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The Roundtable on Population Health Improvement, a convening activity of the National Academies of Sciences, Engineering, and Medicine, held a workshop on March 15-16, 2021, to explore issues related to increasing health care spending in the United States. The workshop, U.S. Health Care Expenditures: Costs, Lessons, and Opportunities, was organized to highlight the persisting challenge of health care expenditures that are not commensurate with the health outcomes they produce. This publication summarizes the presentation and discussion of the workshop.

Marine recreational fishing is a popular activity enjoyed by more than 9 million Americans annually and is a driver of the American ocean-or blue-economy. To ensure that fish populations are not overexploited, the NOAA Fisheries' Marine Recreational Information Program (MRIP) monitors recreational catch through a variety of in-person, telephone, mail-in, and other surveys. NOAA Fisheries' management of recreational catch also must take into account annual catch limits (ACLs) established to prevent overfishing for all managed species in federal waters. While MRIP has worked to improve recreational catch surveys over the past decade, the surveys were never designed to meet the demands of in-season management of ACLs. In some cases, estimates of harvest have triggered accountability measures such as early season closures and reductions in future recreational ACLs, which have been a source of contention with the recreational fishing community. This report presents approaches for optimizing MRIP data and complementary data for in-season management and considers alternatives for managing recreational fisheries with ACLs to better serve both social and economic management objectives.

Antimicrobial resistance is a health problem that threatens to undermine almost a century of medical progress. Moreover, it is a global problem that requires action both in the United States and internationally. Combating Antimicrobial Resistance and Protecting the Miracle of Modern Medicine discusses ways to improve detection of resistant infections in the United States and abroad, including monitoring environmental reservoirs of resistance. This report sets out a strategy for improving stewardship and preventing infections in humans and animals. The report also discusses the strength of the pipeline for new antimicrobial medicines and steps that could be taken to bring a range of preventive and therapeutic products for humans and animals to the market.

There is a void in evidence-based information for making informed decisions on how to optimize care for older adults, particularly those 80 years and over. Because older adults are vastly underrepresented in clinical trials, there is a dearth of information about the appropriate use of drugs in this population. Yet older adults have higher rates of comorbidities and simultaneous use of multiple medications than the general population, and are the majority users of many medications. Additionally, age-related physiological and pathological changes, particularly for adults 80 years of age and older, can lead to significant differences in the pharmacokinetics (PK)2 and pharmacodynamics (PD)3 of a given drug compared to the general population. On August 5 and 6, 2020, the National Academies of Sciences, Engineering, and Medicine hosted a workshop titled Drug Research and Development for Adults Across the Older Age Span. The workshop was designed to examine the challenges and opportunities in drug research and development for older adult populations, explore barriers that impede safety and efficacy studies in these populations, and share lessons learned for better understanding clinical pharmacology for populations over age 65. This publication summarizes the presentation and discussion of the workshop.

Earthquake-induced soil liquefaction (liquefaction) is a leading cause of earthquake damage worldwide. Liquefaction is often described in the literature as the phenomena of seismic generation of excess porewater pressures and consequent softening of granular soils. Many regions in the United States have been witness to liquefaction and its consequences, not just those in the west that people associate with earthquake hazards. Past damage and destruction caused by liquefaction underline the importance of accurate assessments of where liquefaction is likely and of what the consequences of liquefaction may be. Such assessments are needed to protect life and safety and to mitigate economic, environmental, and societal impacts of liquefaction in a cost-effective manner. Assessment methods exist, but methods to assess the potential for liquefaction triggering are more mature than are those to predict liquefaction consequences, and the earthquake engineering community wrestles with the differences among the various assessment methods for both liquefaction triggering and consequences. State of the Art and Practice in the Assessment of Earthquake-Induced Soil Liquefaction and Its Consequences evaluates these various methods, focusing on those developed within the past 20 years, and recommends strategies to minimize uncertainties in the short term and to develop improved methods to assess liquefaction and its consequences in the long term. This report represents a first attempt within the geotechnical earthquake engineering community to consider, in such a manner, the various methods to assess liquefaction consequences.

Valued for its ecological richness and economic value, the U.S. Gulf of Mexico is under substantial pressure from human activities. The Deepwater Horizon platform explosion and oil spill significantly damaged Gulf ecosystems and led to the largest ecological restoration investment in history. The unprecedented number and diversity of restoration activities provide valuable information for future restoration efforts, but assessment efforts are hampered by many factors, including the need to evaluate the interaction of multiple stressors and consider long-term environmental trends such as sea level rise, increasing hurricane intensity, and rising water temperatures. This report offers a comprehensive approach to assess restoration activities beyond the project scale in the face of a changing environment. A main component of this approach is using different types of scientific evidence to develop "multiple lines of evidence" to evaluate restoration efforts at regional scales and beyond, especially for projects that may be mutually reinforcing (synergistic) or in conflict (antagonistic). Because Gulf of Mexico ecosystems cross political boundaries, increased coordination and collaboration is needed, especially to develop standardized data collection, analysis, synthesis, and reporting. With these improvements, program-level adaptive management approaches can be used more effectively to assess restoration strategies against the backdrop of long-term environmental trends.

The United States faces an alarmingly high rate of maternal morbidity and mortality, distinguishing it from other high-income countries that have achieved decreases in these rates in recent years. U.S. maternal morbidity and mortality rates are disproportionate across racial, ethnic, socioeconomic, and geographic groups. Statistics on maternal health outcomes reveal that there are challenges to protecting both the lives and future health of birthing people and their children. Recognizing the urgency of this growing problem, the National Academies Board on Population Health and Public Health Practice convened a 2-day virtual workshop, Advancing Maternal Health Equity and Reducing Maternal Mortality. The workshop examined the current state of maternal health in the United States and explored the factors needed to help communities and health care systems become more effective in reducing maternal morbidity and mortality and improving health outcomes through the fourth trimester. This publication summarizes the presentations and discussions of the workshop.--Publisher's website.

From daily commutes to cross-country road trips, millions of light-duty vehicles are on the road every day. The transportation sector is one of the United States' largest sources of greenhouse gas emissions, and fuel is an important cost for drivers. The period from 2025-2035 could bring the most fundamental transformation in the 100-plus year history of the automobile. Battery electric vehicle costs are likely to fall and reach parity with internal combustion engine vehicles. New generations of fuel cell vehicles will be produced. Connected and automated vehicle technologies will become more common, including likely deployment of some fully automated vehicles. These new categories of vehicles will for the first time assume a major portion of new vehicle sales, while internal combustion engine vehicles with improved powertrain, design, and aerodynamics will continue to be an important part of new vehicle sales and fuel economy improvement. This study is a technical evaluation of the potential for internal combustion engine, hybrid, battery electric, fuel cell, nonpowertrain, and connected and automated vehicle technologies to contribute to efficiency in 2025-2035. In addition to making findings and recommendations related to technology cost and capabilities, Assessment of Technologies for Improving Light-Duty Vehicle Fuel Economy - 2025-2035 considers the impacts of changes in consumer behavior and regulatory regimes.

The National Academies of Sciences, Engineering, and Medicine convened a workshop on February 4th and 5th, 2021 to review the issues related to safety of passengers and employees in commercial air transportation, for domestic and international travel, during the COVID-19 pandemic. The workshop explored best practices to assess and mitigate COVID-19 transmission risks experienced during the travel chain, from the departure airport entrance to the destination airport exit. The workshop also identified areas where more research is needed to address gaps in understanding. This publication documents the presentations and discussions held during the workshop, and is presented as a synthesis of the workshop.

The National Institutes of Health (NIH) asked the National Academies of Sciences, Engineering, and Medicine to conduct a quadrennial review of its Small Business Innovation Research (SBIR) and Small Business Technology Transfer (STTR) programs, in accordance with a legislative mandate. Using quantitative and qualitative analyses of data, this report reviews the operations and outcomes stemming from NIH's SBIR/STTR awards. Drawing on published research and conducting new analyses based on both publicly available data and applicant data provided by NIH, Assessment of the SBIR and STTR Programs at the National Institutes of Health analyzes (1) the effectiveness of NIH's processes and procedures for selecting SBIR and STTR awardees; (2) the effectiveness of NIH's outreach to increase SBIR and STTR applications from small businesses that are new to the programs, from underrepresented states, and from woman-owned and minority-owned businesses; (3) collaborations between small businesses and research institutions resulting from the programs; and (4) a range of direct economic and health care impacts attributable to the programs.

"Retail trade has experienced dramatic changes over the past several decades in the United States, with changes in the types of outlets where goods are sold, the nature of the transactions that provide goods to consumers, and the structure of retail operations behind the scenes. The recent changes include the rise of warehouse stores and e-commerce and the further growth of imports and large retail chains. These changes highlight and typify many aspects of the broader evolution of the economy as a whole in recent years - with the growing role of large firms and information technology - while taking place in a sector that directly serves the vast majority of the American population and provides substantial employment. Despite the everyday experience of these dramatic changes in retail, there is concern that the most transformational aspects of those changes may not be captured well by the economic indicators about the sector. In order to develop appropriate economic policies, we need to be able to capture more detailed data, including data about changes to productivity. At the request of the U.S. Bureau of Labor Statistics, this report evaluates changes in the retail trade sector, assesses measures of employment and labor productivity for the sector, and recommends a new satellite account that could measure retail-related employment and labor productivity in ways that would better capture the transformation."--

The USAir Force human capital management (HCM) system is not easily defined or mapped. It affects virtually every part of the Air Force because workforce policies, procedures, and processes impact all offices and organizations that include Airmen and responsibilities and relationships change regularly. To ensure the readiness of Airmen to fulfill the mission of the Air Force, strategic approaches are developed and issued through guidance and actions of the Office of the Deputy Chief of Staff for Manpower, Personnel and Services and the Office of the Assistant Secretary of the Air Force for Manpower and Reserve Affairs. Strengthening US Air Force Human Capital Management assesses and strengthens the various U.S. Air Force initiatives and programs working to improve person-job match and human capital management in coordinated support of optimal mission capability. This report considers the opportunities and challenges associated with related interests and needs across the USAF HCM system as a whole, and makes recommendations to inform improvements to USAF personnel selection and classification and other critical system components across career trajectories. Strengthening US Air Force Human Capital Management offers the Air Force a strategic approach, across a connected HCM system, to develop 21st century human capital capabilities essential for the success of 21st century Airmen.

"One of the holy grails in biology is the ability to predict functional characteristics from an organism's genetic sequence. Despite decades of research since the first sequencing of an organism in 1995, scientists still do not understand exactly how the information in genes is converted into an organism's phenotype, its physical characteristics. Functional genomics attempts to make use of the vast wealth of data from "-omics" screens and projects to describe gene and protein functions and interactions. A February 2020 workshop was held to determine research needs to advance the field of functional genomics over the next 10-20 years. Speakers and participants discussed goals, strategies, and technical needs to allow functional genomics to contribute to the advancement of basic knowledge and its applications that would benefit society. This publication summarizes the presentations and discussions from the workshop."--

"For many years, laboratory dogs have served as important animal models for biomedical research that has advanced human health. Conducted at the request of the U.S. Department of Veterans Affairs (VA), this report assesses whether laboratory dogs are or will continue to be necessary for biomedical research related to the VA's mission. The report concludes that using laboratory dogs in research at the VA is scientifically necessary for only a few areas of current biomedical research. The report recommends that the VA adopt an expanded set of criteria for determining when it is scientifically necessary to use laboratory dogs in VA biomedical research; that the VA promote the development and use of alternatives to laboratory dogs; and highlights opportunities for the VA to enhance the welfare of laboratory dogs that are being used in biomedical research areas for which they have been deemed necessary."--

Radiation exposure at low doses (below 100 milligray) or low-dose rates (less than 5 milligray per hour) occurs in a wide range of medical, industrial, military, and commercial settings. The effects of exposure at these levels are not fully understood, but there are long-standing concerns that such exposure could negatively affect human health. Although cancer has been linked to low-dose radiation exposure for decades, there is increasing evidence that low-dose radiation exposure may also be associated with cardiovascular disease, neurological disorders, immune dysfunction, and cataracts. Recent advances in research, new tools, and a coordinated multidisciplinary research program could help fill knowledge gaps about the health impacts of low-dose radiation exposures. This report calls for the development of a U.S. research program to study how low doses of radiation affect cancer, cardiovascular disease, neurological disorders, and other disease risks. Research should also better define the impacts of radiation doses, dose rates, types of radiation, and exposure duration. The report estimates $100 million annually for the next 15 years would be required to conduct epidemiological and biological research, and to establish an infrastructure for research.

"The US Global Change Research Program (USGCRP) is a collection of 13 Federal entities charged by law to assist the United States and the world to understand, assess, predict, and respond to human-induced and natural processes of global change. Global Change Research Needs and Opportunities for 2022-2031 advises the USGCRP on how best to meet its mandate in light of climate change impacts happening today and projected into the future. This report identifies critical climate change risks, research needed to support decision-making relevant to managing these risks, and opportunities for the USGCRP's participating agencies and other partners to advance these research priorities over the next decade." --

"Transplantation of a solid organ, such as a kidney, heart, or liver, is a lifesaving procedure and is sometimes the only viable treatment for patients experiencing end-stage organ failure as a result of illness or injury. A growing prevalence of solid organ diseases in the United States is contributing to more people needing a transplant and longer wait times on the national transplant waiting list. While transplantation can lengthen a person's life, the road to recovery is difficult and complex. Transplant recipients commonly experience considerable impairments related to health factors, medication side effects, organ rejection, or other setbacks that can cause functional limitations. A spectrum of services and supports can be beneficial to patient functioning and quality of life, but patient access is variable due to individual, system, and social factors. To gain an understanding of current scientific findings in the field of solid organ transplantation, the U.S. Social Security Administration asked the National Academies of Sciences, Engineering, and Medicine's Board on Health Care Services to organize a virtual public workshop to examine disability associated with organ transplantation. The workshop, held March 22-23, 2021, focused on kidney, heart, liver, and lung transplantation, and to a lesser extent intestine transplantation. Subject-matter experts presented on clinical aspects of post-transplantation recovery and described the implications for physical, cognitive, and psychosocial functioning in adults and children. This publication summarizes the presentations and panel discussions from the workshop." --

"Every year, significant amounts of expensive drugs are discarded. This is due in part to the growing number of prescription drugs that are administered in variable doses (rather than fixed or flat doses) based on a patient's weight or body size. Strict regulations and guidance generally prohibit or severely restrict the acceptable time frame for sharing medication from single-dose vials among patients, and so the unused amount will typically be discarded. Due to the current system for producing, administering, and paying for drugs in the United States, significant - but indeterminate - amounts of expensive prescription drugs are discarded each year. At the request of the Centers for Medicare & Medicaid Services, Medications in Single Dose Vials: Implications of Discarded Drugs explores the federal health care costs, safety, and quality concerns associated with discarded drugs that result from the weight-based dosing of medicines contained in single-dose vials."--

"A Research Strategy to Examine the Taxonomy of the Red Wolf provides independent guidance about taxonomic research on the red wolf, Canis rufus. Building from the 2019 report Evaluating the Taxonomic Status of the Mexican Gray Wolf and the Red Wolf, this report reviews and ranks research applications to determine the taxonomy of wild canid populations in southern Louisiana and other relevant locations. The report then develops a research strategy to examine the evolutionary relationships between ancient red wolves, the extant managed red wolf populations, and the unidentified canid populations." --

"Current von Neumann style computing is energy inefficient and bandwidth limited as information is physically shuttled via electrons between processor, short term non-volatile memory, and long-term storage. Biologically inspired neuromorphic computing, with its inherent autonomous learning capabilities and much lower power requirements based on analog processing, is seen as an avenue for overcoming these limitations. The development of nanoelectronic "memory resistors", or memristors, is essential to neuromorphic architectures as they allow logic-based elements for information processing to be combined directly with nonvolatile memory for efficient emulation of neurons and synapses found in the brain. Memristors are typically composed of a switchable material with nonlinear hysteretic behavior sandwiched between two conducting encoding elements. The design, dynamic control, scaling and fundamental understanding of these materials is essential for establishing memristive devices. To explore the state-of-the-art in the materials fundamentally underlying memristor technologies: their science, their mechanisms and their functional imperatives to realize neuromorphic computing machines, the National Academies of Sciences, Engineering, and Medicine's Board on Physics and Astronomy convened a workshop on February 28, 2020. This publication summarizes the presentation and discussion of the workshop." --

A widespread and rapid transition to a low-carbon energy system by 2050 is essential to keep pace with ambitious policy goals and avoid the worst consequences of climate change. Innovation is necessary to lower costs and improve performance of existing technologies and to develop new clean energy options that address challenges in harder-to-decarbonize sectors. To examine means by which the U.S. federal government can rise to this challenge, the National Academies of Sciences, Engineering, and Medicine hosted a virtual workshop series "Enhancing Federal Clean Energy Innovation" on July 27 to August 7, 2020. The workshop featured timely, action-orientated assessments of how to strengthen development and penetration of new clean energy technologies. This publication summarizes the presentations and discussions that occurred over the course of the workshop.

In 2018, the National Academies of Sciences, Engineering, and Medicine issued an Interim Report evaluating the general viability of the U.S. Department of Energy's National Nuclear Security Administration's (DOE-NNSA's) conceptual plans for disposing of 34 metric tons (MT) of surplus plutonium in the Waste Isolation Pilot Plant (WIPP), a deep geologic repository near Carlsbad, New Mexico. It provided a preliminary assessment of the general viability of DOE-NNSA's conceptual plans, focused on some of the barriers to their implementation. This final report addresses the remaining issues and echoes the recommendations from the interim study.

From 1962 to 1971, the U.S. military sprayed herbicides over Vietnam to strip the thick jungle canopy that could conceal opposition forces, to destroy crops that those forces might depend on, and to clear tall grasses and bushes from the perimeters of US base camps and outlying fire-support bases. Mixtures of 2,4-dichlorophenoxyacetic acid (2,4-D), 2,4,5-trichlorophenoxyacetic acid (2,4,5-T), picloram, and cacodylic acid made up the bulk of the herbicides sprayed. The main chemical mixture sprayed was Agent Orange, a 50:50 mixture of 2,4-D and 2,4,5-T. At the time of the spraying, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), the most toxic form of dioxin, was an unintended contaminant generated during the production of 2,4,5-T and so was present in Agent Orange and some other formulations sprayed in Vietnam. Because of complaints from returning Vietnam veterans about their own health and that of their children combined with emerging toxicologic evidence of adverse effects of phenoxy herbicides and TCDD, the National Academies of Sciences, Engineering, and Medicine was asked to perform a comprehensive evaluation of scientific and medical information regarding the health effects of exposure to Agent Orange, other herbicides used in Vietnam, and the various components of those herbicides, including TCDD. Updated evaluations were conducted every two years to review newly available literature and draw conclusions from the overall evidence. Veterans and Agent Orange: Update 11 (2018) examines peer-reviewed scientific reports concerning associations between various health outcomes and exposure to TCDD and other chemicals in the herbicides used in Vietnam that were published between September 30, 2014, and December 31, 2017, and integrates this information with the previously established evidence database.

Injury and death from use of excessive force by police officers remain a common concern in countries across the globe. Despite local, national, and international attempts to legislate and provide guidance for police use of force, there continue to be global accounts of excessive force by law enforcement. Reports of officer-involved killings, injuries to citizens, and attempts to control protests and demonstrations with chemical irritants, rubber bullets, and sometimes shooting into crowds with live ammunition frequently appear in the press worldwide. However, reliable data on and accounting for these incidents are both lacking. A large network of international and regional organizations, bilateral donors, international financial institutions, and civil society organizations aim to work with governments to improve policing practices and reduce police use of excessive force. As a part of that network, the U.S. Department of State, through its Bureau of International Narcotics and Law Enforcement Affairs (INL), provides foreign assistance to and supports capacity building for criminal justice systems and police organizations in approximately 90 countries. Like many donors, it strives to direct its resources to the most effective approaches to achieve its mission. Policies and Practices to Minimize Police Use of Force Internationally, the third in a series of five reports produced for INL, addresses what policies and practices for police use of force are effective in promoting the rule of law and protecting the population (including the officers themselves). This report looks at what is known about effective practices and their implementation and identifies promising actions to be taken by international donors in their efforts to strengthen the effectiveness of law enforcement agencies.

The U.S. Social Security Administration (SSA) administers the Social Security Disability Insurance program and the Supplemental Security Income program. As part of their process, immune system disorders are evaluated under Listing of Impairments 14.00 for adults and 114.00 for children. At the request of the SSA, the National Academies of Sciences, Engineering, and Medicine assembled a committee to review selected conditions related to the immune system. In particular, the SSA was interested in the current status of the diagnosis, treatment, and prognosis of immune system disorders including systemic lupus erythematosus (SLE), scleroderma, polymyositis, Sjögren's syndrome/disease, and inflammatory arthritis. This report provides an overview of the current status of the diagnosis, treatment, and prognosis of these immune system disorders in the U.S. population and the relative levels of functional limitation typically associated with them, common treatments, and other considerations.