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Importance: Recent discussion has focused on questions related to the repeal and replacement of portions of the Affordable Care Act (ACA). However, issues central to the future of health and health care in the United States transcend the ACA provisions receiving the greatest attention. Initiatives directed to certain strategic and infrastructure priorities are vital to achieve better health at lower cost.Objectives: To review the most salient health challenges and opportunities facing the United States, to identify practical and achievable priorities essential to health progress, and to present policy initiatives critical to the nation's health and fiscal integrity.Evidence Review: Qualitative synthesis of 19 National Academy of Medicine-commissioned white papers, with supplemental review and analysis of publicly available data and published research findings.Findings: The US health system faces major challenges. Health care costs remain high at $3.2 trillion spent annually, of which an estimated 30% is related to waste, inefficiencies, and excessive prices; health disparities are persistent and worsening; and the health and financial burdens of chronic illness and disability are straining families and communities. Concurrently, promising opportunities and knowledge to achieve change exist. Across the 19 discussion papers examined, 8 crosscutting policy directions were identified as vital to the nation's health and fiscal future, including 4 action priorities and 4 essential infrastructure needs. The action priorities-pay for value, empower people, activate communities, and connect care-recurred across the articles as direct and strategic opportunities to advance a more efficient, equitable, and patient- and community-focused health system. The essential infrastructure needs-measure what matters most, modernize skills, accelerate real-world evidence, and advance science-were the most commonly cited foundational elements to ensure progress.Conclusions and Relevance: The action priorities and essential infrastructure needs represent major opportunities to improve health outcomes and increase efficiency and value in the health system. As the new US administration and Congress chart the future of health and health care for the United States, and as health leaders across the country contemplate future directions for their programs and initiatives, their leadership and strategic investment in these priorities will be essential for achieving significant progress. [ABSTRACT FROM AUTHOR]

Importance: Hospitals are hot zones of the US gun injury epidemic. To shelter these facilities from the dangers of gun violence, state legislatures have enacted laws to reduce the carrying of firearms on hospital premises. However, these efforts currently face serious Second Amendment challenges in federal courts. The ongoing legal battles, which have wide-ranging implications for patient and clinician safety as well as public health generally, are setting the stage for a Supreme Court case that may decide the fate of firearm regulations in US hospitals. A permissible pathway for advancing sensible gun regulation in hospitals is urgently needed. Observations: Since the Supreme Court established a new constitutional test for firearm laws in New York State Rifle & Pistol Association v Bruen (2022), states now face unprecedentedly high barriers to enacting health-protecting legislation regarding firearms. Post-Bruen, the Supreme Court requires that laws be consistent with "this Nation's historical tradition of firearms regulation." This means that states hoping to enact laws barring public carry of firearms in hospitals must demonstrate that hospitals are a "sensitive place" as a historical matter (ie, analogous to a location where firearms were traditionally restricted). By reasoning from analogy, it is clear several historical comparators exist for regulating firearms in hospitals. Although the hospital (as understood today) did not exist in the 1700s, it is sufficiently analogous to asylums and schools, to name a few examples. These settings all share a common denominator with the modern-day hospital: serving vulnerable populations or individuals who may be at heightened risk of misusing firearms. Conclusions and Relevance: The Supreme Court's interpretation of the Second Amendment right to bear arms is threatening democratically enacted laws seeking to shelter hospitals from firearm violence. However, it is clear that hospitals and other health care settings are a sensitive place with compelling historical analogies. Policymakers' strategic deployment of the sensitive places designation, along with its rightful judicial recognition in the hospital setting, are critical to upholding laws that protect health care facilities, patients, and professionals from firearm violence—a conclusion consistent with the US Constitution, history, medical ethics, and common sense. This Special Communication explores whether US hospitals fall under the "sensitive places" exception to the Second Amendment and the ethical and practical considerations that support advancing firearm regulations in health care settings. [ABSTRACT FROM AUTHOR]

Key Points: Question: What is the statewide prevalence of 2 emerging pathogens, Acinetobacter baumannii and Candida auris, among patients receiving mechanical ventilation? Findings: A baumannii was identified in 30.7%, carbapenem-resistant A baumannii (CRAB) in 59.5% of those samples, and Candida auris was identified in 6.6% of all patients receiving mechanical ventilation in Maryland. Patients in long-term care facilities were more likely to be colonized with A baumannii, CRAB, and C auris compared with patients in acute care facilities. Meaning: This study should be repeated in other US states to determine the burden of these pathogens among patients receiving mechanical ventilation. Increased surveillance and prevention efforts should be directed at long-term care facilities. Importance: To date, only 1 statewide prevalence survey has been performed for Acinetobacter baumannii (2009) in the US, and no statewide prevalence survey has been performed for Candida auris, making the current burden of these emerging pathogens unknown. Objective: To determine the prevalence of A baumannii and C auris among patients receiving mechanical ventilation in Maryland. Design, Setting, and Participants: The Maryland Multi-Drug Resistant Organism Prevention Collaborative performed a statewide cross-sectional point prevalence of patients receiving mechanical ventilation admitted to acute care hospitals (n = 33) and long-term care facilities (n = 18) between March 7, 2023, and June 8, 2023. Surveillance cultures (sputum, perianal, arm/leg, and axilla/groin) were obtained from all patients receiving mechanical ventilation. Sputum, perianal, and arm/leg cultures were tested for A baumannii and antibiotic susceptibility testing was performed. Axilla/groin cultures were tested by polymerase chain reaction for C auris. Main Outcomes and Measures: Prevalence of A baumannii, carbapenem-resistant A baumannii (CRAB), and C auris. Prevalence was stratified by type of facility. Results: All 51 eligible health care facilities (100%) participated in the survey. A total of 482 patients receiving mechanical ventilation were screened for A baumannii and 470 were screened for C auris. Among the 482 patients who had samples collected, 30.7% (148/482) grew A baumannii, 88 of the 148 (59.5%) of these A baumannii were CRAB, and C auris was identified in 31 of 470 (6.6%). Patients in long-term care facilities were more likely to be colonized with A baumannii (relative risk [RR], 7.66 [95% CI, 5.11-11.50], P <.001), CRAB (RR, 5.48 [95% CI, 3.38-8.91], P <.001), and C auris (RR, 1.97 [95% CI, 0.99-3.92], P =.05) compared with patients in acute care hospitals. Nine patients (29.0%) with cultures positive for C auris were previously unreported to the Maryland Department of Health. Conclusions: A baumannii, carbapenem-resistant A baumannii, and C auris were common among patients receiving mechanical ventilation in both acute care hospitals and long-term care facilities. Both pathogens were significantly more common in long-term care facilities than in acute care hospitals. Patients receiving mechanical ventilation in long-term care facilities are a high-risk population for emerging pathogens, and surveillance and prevention efforts should be targeted to these facilities. This cross-sectional study describes the prevalence of Acinetobacter baumannii and Candida auris among patients receiving mechanical ventilation in hospitals and long-term care facilities in Maryland. [ABSTRACT FROM AUTHOR]

In this Viewpoint, authors from Physicians for Human Rights and the Ukrainian Healthcare Center present findings from a joint report documenting the attacks on health care workers and facilities as a weapon of war in the Russian war with Ukraine. [ABSTRACT FROM AUTHOR]

Importance: Home-based HIV testing is a frequently used strategy to increase awareness of HIV status in sub-Saharan Africa. However, with referral to health facilities, less than half of those who test HIV positive link to care and initiate antiretroviral therapy (ART).Objective: To determine whether offering same-day home-based ART to patients with HIV improves linkage to care and viral suppression in a rural, high-prevalence setting in sub-Saharan Africa.Design, Setting, and Participants: Open-label, 2-group, randomized clinical trial (February 22, 2016-September 17, 2017), involving 6 health care facilities in northern Lesotho. During home-based HIV testing in 6655 households from 60 rural villages and 17 urban areas, 278 individuals aged 18 years or older who tested HIV positive and were ART naive from 268 households consented and enrolled. Individuals from the same household were randomized into the same group.Interventions: Participants were randomly assigned to be offered same-day home-based ART initiation (n = 138) and subsequent follow-up intervals of 1.5, 3, 6, 9, and 12 months after treatment initiation at the health facility or to receive usual care (n = 140) with referral to the nearest health facility for preparatory counseling followed by ART initiation and monthly follow-up visits thereafter.Main Outcomes and Measures: Primary end points were rates of linkage to care within 3 months (presenting at the health facility within 90 days after the home visit) and viral suppression at 12 months, defined as a viral load of less than 100 copies/mL from 11 through 14 months after enrollment.Results: Among 278 randomized individuals (median age, 39 years [interquartile range, 28.0-52.0]; 180 women [65.7%]), 274 (98.6%) were included in the analysis (137 in the same-day group and 137 in the usual care group). In the same-day group, 134 (97.8%) indicated readiness to start ART that day and 2 (1.5%) within the next few days and were given a 1-month supply of ART. At 3 months, 68.6% (94) in same-day group vs 43.1% (59) in usual care group had linked to care (absolute difference, 25.6%; 95% CI, 13.8% to 36.3%; P < .001). At 12 months, 50.4% (69) in the same-day group vs 34.3% (47) in usual care group achieved viral suppression (absolute difference, 16.0%; 4.4%-27.2%; P = .007). Two deaths (1.5%) were reported in the same-day group, none in usual care group.Conclusions and Relevance: Among adults in rural Lesotho, a setting of high HIV prevalence, offering same-day home-based ART initiation to individuals who tested positive during home-based HIV testing, compared with usual care and standard clinic referral, significantly increased linkage to care at 3 months and HIV viral suppression at 12 months. These findings support the practice of offering same-day ART initiation during home-based HIV testing.Trial Registration: clinicaltrials.gov Identifier: NCT02692027. [ABSTRACT FROM AUTHOR]

The article discusses waste in the U.S. health care delivery system, which is described as unsafe, ineffective, inefficient, inequitable, untimely, and not patient-centered. The Dept. of Veterans Affairs' reforms in the 1990s are cited as exemplary at the macrosystem level. Other positive initiatives cited are the Leapfrog Group's agenda to reduce preventable medical errors and the Institute for Healthcare Improvement's 5 Million Lives Campaign, which is engaging U.S. hospitals to improve patient care and prevent avoidable deaths.

Context Hospital report cards are increasingly being implemented for quality improvement despite lack of strong evidence to support their use. Objective To determine whether hospital report cards constructed using linked hospital and prescription administrative databases are effective for improving quality of care for acute myocardial infarction (AMI). Design The Administrative Data Feedback for Effective Cardiac Treatment (AFFECT) study, a cluster randomized trial. Setting and Patients Patients with AMI who were admitted to 76 acute care hospitals in Quebec that treated at least 30 AMI patients per year between April 1, 1999, and March 31, 2003. Intervention Hospitals were randomly assigned to receive rapid (immediate; n = 38 hospitals and 2533 patients) or delayed (14 months; n = 38 hospitals and 3142 patients) confidential feedback on quality indicators constructed using administrative data. Main Outcome Measures Quality indicators pertaining to processes of care and outcomes of patients admitted between 4 and 10 months after randomization. The primary indicator was the proportion of elderly survivors of AMI at each study hospital who filled a prescription for a β-blocker within 30 days after discharge. Results At follow-up, adjusted prescription rates within 30 days after discharge were similar in the early vs late groups (for β-blockers, odds ratio [OR], 1.06; 95% confidence interval [CI], 0.82-1.37; for angiotensin-converting enzyme inhibitors, OR, 1.17; 95% CI, 0.90-1.52; for lipid-lowering drugs, OR, 1.14; 95% CI, 0.86-1.50; and for aspirin, OR, 1.05; 95% CI, 0.84-1.33). In addition, adjusted mortality was similar in both groups, as were length of in-hospital stay, physician visits after discharge, waiting times for invasive cardiac procedures, and readmissions for cardiac complications. Conclusions Feedback based on one-time, confidential report cards constructed using administrative data is not an effective strategy for quality improvement regarding care of patients with AMI. A need exists for further studies to rigorously evaluate the effectiveness of more intensive report card interventions. [ABSTRACT FROM AUTHOR]

Faced with explosive growth in its prison population and a legal mandate to improve medical care for incarcerated offenders, the state of Texas implemented a novel correctional managed health care program in 1994. The organizational structure of the program is based on a series of contractual relationships between the state prison system, 2 of the state's academic medical centers, and a separate governing body composed of 9 appointed members, which include 5 physicians. All medical, dental, and psychiatric care for more than 145,000 offenders, incarcerated under the jurisdiction of the Texas Department of Criminal Justice, is provided by the University of Texas Medical Branch and Texas Tech University Health Sciences Center. The health delivery system is composed of several levels of care, including primary ambulatory care clinics in each prison unit, 16 infirmaries at strategic locations throughout the state, several regional medical facilities, and a dedicated prison hospital with a full range of services. Specialized treatment programs have been established at various units for patients with chronic conditions, such as hypertension, diabetes mellitus, major psychiatric disorders, hepatitis, and human immunodeficiency virus infection. Significant improvements in health outcomes have occurred since the managed care program was established. [ABSTRACT FROM AUTHOR]

Context: Little is known about nursing home residents' injuries that are inflicted by other residents. Objective: To assess risk factors for violent injury to nursing home residents by other residents. Design, Setting, and Subjects: Case-control study using data from the Massachusetts Department of Public Health's Complaint and Incident Reporting System and from Minimum Data Set assessments for Massachusetts nursing home residents. Cases had an injury sustained from an incident with another nursing home resident between January 1, 2000, and December 31, 2000, which left visible evidence (ie, fracture, dislocation, bruise or hematoma, laceration, and reddened area) (median age, 81 years). Controls were randomly selected from all residents who had a Minimum Data Set assessment completed in 2000 (n = 101 429) and no injury report (median age, 83 years). A total of 1994 controls were included in the analyses. Main Outcome Measures: Injury type and risk of being injured by resident-to-resident aggressive physical behaviors based on the specific characteristics of the injured resident. Results: During the first incident, 294 residents sustained fractures (n = 39), dislocations (n = 6), bruises or hematomas (n = 105), lacerations (n = 113), and reddened areas (n = 31). Injured residents (cases) were more likely to be cognitively impaired, exhibit symptoms of wandering, be verbally abusive, and have socially inappropriate behavior than the controls. Residents who were classified as needing extensive assistance (adjusted odds ratio [AOR], 0.3; 95% confidence interval [CI], 0.2-0.6) and being severely dependent (AOR, 0.12; 95% CI, 0.05-0.27) had a significant reduction in being injured. Residents in an Alzheimer disease unit were almost 3 times as likely to be injured than those living in other units (AOR, 3.2; 95% CI, 1.4-7.5). Conclusions: Injured residents were more likely, perhaps unknowingly, to "put themselves in harm's way," be verbally aggressive, and be cognitively impaired. Interventions to prevent these incidents should focus on the behavior of the injured persons. [ABSTRACT FROM AUTHOR]

Presents several articles that reveal medical news as of January 2003. Movement of gene chips or DNA microarrays towards medical use in clinics; John Quackenbush and his opinion on the clinical promise of genetic microarrays; Decline in teenage smoking.

Presents updates on medical care in the U.S. as of May 15, 1991. Release of a reprint of the article 'Guidelines for Treatment of Acute Myocardial Infarction,' featured in the August 1990 issues of 'Circulation' and the 'Journal of the American College of Cardiology.' Information on an award for the best papers on the topic of preventive medicine given by 'The American Journal of Preventive Medicine' and the Ulrich and Ruth Frank for International Health; Search of proposals for partnerships between medical facilities in the U.S. and Europe conducted by the U.S. Agency for International Development.

Discusses the abstract of the paper 'Evaluation of Stat and Routine Turnaround Times As a Component of Laboratory Quality,' by Lee H. Hilnorne et al published in an issue of the periodical 'American Journal of Clinical Pathology.'

The article discusses some key areas of improvements for the U.S. health care system. Topics discussed include encouraging physicians to specialize in certain types of patients or procedures, matching patients to the right type of clinician to reduce waiting days and use of predictive analytics by health organizations to determine patients who need particular types of care to reduce hospitalization and costs.

The article describes MED-1, a mobile hospital used for the first time to treat victims of Hurricane Katrina. The hospital was designed and built at the Center for Prehospital Medicine at Carolinas Medical Center in Charlotte, North Carolina. It was developed with the help of the Metropolitan Medical Response System (MMRS) of the U.S. Department of Homeland Security. MED-1 consists of two tractor trailers: one is used for equipment storage, and the other as a patient care facility. The care facility has three pods that slide out to create a shock and resuscitation unit, and a critical care and emergency care unit. A canvas awning attached to the trailer creates a biologically contained, and climate controlled tent that can house up to 130 beds.

The article presents information on the infections caused by carhapenem resistant Klebsiella pneumoniae in the U.S. According to Abbigail Tumpey, associate director for communications science in the Division of Healthcare Quality Promotion of the U.S. Centers for Disease Control and Prevention (CDC), the spread of this type of infection can be prevented before it becomes endemic as methicillin resistant Staphylococcus aureus (MRSA). An updated guideline published by CDC that includes recommendations for facilities trying to contain infections is also discussed.

The article offers information on challenges faced at the intersection of Team-Based and Patient-Centered Health Care in the U.S. It informs that Team-based care can occur in many places including home, office and hospital including team members from different backgrounds. It informs that in high-functioning health care teams, patients are members of the team and drives all the attention involved in care decisions. It adds the values of high-functioning health care teams including honesty, discipline, and creativity and the principles of including clear roles, mutual trust and effective communications.

The authors reflect on the developments in providing human immunodeficiency virus (HIV) testing and counseling in health facilities. They cite the impact of the "Guidance on Provider-Initiated Testing and Counselling in Health Facilities" on HIV diagnosis and treatment programs. They emphasize the need to recommend provider-initiated testing and counseling (PITC) to all individuals and groups affected by the HIV virus. They also mention the need to integrate PITC into medical care and a major challenge for universal access to HIV prevention by 2010.

Focuses on interning at a medical clinic. Claim that there is no mystery to the patients' ailments at a clinic, who have come after being referred by their primary physician; Paperwork that must be done by interns; Comparison of working in the city to working in Sierra Leone; Differences in the way that people in Sierra Leone live compared with those in the United States; Difficultly of life in a refugee camp.