Child and adolescent injury is one of the leading causes of child death globally with a large proportion occurring in Low- and Middle-Income Countries (LMICs). Similarly, the Eastern Mediterranean Region (EMR) countries borne a heavy burden that largely impact child and adolescent safety and health in the region. We aim to assess child and adolescent injury morbidity and mortality and estimate its burden in the Eastern Mediterranean Region based on findings from the Global Burden of Disease (GBD), Injuries and Risk Factors study 2017.Data from the Global Burden of Disease GBD 2017 were used to estimate injury mortality for children aged 0–19, Years of Life Lost (YLLs), Years lived with Disability (YLDs) and Disability Adjusted Life Years (DALYs) by age and sex from 1990 to 2017.In 2017, an estimated 133,117  children died in EMR compared to 707,755  globally. The highest rate of injury deaths was reported in Syria at 183.7 (95% UI 181.8–185.7) per 100,000 population. The leading cause of injury deaths was self-harm and interpersonal violence followed by transport injury. The primary cause of injury DALYs in EMR in 2017 was self-harm and interpersonal violence with a rate of 1272.95 (95% UI 1228.9 – 1319.2) almost 3-times the global rate.Almost 19% of global child injury related deaths occur in the EMR. Concerted efforts should be integrated to inform policies and adopt injury preventive strategies to reduce injury burden and promote child and adolescent health and well-being in EMR countries. Injury represents one of the leading causes of death and disability in the world, claiming more than 4·4 million lives in 2017 and imposing a substantial burden on global health  and 2017 [3639.7 (UI 3425.8–3846.3)]. The rate of DALYs decreased in 2017 in some EMR countries including Sudan , Iran , and Afghanistan , while increased tremendously up to six folds its early rate in other EMR countries including Syria , Iraq (6694.9) and Yemen (6397.9).In 2017, in EMR countries Socio-Demographic Index (SDI) spans from 0.29 in Afghanistan to 0.79 in Kuwait and the United Arab Emirates. EMR countries with low SDI sustain a high toll of child injury related deaths and DALYs rates exacerbated by ongoing regional war and conflicts including Syria [183.6 (UI 181.8–185.6)], Iraq [(80.12 UI 77.1–83.6)] and Yemen  and Oman [1341.2 (1096.8–1550.2)].Our study shows a high burden of child and adolescent injury morbidity and mortality in the Eastern Mediterranean region. Accounting for almost 8% of the global population, The EMR population bears up to 19% of global child injury related deaths in the world. Injury represents the leading causes of child and adolescent deaths in EMR, surpassing deaths caused by major diseases combined including Malaria, tuberculosis and HIV , and wilFindings from this study’s systematic analyses of child and adolescent injuries shows an evident decrease in the injury mortality rate in EMR countries across time from 1990 to 2017. Nevertheless, this declining rate varies according to mechanisms of injury. While an apparent reduction was reported in death rates for ‘transport injury’ and ‘other unintentional injuries’, ‘self-harm and violence’ injury showed a significant upsurge in mortality rate, more than a 3-fold increase over time from 1990 to 2017. In the first 2 decades 1990–2010, all EMR countries, with no exception, witnessed a clear reduction in injury morbidity and mortality rates. Nevertheless, with the political unrest and protracted conflicts, many countries showed a turning point during the 2010–2017 period of time with sharp resurged inclines in injury morbidity and mortality rates, particularly among regions suffering from wars and conflicts including Syria, Iraq and Yemen that recounted a considerable increase in their death rates from 2010 to 2017, reaching in some countries up to 14-fold its 2010 deaths status.Despite its human and economic impact, injury remains a neglected public health problem in the EMR due to multiple reasons, including mainly protracted regional wars, perpetual political instabilities and conflicts that continue to strongly distract regional health policies and priority programs. Although the rates of injuries in EMR have decreased over the last two decades, the number of child mortality and morbidity associated with war and violence had increased at an unprecedented rate over the last few years, overpassing global regions suffering similar instabilities and violence including African countries. Despite the substantially high number of children killed in African region as a result of internal conflict and sectarian violence , the ratRoad traffic injuries represent another major threat to the health and well-being of children and adolescents, particularly in high income EMR countries. Compared to global estimates, EMR reported high rates of road crashes deaths and injuries mainly due various factors that exacerbate current road hazards and render the environment adversely unsafe and risky and lead to a substantial increase in the number of road crashes responsible for fatalities and long-term disabilities, particularly among the adolescent population –9, 20–25Our study revealed that EMR countries with different SDI levels have large disparities in injury death rates. In the EMR, even countries with high SDI have higher burden from injuries compared to countries with the same level of development. These patterns maybe due to higher risk factors, poor access to health care, and lack of quality health care in these countries. Indeed, these findings call for increased programs and interventions to address the burden of injuries in the EMR region among all countries. Moreover, countries with high SDI and financial means are urged to better address the burden and to have more focused interventions from prevention, response, and treatment.War and Conflict Emergency Plan: The high rates of children and adolescents being victims of self-harm and violence in EMR reflect the destructive impact of armed conflicts on children and adolescents in the region. It is imperative to provide children special protection during wars and man-made disasters to prevent premature deaths and serious injuries. Emergency preparedness plans and child protection humanitarian response should be activated at the onset of any crises  [nflicts) , 27. AdePolicies, Laws and Enforcement: Informing injury prevention policies and laws are pivotal to reducing injuries. Enforcement of safety regulations is key to curtail injury-associated deaths and reduce serious injuries. Many EMR countries have safety laws and legislations in place, however lack of enforcement adversely limits their effects on reducing injury morbidity and mortality. There is an urgent need for EMR to implement and enforce safety policies to control for many types injuries, including transport related injuries- a largely preventable and leading cause of deaths among adolescents.Emergency Medical Services and Healthcare Access: The absence of responsive and timely Emergency Medical Services (EMS) negatively affect patient survival and outcome [ outcome . EMR cou outcome , 30.Injury Surveillance Systems: A limited number of EMR countries have national injury surveillance systems and trauma registries [gistries –34. Exisgistries , 36. InjEducation and Awareness: Educational and awareness programs play a pivotal role in improving people’s knowledge and informing them about various mechanisms of injuries and their associated risk factors [ factors . AwareneConcerted efforts and multi sector approaches should be integrated to save lives and control injuries in EMR. In this paper we propose six recommended strategies that can be adopted to effectively reduce injuries and mitigate their impacts on the child and adolescent population:There are limitations to this study. Firstly, we are using GBD injury categorization and are limited to these categories for our study analyses. Nevertheless, since GBD adopts a systematic approach, these categories allows us to compare between countries of the Eastern Mediterranean Region, children ages, sex, and display trends of injuries over time. Secondly, the study analysis mainly relies on available yet limited EMR injury data. Many EMR countries lack injury surveillance programs, vital statistics, health information systems and trauma registries. Existing hospital administrative and police reports data are inherently limited and suffer from major shortcomings when reporting injury morbidity and mortality. War-affected EMR countries are far more prone to the absence of reliable and well-documented health data. Consequently, many modeling techniques were adopted to fill in this gap in data and estimate the injury burden in EMR countries. Thirdly, the study findings are solely reporting the physical damage sustained by injuries without accounting for the indirect effects of injuries including the psychosocial impact of injuries on the health and well-being of children and adolescents in EMR and its repercussions on their mental health. Fourthly, the number of sustained interpersonal violence may be inaccurate, as it has the tendency of being potentially underreported due to the nature of violence in some EMR countries under fire and the possibility of cover up in other countries with restricted reporting of sensitive information.This study complements exhibiting studies addressing the injury health problem in the Eastern Mediterranean Region , 8, 21. This study analyzed and documented the burden of children and adolescents’ injury morbidity and mortality in the Eastern Mediterranean Region. EMR bares one of the highest rates of child and adolescent injuries and deaths globally. These injuries impose tremendous strains on local health care systems, depleting their infrastructure and limited resources. The noticeable massive number of child morbidity and mortality was impacted by few war-ridden countries and presented a critical indicator on children and adolescents threatened safety and well-being in the region. Reducing child and adolescent injury morbidity and mortality is of utmost importance to substantially lessen the burden on healthcare systems and to secure prosperity and thriving future for this region. Child and adolescent threatened health adversely affects the region’s social and economic progress, particularly with deaths and disabilities affecting the economically active and productive youth population. Findings from this study urge for immediate actions to be taken to protect children in armed conflicts and war zones and to develop and implement safety policies and strategic preventive measures to reduce child injuries and mitigate their impacts on EMR countries.


Successful management of an event where health-care needs exceed regional health-care capacity requires coordinated strategies for scarce resource allocation. Publications for rapid development, training, and coordination of regional hospital triage teams to manage the allocation of scarce resources during coronavirus disease 2019 (COVID-19) are lacking. Over a period of 3 weeks, over 100 clinicians, ethicists, leaders, and public health authorities convened virtually to achieve consensus on how best to save the most lives possible and share resources. This is referred to as population-based crisis management. The rapid regionalization of 22 acute care hospitals across 4500 square miles in the midst of a pandemic with a shifting regulatory landscape was challenging, but overcome by mutual trust, transparency, and confidence in the public health authority. Because many cities are facing COVID-19 surges, we share a process for successful rapid formation of health-care care coalitions, Crisis Standard of Care, and training of Triage Teams. Incorporation of continuous process improvement and methods for communication is essential for successful implementation. Use of our regional health-care coalition communications, incident command system, and the crisis care committee helped mitigate crisis care in the San Diego and Imperial County region as COVID-19 cases surged and scarce resource collaborative decisions were required. San Diego County public health officials gained early management experience with the coronavirus disease 2019 (COVID-19) pandemic as the site for quarantine of US citizens evacuated from Wuhan and cruise ship passengers to Marine Corps Air Station Miramar, which required some local hospitalizations in early February 2020.2 news reports of rapidly rising death rates, infected health-care workers, and health system capacity issues in China, Italy, and Washington State, accelerated our preparedness activities. In collaboration with hospital and operational leadership, community health centers, the Hospital Association of San Diego and Imperial Counties (HASD&IC), and the San Diego County Medical Society (SDCMS), San Diego adopted a 3-pronged strategy for COVID-19 management.3 The framework was to: (1) flatten the curve ; (2) enhance health-care system capacity4; and (3) use an Incident Command System to coordinate and manage resources. San Diego leaders additionally recognized the need to develop a system for Crisis Care that would be ethical and equitable throughout the region in the event that the pandemic evolved to the point where local population health needs exceeded available resources.5 This study describes the process for rapid development of a regional collaborative health-care coalition to optimize scarce resource allocation during COVID-19. Other communities may benefit from the key principles used to create the coalition, the step-by-step processes used to rapidly achieve consensus on a complex topic, ways to include a diverse group of participants, use of virtual communication platforms, and methods for education.When the first San Diego County resident with COVID-19 was identified on March 9, 2020,Establish a county-wide mechanism for shared resource allocation, multi-stakeholder vetting, and a communication process for the establishment of Crisis Care.6Rapidly educate local, community, and hospital systems about the steps necessary for a systematic process to those unfamiliar with the prior Institute of Medicine/National Academies (IOM/NAM) or state frameworks.Complete the above in an abbreviated timeframe  during an environment of rapid regulatory change and evolving science surrounding COVID-19.Communicate virtually due to COVID-19 isolation restrictions.Create Triage Teams and provide training tools for hospital systems.On March 11, 2020, when the World Health Organization (WHO) declared COVID-19 a pandemic and due to the accelerating concerns witnessed around the world, the San Diego County Medical Society and the San Diego Bioethics Commission engaged the County health officials regarding plans for the potential allocation of scarce resources during a surge of patients . By mid-7 The San Diego area maintains collaborative relationships through health system disaster coordinators and the county; however, intensivists are not commonly involved in regional planning and meeting activities, and few physicians can leave patient care responsibilities to prepare for what may be a “never-event.”8 This has resulted in a lapse in knowledge of the formation of health-care coalitions, roles, responsibilities and the Incident Command System (ICS). Using some of the updated framework by the American College of Chest Physicians and the Society of Critical Care Medicine, multiple members worked simultaneously to engage various stakeholders.11 Following US national health-care preparedness guidance,12 our approach also included coordination with the regional ICS. The San Diego ICS involves both an Emergency Operations Center (EOC) and a Medical Operations Center (MOC). Once it was determined that the County elected leadership and the Public Health Officer would be the declaration authority if state or federal declaration was absent for Crisis Care, health-care systems’ alignment rapidly formed.As originally described by Courtney et al. in 2009, the formation of Health-Care Coalitions is vital to respond to a mass critical care event and share resources in a coordinated manner.Regional Public Health/Government AuthorityAdministrative support from Professional Medical Society representativesLeadership from Chief Medical Officer and Chief Executive Officer during weekly  meetings and triage team training14Engagement of each hospital Intensive Care Unit (ICU), Ethics, Triage, and Extracorporeal Membranous Oxygen (ECMO) workgroups designated by leaders from each hospital system, including the Veteran’s Administration (VA), Kaiser, UC San Diego, and the US NavySelection and formation of Community Crisis Care Committee. Representing San Diego area’s Pulmonary, Critical Care, Hospitalists, Out-Patient, Emergency, and Pediatric Medicine, Behavioral/Wellness/Mental Health, Community Health Advocates, Clergy, Government, Hospital Administration, SDCMS Leaders, Medicaid, Nursing, Bioethics, Palliative Care, Hospice, Veterans, Homeless, and Legal Services. Several members represented more than 1 sector. This committee met weekly.Formation of a A core group of 4 individuals was able to initiate the framework for coalition and workgroup formation . Organiz15 There was enthusiastic engagement from all stakeholders who attended videoconferences, frequently lasting over 2 h each. Plans and resource adaptation ideas were freely exchanged among institutions, reflecting the trust provided by leadership authorities toward the workgroups. Mutual trust, transparency, and respect are a necessary requirement for effective coalition development and cannot be understated. During this busy period of activity, short-notice meetings were frequent and at times neglected the hospital ICS (HICS). This early weakness was improved by use of redundant communication and providing advanced notification to workgroup members and executives of meetings.Workgroup and Committee members were solicited by means of email requests to area hospital leaders and disaster experts. Once key members were identified, word rapidly spread regarding the County’s collaborative work and nearly every hospital in the region became engaged. Recommendations from workgroups were discussed with the Crisis Care Committee for feedback regarding fairness and elimination of bias. Throughout this week of planning, teams were informed by, and rapidly adapted to, national and international events as well as evolving ethical debates about scarce resource allocation.17 The shift to population-based health triage as a concept is only used when a health system’s ability to surge has been maximized and exceeded.To ensure resources are shared fairly in the setting of scarcity, it is essential that the triage process for patients requiring critical care resources be consistent across all hospital systems, and includes access to relevant subspecialty expertise. The goals of crisis care triage shift the standard practice of individual patient considerations to a broader population-based public health to extend scare critical resources to ensure the survival of the largest possible number of patients. Identifying patients who might need critical care resources and defining their individual risks for mortality become key to maximize the greatest good for the greatest number.18 The following principles were instrumental in the development and formation of Triage Teams.Health-care systems have triage officers with the following qualities: (a) critical care triage training to provide optimum allocation of resources; (b) situational awareness at both a regional and institutional level; (c) experience in care of the patient being triaged; (d) individual triage officers or teams consisting of a senior critical care physician and an acute care  physician or nurse be designated to make mass critical care triage decisions in accordance with previously prepared, publicly vetted, and widely disseminated guidelines.A vetted triage protocol (SD Crisis Consensus Care Draft document), rather than clinical judgment alone, will be used.Health-care systems will leverage technology in triage to augment clinical assessment in an effort to improve incremental survival and efficiency of resource allocation.The triage decision process will have an appeals mechanism in case of deviation from an approved process (which may be a prospective or retrospective review) or a clinician request for reevaluation in light of novel or updated clinical information (prospective).Intensivists should leverage telemedicine and other technologies when possible to assist those health-care systems with few or no intensivists to help with triage.There will be legal protections for providers conducting triage in a disaster as well as a psychological support system for triage officers and health-care providers. When legal protection is not possible, providers need to follow acceptable, consensus-based community standards of care pertaining to triage in mass critical care.Intensivists should work within their local and regional health-care system to determine the plan for augmentation of critical care resources to care for as many patients as possible. Resources should be shared across geographic regions to maximize lives saved.Triage is a dynamic process that may change rapidly based on available resources, knowledge of the disease process, patient volume, and acuity.To implement Crisis Care and triage of scarce resources, committee organizers established Triage Teams and created Job Action Sheets within HICS.19 Because triage is designed to be used on all patients, it was, therefore, essential to have subspecialty expert input  to ensure fairness for all clinical conditions is built into the triage algorithm. Nonstandardization of hospital medical record systems and variable personnel resources created additional challenges in creating a uniform and unbiased triage team. This was overcome by sharing technological solutions, providing written protocols, and training as an entire county system. All San Diego hospitals identified triage personnel that would be on-call, should a crisis level of surge be declared and crisis standard of care triage need to be implemented . Although each hospital had no visibility of other hospitals’ data, each had seen the aggregate county-wide data during this pandemic and previous surge conditions from influenza and fire seasons. Using the currently available Emergency Medical Services (EMS) data, we created a data workgroup that requested a red-yellow-green display of Staff, Stuff, and Structure to visualize resource capacity. This permits the MOC and Crisis Care Committee Members to determine at a glance if the supply of resources is adequate, or to quickly focus on areas that are low or critically low. Unique to this pandemic, hospital triage officers, CEOs, and CMOs requested to view others’ data, as well as share their own in real time. To achieve the mission, they insisted not only to know the status of their own hospital’s resources, but also to be aware when their neighboring hospital was beginning to run low, so they could prepare to share their own resources.Tabletop exercises are commonly used by emergency management for face to face simulated education of staff roles and responsibilities during disasters. As it pertains to triage education, a tabletop exercise allows the creation of a nonthreatening environment where new triage officers  can reheIn preparing triage officers from area hospitals, San Diego conducted virtual tabletop exercises using Zoom. Our training objectives were to review the regional criteria for transitioning from first-come-first-served patient care to a triage process during crisis standards of care, review the roles and responsibilities of triage officers, practice using the triage protocol in 5 case scenarios, and to use feedback from the case scenarios to further refine the triage protocol. Using Zoom’s virtual break-out rooms, San Diego County successfully conducted tabletop exercises for more than 70 participants at a time, representing all San Diego acute care hospitals and integrated health systems. In addition to a successful training exercise, this permitted the identification of a challenge within the triage protocol, which was able to be remedied through a small modification by the Triage Tool workgroup. The exercises facilitated greater exposure of the triage protocol to the intended audience and resulted in a better instrument.20 (see an example in the Appendix). Due to the separation of patients from family members for safety during COVID-19, the challenge of providing information to patients and family members has been considered and will require duplication of staff efforts and multi-media publication efforts.To achieve the ethical responsibility of transparency, a subgroup was formed from the Crisis Care Committee to create a communication plan for the public in the event of scarce resource allocation. The goal of this endeavor was to mitigate fear, encourage continued social distancing, and offer assurance to the public that the county and community was actively involved in planning for contingency and crisis. This subgroup created a handout for distribution to patients/families if admitted to a hospital when Crisis Standards are invoked. In executing the ethical duties of distributive and procedural justice, the goal of this undertaking is to ensure that every person admitted to any hospital in the county will receive the same information and be subject to the same allocation criteria regardless of the particular hospital21 and to provide a neighboring county that evacuated over 500 patients with protocols based upon the work done in San Diego. As COVID-19 cases accelerated in Southern California, the ECMO workgroup activated, sharing protocols and agreements. The hospital systems’ coalitions, led by hospital chief medical officers and chief executive officers have now assumed the responsibilities for Crisis Care in San Diego following release of California State guidelines in late June 2020.22 The work done by the Crisis Care Committee of San Diego laid the foundation for resource sharing which has mitigated scarce resource situations.As a result of the collaborative process in formation of clinical workgroups, hospital systems communication, and working within the SD County Incident Command System, the Crisis Care Committee and health-care coalitions have been able to assist with the initial allocation of remdesivir provided by means of the federal governmentWithin a span of 3 weeks, San Diego County was able to implement a triage allocation process and form health-care coalitions in response to the COVID-19 pandemic crisis. As the surge of COVID-19 patients outstrips medical resources throughout the world, the need for health-care systems to work together with public health authorities to share scarce resources is more important than ever. Although national and state/regions may develop guidelines for allocation of scarce resources, implementation is at the hospital, clinician, and patient bedside level. This requires changes in communication by means of an incident command system, understanding the concept of triage, and development of transparent situational awareness for providers, the public, government, and health-care systems. To date, only 23 U.S. states have Crisis Care guidelines, and our work was formed during a time when California was developing and revising the state protocol. By addressing this gap, we realized that the process of community, hospital systems, providers, and public health engagement resulted in open and frank communication, establishment of trust and transparency, a pathway to sharing resources, and a method for continuous improvement. Plans for nephrology, pediatrics, and more detailed community engagement are actively being addressed. This dynamic process will be sustained and will provide the foundation for ongoing COVID-19 and other disaster response activities in the region.


This presentation focuses on the development of and recruitment for a Spanish language version of EPIC, a group-based dyadic intervention for people with early-stage dementia (EPs) and their care partners (CPs). EPIC involves activities for the entire group together, separate EP or CP groups, and one individualized session for each dyad. EPIC builds on components of SHARE combined with strategies from other psychoeducational interventions . Findings from 6 focus groups with Latino participants were used to help with cultural responsiveness such as fluent Spanish/bilingual staff, testimonials from Latino families affected by dementia, and minimization of “threatening” language for memory loss. Participants also provided suggestions for recruitment for Spanish speakers such as engaging promotores, using social media across generations, recruiting through Spanish language health classes, and recognizing the impact of the political environment. The presentation will review both recruitment successes and challenges using these approaches.


To examine food and beverage purchasing patterns across formal and informal outlets among Mexican households’ and explore differences by urbanicity and income.Cross-sectional study of a nationally representative sample of households. We calculated the proportion of total food and beverage expenditure in each household by food outlet type overall and by urbanicity and income. We defined informal outlets as those which are not registered or regulated by tax and fiscal laws. Since some of the outlets within community food environments do not fall in clear categories, we defined a continuum from formal to informal outlets, adding mixed outlets as a category.Mexico.n 74 203) from the 2018 National Income and Expenditure Survey.Mexican households  accounted for 15 % of the purchases, 13 % of purchases occurred in outlets within the informal food sector  and 70 % in fiscally mixed outlets . Across levels of urbanicity and income, most food and beverage purchases occurred in mixed outlets. Also, purchases in informal and mixed outlets decreased as levels of urbanicity and income increased. In contrast to informal outlets, purchases in formal outlets were most likely from richer households and living in larger sized cities.Understanding where Mexican households shop for food is relevant to create tailored interventions according to food outlet type, accounting for regulatory and governance structures. Public policies aimed at regulating food outlets could contribute to increasing healthy food access and decrease the burden of obesity and obesity-related non-communicable diseases. Several studies have analysed the link between the food environment, diet quality, obesity and non-communicable diseases,4. Yet, community food environment research has predominantly been undertaken in high-income countries, where most food is sold in the formal sector, such as supermarkets, grocery stores and convenience stores. While low- and middle-income countries have experienced an increasing penetration of formal food outlets,6, the informal food environment remains a critical component of the community food environment–9; however, it is rarely described or studied.A promising approach to improving population-level dietary patterns and associated health outcomes is to intervene in the community food environment, that is, the environment in which food purchasing decisions are made. Community food environment research in low- and middle-income countries, such as Latin America, has been scarce and has focused on formal environments due to lack of data availability–15. While several dietary intake and food purchasing studies show that informal vendors make a significant contribution to energy and protein intake in low- and middle-income countries,16, the majority of research on the informal food sector focuses on food safety and contamination. Most studies recognise the lack of information on informal food markets as a major limitation,18,19. Studies showing that informal food outlets are an important source of food provision are predominantly focused on disadvantaged populations in big cities,16,18,20 and are limited in geographical scope. Most of these studies have focused on specific cities and have not examined empirically for the entire Mexican population how these food consumption patterns vary across households’ socio-economic status and urbanicity. In particular, research on food consumption and urbanisation in low- and middle-income countries have found that differences across the rural–urban continuum behave similarly to socio-economic status, finding that urban areas consume more from formal outlets,22; however, these studies have not included informal food and beverage outlets.Informal food vendors are highly heterogeneous, ranging from highly mobile solitary vendors of a single food to well-organised itinerant street markets,18,23–26. While the national statistics bureaus attempt to quantify the percentage of the Gross Domestic Product that belongs to the informal sector; these small, family-owned establishments are not defined within sectors, depicting the inaccuracy and complication of the binary category of informality. These studies recognise that compared with cities in the USA, there is a multiplicity of food and beverage outlets that are ubiquitous and of high cultural and economic importance. Nevertheless, these studies are either limited in geographic scope or have only focused on packaged food purchases, neglecting produce purchases, products sold in bulk and products sold in informal outlets.Beyond informal food outlets, recent work has also emphasised the importance of mixed outlets, understood as small, family-owned outlets that are widespread in low- and middle-income countries, in contrast to supermarkets or chain convenience stores. However, no policies have been implemented to regulate the quality of food retailers. Due to their regulatory nature, policies that affect formal food retailers are easier to implement than policies focused on the informal sector. While the informal food sector seems to be an important source of food for the urban poor,9,20, we do not know to what extent people in different urban and socio-economic strata purchase their foods in the formal, mixed and informal food sector. By consequence, the effectiveness of food retailer policies may vary across different social groups. For example, policies that can only be implemented in the formal sector may not have an impact on people that primarily shop in the informal sector. Thus, addressing this knowledge gap can lead to more effective, equitable food policy.Mexico, like many other Latin American countries, has implemented food pricing as well as food labelling policies to improve diet healthfulness at the population levelEncuesta Nacional de Ingreso Gasto de los Hogares (ENIGH) from 2018, a nationally representative sample of Mexican households. ENIGH is unique for studying food purchases across food and beverage outlets, including the informal and fiscally mixed food sector. In this descriptive analysis, we addressed two research questions: (1) in which food outlets do Mexican households shop for food and beverages? and (2) does shopping in different food outlets vary by household income and urbanicity?We used the National Income and Expenditure Survey, known as . The 2018 ENIGH was collected between August and November. Detailed information about data collection is available elsewhere.We used data from the 2018 ENIGH, conducted by the National Institute of Statistics and Geography of Mexico (INEGI). The ENIGH is a probabilistic survey with a two-stage stratified clustered sampling design, representative at the national and state levels, and urban and rural strata. It includes data on household expenditures in food and beverages and socio-demographic characteristics such as income and place of residence. Household purchases were reported by the household member responsible for purchasing food and beverages and complemented by individual members using a food diary. The food and beverage diary compiles data on the name of the food or beverage, quantity purchased (litres and kilograms), expenditures (Mexican pesos) and the type of food outlet where the purchase was made. ENIGH also collects information on household expenditures on food consumed away from home, such as restaurants or food services.Data collectors visited each household daily for seven consecutive days to collect information on food and beverage purchasesn 438). We also excluded households that only reported purchases of animal feed, cigars, cigarettes and tobacco (n 6). The final sample size was 74 203 households.ENIGH 2018 included purchases for 74 647 households. We excluded households that did not report any food and beverage monetary purchases , acquaintances , public markets, small neighbourhood stores (abarrotes), specialty stores, low-budget restaurants , restaurants, cafeterias, bars, convenience stores, supermarkets, wholesale stores, department stores, government-owned stores, private companies where workers eat, community kitchens and government social programmes, purchases made outside the country and food sold through the Internet  street vendors; (2) street markets; (3) acquaintances; (4) public markets; (5) small neighbourhood stores; (6) specialty stores; (7) low-budget restaurants; (8) restaurants, cafes and bars; (9) convenience stores; (10) supermarkets and (11) others .. Broadly, most street vendors, street markets and acquaintances engage in operations that are not registered or regulated by fiscal and labour laws. Over the past 17 years, informal labour has accounted for 21·9 %–24·4 % of the Gross Domestic Product  in Mexico, although this includes workers within the formal sector as well. Some public markets, small neighbourhood stores, specialty stores and low-budget restaurants might also be fiscally unregulated, but we chose not to define these categories as informal because many businesses in these categories are regulated. While there are establishments that pay some taxes or have employees that have social security, it is more likely that our definition is conservative since there have been recent efforts to formalise small neighbourhood stores and specialty stores providing incentives for outlets that do not pay taxes and where employees do not have social security. While we are aware that clear-cut definitions of informality are ad hoc, we decided to include this approach since there is little evidence of Mexicans’ food purchasing patterns in these outlets. Thus, we categorised public markets, small neighbourhood stores, specialty stores and low-budget restaurants as mixed food and beverage outlets since many of these outlets are small, family-owned businesses and could be either formal or informal outlets  broad definition of informality as the production and employment carried out in unregistered establishments and without social protection. Quintile groups were created for each urbanicity separately to be able to compare cities of the same size and account for socio-economic differences within each locality . Since the results do not show dramatic differences by household size when looking at the relative contribution of each food outlet to total purchases by income and urbanicity, we did not include household size in the analysis.We also estimated the percentage of food purchases by household size to assess how household size might influence the proportion of food purchases by outlet where households shop for food  are a very important source of food purchases in Mexico, accounting for 70 % of households food and beverage purchases. These outlets also make up the greatest fraction of reported food and beverage expenditures for households in small cities and within the lowest income group. This pattern also holds when we analyse purchases within each urbanicity, showing that the largest percentage of food purchases in mixed outlets is among the lowest income households. The informal food sector accounts for 13 % of food and beverage purchases. Interestingly, our results do not show any clear pattern across income groups within each urbanicity, despite the belief that poorer households buy greater percentages of food from the informal food sector–26,37,38. Previous works from Pedraza and her co-authors–25 have also studied the variation of purchases across store-type, including mixed outlets  in their analyses and illustrating the multiplicity of outlets where Mexicans buy in. However, it is likely that these studies underestimated the proportion of purchases from mixed outlets since their data solely focused on packaged foods, excluding products like fresh produce, tortillas, meat or poultry, and ignoring the informal food sector. Moreover, they only studied areas with more than 50 000 inhabitants, overlooking how purchases vary across urbanicity. Other studies have also argued that the surge of formal retailers like supermarkets and convenience stores and the decline of informal outlets in low and middle-income countries is due to marketing by international and local supermarket chains and a notable increase of foreign direct investment. However, some studies have been critical of the ‘supermarket revolution’ thesis and its negative impact on the informal food sector,38–40.Our findings are consistent with prior studies from Latin America that show that the majority of food and beverage purchases occur in mixed food and beverage outlets provide descriptive findings across South African cities, illustrating that around 70 % of households in their survey sourced their food from informal outlets. Their study also showed different product purchasing patterns such as bulk buying in supermarkets, while basic foodstuffs are mostly purchased in informal outlets. The Hungry Cities Partnership has studied the sources of food purchases and patronage in Bangalore (India), Cape Town (South Africa), Kingston (Jamaica), Maputo (Mozambique), Mexico City (Mexico), Nanjing (China) and Nairobi (Kenya). Using this data, these studies,26 argue that formal and informal outlets coexist across cities, showing that high levels of supermarket patronage do not rule out high levels of patronage of informal food outlets. They also show that street vendors in Mexico City have the lowest percentage of patronage compared with the other cities. However, their definition of formal and informality differs from the one defined in our study, and they do not account for the quantity bought in each outlet. Other studies have also used these data to show the importance of supermarkets across cities in Africa,42 and the prevalence of certain food products across different food outlets, like wet markets selling mostly fresh produce while supermarkets rely heavily on processed foods purchasing in China. Likewise, some studies in the USA have shown the impacts that street vendors and farmers markets have on healthy food availability in lower income neighbourhoods,45. Most importantly, the variation that the informal and formal food sectors play within and between cities in these studies highlights the importance of context-specific analyses to have a better understanding of food and beverage purchasing patterns.Few studies have quantified the role of the informal food sector in contrast to supermarkets across countries, apart from the data collection effort from the African Food Security Urban Network and the Healthy Cities Partnership. Jonathan Crush and Bruce Frayne also depict a large increase in the number of supermarkets and convenience stores from 2010 to 2016 in Mexico, they do not find a decline in small neighbourhood stores or specialty stores, exposing the resilience of the mixed food sector and the expansion of multiple food and beverage outlets. Similarly, our results show that despite the ‘modernisation’ of the food environment, the prevalence of mixed food and beverage purchases holds even for households in the highest income group and in the largest cities (43 %). Our results also portray gradients across income and urbanicity strata in formal and informal outlets showing that households in the poorest stratum in rural areas purchased more in informal outlets (20 %) and less in formal outlets (1 %) than the richest households in metropolitan areas . However, a longitudinal analysis is needed to assess how fast purchases have been changing across the formal, mixed and informal sectors in the past 20 years. While we did not examine purchasing patterns longitudinally, this is the first study analysing food and beverage purchases which includes the informal food sector at a national scale. This finding is important since informal food outlets have been excluded from governmental censuses with little information gathered from these outlets.While findings from Pérez-Ferrer and her co-authors. These results also reveal that in order to create equitable interventions, we cannot have one-size-fits-all policies across informal, mixed, formal outlets. As an example of such policies, the Tax Administration Service implemented the programme Crezcamos Juntos (Let’s Grow Together) to incentivise formalisation among small neighbourhood stores and specialised stores. The programme offered a year free of taxes and discounts within the first 10 years of registration. Registering these outlets within the taxation and social security systems is a first step to recognise the importance of these outlets within community food environments so policymakers can start thinking about regulation of quality of food within these outlets. Policies intervening in the food environment must consider the cost, complexity of enforcement and existing governance structures across different food outlets. Our results provide a nuanced view of Mexico’s food environment, providing policymakers insights to create innovative policies accounting for outlets’ regulatory differences and conditions, since intervening an informal vendor is just as important as regulating a supermarket in terms of food and beverage purchases. Moreover, future studies should analyse which types of food and beverages are being purchased in each outlet to have more impactful policies.In order to design programmes and public policies to improve the community food environment, we first need to understand where people purchase their food. Until now, most potential interventions are thought within the formal food sector; however, as our results show, people buying in these outlets are most likely from richer households and living in larger cities. The proportion of households in the highest income level and most urban level accounts for 9·6 % of the overall population. By disaggregating households by income and urbanicity, we show that households buying the largest proportion of foods at supermarkets account for a small percentage of the population. Thus, public policies neglecting the mixed and informal food sector are impacting a small proportion of the population and potentially promoting greater health disparities, targeting more advantaged populations who already have a lower burden of obesity and associated chronic diseases. It is likely that data on food and beverage purchases are underestimated differently across food outlets, underestimating household purchases in smaller outlets more than in larger outlets. Second, it is also important to acknowledge that purchases are not equivalent to consumption. Not all foods purchased at a store are consumed, and we were not able to account for food waste. In addition, if purchases vary across the year, the data may have seasonality issues since it only captures purchases from August to November.Despite the richness of data provided by ENIGH, our analysis is not without limitations. First, data on food and beverage purchases are commonly underestimated,50. Third, we created an ad hoc categorisation of informal, mixed and formal outlets. Without an international standard definition of informality, the categorisation of stores as formal, informal and mixed becomes complex and reflects the limitations of quantifying informality. The main challenge was that ENIGH does not provide the name of the establishments where purchases were made. The only information we had is the type of store, limiting our ability to determine whether a specific mixed store tends more towards a formal establishment or an informal one.However, the nutritional profile of purchases is correlated with diet quality as measured by 7 d, 24-h recalls and therefore a good representation of an entire week overall intakeWe chose to create a strict fiscal definition even though many public markets, small neighbourhood stores, specialty stores and low-budget restaurants can also be unregulated in terms of social security and tax and fiscal laws. However, despite our conservative definition, 13 % of all food and beverage purchases occur in the informal food sector. These limitations notwithstanding, we have presented the most comprehensive view of the types of food outlets from which Mexicans purchase food across different urbanicities and social strata. Strengths of the ENIGH data include the large, nationally representative sample and that purchases were assessed daily via recurring interviewer visits, that the food source was captured for each purchase and, critically, that food retailers included the formal, mixed and informal sector.In summary, small neighbourhood stores and specialty stores are the main source of food and beverage purchases in Mexico, across all income strata and levels of urbanicity. Purchases from the formal and informal sector represent the same proportion of total food purchases in Mexico. Understanding where Mexican households shop for food is relevant for designing outlet-focused food policies and interventions. Future studies should analyse how these food and beverage shopping patterns have shifted across time to quantify the ‘modernisation’ of the food environment and the scope of impact on mixed and informal outlets. Future work should also examine the quality of food and beverages across all outlets, studying how these purchases vary across urbanicity and income level.


Here, we review current understanding  on the impact of OA on marine sources of key climate-active trace gases, including dimethyl sulfide (DMS), nitrous oxide (N2O), ammonia and halocarbons. We focus on DMS, for which available information is considerably greater than for other trace gases. We highlight OA-sensitive regions such as polar oceans and upwelling systems, and discuss the combined effect of multiple climate stressors (ocean warming and deoxygenation) on trace gas fluxes. To unravel the biological mechanisms responsible for trace gas production, and to detect adaptation, we propose combining process rate measurements of trace gases with longer term experiments using both model organisms in the laboratory and natural planktonic communities in the field. Future ocean observations of trace gases should be routinely accompanied by measurements of two components of the carbonate system to improve our understanding of how in situ carbonate chemistry influences trace gas production. Together, this will lead to improvements in current process model capabilities and more reliable predictions of future global marine trace gas fluxes.Surface ocean biogeochemistry and photochemistry regulate ocean–atmosphere fluxes of trace gases critical for Earth's atmospheric chemistry and climate. The oceanic processes governing these fluxes are often sensitive to the changes in ocean pH (or  It controls not only the exchange of substances which influence the chemistry of the atmosphere and our climate, but also the transfer of essential elements vital for human health and ecosystem functioning, from the ocean to the land. The Earth system is currently facing unprecedented changes in global biogeochemical and physical processes, driven by human emissions of greenhouse gases . In this2.2), nitrous oxide (N2O) and methane (CH4), that have relatively well-understood effects on global radiative forcing and atmospheric chemistry  and a drop in pH of 0.21 units since pre-industrial times, which exceeds the global mean decline by a factor of two )To provide reliable projections of future marine emissions of climate-relevant gases, studies will need to characterize and quantify the nature of the adaptation and/or resilience of diverse trace gas-producing communities. The complexities of these investigations are compounded by the multitude of environmental changes, including OA, that affect these communities. Such studies would be complex in design and implementation, and require community-wide collaborative efforts, involving researchers from multiple disciplines and significant levels of financial investment see ,249,255),255249,2


Surprise medical bills received after care delivery in both emergency and non-emergency situations for out-of-network (OON) or other contractual health plan regulations adds additional stress upon the care guarantor, most often the patient. The passing and continued implementation of the federal No Surprises Act (NSA) and related state-level legislation continues to influence the processes of care delivery in the United States. This rapid review evaluated the literature specific to surprise medical billing in the United States since the passing of the No Surprise Act, guided by the preferred reporting items for systematic reviews and meta-analyses (PRISMA) protocol. A total of 33 articles were reviewed by the research team and the results demonstrate industry stakeholder perceptions related to two primary industry themes (constructs) surrounding surprise billing: healthcare stakeholder perspectives and medical claim dispute (arbitration) processes. Further investigation identified sub-constructs for each: the practice of balance-billing patients for OON care and healthcare provider, and facility equitable reimbursement challenges (primary theme 1), and arbitration observations and challenges surrounding (a) the NSA medical dispute process, (b) state-level arbitration processes and perceptions, and (c) use of the Medicare fee schedule as a benchmark for arbitration decisions (primary theme 2). The results indicate the need for formative policy improvement initiatives to address the generation of surprise billing. The United States (US) healthcare system continues to be challenged by the high costs of care. These costs are experienced by all healthcare stakeholders involved, including the patient, the provider, and the healthcare organization. Often, patients and/or their payment guarantor (third-party insurers/payers) are ‘surprised’ by healthcare facility or provider bills after the delivery of care has ended. Such surprises continue to spur conversation and effort to alleviate financial burdens after the delivery of care by industry leaders, and now federal and state legislators. These surprises are known to occur for both emergency and routine/non-emergency healthcare services and are usually related to care provided behind-the-scenes for the patient, or otherwise indirect care.While price transparency continues to be addressed with ongoing initiatives as related to shoppable services, either online or at the site of care delivery , effortsAdditionally, if a third-party payer processes an OON medical claim and permits some reimbursement to the medical provider and/or healthcare organization, any difference between such reimbursement and the billed charge is often balance-billed to the patient, due upon receipt. Again, processed as OON care, no contractual agreement or allowed amount fee schedule exists and the provider’s full billed charge for care will need to be paid eventually.Effective from 1 January 2022, the federal No Surprises Act (NSA) disallows any surprise OON medical bill  for patients receiving care without prior authorization from the OON provider, any OON cost sharing (to include coinsurance and/or copayment amounts for emergency and some non-emergency services), and behind-the-scenes care such as radiology, laboratory, or anesthesiology (for example) . While mMany states in the US previously adopted no surprise legislation at the state level. Both state legislation and now the federal NSA address the inability of a medical provider to balance-bill an insured patient for OON care provided without prior notice . HoweverIndependent Dispute Resolution (IDR) is the process used per the federal NSA to address any disagreement in amount due for care as a result of a surprise medical bill. This is an arbitration approach where a dispute is submitted, and an arbitrator makes a binding decision on the matter in the end. Here, both parties (often the insurer and the provider/organization) offer an amount to be paid and one side is selected by the arbiter ,6. ThereTo date, limited research has been conducted to investigate the industry perceptions and challenges related to surprise billing and the federal No Surprises Act (NSA) and ongoing state-level legislation. While financial studies imply the potential for industry challenges and benefits from the legislative efforts, further understanding of the application of policy upon the industry and those receiving care is needed to address potential policy implications and contribute to the policy revision process. To our knowledge, no rapid systematic literature review surrounding perceptions and observations of surprise billing associated with the NSA has been conducted to date. This review initiative attempts to provide additional insight into this gap in the literature as policy implementation continues and healthcare stakeholders are affected.The research team’s intent was to specifically investigate surprise billing concepts and related perceptions by industry stakeholders in the United States present in the literature guided by the PRISMA review standard. Four main research databases were queried using the EBSCOhost platform via the Texas State University’s library website: the Cumulative Index to Nursing and Allied Health Literature, PubMed/MEDLINE, Complementary Index, and Academic Search Complete.Study search terms were carefully chosen for this study based upon the proper identification of current publications/research surrounding the surprise billing policy, stakeholder perceptions, and/or other related topics. The research team initially reviewed the listed MeSH  controlled vocabulary thesaurus, utilized for indexing articles for PubMed. However, no specific ‘surprise billing’ and/or related terminology was identified in this resource. As a result, typical healthcare industry billing and reimbursement terminology provided too broad a database query, not specific to the team’s “surprise” billing topic.As a result, the research team utilized Google search queries to establish a search staring terminology and Boolean operators that identified applicable publications surrounding the research topic. The final search string utilized was:Initial search results were 132,269 articles and, after filtering for publication dates between 1 January 2021 and 5 July 2022, the research team identified 7709 articles. The 1 January 2021 date was utilized in the search criteria based upon the US Congress passing of the CAA of 2021 (which included the No Surprises Act) on 27 December 2020, with an implementation date of 1 January 2021 to the current date of the research team’s investigation (5 July 2022).Published articles were included in this review if eligible surprise billing was specifically addressed as either the publication’s main topic, or potentially as an underlying theme within any identified article. Publications included in the review analysis had to be reported in quality journals (peer-reviewed) and also meet the January–July publication date range. The review team immediately recognized that publications identified in the initial database queries did not address healthcare industry outcomes as related to surprise billing identified instances. Therefore, the team’s research objective was to focus primarily on surprise billing perceptions by industry stakeholders and related sub-topics later identified during the review/analysis process.Additional database search engine parameters were applied to produce focused, applicable results to meet the research objective. The EBSCOhost database platform automatically removed 35 duplicate publications from the initial search query. In additional to filtering for publication date, the research team further excluded any publications that were not available in full-text format (−533 articles); were not published in peer-reviewed publication outlets (−6734 articles); were not available in the English language (−3 articles); and not a United States-based study (−400 articles). These exclusion steps were conducted using the EBSCOhost platform’s available menu/check-box filter options before any abstract and/or full text investigation initiated and yielded 39 remaining articles. A review of the studies included in this review was conducted by the authors, to include full manuscript review with each identified publication being reviewed by at least two members of the research team. Four articles were deemed not germane to the research topic. Either erroneously added by the initial database search, or somehow mentioning “surprises” in healthcare delivery, yet not related to “surprise billing” practices and/or perceptions.Two articles were removed for focusing on themes unrelated to this study, yet still mentioning “surprise billing.” While briefly mentioned, the articles were not addressing surprise billing specifically but rather just listing it as a potential reason for a variety of patient cost-shifting methods occurring in the industry.The research team’s full text review for eligibility resulted in 33 remaining publications remaining in the review. Six of the 39 articles were removed from the review by the research team as follows:The research team collaborated both in-person and online via webinars to address any potential article bias or conflict with the application of the selection criteria for the review. Several consensus meetings resulted in no disagreement among the research team members in this regard.The team’s full-text review of the 33 articles identified underlying constructs (characteristics) associated with surprise billing  within the US healthcare system. A summary of review findings for each article is provided in Early in the review team’s consensus meetings, two primary themes were identified in the literature, supporting the research topic of perceptions and challenges related to the occurrence of surprise billing in the United States .Further review and analysis supported the investigation into the impact and related perceptions of surprise billing upon various healthcare industry stakeholders. Initially the research team proposed delineating the impact of surprise billing by stakeholder type . However, ongoing analysis and discussion by the review team resulted in dichotomous, financially related sub-topics, centered around the healthcare organization’s balance-billing of patients for out-of-network (OON) care and reimbursement challenges for medical providers and hospital organizations . FindingHealthcare provider and hospital reimbursement challenges were identified to focus specifically on the topic of medical claims arbitration and related observations of various independent dispute resolution (IDR) perceptions within the industry. This construct was deconstructed into three sub-constructs: the No Surprises Act processes and transparency initiatives; state-level arbitration process perceptions; and observations related to the comparison of the Medicare programs’ arbitration outcomes, as compared to commercial insurance arbitration practices and outcomes . FindingThe US government’s initiative to monitor and support transparency and price control within the healthcare industry continues to challenge all stakeholders, including patients, providers, and organizations. As with any policy implementation process, unintended consequences during implementation phases will often occur and these experiences and related information are vital to ensure quality improvement goals. Evidence from this review suggests that US healthcare system stakeholders are all affected by the occurrence of surprise billing and the No Surprises Act in one primary way—financially. Individuals seeking medical care may experience medical bills after seeking care, associated with balance-billing for OON services rendered—often without their knowledge of the OON medical provider participating in their care in the first place ,13,21,38Additionally, healthcare provider and organization reimbursement challenges will continue to relate to and rely upon an arbitration process (or processes), also often occurring long after the provision of medical care has ended ,27,33. AThe research team identified surprise billing to be experienced by the patient primarily as a result of care received from OON medical providers  ,21,38. SThe research team also identified several articles explaining the patient experiences of OON care and surprise billing as related to mental health concerns after initial care has been completed. Unexpected medical bills has been cited as a leading cause for stress among insured Americans, compromising up to two-thirds of adults ,26. On aA hospital’s ethics committee may decide whether a physician can set and charge a fee as an OON provider involved in the process of care. For example, hospital ethics committees are often asked to consider if unanticipated billing of a patient for the cost of healthcare services that are not covered by the patient’s health insurance by physicians in the hospital emergency department (ED) is unethical when the patient has contractual in- network coverage for the hospital itself . Here, tAlternatively, while medical providers and organizations are to now disclose any financial and other factors that could affect the patient’s care, this price transparency initiative has been observed as both complicated and flawed in the US. . Some emEffective this past January 2022, the No Surprises Act affects who and how out-of-network rates will be set under the new legislation ,18. FurtIn further review of the literature, the research team identified several arbitration-related topics and sub-themes. These observations, often presented from the viewpoint(s) of various stakeholder perceptions in the articles, focused on the financial outcomes and experiences as related to the arbitration processes and transparency of such outcomes, various state-level arbitration regulations and related financial outcomes and perspectives, and also articles addressing a comparison of financial equity by comparison of arbitration outcomes for Medicare beneficiary claims versus that of commercial insurance claims.The research team was overwhelming convinced that the dispute resolution process with healthcare financial reimbursement challenges for patients, providers, and healthcare organization existed as a primary theme in the literature surrounding surprise billing. No Surprise Act literature is particularly useful in understanding some of the aspects of the new legislation, including who it affects, what political ramifications it has, and how out-of-network prices will be determined under the new legislation ,24. WhilHall  specificThe arbitration processes and procedures between insurers and providers and/or organizations are thoroughly described in the literature ,32, whilMany states such as Florida, California, Texas, and New York had prior legislation (statewide) in place addressing surprise billing before the No Surprises Act was passed at the federal level ,18,30. PFor instance, New York’s solution to surprise billing discrepancy is arbitration between provider and insurers . ResolutOverall, the federal legislation was well intended, addressing the need to end patient burden through surprise billing. The legislation, highlighted through state programs, shows the lack of federal initiative to make payment fair to both the provider and the patient at times. Reimbursement is a critical talking point at both the state and federal levels surrounding arbitration processes and outcomes, and the nation will likely see future amendments to address them.The research team identified that arbitrators adjudicating out-of-network payment disputes under the No Surprises Act often award (on average) about 314% higher allowed payment for commercial insurance dispute resolution compared to traditional Medicare allowed reimbursement . This obWhile an option to balance-bill the Medicare beneficiary does not exist, the use of allowed amounts—as utilized appropriately with applicable conversion factors—did seem appropriate and feasible . ProvideThe state of New Jersey’s arbitration system was assessed with Medicare claims’ adjudication processes and outcomes, yielding multiple recommendations for guiding future legislation around surprise billing initiatives and the known (or unknown) provision of out-of-network care . SpecifiThe United States healthcare industry continues to struggle with third-party payer contractual network agreements and related reimbursement challenges. As long as medical providers and their organizations are categorized into in- and out-of-network contractual arrangements, surprise medical bills will continue to be generated based upon the fragmented structure of care delivery in the United States.This systematic review identified perceptions and challenges experienced by industry stakeholders  since the recent passing of the NSA, implemented in January 2022. Such stakeholder observations were able to be sub-categorized into the balance-billing of OON for patients, as well as hospital and provider reimbursement equity challenges as a result of the adapted arbitration processes. Additionally, the arbitration process (dispute resolution) was able to be assessed into the process itself and related industry stakeholder perceptions regarding the process, state-level arbitration practices, and use of the Medicare fee schedule in arbitration proceedings and arbiter decisions.Several limitations were identified in this review and, therefore, offer additional areas for future research and investigation. A majority of the articles identified by the PRISMA review process (method) are qualitative in nature and provide descriptive experiences of patients and other third-party guarantors receiving surprise bills for medical services provided. The review process involved a research database search that included articles published within a specific time period, up to the date of the researcher team’s effort to conclude the search for potential articles on surprise billing and begin the manuscript review and analysis steps. However, the surprise billing topic is quite dynamic, and ongoing publications and potentially new constructs (themes) may be identified with updated systematic reviews and related research efforts. Limitations of the systematic literature review methodology include the date range of manuscripts included in the review process, time between the database search process, and the review team’s analysis/write-up of findings and publication. The review’s methodology was only able to identify 33 articles on the topic to date at the time of the database search. Finally, ongoing changes with such a dynamic industry subject may be addressed within updated and/or completely new systematic literature reviews.Future research surrounding the NSA and related industry perceptions and challenges may involve assessment of ongoing NSA updates and policy amendments (which continue to occur), and additional/other attempts to map arbitration decision outcomes to practical and usual/customary fee schedules without influencing price inflationary practices by the provider and/or healthcare organization.


This paper critically evaluates the current status of Information and Communication Technology (ICT) policies for gifted education in Australia, highlighting the lack of a comprehensive understanding and analysis of the heterogeneity across these policies. Despite the increasing recognition of the importance of ICT's importance in meeting the unique needs of gifted learners, there is a dearth of research systematically investigating the variations in policy frameworks, approaches to ICT integration, and their impact on educational outcomes for gifted students. This research problem necessitates an in-depth exploration of the heterogeneous nature of Australian ICT policies and their implications for promoting equitable access and fostering effective educational experiences. To address this gap, relevant policy documents and research articles on Australian ICT policies for gifted education were collected via Scopes, Web of Sciences, and Google Scholar. The search yielded six policy documents and 14 critical research articles. Our findings reveal that while Australia has definite policies for educating gifted students, these policy documents rarely mention ICT policies specifically related to gifted education. In fact, many elements of these policies only imply use of ICT as facilitation factors. Research articles highlight the inadequacies of sufficient ICT policies for gifted children in rural and remote locations, especially as they pertain to Aboriginal peoples, thereby violating the principles of equity in education. Moreover, the performance of gifted students on Science, Technology, Engineering, and Mathematics (STEM) subjects has been declining on international tests, indicating the inadequacies of Australian policies for the education of gifted students in these areas. Here, ICT policies can provide substantial solutions to address these challenges. In any population, only a small percentage of individuals stand out as gifted, possessing exceptional abilities that require differentiated educational programmes and services to meet their unique learning needs . EstimatFrancoys Gagné’s  DifferenTwo key steps in meeting this challenge involve proper identification of gifted students and investing in the delivery of gifted education itself. In addition, leveraging special tools and teaching methods, including educational technologies, can significantly contribute to the realisation of gifted students' full potential. Information, Communication, and Technology (ICT) offer unprecedented opportunities to enhance the educational experiences of gifted students. By fostering high-level thinking skills such as creative, critical, and reflective thinking , facilitHowever, determining best practices in gifted education is a complex task, primarily due to the limited research evaluating the effectiveness of existing provisions . The divTo effectively utilise ICT in gifted education, it is important to consider specific educational strategies that go beyond technological availability. Stratford and Brown  emphasisICT is a global phenomenon that encompasses different cultural and social perspectives . In AustBy considering specific educational strategies and recognising the diverse cultural and social perspectives surrounding ICT, educators and policy makers can navigate the complexities associated with integrating ICT into gifted education. This approach ensures that the use of technology aligns with pedagogical goals and addresses the unique needs of gifted students, ultimately leading to enhanced educational experiences and outcomes.2This study aims to address the aforementioned challenges by investigating the heterogeneous nature of ICT policies for gifted education in Australia. By analysing relevant policy documents and research articles, the study aims to identify gaps, variations, and shortcoming existing policies, particularly concerning the integration of ICT. The research will specifically focus on promoting equitable access to gifted education and enhancing educational outcomes, with a particular emphasis on Science, Technology, Engineering, and Mathematics (STEM) subjects. Six policy documents were collected from publicly available state websites, and 14 research articles critically evaluating Australian ICT policies were collected by searching Scopes, Web of Sciences and Google Scholar.3This research article analyses ICT policies related to gifted education in public documents from Australian National and State governments and surveys previous literature evaluating these policies. Thus, the research questions are:What are the ICT policies in Australian gifted education programmes at the national and state levels?Based on critical evaluations of ICT policies, how are these policies implemented across Australia?The methodology used to answer these research questions is described in the section below.4The guiding framework for this review is based on the work of Petticrew and Roberts  and Libe4.1●Content: The search was limited to studies related to analyses of Australia's ICT policies in gifted education as well as gifted education policies in general. It contained the key words ‘Australia,’ ‘ICT policy,’ ‘gifted education,’ ‘gifted students,’ ‘gifted learners,’ ‘education,’ ‘technology,’ ‘analysis,’ ‘evaluation,’ and ‘review’ in the title or body of the article's abstract. The review was further limited to high-quality peer-reviewed journals (English only) as well as analysis reviews in the field of Education, particularly. When multiple articles from the same author appeared, these were excluded in an effort to eliminate bias.●Setting: The scope of the review included those studies conducted only in traditional educational environments.●Participants: The review is limited to studies evaluating policies related to gifted students in primary and secondary school. No further exclusions were implemented on the basis of ethnicity, gender, nationality, or other group identification.●Study Type: The review considered only the literature for articles that evaluated the ICT policies for gifted education in Australia.●Exclusions: After considering the above inclusion criteria, exclusions involved:1.Non-English publications2.Studies unrelated to Australia3.Studies unrelated to gifted education4.Studies unrelated to ICT policy5.Studies published before 20066Duplicate studies across databasesThis review used narrow inclusion criteria, and every effort was made to ensure that the literature met minimum requirements. The inclusion criteria were defined as:4.2Despite the lack of a set criteria regarding how reviews should incorporate articles , the selThis study utilised the most common databases among education scholars, such as Web of Science, SCOPUS, and Google Scholar, to source academic articles that review Australian ICT policy in gifted education. For the first iteration of screening, Boolean operators were used for combining and/or excluding specific terms, and for generating more effective search results. A list of search terms written in boolean script included: ‘Australia,’ ‘ICT policy,’ ‘gifted education,’ ‘gifted students,’ ‘gifted learners,’ ‘education,’ ‘technology,’ ‘analysis,’ ‘evaluation,’ and ‘review.’ This first phase yielded 205 records of article titles and abstracts.Article titles and abstracts can provide readers with critical information about the scope of the study , which tThe second screening iteration improved the screening process's sensitivity. The authors reviewed the thirty-six articles that had passed the first round of screening. The eligibility criteria were applied to the article titles, abstracts, and full text. There was no issue about how many documents were retained for review, and a list of the rejected articles and the reason for their exclusion was kept for record-keeping purposes. In summary, twenty-two articles were excluded in the second round of screening due to participant or study type disqualifications. This review considered fourteen articles in total see .Fig. 1Pr5The results are divided into two sections, pertaining to each of the research questions. The first section discusses the current status of ICT policies of Australian national, state, and territorial governments, and the second section relates to critical evaluation of Australian ICT policies for gifted students.5.1The current status of ICT policies in Australia can be understood by examining both national systemic policies and related policies involving ICT, such as Science, Technology, Engineering, and Mathematics (STEM), digital technologies, and distance education. The 2008 Melbourne Declaration on Educational Goals for Young Australians, which outlines the Australian educational curriculum, emphasises equity and excellence and addresses the educational needs of gifted students . The des10.13039/100010424STEM competence among students, develop teacher capacity to deliver 10.13039/100010424STEM education, and provide support to schools. Gifted students, who frequently continue their educational journey in STEM fields, are inherently encompassed within STEM policies, which also involve policies for gifted education and the integration of ICT elements. The report provides a comprehensive list of STEM policies targeting students, teachers, and curriculum, with a significant number of them directly related to ICT and accompanied by relevant resource links. Notably, the policy on summer schools for students incorporates ICT initiatives called DigIT and Curious Minds. In terms of instructional support, there are programs like CSER Digital Technologies Education programmes and digital literacy school grants aimed at training teachers in essential ICT skills. In addition, the curriculum encompasses a digital technologies curriculum, computer coding, and Australian Digital Technology challenges for Year 5 and 7 students.STEM policies, falling under the ICT umbrella, are also relevant to the discussion of ICT policies. Timms et al.  criticalICT policies.In rural and remote locations, distance education has been utilised since the early 1900s, with ICT increasingly facilitating synchronous and asynchronous learning interactions . Downes,However, policy deficits have been identified in addressing the needs of teachers in rural and remote areas, particularly in utilising ICT to teach gifted and talented students and Indigenous students . The limThe Northern Territory policy document on education of gifted and talented students  includesICT into these policies is crucial to support the educational experiences of gifted students and ensure their inclusion and access to appropriate learning opportunities.These findings highlight the varied landscape of ICT policies in Australia, emphasising the importance of addressing the specific needs of gifted students within national, STEM, distance education, and rural/remote education policies. The integration of 5.2This section provides critical evaluation of the Australian ICT policies for gifted based on various studies and reports. The initial review conducted by Batanero, Rebollo, and Rueda  focused One crucial aspect of the Australian ICT policies for gifted students is the disparity faced by Aboriginal gifted students in rural areas regarding access to ICT. Townend, Hay, Jung, and Smith  emphasisThe TIMSS results of 2019 shed light on Australia's ranking in STEM subjects. While there was improvement in Year 8 mathematics and science as well as Year 4 science, Year 4 mathematics showed no progress since 2007. According to a 2020 report by the Australian Council for Educational Research (ACER), only 68–78% of Australian students achieved the international intermediate STEM proficiency standard, in contrast to leading countries like Singapore where more than 90% of students reached this standard. ICT has been identified as an essential component in improving students' performance in STEM subjects nationally and internationally, as discussed by Timms, Moyle, Weldon, and Mitchell . DespiteExamining the existing ICT policies mentioned in the 2020 ACER report, it becomes apparent that only a few states and territories  have specified policies for students, teachers, and curriculum. The declining performance in ICT literacy since 2011 and the varying policies for assessing ICT literacy pose barriers to developing an integrated ICT policy. There is a need to emphasise ICT literacy in STEM curricula and bridge the gap between traditional and STEM subjects. Efforts have been made to integrate technology into the curriculum and address real-world problems through interdisciplinary STEM curricula. Nevertheless, effectively implementing these policies is not a straightforward task, demanding targeted teacher training and careful planning to ensure consistent outcomes.In considering the use of ICT for teaching and learning among gifted students, Bannister, Cornish, Bannister-Tyrrell, and Gregory  highlighWhile ICT plays a significant role in enhancing education for gifted students, it is important to strike a balance. The School of Education at the University of New England, with funding SiMEER NSW, developed an innovative enrichment program for gifted rural and regional school students. This program incorporated ICT to assess problem-solving abilities, animation design skills, and knowledge of specific subjects among gifted students . On the Furthermore, Australia recognises the importance of ICT in work and daily life, as highlighted in the ACER report. As part of the National Assessment Program, ICT literacy has been integrated into the assessment program conducted by ACER on behalf of the national government. The report revealed that Year 6 students have shown notable progress since the last assessment in 2005, while Year 10 students demonstrated only slight improvement. To facilitate ICT learning in challenging rural conditions, Australia launched the One Laptop per Child program, which has yielded positive results. Additionally, ACER established the Digital Education Research Network (DERN) to foster research on the use of digital technologies in education. Although these initiatives were not specifically targeted at gifted students, many of the ICT strategies driven by these policies have benefitted gifted students as well .A comprehensive review of policies across different states and territories of Australia regarding the education of gifted students conducted by Walsh and Jolly  identifiThe training and development of teachers in utilising ICT for teaching gifted students is another essential aspect of ICT policies. Hardy  noted thIn summary, the evaluation of Australian ICT policies for gifted students reveals both strengths and areas for improvement. While the integration of ICT literacy into the National Assessment Program and the implementation of initiatives like the One Laptop per Child program demonstrate the recognition of ICT's importance, there is still a lack of explicit ICT policies for gifted education. The diversity in policies across states and territories underscores the need for greater consistency in identifying and catering to the needs of gifted students. In addition, the training and development of teachers to effectively utilise ICT in teaching gifted students is crucial for ensuring their educational success.6Although educational policies for gifted students can be found in national, state, and territorial government documents, no single standard for identifying gifted students or providing gifted education is equally applied across Australia. Furthermore, few explicit statements or policies about ICT in gifted education have been specified by state governments. Some policies only imply use of ICT to benefit learning for gifted students in rural and remote locations, of whom the majority includes Aboriginal and Torres Strait Islanders. Absence of clearly spelt-out ICT policies in government documents is a major limitation to ensuring equal access to high quality gifted education for all people in Australia.1.Implement consistent identification processes: Establish clear and consistent procedures for identifying gifted students, ensuring that identification practices are fair, transparent, and inclusive. These processes should incorporate multiple measures to identify students' strengths and talents across various domains, including intellectual, creative, artistic, and leadership abilities.2.Explicitly integrate ICT in gifted education policies: Revise national systemic policies and frameworks, such as the 2008 Melbourne Declaration on Educational Goals for Young Australians, to explicitly acknowledge the importance of ICT in supporting the educational needs of gifted students. This can ensure that ICT is recognized as an essential tool for personalised learning, enrichment, and engagement.3.Develop targeted professional development programs: Implement comprehensive professional development programs for teachers that specifically focus on utilising ICT to meet the needs of gifted students. These programs should provide training on incorporating advanced technologies, digital resources, and online collaboration platforms to create challenging and stimulating learning environments for gifted students.4.Expand access to ICT resources in rural and remote areas: Address the existing policy deficits in rural and remote areas by allocating resources and infrastructure to improve ICT access. This includes providing reliable internet connectivity, adequate hardware and software, and technical support to schools in these areas. Efforts should be made to bridge the digital divide and ensure equitable opportunities for gifted students in all geographical locations.5.Foster partnerships and collaborations: Encourage collaboration between educational institutions, government agencies, and industry partners to support the integration of ICT in gifted education. Foster partnerships that provide access to cutting-edge technologies, mentorship programs, and real-world experiences for gifted students. These collaborations can enhance the learning opportunities and expose gifted students to emerging fields and career pathways.6.Develop ICT guidelines for gifted education: Create specific guidelines or frameworks that outline best practices for incorporating ICT in gifted education. These guidelines can offer recommendations on selecting appropriate digital resources, designing challenging projects, and leveraging online platforms for collaboration and knowledge sharing among gifted students.7.Support research and innovation: Allocate resources to support research and innovation in the field of ICT-enabled gifted education. Encourage studies -- particularly longitudinal in nature -- that explore effective strategies, evaluate the impact of ICT integration, and identify emerging technologies and trends that can enhance educational experiences for gifted students. Additional qualitative data is necessary to shed light on the emic perspectives of various stakeholders, such as gifted students and their parents, to understand how to better serve the recipients of gifted education themselves.Based on the discussion of ICT policies for gifted students in Australia and the identified gaps and limitations, here are some recommendations:By implementing these recommendations, policymakers and educators can better address the specific needs of gifted students within ICT policies, promote their inclusion, and provide them with enhanced learning opportunities that foster their full potential.An ethics statement is not applicable because this study is based exclusively on published literature.All authors listed have significantly contributed to the development and the writing of this article.No data was used for the research described in the article.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.ss


Journal of Managed Care & Specialty Pharmacy (JMCP). Most of the reviewed and unreviewed abstracts are presented as posters so that interested AMCP meeting attendees can review findings and query authors. The Student/Resident/ Fellow poster presentation (unreviewed) is Wednesday, April 20, 2016, and the Professional poster presentation (reviewed) is Thursday, April 21. The Professional posters will also be displayed on Friday, April 22. The reviewed abstracts are published in the JMCP Meeting Abstracts supplement.The AMCP Abstracts program provides a forum through which authors can share their insights and outcomes of advanced managed care practice through publication in AMCP’s The AMCP Managed Care & Specialty Pharmacy Annual Meeting 2016 in San Francisco, California, is expected to attract more than 3,500 managed care pharmacists and other health care professionals who manage and evaluate drug therapies, develop and manage networks, and work with medical managers and information specialists to improve the care of all individuals enrolled in managed care programs.Abstracts were submitted in the following categories:Research Report: describe completed original research on managed care pharmacy services or health care interventions. Examples include (but are not limited to) observational studies using administrative claims, reports of the impact of unique benefit design strategies, and analyses of the effects of innovative administrative or clinical programs.Economic Model:  describe models that predict the effect of various benefit design or clinical decisions on a population. For example, an economic model could be used to predict the budget impact of a new pharmaceutical product on a health care system.Solving Problems in Managed Care: describe the specific steps taken to introduce a needed change, develop and implement a new system or program, plan and organize an administrative function, or solve other types of problems in managed care settings. These abstracts describe a course of events; they do not test a hypothesis, but they may include data.