Monitoring concentration and isotopic composition of methane in groundwater in the Utica Shale hydraulic fracturing region of Ohio.

Degradation of groundwater quality is a primary public concern in rural hydraulic fracturing areas. Previous studies have shown that natural gas methane (CH4) is present in groundwater near shale gas wells in the Marcellus Shale of Pennsylvania, but did not have pre-drilling baseline measurements. Here, we present the results of a free public water testing program in the Utica Shale of Ohio, where we measured CH4 concentration, CH4 stable isotopic composition, and pH and conductivity along temporal and spatial gradients of hydraulic fracturing activity. Dissolved CH4 ranged from 0.2 µg/L to 25 mg/L, and stable isotopic measurements indicated a predominantly biogenic carbonate reduction CH4 source. Radiocarbon dating of CH4 in combination with stable isotopic analysis of CH4 in three samples indicated that fossil C substrates are the source of CH4 in groundwater, with one 14C date indicative of modern biogenic carbonate reduction. We found no relationship between CH4 concentration or source in groundwater and proximity to active gas well sites. No significant changes in CH4 concentration, CH4 isotopic composition, pH, or conductivity in water wells were observed during the study period. These data indicate that high levels of biogenic CH4 can be present in groundwater wells independent of hydraulic fracturing activity and affirm the need for isotopic or other fingerprinting techniques for CH4 source identification. Continued monitoring of private drinking water wells is critical to ensure that groundwater quality is not altered as hydraulic fracturing activity continues in the region. Graphical abstract A shale gas well in rural Appalachian Ohio. Photo credit: Claire Botner.

The Role of Proteomic Testing in Improving Prognosis And Care Planning Quality Measures for Lung Cancer.

PURPOSE: The Oncology Care Model (OCM) is a payment model from the Centers for Medicare and Medicaid Services designed to reduce costs and improve quality in cancer care. Key components of quality for the OCM originate from the 13-component cancer care plan. We surveyed the literature to understand the value of prognosis in OCM-directed planning for non-small-cell lung cancer (NSCLC) care and to investigate how the results of a prognostic, proteomic biomarker test, the VeriStrat test, can help OCM-participating providers meet the specific quality measures. DESIGN: A targeted literature review was supplemented by real-world author experience. METHODOLOGY: Available MEDLINE-indexed literature on the topic of lung cancer prognosis and cancer care planning (1997-2017) were reviewed. Authors also included relevant commentary based on their own real-world experience with VeriStrat testing and prognostic conversations. RESULTS: There was near-universal consensus in guidelines and literature about the critical importance of early, candid, and ongoing physician-patient discussions about prognosis, which informs most components of the OCM care plan. The VeriStrat test has been shown to provide accurate predictions of outcomes in all lines of therapy and in various treatments for patients with NSCLC, including chemotherapies and EGFR-TKI therapies. CONCLUSION: Accurate prognostic estimates, such as those provided by the VeriStrat test, are useful for predicting and documenting expected response to treatment, avoiding ineffective and costly overtreatment and for facilitating meaningful conversations with NSCLC patients about the timing of best supportive care and hospice care when appropriate, thereby improving cancer care planning and quality scores.

The Social Determinants of Health Industry: Two Years On.

Social determinants of health (SDOH) have been insufficiently addressed by payers and providers despite increased prioritization at the national level. This led to the development of a separate, for-profit "SDOH industry" found to have a valuation of $18.5 billion (all dollar amounts in U.S. dollars) with $2.4 billion in funding as of July 2021. The purpose of this article is to determine the growth of the industry from 2021 to 2023 and provide a multifaceted explanation for this development. The authors conducted an analysis of 57 SDOH industry companies using a third-party market research platform. Over the previous two-year period, 10 out of 57 (18%) companies were acquired, and the industry gained an additional $1.1 billion (46% increase) in funding and $13.7 billion (74% increase) in valuation. The authors propose four contributing factors to explain the nature of this industry's evolution. They include developments in national health care policy favoring SDOH, standardization of SDOH information as actionable claims data, multi-source investment in SDOH, and improved methods of industry intervention measurement. These trends appear likely to continue, requiring additional scrutiny by all relevant stakeholders to ensure maximum improvement of rampant SDOH disparities that impact millions of individuals daily.

Charting a Path to the Quintuple Aim: Harnessing AI to Address Social Determinants of Health.

The Quintuple Aim seeks to improve healthcare by addressing social determinants of health (SDOHs), which are responsible for 70-80% of medical outcomes. SDOH-related concerns have traditionally been addressed through referrals to social workers and community-based organizations (CBOs), but these pathways have had limited success in connecting patients with resources. Given that health inequity is expected to cost the United States nearly USD 300 billion by 2050, new artificial intelligence (AI) technology may aid providers in addressing SDOH. In this commentary, we present our experience with using ChatGPT to obtain SDOH management recommendations for archetypal patients in Philadelphia, PA. ChatGPT identified relevant SDOH resources and provided contact information for local organizations. Future exploration could improve AI prompts and integrate AI into electronic medical records to provide healthcare providers with real-time SDOH recommendations during appointments.

The Academic Payvider Model: Care and Coverage.

The US health care system has significant room for growth to achieve the Quintuple Aim. Reforming the relationship between payers and providers is pivotal to enhancing value-based care (VBC). The Payvider model, a joint approach to care and coverage rooted in vertical integration, is a potential solution. The authors aimed to investigate academic medical institutions adopting this model, termed Academic Payviders. All Association of American Medical Colleges (AAMC)-member allopathic medical schools were evaluated to identify programs meeting the inclusion criteria of offering both medical care and insurance coverage to patients via partnership with a payer or ownership of, or by, a payer. Twenty-five Academic Payvider systems were identified from 171 total AAMC-member programs. Most programs were founded after 2009 (n = 20), utilized a provider-dominant structural model (n = 17), and offered health plans to patients via Medicare Advantage (n = 23). Passage of the Affordable Care Act, recent trends in health care consolidation, and increased political and financial prioritization of social determinants of health (SDOH) may help to explain the rise of this care and coverage model. The Academic Payvider movement could advance academic medicine toward greater acceptance of VBC via innovations in medical education, resource stewardship in residency, and the establishment of innovative leadership positions at the administrative level.

Physician Burnout and Medical Errors: Exploring the Relationship, Cost, and Solutions.

Physician burnout has demonstrated risks to providers and patients through medical errors. This review aims to synthesize current data surrounding burnout and its impacts on quality to inform targeted interventions that benefit providers and patients. Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review methodology was utilized to identify studies of quantitative metrics for burnout and medical errors. Three independent reviewers conducted screening, study selection, and data extraction. Of 1096 identified articles, 21 were analyzed. Overall, 80.9% used the Maslach Burnout Inventory to evaluate for burnout. Moreover, 71.4% used self-reported medical errors as their primary outcome measure. Other outcome measures included observed/identified clinical practice errors and medication errors. Ultimately, 14 of 21 studies found links between burnout and clinically significant errors. Significant associations exist between burnout and medical errors. Physician demographics, including psychological factors, well-being, and training level, modulate this relationship. Better metrics are necessary to quantify errors and their impacts on outcomes. These findings may inform novel interventions that target burnout and improve experiences.

For Profit, but Socially Determined: The Rise of the SDOH Industry.

Social determinants of health (SDOH) are the greatest predictors of one's health status. There are clear SDOH disparities present in the United States, many of which have been especially evident during the COVID pandemic. SDOH have become a greater focus of payers, including Centers for Medicare & Medicaid Services (CMS). CMS has updated the reimbursement structure of Medicare and Medicaid to incentivize more SDOH-related interventions. Providers are also growing increasingly attentive to the SDOH needs of their patients, but often are unable to sufficiently address them outside of care settings. The combination of increased SDOH funding with inefficient mechanisms to meet patients' SDOH needs has led to the emergence of the for-profit SDOH industry. The purpose of this paper was to investigate the industry and identify its size, scope, and future implications. The authors conducted an analysis of for-profit SDOH companies using a third-party industry research platform. A collection of 58 companies was identified with $2.4 billion in funding and a total valuation of over $18.5 billion as of July, 2021. Two literature searches were conducted to support strategy recommendations for critically evaluating SDOH outcomes from these companies, and to determine the downstream effects they will have on community-based organizations also working to improve SDOH.

The Evolving Curriculum in Quality Improvement and Patient Safety in Undergraduate and Graduate Medical Education: A Scoping Review.

Quality Improvement and Patient Safety (QIPS) has become an increasingly important area of focus within undergraduate and graduate medical education. A variety of different QIPS curriculums have been developed, but standardization and effectiveness of these curriculums is largely unknown. The authors conducted a scoping review to explore the status of undergraduate and graduate nondegree QIPS curriculum in the United States. A scoping review was performed using The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model as a guide. Two databases were screened from January 2019 to March 2022 to identify relevant articles. Forty-seven articles met eligibility criteria, with most articles (n = 38) focused on graduate medical education. Of those 38, 86.8% (33/38) were developed as curriculum specific to a particular specialty. The article highlights similarities and differences in structure, evaluation metrics, and outcomes, and subsequently offers insight into curriculum components that should help guide standardization of successful curriculum development moving forward.

The Hearst Health Prize: The First Five Years.

The Hearst Health Prize is the first national annual award for excellence in population health. The prize was established "to discover, support, and showcase the work of an individual, group, organization, or institution that has successfully implemented a population health program or intervention that has made a measurable difference" in health outcomes. Now, 5 years since the award's inception, this article reflects on how submissions for the prize collectively mirror - and may even predict - changes within the field of population health. It examines how the most successful programs demonstrated genuine, measurable improvements in health outcomes and/or health behaviors. In exploring the work of these outstanding programs, the aim of this article is to help disseminate best practices, advance the mission of the prize, and inspire improvements in population health practices.

An Update to "Understanding Ambulatory Care Practices in the Context of Patient Safety and Quality Improvement".

The aim of this article is to summarize and interpret the current literature on patient quality and safety measures in the ambulatory setting. The authors reviewed the MEDLINE database from 2016 to the present for articles on patient quality and safety measures in the ambulatory setting. The search was guided by the use of specific keywords and medical subject heading terms, including patient safety, ambulatory care, quality, measurements, medical errors, medication safety and electronic prescribing, safety culture, diagnostic error, team training, continuity, care coordination, simulation exercises, and patient-centered. Studying ambulatory quality and safety remains challenging because of the heterogeneity and complexity of the outpatient environment. This review shows that since 2016, very modest progress has been made in this critical area. Effective change in ambulatory quality and safety will require a prioritization and redoubling of efforts.

Disparities in SARS-CoV-2 Positivity Rates: Associations with Race and Ethnicity.

Numerous reports indicate that African Americans and Latinos are being affected disproportionately by coronavirus disease 2019 (COVID-19). Positivity rates have not been analyzed on scale because only 4 states report race/ethnicity as part of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing. Previous studies also have had little ability to control for many known risk factors to better identify the effects of COVID-19 on racial and ethnic communities. Using test results from a large national reference laboratory database that included patients from all 50 states and the District of Columbia, this study compared positivity rates for SARS-CoV-2 nucleic acid amplification tests (NAAT) among various race/ethnicity groups by linking zip code-based race/ethnicity proportions from US Census data. Analysis of 2,331,175 unique patients tested March-May 2020 demonstrated an increasing trend in SARS-CoV-2 NAAT positivity across Black non-Hispanic community progressive quintiles (from 7.8% to 17.2%, P < 0.0001) and Hispanic community progressive quintiles (from 8.4% to 15.5%, P < 0.0001) and a decreasing trend across White non-Hispanic community progressive quintiles (from 17.4% to 7.1%, P < 0.0001). These trends in viral ribonucleic acid positivity remained in stratified analyses and in multivariable models that controlled for known risk factors including sex, population density, and the states initially hardest hit by COVID-19. These findings indicate that communities with the highest proportions of Black non-Hispanic and Hispanic populations have the highest SARS-CoV-2 NAAT positivity rates, even after controlling for other risk factors. More efforts are needed to mitigate the increased impact of COVID-19 on both the African American and Hispanic communities.

Accrediting Graduate Programs in Healthcare Quality and Safety.

The number of master's degree programs in healthcare quality and safety (HQS) has increased significantly over the past decade. Academic accreditation provides assurance that educational programs are of a high quality and meet the needs of students, employers, and the general public. Under the guidance of the Commission on Accreditation of Healthcare Management Education, faculty from 9 universities collaborated in the development of criteria and related content domains to be used in the accreditation of graduate programs in HQS. Thirteen content domains were identified. Four of the content domains, safety and error science, improvement science and quality principles, evidence-based practice, and measurement and process improvement are thought to be foundational domains for graduate education in HQS. This article describes the development of the content domains and accompanying standards for accreditation of graduate programs in HQS.

We Know Health Is Not Elective: Impacts of COVID-19.

Several months into the impact of the global COVID-19 pandemic, the authors use the framework of "radical uncertainty" and specific regional health care data to understand current and future health and economic impacts. Four key areas of discussion included are: (1) How did structural health care inequality manifest itself during the closure of all elective surgeries and visits?; (2) How can we really calculate the so-called untold burden that resulted from the closure, with a special emphasis on primary care?; (3) The Pennsylvania experience - using observations from the population of one major delivery ecosystem (Jefferson Health), a major accountable care organization (Delaware Valley ACO), and statewide data from Pennsylvania; and (4) What should be the priorities and focus of the delivery system of the future given the dramatic financial and clinical disruption of COVID-19?

The Evolution of Disease State Management: Historical Milestones and Future Directions.

Twenty-five years ago, the Journal of Managed Care Pharmacy introduced its readers to disease state management, which attempted to break the siloed culture of the U.S. health care system. Disease state management has been transformed, in part, to population health management. This shift was marked by 3 main inflection points: the rise of the web-enabled smartphone, the Patient Protection and Affordable Care Act (ACA), and the adoption of artificial intelligence (AI). The introduction of smartphones filled the communication gap through improved patient engagement and accessible mobile applications, giving patients access to their clinical data. In addition, through the ACA, bundled payment models moved away from a volume-based to a value-based payment approach and attempted to incorporate population health concerns, such as the social determinants of health. The advancement of AI will allow the health care system to collect comprehensive health data and to predict the population at higher risk. Despite these advancements, some challenges from 25 years ago remain, yet rapid technology advancements may expedite the next wave of change. DISCLOSURES: No funding contributed to the writing of this article. The authors have nothing to disclose with respect to research, authorship, and/or publication of this article.

Ambulatory quality improvement in academic medical centers: a changing landscape.

Efforts to improve the quality of ambulatory care have received tremendous attention as bold new initiatives aimed at influencing the environment of care through financial incentives, public transparency, and information technology rapidly spread. Academic medical centers, which represent a long tradition of excellence and innovation in medical care, might be expected to lead the charge in these new arenas, but motivation for change may be mitigated by the unique complexity and multiple goals of these institutions. A survey conducted in the fall of 2006 examined the early impact of these major new influences on faculty practice plans. Respondents reported that many institutions have begun to develop key components of a quality infrastructure, but much work remains before a robust model emerges at most sites. Some academic medical centers have also embraced pay-for-performance and public reporting efforts, but many are not equipped or eager to engage in these new initiatives.

Approaching the Evidence Basis for Aviation-Derived Teamwork Training in Medicine.

The Institute of Medicine has suggested that training in team behavior, leadership, communication, and other human factors could reduce medical errors and improve patient safety. Training on such topics has been adapted from teamwork training programs used in military and commercial aviation, called crew resource management (CRM). The principles behind CRM programs have been deployed in a number of clinical settings over the past 2 decades, and there are now several CRM vendors. Little is known about this nascent industry, and the emerging research supporting CRM programs lacks standardization and conclusive evidence. The objectives of this study were to report on the body of empirical data about CRM training in clinical settings and to provide a conceptual framework for evaluating its effectiveness in medicine. Using the proposed conceptual framework, the authors further examine currently published methods of measuring effectiveness and identify future directions for the use of teamwork training in medicine.