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Patients Charting the Course

by The National Academy of Sciences

As past, current, or future patients, the public should be the health care system's unwavering focus and serve as change agents in its care. Taking this into account, the quality of health care should be judged not only by whether clinical decisions are informed by the best available scientific evidence, but also by whether care is tailored to a patient's individual needs and perspectives. However, too often it is provider preference and convenience, rather than those of the patient, that drive what care is delivered. As part of its Learning Health System series of workshops, the Roundtable on Value & Science-Driven Health Care hosted a workshop to assess the prospects for improving health and lowering costs by advancing patient involvement in the elements of a learning health system.

Bridging the Evidence Gap in Obesity Prevention: A Framework to Inform Decision Making

by Institute of Medicine of the National Academies

To battle the obesity epidemic in America, health care professionals and policymakers need relevant, useful data on the effectiveness of obesity prevention policies and programs. ridging the Evidence Gap in Obesity Prevention identifies a new approach to decision making and research on obesity prevention to use a systems perspective to gain a broader understanding of the context of obesity and the many factors that influence it.

Future Directions for the National Healthcare Quality and Disparities Reports

by Institute of Medicine of the National Academies

As the United States devotes extensive resources to health care, evaluating how successfully the U.S. system delivers high-quality, high-value care in an equitable manner is essential. At the request of Congress, the Agency for Healthcare Research and Quality (AHRQ) annually produces the National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR). The reports have revealed areas in which health care performance has improved over time, but they also have identified major shortcomings. After five years of producing the NHQR and NHDR, AHRQ asked the IOM for guidance on how to improve the next generation of reports. The IOM concludes that the NHQR and NHDR can be improved in ways that would make them more influential in promoting change in the health care system. In addition to being sources of data on past trends, the national healthcare reports can provide more detailed insights into current performance, establish the value of closing gaps in quality and equity, and project the time required to bridge those gaps at the current pace of improvement.

Technologies and Approaches to Reducing the Fuel Consumption of Medium- and Heavy-Duty Vehicles

by National Research Council of the National Academies

Technologies and Approaches to Reducing the Fuel Consumption of Medium- and Heavy-Duty Vehicles evaluates various technologies and methods that could improve the fuel economy of medium- and heavy-duty vehicles, such as tractor-trailers, transit buses, and work trucks. The book also recommends approaches that federal agencies could use to regulate these vehicles' fuel consumption. Currently there are no fuel consumption standards for such vehicles, which account for about 26 percent of the transportation fuel used in the U.S. The miles-per-gallon measure used to regulate the fuel economy of passenger cars. is not appropriate for medium- and heavy-duty vehicles, which are designed above all to carry loads efficiently. Instead, any regulation of medium- and heavy-duty vehicles should use a metric that reflects the efficiency with which a vehicle moves goods or passengers, such as gallons per ton-mile, a unit that reflects the amount of fuel a vehicle would use to carry a ton of goods one mile. This is called load-specific fuel consumption (LSFC). The book estimates the improvements that various technologies could achieve over the next decade in seven vehicle types. For example, using advanced diesel engines in tractor-trailers could lower their fuel consumption by up to 20 percent by 2020, and improved aerodynamics could yield an 11 percent reduction. Hybrid powertrains could lower the fuel consumption of vehicles that stop frequently, such as garbage trucks and transit buses, by as much 35 percent in the same time frame.

Selling the Nation's Helium Reserve

by National Research Council of the National Academies

Helium has long been the subject of public policy deliberation and management, largely because of its many strategic uses and its unusual source-it is a derived product of natural gas and its market has several anomalous characteristics. Shortly after sources of helium were discovered at the beginning of the last century, the U.S. government recognized helium's potential importance to the nation's interests and placed its production and availability under strict governmental control. In the 1960s, helium's strategic value in cold war efforts was reflected in policies that resulted in the accumulation of a large reserve of helium owned by the federal government. The latest manifestation of public policy is expressed in the Helium Privatization Act of 1996 (1996 12 Act), which directs that substantially all of the helium accumulated as a result of those earlier policies be sold off by 2015 at prices sufficient to repay the federal government for its outlays associated with the helium program. The present volume assesses whether the interests of the United States have been well served by the 1996 Act and, in particular, whether selling off the helium reserve has had any adverse effect on U.S. scientific, technical, biomedical, and national security users of helium.

Defending Planet Earth: Near-Earth-Object Surveys and Hazard Mitigation Strategies

by National Research Council of the National Academies

The United States spends approximately four million dollars each year searching for near-Earth objects (NEOs). The objective is to detect those that may collide with Earth. The majority of this funding supports the operation of several observatories that scan the sky searching for NEOs. This, however, is insufficient in detecting the majority of NEOs that may present a tangible threat to humanity. A significantly smaller amount of funding supports ways to protect the Earth from such a potential collision or "mitigation." In 2005, a Congressional mandate called for NASA to detect 90 percent of NEOs with diameters of 140 meters of greater by 2020. Defending Planet Earth: Near-Earth Object Surveys and Hazard Mitigation Strategies identifies the need for detection of objects as small as 30 to 50 meters as these can be highly destructive. The book explores four main types of mitigation including civil defense, "slow push" or "pull" methods, kinetic impactors and nuclear explosions. It also asserts that responding effectively to hazards posed by NEOs requires national and international cooperation. Defending Planet Earth: Near-Earth Object Surveys and Hazard Mitigation Strategies is a useful guide for scientists, astronomers, policy makers and engineers.

Gulf War and Health, Volume 8: Update of Health Effects of Serving in the Gulf War

by Institute of Medicine of the National Academies

For the United States, the 1991 Persian Gulf War was a brief and successful military operation with few injuries and deaths. However, soon after returning from duty, a large number of veterans began reporting health problems they believed were associated with their service in the Gulf. At the request of Congress, the IOM is conducting an ongoing review of the evidence to determine veterans' long-term health problems and what might be causing those problems. The fourth volume in the series, released in 2006, summarizes the long-term health problems seen in Gulf War veterans. In 2008, the IOM began an update to look at existing health problems and identify possible new ones, considering evidence collected since the initial summary. In this report, the IOM determines that Gulf War service causes post-traumatic stress disorder (PTSD) and that service is associated with multisymptom illness; gastrointestinal disorders such as irritable bowel syndrome; alcohol and other substance abuse; and anxiety disorders and other psychiatric disorders. To ensure that our veterans receive the best possible care, now and in the future, the government should continue to monitor their health and conduct research to identify the best treatments to assist Gulf War veterans still suffering from persistent, unexplained illnesses.

Persistent Forecasting of Disruptive Technologies - Report 2

by National Research Council of the National Academies

The term "disruptive technology" describes a technology that results in a sudden change affecting already established technologies or markets. Disruptive technologies cause one or more discontinuities in the normal evolutionary life cycle of technology. This may lead to an unexpected destabilization of an older technology order and an opportunity for new competitors to displace incumbents. Frequently cited examples include digital photography and desktop publishing. The first report of the series, Persistent Forecasting of Disruptive Technologies, discussed how technology forecasts were historically made, assessed various existing forecasting systems, and identified desirable attributes of a next-generation persistent long-term forecasting system for disruptive technologies. This second book attempts to sketch out high-level forecasting system designs. In addition, the book provides further evaluation of the system attributes defined in the first report, and evidence of the feasibility of creating a system with those attributes. Together, the reports are intended to help the Department of Defense and the intelligence community identify and develop a forecasting system that will assist in detecting and tracking global technology trends, producing persistent long-term forecasts of disruptive technologies, and characterizing their potential impact on future U.S. warfighting and homeland defense capabilities.

Toward Sustainable Agricultural Systems in the 21st Century

by National Research Council of the National Academies

In the last 20 years, there has been a remarkable emergence of innovations and technological advances that are generating promising changes and opportunities for sustainable agriculture, yet at the same time the agricultural sector worldwide faces numerous daunting challenges. Not only is the agricultural sector expected to produce adequate food, fiber, and feed, and contribute to biofuels to meet the needs of a rising global population, it is expected to do so under increasingly scarce natural resources and climate change. Growing awareness of the unintended impacts associated with some agricultural production practices has led to heightened societal expectations for improved environmental, community, labor, and animal welfare standards in agriculture. Toward Sustainable Agricultural Systems in the 21st Century assesses the scientific evidence for the strengths and weaknesses of different production, marketing, and policy approaches for improving agricultural sustainability and reducing the costs and unintended consequences of agricultural production. It discusses the principles underlying farming systems and practices that could improve the sustainability. It also explores how those lessons learned could be applied to agriculture in different regional and national settings, with an emphasis on sub-Saharan Africa. By presenting practices and how they could be combined in a systems approach to improving the sustainability of U.S. agriculture, this book can have a profound impact on the development and implementation of sustainable farming systems. Toward Sustainable Agricultural Systems in the 21st Century serves as a valuable resource for policy makers, farmers, experts in food production and agribusiness, and federal regulatory agencies.

Realizing the Energy Potential of Methane Hydrate for the United States

by National Research Council of the National Academies

Natural gas, composed mostly of methane, is the cleanest of all the fossil fuels, emitting 25-50% less carbon dioxide than either oil or coal for each unit of energy produced. In recent years, natural gas supplied approximately 20-25% of all energy consumed in the United States. Methane hydrate is a potentially enormous and as yet untapped source of methane. The Department of Energy's Methane Hydrate Research and Development Program has been tasked since 2000 to implement and coordinate a national methane hydrate research effort to stimulate the development of knowledge and technology necessary for commercial production of methane from methane hydrate in a safe and environmentally responsible way. Realizing the Energy Potential of Methane Hydrate for the United States evaluates the program's research projects and management processes since its congressional re-authorization in 2005, and presents recommendations for its future research and development initiatives.

Demographic Changes, a View from California: Implications for Framing Health Disparities

by Institute of Medicine of the National Academies

The IOM held a workshop on July 28, 2008, to examine strategies for discussing health disparities in ways that engage the public and motivate change. Speakers focused on health disparities in California, which continues to see dramatic demographic shifts.

CNS Clinical Trials: Suicidality And Data Collection - Workshop Summary

by Institute of Medicine of the National Academies

The Food and Drug Administration (FDA) now requires that all clinical trials for drugs that affect the central nervous system--including psychiatric drugs--are assessed for whether that drug might cause suicidal ideation or behavior. The IOM's Forum on Neuroscience and Nervous System Disorders hosted a meeting on June 26, 2009, to discuss the FDA's new policy and how to analyze best whether suicidal thoughts predict actual suicidal behavior in the near future.

Understanding Climate's Influence on Human Evolution

by National Research Council of the National Academies

The hominin fossil record documents a history of critical evolutionary events that have ultimately shaped and defined what it means to be human, including the origins of bipedalism; the emergence of our genus Homo; the first use of stone tools; increases in brain size; and the emergence of Homo sapiens, tools, and culture. The Earth's geological record suggests that some evolutionary events were coincident with substantial changes in African and Eurasian climate, raising the possibility that critical junctures in human evolution and behavioral development may have been affected by the environmental characteristics of the areas where hominins evolved. Understanding Climate's Change on Human Evolution explores the opportunities of using scientific research to improve our understanding of how climate may have helped shape our species. Improved climate records for specific regions will be required before it is possible to evaluate how critical resources for hominins, especially water and vegetation, would have been distributed on the landscape during key intervals of hominin history. Existing records contain substantial temporal gaps. The book's initiatives are presented in two major research themes: first, determining the impacts of climate change and climate variability on human evolution and dispersal; and second, integrating climate modeling, environmental records, and biotic responses. Understanding Climate's Change on Human Evolution suggests a new scientific program for international climate and human evolution studies that involve an exploration initiative to locate new fossil sites and to broaden the geographic and temporal sampling of the fossil and archeological record; a comprehensive and integrative scientific drilling program in lakes, lake bed outcrops, and ocean basins surrounding the regions where hominins evolved and a major investment in climate modeling experiments for key time intervals and regions that are critical to understanding human evolution.

Achieving Effective Acquisition of Information Technology in the Department of Defense

by National Research Council of the National Academies

In the military, information technology (IT) has enabled profound advances in weapons systems and the management and operation of the defense enterprise. A significant portion of the Department of Defense (DOD) budget is spent on capabilities acquired as commercial IT commodities, developmental IT systems that support a broad range of warfighting and functional applications, and IT components embedded in weapons systems. The ability of the DOD and its industrial partners to harness and apply IT for warfighting, command and control and communications, logistics, and transportation has contributed enormously to fielding the world's best defense force. However, despite the DOD's decades of success in leveraging IT across the defense enterprise, the acquisition of IT systems continues to be burdened with serious problems. To address these issues, the National Research Council assembled a group of IT systems acquisition and T&E experts, commercial software developers, software engineers, computer scientists and other academic researchers. The group evaluated applicable legislative requirements, examined the processes and capabilities of the commercial IT sector, analyzed DOD's concepts for systems engineering and testing in virtual environments, and examined the DOD acquisition environment. The present volume summarizes this analysis and also includes recommendations on how to improve the acquisition, systems engineering, and T&E processes to achieve the DOD's network-centric goals.

A Population-Based Policy and Systems Change Approach to Prevent and Control Hypertension

by Institute of Medicine of the National Academies

Hypertension is one of the leading causes of death in the United States, affecting nearly one in three Americans. It is prevalent in adults and endemic in the older adult population. Hypertension is a major contributor to cardiovascular morbidity and disability. Although there is a simple test to diagnose hypertension and relatively inexpensive drugs to treat it, the disease is often undiagnosed and uncontrolled. A Population-Based Policy and Systems Change Approach to the Prevention and Control Hypertension identifies a small set of high-priority areas in which public health officials can focus their efforts to accelerate progress in hypertension reduction and control. It offers several recommendations that embody a population-based approach grounded in the principles of measurement, system change, and accountability. The recommendations are designed to shift current hypertension reduction strategies from an individual-based approach to a population-based approach. They are also designed to improve the quality of care provided to individuals with hypertension and to strengthen the Center for Disease Control and Prevention's leadership in seeking a reduction in the sodium intake in the American diet to meet dietary guidelines. The book is an important resource for federal public health officials and organizations, especially the Center for Disease Control and Prevention, as well as medical professionals and community health workers.

Strategies to Reduce Sodium Intake in the United States

by Institute of Medicine of the National Academies

Reducing the intake of sodium is an important public health goal for Americans. Since the 1970s, an array of public health interventions and national dietary guidelines has sought to reduce sodium intake. However, the U.S. population still consumes more sodium than is recommended, placing individuals at risk for diseases related to elevated blood pressure.Strategies to Reduce Sodium Intake in the United States evaluates and makes recommendations about strategies that could be implemented to reduce dietary sodium intake to levels recommended by the Dietary Guidelines for Americans. The book reviews past and ongoing efforts to reduce the sodium content of the food supply and to motivate consumers to change behavior. Based on past lessons learned, the book makes recommendations for future initiatives. It is an excellent resource for federal and state public health officials, the processed food and food service industries, health care professionals, consumer advocacy groups, and academic researchers.

Promoting Cardiovascular Health in the Developing World: A Critical Challenge to Achieve Global Health

by Institute of Medicine of the National Academies

Cardiovascular disease (CVD), once thought to be confined primarily to industrialized nations, has emerged as a major health threat in developing countries. Cardiovascular disease now accounts for nearly 30 percent of deaths in low and middle income countries each year, and is accompanied by significant economic repercussions. Yet most governments, global health institutions, and development agencies have largely overlooked CVD as they have invested in health in developing countries. Recognizing the gap between the compelling evidence of the global CVD burden and the investment needed to prevent and control CVD, the National Heart, Lung, and Blood Institute (NHLBI) turned to the IOM for advice on how to catalyze change. In this report, the IOM recommends that the NHLBI, development agencies, nongovernmental organizations, and governments work toward two essential goals: creating environments that promote heart healthy lifestyle choices and help reduce the risk of chronic diseases, and building public health infrastructure and health systems with the capacity to implement programs that will effectively detect and reduce risk and manage CVD. To meet these goals, the IOM recommends several steps, including improving cooperation and collaboration; implementing effective and feasible strategies; and informing efforts through research and health surveillance. Without better efforts to promote cardiovascular health, global health as a whole will be undermined.

A Database for a Changing Economy: Review of the Occupational Information Network (O*NET)

by National Research Council of the National Academies

Information about the characteristics of jobs and the individuals who fill them is valuable for career guidance, reemployment counseling, workforce development, human resource management, and other purposes. To meet these needs, the U.S. Department of Labor (DOL) in 1998 launched the Occupational Information Network (O*NET), which consists of a content model--a framework for organizing occupational data--and an electronic database. The O*NET content model includes hundreds of descriptors of work and workers organized into domains, such as skills, knowledge, and work activities. Data are collected using a classification system that organizes job titles into 1,102 occupations. The National Center for O*NET Development (the O*NET Center) continually collects data related to these occupations. In 2008, DOL requested the National Academies to review O*NET and consider its future directions. In response, the present volume inventories and evaluates the uses of O*NET; explores the linkage of O*NET with the Standard Occupational Classification System and other data sets; and identifies ways to improve O*NET, particularly in the areas of cost-effectiveness, efficiency, and currency.

Provision of Mental Health Counseling Services Under Tricare

by Institute of Medicine of the National Academies

In this book, the IOM makes recommendations for permitting independent practice for mental health counselors treating patients within TRICARE--the DOD's health care benefits program. This would change current policy, which requires all counselors to practice under a physician's supervision without regard to their education, training, licensure or experience.

Returning Home from Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and their Families

by Institute of Medicine of the National Academies

Nearly 1.9 million U.S. troops have been deployed to Afghanistan and Iraq since October 2001. Many service members and veterans face serious challenges in readjusting to normal life after returning home. This initial book presents findings on the most critical challenges, and lays out the blueprint for the second phase of the study to determine how best to meet the needs of returning troops and their families.

Research at the Intersection of the Physical and Life Sciences

by National Research Council of the National Academies

Traditionally, the natural sciences have been divided into two branches: the biological sciences and the physical sciences. Today, an increasing number of scientists are addressing problems lying at the intersection of the two. These problems are most often biological in nature, but examining them through the lens of the physical sciences can yield exciting results and opportunities. For example, one area producing effective cross-discipline research opportunities centers on the dynamics of systems. Equilibrium, multistability, and stochastic behavior--concepts familiar to physicists and chemists--are now being used to tackle issues associated with living systems such as adaptation, feedback, and emergent behavior. Research at the Intersection of the Physical and Life Sciences discusses how some of the most important scientific and societal challenges can be addressed, at least in part, by collaborative research that lies at the intersection of traditional disciplines, including biology, chemistry, and physics. This book describes how some of the mysteries of the biological world are being addressed using tools and techniques developed in the physical sciences, and identifies five areas of potentially transformative research. Work in these areas would have significant impact in both research and society at large by expanding our understanding of the physical world and by revealing new opportunities for advancing public health, technology, and stewardship of the environment. This book recommends several ways to accelerate such cross-discipline research. Many of these recommendations are directed toward those administering the faculties and resources of our great research institutions--and the stewards of our research funders, making this book an excellent resource for academic and research institutions, scientists, universities, and federal and private funding agencies.

Choosing the Nation's Fiscal Future

by National Research Council National Academy of Public Administration

A mismatch between the federal government's revenues and spending, now and in the foreseeable future, requires heavy borrowing, leading to a large and increasing federal debt. That increasing debt raises a serious challenge to all of the goals that various people expect their government to pursue. It also raises questions about the nation's future wealth and whether too much debt could lead to higher interest rates and even to loss of confidence in the nation's long-term ability and commitment to honor its obligations. Many analysts have concluded that the trajectory of the federal budget set by current policies cannot be sustained. In light of these projections, Choosing the Nation's Fiscal Future assesses the options and possibilities for a sustainable federal budget. This comprehensive book considers a range of policy changes that could help put the budget on a sustainable path: reforms to reduce the rate of growth in spending for Medicare and Medicaid; options to reduce the growth rate of Social Security benefits or raise payroll taxes; and changes in many other government spending programs and tax policies. The book also examines how the federal budget process could be revised to be more far sighted and to hold leaders accountable for responsible stewardship of the nation's fiscal future. Choosing the Nation's Fiscal Future will provide readers with a practical framework to assess budget proposals for their consistency with long-term fiscal stability. It will help them assess what policy changes they want, consistent with their own values and their views of the proper role of the government and within the constraints of a responsible national budget. It will show how the perhaps difficult but possible policy changes could be combined to produce a wide range of budget scenarios to bring revenues and spending into alignment for the long term. This book will be uniquely valuable to everyone concerned about the current and projected fiscal health of the nation.

Expanding Biofuel Production and the Transition to Advanced Biofuels: Lessons for Sustainability from the Upper Midwest

by National Research Council of the National Academies

While energy prices, energy security, and climate change are front and center in the national media, these issues are often framed to the exclusion of the broader issue of sustainability--ensuring that the production and use of biofuels do not compromise the needs of future generations by recognizing the need to protect life-support systems, promote economic growth, and improve societal welfare. Thus, it is important to understand the effects of biofuel production and use on water quality and quantity, soils, wildlife habitat and biodiversity, greenhouse gas emissions, air quality, public health, and the economic viability of rural communities.

The Impact of Genetically Engineered Crops on Farm Sustainability in the United States

by National Research Council of the National Academies

Since genetically engineered (GE) crops were introduced in 1996, their use in the United States has grown rapidly, accounting for 80-90 percent of soybean, corn, and cotton acreage in 2009. To date, crops with traits that provide resistance to some herbicides and to specific insect pests have benefited adopting farmers by reducing crop losses to insect damage, by increasing flexibility in time management, and by facilitating the use of more environmentally friendly pesticides and tillage practices. However, excessive reliance on a single technology combined with a lack of diverse farming practices could undermine the economic and environmental gains from these GE crops. Other challenges could hinder the application of the technology to a broader spectrum of crops and uses. Several reports from the National Research Council have addressed the effects of GE crops on the environment and on human health. However, The Impact of Genetically Engineered Crops on Farm Sustainability in the United States is the first comprehensive assessment of the environmental, economic, and social impacts of the GE-crop revolution on U.S. farms. It addresses how GE crops have affected U.S. farmers, both adopters and nonadopters of the technology, their incomes, agronomic practices, production decisions, environmental resources, and personal well-being. The book offers several new findings and four recommendations that could be useful to farmers, industry, science organizations, policy makers, and others in government agencies.

Ecosystem Concepts for Sustainable Bivalve Mariculture

by National Research Council of the National Academies

U.S. mariculture production of bivalve molluscs-those cultivated in the marine environment-has roughly doubled over the last 25 years. Although mariculture operations may expand the production of seafood without additional exploitation of wild populations, they still depend upon and affect natural ecosystems and ecosystem services. Every additional animal has an incremental effect arising from food extraction and waste excretion. Increasing domestic seafood production in the United States in an environmentally and socially responsible way will likely require the use of policy tools, such as best management practices (BMPs) and performance standards. BMPs represent one approach to protecting against undesirable consequences of mariculture. An alternative approach to voluntary or mandatory BMPs is the establishment of performance standards for mariculture. Variability in environmental conditions makes it difficult to develop BMPs that are sufficiently flexible and adaptable to protect ecosystem integrity across a broad range of locations and conditions. An alternative that measures performance in sustaining key indicators of ecosystem state and function may be more effective. Because BMPs address mariculture methods rather than monitoring actual ecosystem responses, they do not guarantee that detrimental ecosystem impacts will be controlled or that unacceptable impact will be avoided. Ecosystem Concepts for Sustainable Bivalve Mariculture finds that while performance standards can be applied for some broad ecosystem indicators, BMPs may be more appropriate for addressing parameters that change from site to site, such as the species being cultured, different culture methods, and various environmental conditions. This book takes an in-depth look at the environmental, social, and economic issues to present recommendations for sustainable bivalve mariculture.

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