Healthcare Getting It Right : September 2022

Sunday, September 25, 2022

Medication Error Prevention

Medication errors are costly, preventable and a major component to keeping patients safe as they receive their care.

Healthcare has excelled with attention to medication errors as well as prevention initiatives. We’re getting a lot right.

World health and international healthcare partners do a fantastic job spotlighting medical errors. A 2017 international goal tp reduce medication errors by 50% within 5 years was commendable [1]. While the pandemic may have redirected resources, the pandemic also offered time to structure national to international health efforts. Setting a renewed goal should be tied to specific, actionable items, including definitions, standards for reporting, intervention categories, regulatory and pharmacy leadership and involvement beyond acute care. Additionally, comparison and international reports could tier high income and low and middle income (LMIC) focus. A high income country focus on bar code scanning [2] as well as LMIC focus on resource efforts [3-5] are country-specific and can be equally impactful. Steps to improve medication safety can be supported, regardless of technology or resource constraint, with foundations that international excellence has already established. Intervention planning has an opportunity to draw from, validate and appreciate the voices that have spoken up, such as the East African nursing team’s concerns related to patient safety and lack of overall healthcare infrastructure [6], or Malaysian maternal caregivers who reported no access to measuring devices [7]. All of this is possible because WHO and international partners have set the foundation.

FDA efforts to reduce potential medication errors are important. As international medical regulation continues to unite, the comparison and percentage of regulator recommendations, types of recommendations, and protocol to initiate the recommendations will be a welcomed contribution to patient safety [8]. This could also be an International Coalition of Medicines Regulatory Authorities (ICMRA) leadership opportunity [9].

International publications have taken strong action toward medication error prevention. It is unknown how issues and concerns highlighted[10-11] will be incorporated into strategic plans, however WHO guidance has made space for all [12]. The advancement of patient safety literature has not yet seen organization of high quality documents in a collective library. It would be helpful to have quality rankings to the literature, as well as flags on out of date literature where more up to date, relevant literature may apply [13] . All of these opportunities are possible because we have strong publication attention toward medication errors.

Improved epidemiology with medical error tracking and reporting continues to be a focus. The leveraging of technology and current reporting systems remains unclear. International alignment on these reporting systems also remains unclear. Definitions and minimal standards to the tracking could be standardized through world health efforts. A universal, clear and concise definition of the term “medication error” could support international efforts , for example [14]. Definition of harm could also be clearer This is especially noticeable when journals publish conflicting information, such as most medication errors have no negative consequences versus more than 25% of medication errors are severe or life-threatening [15-16]. Epidemiological expertise could also be tasked with quantifying the burden of medical errors. Future potential within current epidemiology improvements are exciting.

Epidemiological work on medical error tracking and reporting continues to expand. Standardized reporting helps organizations like the Institute for Safe Medication Practices (ISMP) with responsibilities as well. The collective efforts toward consumer safety improvements could be supported with robust data. Continued evaluation of home medical errors, accompanied by social service and caregiver metrics, would strengthen the value of the work.

ISPM and other fantastic organizations have dedicated resources and websites on medication errors [17]. The opportunity for these sites to interact with providers and pharmacy resources is here. The opportunity for international alignment of ISPM-related organizations could enhance standards for consumer safety.

Pharmacist professional responsibilities to medication errors are a key to patient safety. Professional organizations should be valued for their organization to medication safety. International work could align to identifying standards to interventions, as well as measures of impact of these interventions [18-19]. Pharmacy professionals could and should also be involved in reporting and error surveillance decision-making.

Primary care recommendations for patient and physician medication education are important [20] . Quality accreditation or oversight could also help standardize the outpatient setting, so that physician groups are held to minimal standards in patient safety. ISPM, for example, offers training and targeted focus for ambulatory care. There are many ways to assess training, set expectations and identify standards for outpatient culture. Therapeutic objectives [21] reviewed as part of the patient visit, for example, could include whether or not errors at home were discussed at the visit. Opportunities to reduce medication errors through primary care improvements are feasible, and recent attention to this has gotten it right.

Medication safety training is offered without barriers, such as the ISMP [22] training . How these trainings are offered internationally, and in what languages, would be an interesting addition to international reports. Training toward various healthcare settings, as opposed to the traditional response that this is part of a clinician’s training before degree, should add to the conversation.

Medication errors involving veterans are frequently studied and often rely on VA data. [23-26]. VA inspector work on specific medication errors are transparent and welcomed., as well [27]. The applicability of recommendations for one VA to all VAs, and improvement projects that can be designed across the VA, non-VA and MHS systems, are exciting prospects. Studies to examine non-VA and VA comparisons bring added depth[28], and continued work on transition and care coordination can target medication errors. Multi-disciplinary approaches are also important. A recent pharmacist intervention for VA-users at a non-VA care center [29], for example, ties error prevention across systems.

Public health has an opportunity to acknowledge veteran medication error prevention partners. For example, VA community health nurse work with medication efforts[30] may or may not be a component to the greater local community health work of the area. Partnerships and potential future public health responsibilities are an opportunity.

Military responsibilities to medical error prevention have been highlighted in recent government reports. GAO and government inspection details have highlighted serious gaps in DoD/DHA medication error management [31] . There is tremendous opportunity to align DHA, VA and civilian definitions, terms, reporting criteria and management metrics (therapeutic objectives, quantified harm, quantified burden) with implementation recommendations. There is also opportunity to tie reimbursement, contract terms and quality improvement expectations to the medication error prevention work. Additionally, there is opportunity to invite ISPM to any challenges specific to the MHS or VA. These opportunities are possible because of the outstanding focus already in place.

Caregiver involvement is critical to address medication errors, particularly for children, those with special needs and the elderly. Recent public health acknowledgement of the caregiving population [32] will only enhance the portfolio of work on caregiver medication errors[33-36].

This is an area where teamwork has tremendous opportunity, and teamwork has already demonstrated commitment.

Continued medical error prevention excellence creates continued opportunities for better healthcare.

Saturday, September 17, 2022

Medical Debt, and Improper Medical Billing

Medical debt and billing is complex. At times, intentional complexity messages that administrations and finances prefer the public as an underdog. There’s no reason to maintain this status quo, the issue is not insurmountable, and there’s no reason treat the financial fracture anything more than what it is: beatable.

Teamwork continues to respond to medical billing and medical debt, and the players are getting a lot of things right.

Military families spend time and worry on medical debt and improper medical billing. The consequences of poor financial administration directly affect their wellbeing and futures, including credit scores. Consequences have been highlighted through great reporting. Watchdogs continue to share concerns using data and personal stories [1,2,3,4,5]. Tying healthcare reimbursement to new quality metrics in billing processes, as well as system accountability with an individual’s debt management, are just two of the ways the future remains exciting.
Military families are supported by continued legislative agenda toward improved debt collection and improved proper billing. The teamwork itself is an opportunity toward financial integrity. For example, if 7% of a recent $716 million in improperly processed payments resulted in improper veteran bills [6], and likely contributed to credit score issues and other debt considerations. Improvement expectations could be set. Conversations with credit and debt players could also enhance security for these families, given the assumptions of human error, as well as civilian families. Reports indirectly suggest that opportunities to alter methodology for total debt estimates could be created, including risk-adjustment for the improper billing that adds to the total debt.
National medical debt and improper medical billing reports are increasingly on point. The percentage of Americans with medical debt by report. Kaiser’s use of the 2019 Census Bureau data states 1 in 10 Americans, or 23 million people [7], are indebted. Kaiser’s use of 2,375 in-depth interviews included dental debt [8] and stated that 41% of Americans have medical debt. In another study. 17.8% of people with a credit report had medical debt [9, 10]. Polled through debt.com, 50% of Americans have medical debt [11]. Given the spotlight, clarity and quality to the data will likely improve. Improvement will also help sharpen statements, like the report that indicated a more than 10% increase in debt for those living in the south and those in states that denied Medicaid expansion. Health outcome comparisons could also support [12]. Reports could ensure dental inclusion and account for personal loans, particularly loans from loved ones.
National medical debt and billing practices should be a national conversation between hospital associations, physician associations, the Department of Health and Human Services, the VA and the DoD. There is no reason for some of the discrepancies detailed in these reports. Additionally, there is no reason to continue status quo with charitable contributions with unknown effects on the hospital an healthcare system. If a hospital decides to cover an unpaid bill, and a military hospital doesn’t, the indirect advantages and disadvantages for these moves can be part of the national improvement conversation. Accountability to match is an exciting future for us all.
National reports demonstrate an opportunity to include active duty and veteran status for clarity. For example, authors with the Uniformed Services University of the Health Sciences and the Henry M. Jackson Foundation for the Advancement of Military Medicine (affiliated with the Department of Defense) used Panel Study of Income Dynamics (PSID ) [13]. The PSID collects data on employment, it is unknown if military employment is stratified, yet the study did not take the opportunity to include data covering employment or income. Asking about one’s veteran or active duty status is an opportunity that creates a compelling future for improved analytics and for research on health. In fact, medical debt has been debated as a social determinant of health [14].
National reports on improper billing are conducted by experts, and these experts are wholly capable of delving into operational details. Rules and regulations for healthcare billing are readily found. Common billing mistakes and poor practices are also easy to find online, though there is no public accountability where private authors have commented. The training, education and management of medical billing, claims specialists and coders would be important to understand. How common the errors are, and the reasons for the errors, are also important. If practices have altered billing for perceived fairness to the practice or to the patient who cannot afford care, we should better understand. If healthcare is assuming claims were denied just because they were rejected, or if practices are duplicate billing by mistake, trends should be known. The underlying reasons for common behaviors are important, and better transparency on the issue is welcomed.
Personal loans have seen new attention in reports [15]. Borrowing money is rarely included in medical debt data, particularly informal loans between loved ones. There is no clear literature on financial stress, nor financial assistance between these groups. Given intimate pressures of deployment and physical distance, the lack of priority to obtain this data is intriguing. If approximately 8% of the US population are active duty or veteran status [16, 17], it would be critical to understand this population’s involvement with US medical debt. This is especially true given recent headlines, concerns and legislation on the issue [18,19, 20]. And, this is especially true given the reported link between medical debt and poorer mental health[14]. Watchdogs, data analysts and reports could also begin to include non-dependent, non-household love ones’ medical debt and medical billing anxiety shouldered by the military serviceperson. The data could include socioeconomics as well as deployment status.
Racial and ethnic differences in medical debt reports are critical, helpful and should continue to be spotlighted [21,22]. Analyses for solutions to racial gaps in medical debt should be utilized for consensus on forward movement [23,24]. Teamwork has excelled here, and will continue to excel.
Legislation that helps protect the public from surprise medical billing is crucial [25]. Ongoing analysis and actions for known gaps in surprise billing oversight will help. Summarizing ongoing bill issues or addressing ambulance payment gaps could be advanced without delay, for example. When legislation steps in to support, poor performing players who sparked the need for oversight can be assigned accountability for improvement.
Analysis of major differences in Medicare and Medicaid payments are important, and we are fortunate for analyses initiatives. Differences by state and by insurer could assist [26]. Concern for the Medicare program’s financial stability have been noted in continued analyses[28]. Experts continue to examine best paths forward, thankfully. These assessments could include VA leadership at the tables [29].
Crowd-sourcing cash assistance is a significant component to health finances. It is important to note the $3 million granted, as well as the $10 million requested, on Go Fund me from 2010-2018 [27]. Reports that cash assistance supports a patient’s health decision making, and that it increases positive health outcomes, should be backed by scientific research. These are true opportunities offered by initial inclusion of crowd-sourcing reports.
Global health has worked very hard to organize the frameworks for health-related financial risk protection, access to quality essential health services and access to safe, effective, quality and affordable essential medicines and vaccines for all. Reports on individual out of pocket (OOP) spending by OECD country are extremely helpful, especially spotlight that 2/3 of OOP spending goes to outpatient, dental and pharmaceuticals [30]. Resources used as indicators for comparison are helpful[31]. Incorporating these indicators into standing reports is feasible, as is reporting on data source quality[32]. Indicators could also include dental components, given the outstanding work that has already accomplished insight. Additionally, this work offers opportunities for policy. Policies and legislation that tackle reasons for outpatient, dental and pharmaceutical financial differences (staffing, education, supply, markets) are possible and offer hope. Global health could also define and shape fraud, from legal frameworks to justice routes.
OCED reports are specific. Opportunities to include surprise billing and medical debt [33] have potential. Other global universal health coverage efforts could also be included[34]. Assessment of OOP expenditures, using various methods, has been notable. A 2007 assessment on OOP for the continent of Africa [35] is noteworthy, and updates would be welcomed. Updates to comparisons of health systems could be assess for potential metrics adoption [36].
WHO and partners have worked tirelessly to initiate and carry the conversation of affordable and accessible universal healthcare [37,38,39,40]. Efforts to categorize payer models and coverage paradigms would also be welcomed. Misunderstanding over universal health coverage terminology can also be confronted. When countries are facing major medical finance concerns, it becomes increasingly difficult to advocate for tax-paid international aid. The potential for political winds to censure international aid rather than fix what’s domestically broken increases without transparency around healthcare finances. In the context of aid, universal healthcare could be better clarified.
World health has been observant and involved in healthcare financing. Conversations with high-income countries on comparative metrics should continue, and conversations that support best implementation for low and middle income (LMIC) financing designs should include honesty and transparency over the limitations of the design. The honesty should come from those managing these designs, and from those with implementation. A conversation between LMIC Asia and the United States on efficiency, outcomes and access to hospitals[41], for example, could commit to healthcare financing planning through metrics and comparisons.

1. https://www.consumerfinance.gov/about-us/newsroom/cfpb-report-highlights-experiences-of-

military-families-with-medical-billing-credit-reporting-and-debt-collection/

2. https://files.consumerfinance.gov/f/documents/cfpb_osa-annual-report-2021.pdf

3. https://www.consumerfinance.gov/about-us/blog/new-va-rule-relieves-financial-distress-for-

thousands-of-veterans-with-medical-bills/

4. https://reservenationalguard.com/money/new-report-highlights-top-military-concerns-on-

medical-billing-errors-credit-reporting-issues/

5. https://www.moaa.org/content/publications-and-media/news-articles/2022-news-

articles/medical-debt,-credit-report-errors-drive-rise-in-military-consumer-complaints/

6. https://www.militarytimes.com/news/pentagon-congress/2019/08/14/investigators-find-53-

million-in-improper-medical-bills-for-veterans/

7. https://www.healthsystemtracker.org/brief/the-burden-of-medical-debt-in-the-united-

states/#Share%20of%20aggregate%20total%20medical%20debt%20in%20the%20U.S.,%20by%20th

e%20amount%20of%20debt%20individuals%20owe,%202019

8. https://www.kff.org/report-section/kff-health-care-debt-survey-main-findings/

9. https://siepr.stanford.edu/news/americas-medical-debt-much-worse-we-think

10. https://jamanetwork.com/journals/jama/article-abstract/2782187

11. https://www.forbes.com/sites/debgordon/2021/10/13/50-of-americans-now-carry-medical-

debt-a-new-chronic-condition-for-millions/?sh=448a7b245e5d

12. https://www.consumerreports.org/medical-billing/could-your-medical-bills-make-you-sick/

13. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0199598

14. https://jamanetwork.com/journals/jama/article-abstract/2782205

15. https://www.kff.org/report-section/the-burden-of-medical-debt-section-3-consequences-of-

medical-bill-problems/

16. https://www.cfr.org/backgrounder/demographics-us-military

17. https://www.census.gov/topics/population/veterans.html#:~:text=This%20report%20looks%20

at%20the,U.S.%20Armed%20Forces%20in%202018.&text=This%20report%20examines%20the%

20demographic,years%20compared%20with%20nonveteran%20women

18. https://www.nclc.org/media-center/president-bidens-announcement-on-veterans-medical-

debt-will-lift-a-burden-from-veteran-families.html

19. https://www.businessinsider.com/va-veterans-medical-debt-unreported-credit-bureau-cfpb-

financial-distress-2022-2

20. https://www.whitehouse.gov/briefing-room/statements-releases/2022/03/01/fact-sheet-

supporting-veterans-experiencing-financial-hardship-and-addressing-the-harmful-effects-of-

military-environmental-exposures/

21. https://www.urban.org/research/publication/medical-debt-fell-during-pandemic-how-can-

decline-be-sustained

22. https://www.brookings.edu/research/the-racial-implications-of-medical-debt-how-moving-

toward-universal-health-care-and-other-reforms-can-address-them/

23. https://www.commonwealthfund.org/blog/2022/how-health-care-coverage-expansions-can-

address-racial-equity

24. https://www.commonwealthfund.org/publications/scorecard/2021/nov/achieving-racial-ethnic-

equity-us-health-care-state-performance

25. https://www.commonwealthfund.org/blog/2020/surprise-billing-protections-cusp-becoming-

law

26. https://www.commonwealthfund.org/blog/2022/how-differences-medicaid-medicare-and-

commercial-health-insurance-payment-rates-impact

27. https://www.commonwealthfund.org/blog/2022/cash-assistance-eases-financial-burden-

associated-medical-emergencies

28. https://www.commonwealthfund.org/blog/2021/addressing-medicare-solvency-will-require-

both-revenue-and-spending-changes

29. https://www.medicareinteractive.org/get-answers/coordinating-medicare-with-other-types-of-

insurance/veterans-affairs-va-benefits-and-medicare/making-part-b-enrollment-decisions-with-

va-benefits

30. https://www.oecd.org/health/health-systems/OECD-Focus-on-Out-of-Pocket-Spending-April-

2019.pdf

31. https://data.oecd.org/healthres/pharmaceutical-spending.htm

32. https://read.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-

2021_919b5f62-en#page2

33. https://www.oecd.org/els/health-systems/health-data.htm

34. https://www.worldbank.org/en/topic/universalhealthcoverage

35. https://apps.who.int/iris/bitstream/handle/10665/85677/HSS_HSF_DP.07.7_eng.pdf?sequence

=1&isAllowed=y

36. https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-

reflecting-poorly

37. https://www.uhc2030.org/what-we-do/improving-collaboration/health-systems-strengthening/

38. https://www.uhc2030.org/what-we-do/improving-collaboration/country-compacts/

39. https://www.uhc2030.org/what-we-do/improving-collaboration/health-systems-

strengthening/financial-management-assessment/

40. https://www.uhc2030.org/fileadmin/uploads/uhc2030/Documents/Key_Issues/Advocacy/UHC2

030_Health_systems_narrative__actions_paper.pdf

41. https://www.who.int/publications/i/item/9789290617327

Saturday, September 10, 2022

Cardiovascular Excellence

We are so fortunate for cardiovascular medicine.

Cardiology professionals have organized the division so well. From cardiovascular surgeons to tomography and imaging professionals to electrocardiogram technicians, the education, certification and professional associations are not only ordered, they are organized to patient needs. The cardiovascular field demonstrates true excellence in organized professionalism. It is encouraging to know that guidelines and recommendations from specific cardiovascular fields continue, and it will be awesome to observe certification standards align across borders. There are over 100,000 publications from 2021-present on Google Scholar and there are over 20,000 on PubMed related to "heart disease". Here are a select few highlights that inspire our future.

Cardiovascular epidemiology is sharp [1]. This is a result of multidisciplinary attention and prioritization of the statistics, quality to epidemiology and dedication of healthcare professionals. Opportunities to secure epidemiological quality across international borders and opportunities to enhance the gaps identified are exciting.

Cardiovascular imaging groups, like the Society of Cardiovascular Computed Tomography, continue to develop guidelines[2]-[4]. Opportunities to develop the profession across the world, and opportunities to align standards across the world, remain with competent hands.

Cardiovascular publications remain professional, and they update evidence-based work [5]. How the specialty creates an international gameplan around research gaps, research priorities [6], strategies for limitation avoidance, and funding strategies tied to quality of trial design will be exciting to see. With over 20,000 PubMed results and over 100,000 Google Scholar results from 2021-present, there are many professionals to entrust aligned research organization,

Tools for heart disease prediction continue to be created and assessed, and this work enhances the professionalism of the division [7].

Healthcare delivery continues to assess and improve, including with potential unnecessary electrocardiogram use [8]. Better patient care, efficient delivery and cost reduction strategies are valued, and it is good to know these are priorities for the cardiovascular field.

Cardiovascular professionals anticipate trends, such as the effects of aging [9]. Anticipation helps healthcare delivery and coverage payers prepare for disease increases, including for endocarditis. Planning and preparedness, for high, middle and low income countries, benefits the public.

Cardiovascular specialists have detailed disease differences in low and middle income countries (LMIC). If rheumatic heart disease is primarily encountered in middle-income and low-income countries, with indigenous groups of high income countries also primarily affected [9], targeted assistance to LMIC and the groups can be applied. Additionally, work can be organized through an international gameplan that aligns with international guidelines [10], and the work progress can be tracked.

Strategic plans from public health partners continue, particularly as lifestyle modifications can be game changers for heart disease. The WHO mention of “access to noncommunicable disease medicines and basic health technologies” for better cardiovascular care is crucial. Cessation of tobacco use, reduction of salt in the diet, eating more fruit and vegetables, regular physical activity and avoiding harmful use of alcohol [11] is also important. As the CDC [12] and international peers align with WHO, opportunities such as labor recommendations, professional standards, and evaluation of hospital response in rural areas will present. Opportunities to include first response assurance for countries, including basic life support (BLS/CPR), AED basics and paramedic first response in LMIC, would also be exciting additions. Enhancing pharmaceutical oversight could be considered. Additionally, accounting for heart disease not modifiable by lifestyle changes by identifying country measures for healthcare delivery will present incredible potential. Updates to the 2014 CDC strategic plan will be compelling.

Cardiovascular research traditions, such as the use of dogs in atrial fibrillation research, have identified gaps between animal models and human application [13]. Researchers are not shy when publishing limitations. Changes and reduction to animal model use, including through innovative model development [14] and mapping strategies [15], are truly awesome. And, this inspires hope.

[1] C. W. Tsao et al., “Heart Disease and Stroke Statistics—2022 Update: A Report From the American Heart Association,” Circulation, vol. 145, no. 8, pp. e153–e639, Feb. 2022.

[2] Writing Group et al., “The role of cardiovascular CT in occupational health assessment for coronary heart disease: An expert consensus document from the Society of Cardiovascular Computed Tomography (SCCT),” J. Cardiovasc. Comput. Tomogr., vol. 15, no. 4, pp. 290–303, Jul. 2021.

[3] S. S. Pickard et al., “Abstract 10063: Implementation of Appropriate Use Criteria for Cardiac Computed Tomography and Magnetic Resonance Imaging in the Follow-Up Care of Patients with Conotruncal Congenital Heart Disease,” Circulation, vol. 144, no. Suppl_1, pp. A10063–A10063, Nov. 2021.

[4] Caruso and Farruggio, “Impact of computerized tomography scan and three-dimensional printing model for surgical procedure in complex congenital heart disease,” J. At. Mol. Phys., [Online]. Available: https://www.researchgate.net/profile/Elio-Caruso-2/publication/350166748_Impact_of_computerized_tomography_scan_and_three-dimensional_printing_model_for_surgical_procedure_in_complex_congenital_heart_disease/links/60625311299bf1736779402a/Impact-of-computerized-tomography-scan-and-three-dimensional-printing-model-for-surgical-procedure-in-complex-congenital-heart-disease.pdf

[5] G. Dibben et al., “Exercise-based cardiac rehabilitation for coronary heart disease,” Cochrane Database Syst. Rev., vol. 11, p. CD001800, Nov. 2021.

[6] H. Korpela et al., “Gene therapy for ischaemic heart disease and heart failure,” J. Intern. Med., vol. 290, no. 3, pp. 567–582, Sep. 2021.

[7] M. Diwakar, A. Tripathi, K. Joshi, M. Memoria, P. Singh, and N. Kumar, “Latest trends on heart disease prediction using machine learning and image fusion,” Mater. Today, vol. 37, pp. 3213–3218, 2021.

[8] B. Appold et al., “Reining in Unnecessary Admission EKGs: A Successful Interdepartmental High-Value Care Initiative,” Cureus, vol. 13, no. 9, p. e18351, Sep. 2021

[9] S. Coffey et al., “Global epidemiology of valvular heart disease,” Nat. Rev. Cardiol., vol. 18, no. 12, pp. 853–864, Jun. 2021.

[10] A. P. Ralph, S. Noonan, V. Wade, and B. J. Currie, “The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease,” Med. J. Aust., vol. 214, no. 5, pp. 220–227, Mar. 2021.

[11] “Cardiovascular Diseases,” World Health Organisation, 2022. https://www.who.int/health-topics/cardiovascular-diseases#tab=tab_1

[12] Centers for Disease Control and Prevention, “DHDSP Strategic Plan.” Mar. 14, 2014. [Online]. Available: https://www.cdc.gov/dhdsp/strategic_plan.htm

[13] M. E. Czick, C. L. Shapter, and D. I. Silverman, “Atrial Fibrillation: The Science behind Its Defiance,” Aging Dis., vol. 7, no. 5, pp. 635–656, Oct. 2016.

[14] Y. R. Lewis-Israeli et al., “Self-assembling human heart organoids for the modeling of cardiac development and congenital heart disease,” Nat. Commun., vol. 12, no. 1, pp. 1–16, Aug. 2021.

[15] D. H. Lau, D. Linz, and P. Sanders, “New Findings in Atrial Fibrillation Mechanisms,” Card. Electrophysiol. Clin., vol. 11, no. 4, pp. 563–571, Dec. 2019.