Feasibility of Social Distancing Practices in US Schools to Reduce Influenza Transmission During a Pandemic.

BACKGROUND: Schools are socially dense environments, and school-based outbreaks often predate and fuel community-wide transmission of seasonal and pandemic influenza. While preemptive school closures can effectively reduce influenza transmission, they are disruptive and currently recommended only for pandemics. We assessed the feasibility of implementing other social distancing practices in K-12 schools as a first step in seeking an alternative to preemptive school closures. METHODS: We conducted 36 focus groups with education and public health officials across the United States. We identified and characterized themes and compared feasibility of practices by primary versus secondary school and region of the United States. RESULTS: Participants discussed 29 school practices (25 within-school practices implemented as part of the school day and 4 reduced-schedule practices that impact school hours). Participants reported that elementary schools commonly implement several within-school practices as part of routine operations such as homeroom stay, restriction of hall movement, and staggering of recess times. Because of routine implementation and limited use of individualized schedules within elementary schools, within-school practices were generally felt to be more feasible for elementary schools than secondary schools. Of reduced-schedule practices, shortening the school week and the school day was considered the most feasible; however, reduced-schedule practices were generally perceived to be less feasible than within-school practices for all grade levels. CONCLUSIONS: Our findings suggest that schools have many options to increase social distance other than closing. Future research should evaluate which of these seemingly feasible practices are effective in reducing influenza transmission in schools and surrounding communities.

Predicting support for non-pharmaceutical interventions during infectious outbreaks: a four region analysis.

Non-pharmaceutical interventions (NPIs) are an important public health tool for responding to infectious disease outbreaks, including pandemics. However, little is known about the individual characteristics associated with support for NPIs, or whether they are consistent across regions. This study draws on survey data from four regions--Hong Kong, Singapore, Taiwan, and the United States--collected following the Severe Acute Respiratory Syndrome (SARS) outbreak of 2002-03, and employs regression techniques to estimate predictors of NPI support. It finds that characteristics associated with NPI support vary widely by region, possibly because of cultural variation and prior experience, and that minority groups tend to be less supportive of NPIs when arrest is the consequence of noncompliance. Prior experience of face-mask usage also results in increased support for future usage, as well as other NPIs. Policymakers should be attentive to local preferences and to the application of compulsory interventions. It is speculated here that some public health interventions may serve as 'gateway' exposures to future public health interventions.

Systematic review of strategies to manage and allocate scarce resources during mass casualty events.

STUDY OBJECTIVE: Efficient management and allocation of scarce medical resources can improve outcomes for victims of mass casualty events. However, the effectiveness of specific strategies has never been systematically reviewed. We analyze published evidence on strategies to optimize the management and allocation of scarce resources across a wide range of mass casualty event contexts and study designs. METHODS: Our literature search included MEDLINE, Scopus, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Global Health, Web of Science, and the Cochrane Database of Systematic Reviews, from 1990 through late 2011. We also searched the gray literature, using the New York Academy of Medicine's Grey Literature Report and key Web sites. We included both English- and foreign-language articles. We included studies that evaluated strategies used in actual mass casualty events or tested through drills, exercises, or computer simulations. We excluded studies that lacked a comparison group or did not report quantitative outcomes. Data extraction, quality assessment, and strength of evidence ratings were conducted by a single researcher and reviewed by a second; discrepancies were reconciled by the 2 reviewers. Because of heterogeneity in outcome measures, we qualitatively synthesized findings within categories of strategies. RESULTS: From 5,716 potentially relevant citations, 74 studies met inclusion criteria. Strategies included reducing demand for health care services (18 studies), optimizing use of existing resources (50), augmenting existing resources (5), implementing crisis standards of care (5), and multiple categories (4). The evidence was sufficient to form conclusions on 2 strategies, although the strength of evidence was rated as low. First, as a strategy to reduce demand for health care services, points of dispensing can be used to efficiently distribute biological countermeasures after a bioterrorism attack or influenza pandemic, and their organization influences speed of distribution. Second, as a strategy to optimize use of existing resources, commonly used field triage systems do not perform consistently during actual mass casualty events. The number of high-quality studies addressing other strategies was insufficient to support conclusions about their effectiveness because of differences in study context, comparison groups, and outcome measures. Our literature search may have missed key resource management and allocation strategies because of their extreme heterogeneity. Interrater reliability was not assessed for quality assessments or strength of evidence ratings. Publication bias is likely, given the large number of studies reporting positive findings. CONCLUSION: The current evidence base is inadequate to inform providers and policymakers about the most effective strategies for managing or allocating scarce resources during mass casualty events. Consensus on methodological standards that encompass a range of study designs is needed to guide future research and strengthen the evidence base. Evidentiary standards should be developed to promote consensus interpretations of the evidence supporting individual strategies.

Development of Palliative Care Quality Measures for Outpatients in a Clinic-Based Setting: A Report on Information Gathering Activities.

Palliative care has expanded rapidly in recent years. Hence, there has been a growing awareness of and emphasis on the importance of developing quality measures specific to palliative care. This article describes information-gathering activities conducted by RAND to develop two measures of palliative care quality for patients receiving such care in outpatient, clinic-based settings. The authors describe the consensus that has developed for measurement priorities in the palliative care community, provide a summary of clinical practice guidelines, and review the evidence base for palliative care. The authors also review current relevant regulations, existing measures of patient and caregiver experience, findings from a gap analysis on palliative care assessment, and findings from provider focus groups and interviews with patients and caregivers or family members.

Assessing and Improving Hospital Mass-Casualty Preparedness: A No-Notice Exercise.

In recent years, mass-casualty incidents (MCIs) have become more frequent and deadly, while emergency department (ED) crowding has grown steadily worse and widespread. The ability of hospitals to implement an effective mass-casualty surge plan, immediately and expertly, has therefore never been more important. Yet, mass-casualty exercises tend to be highly choreographed, pre-scheduled events that provide limited insight into hospitals' true capacity to respond to a no-notice event under real-world conditions. To address this gap, the US Department of Health and Human Services (Washington, DC USA), Office of the Assistant Secretary for Preparedness and Response (ASPR), sponsored development of a set of tools meant to allow any hospital to run a real-time, no-notice exercise, focusing on the first hour and 15 minutes of a hospital's response to a sudden MCI, with the goals of minimizing burden, maximizing realism, and providing meaningful, outcome-oriented metrics to facilitate self-assessment. The resulting exercise, which was iteratively developed, piloted at nine hospitals nationwide, and completed in 2015, is now freely available for anyone to use or adapt. This report demonstrates the feasibility of implementing a no-notice exercise in the hospital setting and describes insights gained during the development process that might be helpful to future exercise developers. It also introduces the use of ED "immediate bed availability (IBA)" as an objective, dynamic measure of an ED's physical capacity for new arrivals. Waxman DA , Chan EW , Pillemer F , Smith TWJ , Abir M , Nelson C . Assessing and improving hospital mass-casualty preparedness: a no-notice exercise. Prehosp Disaster Med. 2017;32(6):662-666.

Understanding Treatment of Mild Traumatic Brain Injury in the Military Health System.

Traumatic brain injury (TBI) is considered a signature injury of modern warfare, though TBIs can also result from training accidents, falls, sports, and motor vehicle accidents. Among service members diagnosed with a TBI, the majority of cases are mild TBIs (mTBIs), also known as concussions. Many of these service members receive care through the Military Health System, but the amount, type, and quality of care they receive has been largely unknown. A RAND study, the first to examine the mTBI care of a census of patients in the Military Health System, assessed the number and characteristics (including deployment history and history of TBI) of nondeployed, active-duty service members who received an mTBI diagnosis in 2012, the locations of their diagnoses and next health care visits, the types of care they received in the six months following their mTBI diagnosis, co-occurring conditions, and the duration of their treatment. While the majority of service members with mTBI recover quickly, the study further examined a subset of service members with mTBI who received care for longer than three months following their diagnosis. Diagnosing and treating mTBI can be especially challenging because of variations in symptoms and other factors. The research revealed inconsistencies in the diagnostic coding, as well as areas for improvement in coordinating care across providers and care settings. The results and recommendations provide a foundation to guide future clinical studies to improve the quality of care and subsequent outcomes for service members diagnosed with mTBI.

Direct Release of Test Results to Patients Increases Patient Engagement and Utilization of Care.

An important focus for meaningful use criteria is to engage patients in their care by allowing them online access to their health information, including test results. There has been little evaluation of such initiatives. Using a mixed methods analysis of electronic health record data, surveys, and qualitative interviews, we examined the impact of allowing patients to view their test results via patient portal in one large health system. Quantitative data were collected for new users and all users of the patient portal. Qualitative interviews occurred with patients who had received an HbA1c or abnormal Pap result. Survey participants were active patient portal users. Our main measures were patient portal usage, factors associated with viewing test results and utilizing care, and patient and provider experiences with patient portal and direct release. Usage data show 80% of all patient portal users viewed test results during the year. Of survey respondents, 82.7% noted test results to be a very useful feature and 70% agreed that patient portal has made their provider more accessible to them. Interviewed patients reported feeling they should have direct access to test results and identified the ability to monitor results over time and prepare prior to communicating with a provider as benefits. In interviews, both patients and physicians reported instances of test results leading to unnecessary patient anxiety. Both groups noted the benefits of results released with provider interpretation. Quantitative data showed patient utilization to increase with viewing test results online, but this effect is mitigated when results are manually released by physicians. Our findings demonstrate that patient portal access to test results was highly valued by patients and appeared to increase patient engagement. However, it may lead to patient anxiety and increase rates of patient visits. We discuss how such unintended consequences can be addressed and larger implications for meaningful use criteria.

Authorities and Mechanisms for Purchased Care at the Department of Veterans Affairs.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the authorities and mechanisms by which the Department of Veterans Affairs (VA) pays for health care services from non-VA providers. Purchased care accounted for 10 percent, or around $5.6 billion, of VA's health care budget in fiscal year 2014, and the amount of care purchased from outside VA is growing rapidly. VA purchases non-VA care through an array of programs, each with different payment processes and eligibility requirements for veterans and outside providers. A review and analysis of statutes, regulations, legislation, and literature on VA purchased care, along with interviews with expert stakeholders, a survey of VA medical facilities, and an evaluation of local-level policy documents revealed that VA's purchased care system is complex and decentralized. Inconsistencies in procedures, unclear goals, and a lack of cohesive strategy for purchased care could have ramifications for veterans' access to care. Adding to the complexity of VA's purchased care system is a lack of systematic data collection on access to and quality of care provided through VA's purchased care programs. The analysis also explored concepts of "episodes of care" and their implications for purchased care by VA.

Resources and Capabilities of the Department of Veterans Affairs to Provide Timely and Accessible Care to Veterans.

The Veterans Access, Choice, and Accountability Act of 2014 addressed the need for access to timely, high-quality health care for veterans. Section 201 of the legislation called for an independent assessment of various aspects of veterans' health care. The RAND Corporation was tasked with an assessment of the Department of Veterans Affairs (VA) current and projected health care capabilities and resources. An examination of data from a variety of sources, along with a survey of VA medical facility leaders, revealed the breadth and depth of VA resources and capabilities: fiscal resources, workforce and human resources, physical infrastructure, interorganizational relationships, and information resources. The assessment identified barriers to the effective use of these resources and capabilities. Analysis of data on access to VA care and the quality of that care showed that almost all veterans live within 40 miles of a VA health facility, but fewer have access to VA specialty care. Veterans usually receive care within 14 days of their desired appointment date, but wait times vary considerably across VA facilities. VA has long played a national leadership role in measuring the quality of health care. The assessment showed that VA health care quality was as good or better on most measures compared with other health systems, but quality performance lagged at some VA facilities. VA will require more resources and capabilities to meet a projected increase in veterans' demand for VA care over the next five years. Options for increasing capacity include accelerated hiring, full nurse practice authority, and expanded use of telehealth.

CMS Innovation Center Health Care Innovation Awards: Evaluation Plan.

The Center for Medicare and Medicaid Innovation within the Centers for Medicare & Medicaid Services (CMS) has funded 108 Health Care Innovation Awards, funded through the Affordable Care Act, for applicants who proposed compelling new models of service delivery or payment improvements that promise to deliver better health, better health care, and lower costs through improved quality of care for Medicare, Medicaid, and Children's Health Insurance Program enrollees. CMS is also interested in learning how new models would affect subpopulations of beneficiaries (e.g., those eligible for Medicare and Medicaid and complex patients) who have unique characteristics or health care needs that could be related to poor outcomes. In addition, the initiative seeks to identify new models of workforce development and deployment, as well as models that can be rapidly deployed and have the promise of sustainability. This article describes a strategy for evaluating the results. The goal for the evaluation design process is to create standardized approaches for answering key questions that can be customized to similar groups of awardees and that allow for rapid and comparable assessment across awardees. The evaluation plan envisions that data collection and analysis will be carried out on three levels: at the level of the individual awardee, at the level of the awardee grouping, and as a summary evaluation that includes all awardees. Key dimensions for the evaluation framework include implementation effectiveness, program effectiveness, workforce issues, impact on priority populations, and context. The ultimate goal is to identify strategies that can be employed widely to lower cost while improving care.

Analysis of the Cities Readiness Initiative.

The Centers for Disease Control and Prevention's (CDC's) Cities Readiness Initiative (CRI) provides funding, program guidance, and technical assistance to improve communities' ability to rapidly provide life-saving medications in response to a large-scale bioterrorist attack, naturally occurring disease outbreak, or other public health emergency. Focusing on both capacities and operational capabilities, the authors examine (1) the current status of communities' operational capability to meet CRI program goals related to delivering medical countermeasures within 48 hours of a federal decision to deploy assets and (2) whether there is evidence that CRI has improved communities' capability to meet the 48-hour goal. Analysis shows that, overall, state capacity appears to be strong; CRI appears to have improved state capacity, but the data are not conclusive. Performance across Metropolitan Statistical Areas varies considerably, as does performance in particular functional areas. The authors also note that testing of operational capabilities has not been conducted at a large enough scale to measure readiness for the 48-hour scenario, recommending that jurisdictions be required to conduct drills at a larger scale. Other proposed recommendations include improving CDC feedback to jurisdictions, attempting to leverage assessments of non-CRI sites as a comparison group, and assessing program cost-effectiveness.

Bioterrorism and biological threats dominate federal health security research; other priorities get scant attention.

The federal government plays a critical role in achieving national health security by providing strategic guidance and funding research to help prevent, respond to, mitigate, and recover from disasters, epidemics, and acts of terrorism. In this article we describe the first-ever inventory of nonclassified national health security-related research funded by civilian agencies of the federal government. Our analysis revealed that the US government's portfolio of health security research is currently weighted toward bioterrorism and emerging biological threats, laboratory methods, and development of biological countermeasures. Eight of ten other priorities identified in the Department of Health and Human Services' National Health Security Strategy-such as developing and maintaining a national health security workforce or incorporating recovery into planning and response-receive scant attention. We offer recommendations to better align federal spending with health security research priorities, including the creation of an interagency working group charged with minimizing research redundancy and filling persistent gaps in knowledge.

Allocation of scarce resources during mass casualty events.

OBJECTIVES: This systematic review sought to identify the best available evidence regarding strategies for allocating scarce resources during mass casualty events (MCEs). Specifically, the review addresses the following questions: (1) What strategies are available to policymakers to optimize the allocation of scarce resources during MCEs? (2) What strategies are available to providers to optimize the allocation of scarce resources during MCEs? (3) What are the public's key perceptions and concerns regarding the implementation of strategies to allocate scarce resources during MCEs? (4) What methods are available to engage providers in discussions regarding the development and implementation of strategies to allocate scarce resources during MCEs? DATA SOURCES: We searched Medline, Scopus, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Global Health, Web of Science®, and the Cochrane Database of Systematic Reviews from 1990 through 2011. To identify relevant non-peer-reviewed reports, we searched the New York Academy of Medicine's Grey Literature Report. We also reviewed relevant State and Federal plans, peer-reviewed reports and papers by nongovernmental organizations, and consensus statements published by professional societies. We included both English- and foreign-language studies. REVIEW METHODS: Our review included studies that evaluated tested strategies in real-world MCEs as well as strategies tested in drills, exercises, or computer simulations, all of which included a comparison group. We reviewed separately studies that lacked a comparison group but nonetheless evaluated promising strategies. We also identified consensus recommendations developed by professional societies or government panels. We reviewed existing State plans to examine the current state of planning for scarce resource allocation during MCEs. Two investigators independently reviewed each article, abstracted data, and assessed study quality. RESULTS: We considered 5,716 reports for this comparative effectiveness review (CER); we ultimately included 170 in the review. Twenty-seven studies focus on strategies for policymakers. Among this group were studies that examined various ways to distribute biological countermeasures more efficiently during a bioterror attack or influenza pandemic. They provided modest evidence that the way these systems are organized influences the speed of distribution. The review includes 119 studies that address strategies for providers. A number of these studies provided evidence suggesting that commonly used triage systems do not perform consistently in actual MCEs. The number of high-quality studies addressing other specific strategies was insufficient to support firm conclusions about their effectiveness. Only 10 studies included strategies that consider the public's perspective. However, these studies were consistent in their findings. In particular, the public believes that resource allocation guidelines should be simple and consistent across health care facilities but should allow facilities some flexibility to make allocation decisions based on the specific demand and supply situation. The public also believes that a successful allocation system should balance the goals of ensuring the functioning of society, saving the greatest number of people, protecting the most vulnerable people, reducing deaths and hospitalizations, and treating people fairly and equitably. The remaining 14 studies provided strategies for engaging providers in discussions about allocating and managing scarce medical resources. These studies did not identify one engagement approach as clearly superior; however, they consistently noted the importance of a broad, inclusive, and systematic engagement process. CONCLUSIONS: Scientific research to identify the most effective adaptive strategies to implement during MCEs is an emerging area. While it remains unclear which of the many options available to policymakers and providers will be most effective, ongoing efforts to develop a focused, well-organized program of applied research should help to identify the optimal methods, techniques, and technologies to strengthen our nation's capacity to respond to MCEs.