turicatae Infection in Febrile Soldier, Texas, USA.

In August 2015, a soldier returned from field exercises in Texas, USA, with nonspecific febrile illness. Culture and sequencing of spirochetes from peripheral blood diagnosed Borrelia turicatae infection. The patient recovered after receiving doxycycline. No illness occurred in asymptomatic soldiers potentially exposed to the vector tick and prophylactically given treatment.

What Factors Influence States' Capacity to Report Children's Health Care Quality Measures? A Multiple-Case Study.

Objectives The objective of this study was to describe factors that influence the ability of state Medicaid agencies to report the Centers for Medicare & Medicaid Services' (CMS) core set of children's health care quality measures (Child Core Set). Methods We conducted a multiple-case study of four high-performing states participating in the Children's Health Insurance Program Reauthorization Act (CHIPRA) Quality Demonstration Grant Program: Illinois, Maine, Pennsylvania, and Oregon. Cases were purposively selected for their diverse measurement approaches and used data from 2010 to 2015, including 154 interviews, semiannual grant progress reports, and annual public reports on Child Core Set measures. We followed Yin's multiple-case study methodology to describe how and why each state increased the number of measures reported to CMS. Results All four states increased the number of Child Core Set measures reported to CMS during the grant period. Each took a different approach to reporting, depending on the available technical, organizational, and behavioral inputs in the state. Reporting capacity was influenced by a state's Medicaid data availability, ability to link to other state data systems, past experience with quality measurement, staff time and technical expertise, and demand for the measures. These factors were enhanced by CHIPRA Quality Demonstration grant funding and other federal capacity building activities, as hypothesized in our conceptual framework. These and other states have made progress reporting the Child Core Set since 2010. Conclusion With financial support and investment in state data systems and organizational factors, states can overcome challenges to reporting most of the Child Core Set measures.

Stimulation of Arabidopsis thaliana Seed Germination at Suboptimal Temperatures through Biopriming with Biofilm-Forming PGPR Pseudomonas putida KT2440.

This study investigated the germination response to temperature of seeds of nine Arabidopsis thaliana ecotypes. They are characterized by a similar temperature dependency of seed germination, and 10 °C and 29 °C were found to be suboptimal low and high temperatures for all nine ecotypes, even though they originated from regions with diverse climates. We tested the potential of four PGPR strains from the genera Pseudomonas and Bacillus to stimulate seed germination in the two ecotypes under these suboptimal conditions. Biopriming of seeds with only the biofilm-forming strain Pseudomonas putida KT2440 significantly increased the germination of Cape Verde Islands (Cvi-0) seeds at 10 °C. However, biopriming did not significantly improve the germination of seeds of the widely utilized ecotype Columbia 0 (Col-0) at any of the two tested temperatures. To functionally investigate the role of KT2440's biofilm formation in the stimulation of seed germination, we used mutants with compromised biofilm-forming abilities. These bacterial mutants had a reduced ability to stimulate the germination of Cvi-0 seeds compared to wild-type KT2440, highlighting the importance of biofilm formation in promoting germination. These findings highlight the potential of PGPR-based biopriming for enhancing seed germination at low temperatures.

Incidence of intraoperative hypotension during non-cardiac surgery in community anesthesia practice: a retrospective observational analysis.

BACKGROUND: Intraoperative hypotension (IOH) is well-described in the academic setting but not in community practice. IOH is associated with risk of postoperative morbidity and mortality. This is the first report of IOH in the community setting using the IOH measure definition from the Centers for Medicare and Medicaid Services Merit-based Incentive Payment System program. OBJECTIVES: To describe the incidence of IOH in the community setting; assess variation in IOH by patient-, procedure-, and facility-level characteristics; and describe variation in risk-adjusted IOH across clinicians. METHODS: Design Cross-sectional descriptive analysis of retrospective data from anesthesia records in 2020 and 2021. Setting Forty-five facilities affiliated with two large anesthesia providers in the USA. Participants Patients aged 18 years or older having non-emergent, non-cardiac surgery under general, neuraxial, or regional anesthesia. Cases were excluded based on criteria for the IOH measure: baseline mean arterial pressure (MAP) below 65 mmHg prior to anesthesia induction; American Society of Anesthesiologists (ASA) physical status classification of I, V, or VI; monitored anesthesia care only; deliberate induced hypotension; obstetric non-operative procedures; liver or lung transplant; cataract surgery; non-invasive gastrointestinal cases. Main outcomes IOH, using four definitions. Primary definition: binary assessment of whether the case had MAP < 65 mmHg for 15 min or more. Secondary definitions: total number of minutes of MAP < 65 mmHg, total area under MAP of 65 mmHg, time-weighted average MAP < 65 mmHg. RESULTS: Among 127,095 non-emergent, non-cardiac cases in community anesthesia settings, 29% had MAP < 65 mmHg for at least 15 min cumulatively, with an overall mean of 12.4 min < 65 mmHg. IOH was slightly more common in patients who were younger, female, and ASA II (versus III or IV); in procedures that were longer and had higher anesthesia base units; and in ambulatory surgery centers. Incidence of IOH varied widely across individual clinicians in both unadjusted and risk-adjusted analyses. CONCLUSION: Intraoperative hypotension is common in community anesthesia practice, including among patients and settings typically considered "low risk." Variation in incidence across clinicians remains after risk-adjustment, suggesting that IOH is a modifiable risk worth pursuing in quality improvement initiatives.

Intraoperative hypotension in ambulatory surgery centers.

STUDY OBJECTIVES: To measure the incidence of intraoperative hypotension (IOH) during surgery in ambulatory surgery centers (ASCs) and describe associated characteristics of patients and procedures. DESIGN: Retrospective analysis. SETTING: 20 ASCs. PATIENTS: 16,750 patients having non-emergent, non-cardiac surgery; ASA physical status 2 through 4. INTERVENTIONS: None. MEASUREMENTS: We assessed incidence of IOH using the definition from the Centers for Medicare & Medicaid Services (CMS) Merit-based Incentive Payment System (MIPS)-mean arterial pressure (MAP) < 65 mmHg for at least 15 cumulative minutes-and three secondary definitions: minutes of MAP <65 mmHg, area under MAP of 65 mmHg, and time-weighted average MAP <65 mmHg. MAIN RESULTS: 30.9% of ASC cases had a MAP <65 mmHg for at least 15 min. The incidence of IOH varied significantly, and was higher among younger adults (age 18-39; 36.2%), females (35.2%), and patients with ASA physical status 2 (32.8%). IOH increased with increasing surgery length, even when time-weighted, and was higher among low complexity (30.6%) than moderate complexity (28.8%) procedures, and highest among high complexity procedures (44.1%). CONCLUSIONS: There was substantial occurrence of IOH in ASCs, similar to that described in academic hospital settings in previous literature. We hypothesize that this may reflect clinician preference not to intervene in perceived healthy patients or assumptions about ability to tolerate lower blood pressures on behalf of these patients. Future research will determine whether IOH in ACSs is associated with adverse outcomes to the same extent as described in more complex hospital-based surgeries.

Application of the Spanish-Language Consultation and Relational Empathy (CARE) Measure to Assess Patient-Centered Care Among Latino Populations.

INTRODUCTION: Reliable and valid measures are needed to assess the patient-centeredness of clinical care among Latino populations. METHODS: We translated the Consultation and Relational Empathy (CARE) measure from English to Spanish and assessed its psychometric properties using data from 349 Latino parents/guardians visiting a pediatric clinic. Using confirmatory factor analysis, we examined the psychometric properties of the Spanish CARE measure. RESULTS: Internal reliability of the Spanish CARE measure was high (Omega coefficient = 0.95). Similar to the English-language CARE measure, factor analysis of the Spanish CARE measure yielded a single domain of patient-centeredness with high item loadings (factor loadings range from 0.79 to 0.96). CONCLUSION: This preliminary analysis supports the reliability and validity of the Spanish version of the CARE measure among Latinos in pediatric care settings. With further testing, the Spanish CARE measure may be a useful tool for tracking and improving the health care delivered to Latino populations.

Unintended pregnancy and perinatal depression trajectories in low-income, high-risk Hispanic immigrants.

Perinatal depression is a prevalent and detrimental condition. Determining modifiable factors associated with it would identify opportunities for prevention. This paper: 1) identifies depressive symptom trajectories and heterogeneity in those trajectories during pregnancy through the first-year postpartum, and 2) examines the association between unintended pregnancy and depressive symptoms. Depressive symptoms (BDI-II) were collected from low-income Hispanic immigrants (n=215) five times from early pregnancy to 12-months postpartum. The sample was at high-risk for perinatal depression and recruited from two prenatal care settings. Growth mixture modeling (GMM) was used to identify distinct trajectories of depressive symptoms over the perinatal period. Multinomial logistic regression was then conducted to examine the association between unintended pregnancy (reported at baseline) and the depression trajectory patterns. Three distinct trajectory patterns of depressive symptoms were identified: high during pregnancy, but low postpartum ("Pregnancy High": 9.8%); borderline during pregnancy, with a postpartum increase ("Postpartum High": 10.2%); and low throughout pregnancy and postpartum ("Perinatal Low": 80.0%). Unintended pregnancy was not associated with the "Pregnancy High" pattern, but was associated with a marginally significant nearly four fold increase in risk of the "Postpartum High" pattern in depressive symptoms (RRR=3.95, p<0.10). Family planning is a potential strategy for the prevention of postpartum depression. Women who report unintended pregnancies during prenatal care must be educated of their increased risk, even if they do not exhibit antenatal depressive symptoms. Routine depression screening should occur postpartum, and referral to culturally appropriate treatment should follow positive screening results.

Atypical vaginal location of endometriosis following repeated urogynaecological surgery.

We outline a case of vaginal endometriosis in scar tissue located in the distal part of the anterior vaginal wall close to the urethra following repeated urogynaecological surgery. Our case presents a 45-year-old woman diagnosed with pelvic endometriosis in her youth. She underwent several vaginal surgeries due to pelvic organ prolapse, symptoms of stress incontinence and decreased urinary flow. One year after her most recent vaginal surgery, she developed a tender lump in the lower part of the anterior vaginal wall. A urethral diverticulum was suspected, but a diagnostic puncture and biopsy unexpectedly showed histologically verified endometriosis. As the cyst recurred, surgical excision of all visible endometriosis tissue was performed. After 3 years of follow-up, the patient remained without recurrence. This case illustrates the risk of atypical implantation of endometriosis related to repeated urogynaecological surgery and that treatment requires surgery with thorough removal of all visible tissues.

Functional characterization of Arabidopsis calreticulin1a: a key alleviator of endoplasmic reticulum stress.

The chaperone calreticulin plays important roles in a variety of processes in the endoplasmic reticulum (ER) of animal cells, such as Ca2+ signaling and protein folding. Although the functions of calreticulin are well characterized in animals, only indirect evidence is available for plants. To increase our understanding of plant calreticulins we introduced one of the Arabidopsis isoforms, AtCRT1a, into calreticulin-deficient (crt-/-) mouse embryonic fibroblasts. As a result of calreticulin deficiency, the mouse crt-/- fibroblasts have decreased levels of Ca2+ in the ER and impaired protein folding abilities. Expression of the AtCRT1a in mouse crt-/- fibroblasts rescued these phenotypes, i.e. AtCRT1a restored the Ca2+-holding capacity and chaperone functions in the ER of the mouse crt-/- fibroblasts, demonstrating that the animal sorting machinery was also functional for a plant protein, and that basic calreticulin functions are conserved across the Kingdoms. Expression analyses using a beta-glucuronidase (GUS)-AtCRT1a promoter construct revealed high expression of CRT1a in root tips, floral tissues and in association with vascular bundles. To assess the impact of AtCRT1a in planta, we generated Atcrt1a mutant plants. The Atcrt1a mutants exhibited increased sensitivity to the drug tunicamycin, an inducer of the unfolded protein response. We therefore conclude that AtCRT1a is an alleviator of the tunicamycin-induced unfolded protein response, and propose that the use of the mouse crt-/- fibroblasts as a calreticulin expression system may prove useful to assess functionalities of calreticulins from different species.

The pregnancy experience scale-brief version.

The role of maternal stress during pregnancy remains a focus of academic and clinical inquiry, yet there are few instruments available that measure pregnancy-specific contributors to maternal psychological state. This report examines the psychometric properties of an abbreviated version of the Pregnancy Experience Scale (PES) designed to evaluate maternal appraisal of positive and negative stressors during pregnancy. The PES-Brief consists of the top 10 items endorsed as pregnancy hassles and 10 pregnancy uplifts from the original scale. The PES-Brief was administered to 112 women with low risk, singleton pregnancies five times between 24 and 38 weeks gestation. Scoring includes frequency and intensity measures for hassles and uplifts, as well as composite measures for the relation between the two. Internal reliability, test-retest reliability and convergent validity were comparable with the original version. The PES-Brief provides an economical source of information on stress appraisal and emotional valence towards pregnancy.

Association between Practice Participation in a Pediatric-focused Medical Home Learning Collaborative and Reduction of Preventable Emergency Department Visits by Publicly-insured Children in Massachusetts.

INTRODUCTION: This study evaluates the impact of practice participation in a pediatric patient-centered medical home learning collaborative on preventable emergency department (ED) visits among children in MassHealth (Massachusetts Medicaid/Children's Health Insurance Program). METHODS: Claims and enrollment data were extracted for child MassHealth members (aged 3-18) comprising 2 groups: members enrolled in a group of 13 child-serving practices that participated in an intensive, 29-month long patient-centered medical home learning collaborative (intervention group), and members enrolled in a group of 12 comparison practices with roughly similar panel size, type, and geographic location (comparison group). Preventable ED visits were identified using a modified version of the New York University ED algorithm. Two analyses were then conducted: (1) a repeat cross-sectional analysis among children enrolled in intervention or comparison group practices during baseline (first half of 2011) and follow-up (second half of 2013) periods; and (2) a longitudinal analysis among a subset of children enrolled for the full study period (2011-2013). Both analyses tested whether the effect of the intervention differed for children with versus without chronic conditions (effect modification). RESULTS: Preventable ED visits declined from baseline to follow-up among children in both intervention and comparison practices. In the cross-sectional analysis, the decrease was the same in both practice groups, and for children with versus without chronic conditions. The longitudinal analysis shows a statistically significantly greater decrease among children with chronic conditions enrolled in the intervention practices (P = 0.02). CONCLUSION: Children with chronic conditions might receive the greatest benefit from receiving care in a medical home setting.

Willingness to use microbicides varies by race/ethnicity, experience with prevention products, and partner type.

OBJECTIVE: To investigate women's willingness to use vaginal microbicides to reduce/prevent HIV infection, using measures grounded in the individual, behavioral, and social contexts of sex. DESIGN: A cross-sectional study that enrolled a sample (N = 531) of 18-55 year old Latina, African-American, and White women in the U.S. between October, 2004, and July, 2005. MAIN OUTCOME MEASURES: Willingness to use microbicides and individual- and context-related variables (e.g., demographics, relationship status). RESULTS: Exploratory and confirmatory factor analyses supported a one-dimensional, 8-item scale, with high internal consistency (alpha = .91). Subgroup analyses within the Latina (n = 166), African- American (n = 193), and White sub-samples (n = 172) also supported a unidimensional scale with strong internal validity and high reliability. Race/ethnicity as a contextual factor, a woman's history of using prevention products, and the nature of the sexual partnership were predictive of willingness to use microbicides (R = .41). That is, women with greater frequencies of condom use, a history of spermicide use, and non-main sexual partners had higher predicted Willingness to Use Microbicides scale scores, while White women had lower predicted scores. CONCLUSION: The Willingness to Use Microbicides scale serves as the first psychometrically validated measure of factors related to microbicide acceptability. Developing and implementing psychometrically validated and contextualized microbicide acceptability measures, in an effort to understand microbicide users and circumstances of use, is crucial to both clinical trials and future intervention studies.

Identification and bioactive potential of marine microorganisms from selected Florida coastal areas.

The ocean, with its rich untapped chemical biodiversity, continues to serve as a source of potentially new therapeutic agents. The evaluation of the diversity of cultivable microorganisms from the marine sponge Halichondria panicea and ocean sediment samples were examined and their potential as sources of antimicrobial and antiproliferative agents were investigated. The marine sponge and sediments were collected at different depths (0.9-6 meters) and locations in Florida, including Florida Keys, Port St. Joe in Pensacola, Pensacola Bay, Pensacola Beach, and Fort Pickens. Twenty-one cultivatable isolates were grouped according to their morphology and identified using 16S rRNA molecular taxonomy. The bacterial community identified consisted of members belonging to the Actinobacteria, Bacteroidetes, Proteobacteria (Alpha- and Gamma-classes) and Firmicutes phylogeny. Seven of the microbes exhibited mild to significant cytotoxic activities against five microbial indicators but no significant cytotoxic activities were observed against the pancreatic (PANC-1) nor the multidrug-resistant ovarian cancer cell lines (NCI/ADR). This work reaffirms the phyla Actinobacteria and Proteobacteria as sources of potential bioactive natural product candidates for drug discovery and development.

The Early Awareness and Alert System in Sweden: History and Current Status.

Introduction: Over the past decades, early awareness and alert (EAA) activities and systems have gained importance and become a key early health technology assessment (HTA) tool. While a pioneer in HTA, Sweden had no national level EAA activities until 2010. We describe the evolution and current status of the Swedish EAA System. Methods: This was a historical analysis based on the knowledge and experience of the authors supplemented by a targeted review of published and gray literature as well as documents relating to EAA activities in Sweden. Key milestones and a description of the current state of the Swedish EAA System is presented. Results: Initiatives to establish a system for the identification and assessment of emerging health technologies in Sweden date back to the 1980s. In the 1990s, the Swedish Agency for HTA and Assessment of Social Services (SBU) supported the development of EuroScan as one of its founder members. In the mid-2000s, an independent regional initiative, driven by the Stockholm County Drug and Therapeutics Committee, resulted in the establishment of a regional horizon scanning function. By 2009, this work had expanded to a collaboration between the four biggest counties in Sweden. The following year it was further expanded to the national level and since then the Swedish EAA System has been carrying out identification, filtration and prioritization of new medicines, early assessment of the prioritized medicines, and dissemination of information. In 2015, the EAA System was incorporated into the Swedish national process for managed introduction and follow-up of new medicines. Outputs from the EAA System are now used to select new medicines for inclusion in this process. Conclusions: The Swedish EAA System started as a regional initiative and rapidly grew to become a national level activity. An important feature of the system today is its complete integration into the national process for managed introduction and follow-up of new medicines. The system will continue to evolve as a response both to the changing landscape of health innovations and to new policy initiatives at the regional, national and international level.