A task force composed of American Heart Association (AHA) Research Committee members established processes to measure the performance of the AHA's research portfolio and evaluated key outcomes that are fundamental to the overall success of the program. This report reviews progress that the AHA research program has had in achieving its goals relevant to the research programs in the AHA's research portfolio from 2008 to 2017. Comprehensive performance metrics were identified to assess the impact of AHA funding on researchers' career progress and research outcomes. Metrics included bibliometric analysis (ie, tracking of publications and their impact) and career development measures (ie, subsequent grant funding, intellectual property, faculty appointment/promotion, or industry position). Publication rates ranged from ≈0.5 to 4 publications per year, with a strong correlation between number of publications per year and later career stage. The Field-Weighted Citation Index, a metric of bibliometric impact, was between 1.5 and 3.0 for all programs, indicating that AHA awardee publications had a higher citation impact compared with similar publications. To gain insight into the career progression of AHA awardees, a 2-year postaward survey was distributed. Of the Postdoctoral Fellowship recipient respondents, 72% obtained academic research positions, with the remaining working in industry or government research settings; 72% of those in academic positions obtained additional funding. Among respondents who were Beginning Grant-in-Aid and Scientist Development Grant awardees, 45% received academic promotions and 83% obtained additional funding. Measuring performance of the AHA's research portfolio is critical to ensure that its strategic goals are met and to show the AHA's commitment to high-quality, impactful research.

HomeCirculationVol. 143, No. 252020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: A Consensus Conference Report Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessReview ArticlePDF/EPUB2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: A Consensus Conference Report Ivor J. Benjamin, MD, FAHA, FACC, Conference Co-Chair, AHA C. Michael Valentine, MD, MACC, FAHA, Conference Co-Chair, ACC William J. Oetgen, MD, MBA, MACC, Executive Committee Author Task Force 2 Author, ACC Katherine A. Sheehan, PhD, Executive Committee Author, AHA Ralph G. Brindis, MD, MPH, MACC, FAHA, Task Force Co-Chair, ACC William H. Roach Jr, MS, JD, Task Force Co-Chair, AHA Robert A. Harrington, MD, FAHA, MACC, Author Glenn N. Levine, MD, FACC, FAHA, Author Rita F. Redberg, MS, MD, FACC, FAHA, Author Bernadette M. Broccolo, JD, Discussant Adrian F. Hernandez, MD, MHS, FAHA, Discussant Pamela S. Douglas, MD, MACC, FAHA, Task Force Co-Chair, ACC Ileana L. Piña, MD, MPH, FAHA, FACC, Task Force Co-Chair, AHA Emelia J. Benjamin, MD, ScM, FAHA, FACC, Author Megan J. Coylewright, MD, MPH, FACC, Author Jorge F. Saucedo, MD, MBA, FACC, FAHA, Author Keith C. Ferdinand, MD, FACC, FAHA, Discussant Sharonne N. Hayes, MD, FACC, FAHA, Discussant Athena Poppas, MD, FACC, FAHA, Discussant Karen L. Furie, MD, MPH, FAHA, Task Force Co-Chair, AHA Laxmi S. Mehta, MD, FACC, FAHA, Task Force Co-Chair, ACC John P. Erwin III, MD, FACC, FAHA, Author Jennifer H. Mieres, MD, FACC, FAHA, Author Daniel J. Murphy Jr, MD, FACC, Author Gaby Weissman, MD, FACC, Author and Discussant Colin P. West, MD, PhD, Author and Discussant Willie E. Lawrence Jr, MD, FACC, FAHA, Task Force Co-Chair, AHA Frederick A. Masoudi, MD, MSPH, FACC, FAHA, Task Force Co-Chair, ACC Camara P. Jones, MD, MPH, PhD, Author Daniel D. Matlock, MD, MPH, Author Jennifer E. Miller, PhD, Author John A. Spertus, MD, MPH, FACC, FAHA, Discussant Lynn Todman, PhD, Discussant Cathleen Biga, MSN, FACC, Task Force Co-Chair, ACC Richard A. Chazal, MD, FAHA, MACC, Task Force Co-Chair, AHA Mark A. Creager, MD, FAHA, FACC, Author Edward T. Fry, MD, FACC, Author Michael J. Mack, MD, MACC, Author Clyde W. Yancy, MD, MSc, MACC, FAHA, Author and Discussant Richard E. AndersonMD, Discussant Ivor J. BenjaminIvor J. Benjamin , C. Michael ValentineC. Michael Valentine , William J. OetgenWilliam J. Oetgen , Katherine A. SheehanKatherine A. Sheehan , Ralph G. BrindisRalph G. Brindis , William H. Roach JrWilliam H. Roach Jr , Robert A. HarringtonRobert A. Harrington , Glenn N. LevineGlenn N. Levine , Rita F. RedbergRita F. Redberg , Bernadette M. BroccoloBernadette M. Broccolo , Adrian F. HernandezAdrian F. Hernandez , Pamela S. DouglasPamela S. Douglas , Ileana L. PiñaIleana L. Piña , Emelia J. BenjaminEmelia J. Benjamin , Megan J. CoylewrightMegan J. Coylewright , Jorge F. SaucedoJorge F. Saucedo , Keith C. FerdinandKeith C. Ferdinand , Sharonne N. HayesSharonne N. Hayes , Athena PoppasAthena Poppas , Karen L. FurieKaren L. Furie , Laxmi S. MehtaLaxmi S. Mehta , John P. Erwin IIIJohn P. Erwin III , Jennifer H. MieresJennifer H. Mieres , Daniel J. Murphy JrDaniel J. Murphy Jr , Gaby WeissmanGaby Weissman , Colin P. WestColin P. West , Willie E. Lawrence JrWillie E. Lawrence Jr , Frederick A. MasoudiFrederick A. Masoudi , Camara P. JonesCamara P. Jones , Daniel D. MatlockDaniel D. Matlock , Jennifer E. MillerJennifer E. Miller , John A. SpertusJohn A. Spertus , Lynn TodmanLynn Todman , Cathleen BigaCathleen Biga , Richard A. ChazalRichard A. Chazal , Mark A. CreagerMark A. Creager , Edward T. FryEdward T. Fry , Michael J. MackMichael J. Mack , Clyde W. YancyClyde W. Yancy , and Richard E. AndersonRichard E. Anderson Originally published11 May 2021https://doi.org/10.1161/CIR.0000000000000963Circulation. 2021;143:e1035–e1087is corrected byCorrection to: 2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics: A Consensus Conference ReportTable of Contents1. Introduction e10361.1. Historical Perspective and Current Plan e10371.2. Context Framing e10381.3. The Tenets of Medical Ethics e10391.4. The Principles and Commitments of Medical Professionalism e10391.4.1. Principles of Professionalism e10391.4.2. Commitments of Professionalism e10391.5. The Obligations of Medicine's Social Contract e10401.5.1. Medical Practitioners Agree to:e10401.5.2. Society Agrees to:e10411.6. Organization of Writing Committee e10421.7. Document Review and Publication Approval e10421.8. Abbreviations e10422. Task Force Reports e10422.1. Task Force 1: Navigating Conflicts: RWIs and COIs in Teaching and Publications, Peer Review, Research Data, Technology, and Expert Testimony e10422.1.1. Recommendations Related to Disclosure of RWIs in Educational Activities and Scientific Publications e10432.1.2. Recommendations Related to Associational and Intellectual Interests e10442.1.3. Recommendations Related to External Assessments of Interests e10452.1.4. Recommendations Related to Research, Publication, Educational Activities, and Implementation Ethics e10462.1.5. Recommendations Related to Peer Review and Grant Study Sections e10472.1.6. Recommendations Related to Expert Testimony and Opinions e10482.2. Task Force 2: Diversity, Equity, Inclusion, and Belonging: Optimizing Cardiovascular Health Care, Research, and Education Through Equity and Respect and Eliminating Bias, Discrimination, Harassment, and Racism e10492.2.1. DEIB: General Concepts e10512.2.2. Specific Accountabilities and Special Groups e10522.2.3. Eradicating Bias, Harassment, Structural Racism, and Structural Sexism, Including Sexual Harassment e10542.2.4. Achieving Equity, Inclusion, and Belonging: A Road Map e10552.2.5. Coda e10562.3. Task Force 3: Enhancing the Well-Being of Clinicians e10562.3.1. Organizational Strategies to Promote Well-Being e10592.3.2. Addressing Well-Being Among Trainees and Researchers e10602.3.3. Well-Being Strategies Focused on Health Information Technology e10612.3.4. Identifying Symptoms of the Disruptive Physician e10622.3.5. Identifying and Assisting the Impaired Clinician e10632.3.6. Additional Considerations and Caveats e10642.4. Task Force 4: Patient Autonomy, Privacy, and Social Justice in Health Care e10642.4.1. Patient Autonomy e10652.4.2. Data Privacy, Transparency, and Access e10652.4.3. Social Justice e10652.4.4. Recommendations: Patient Autonomy e10662.4.5. Recommendations: Data Privacy, Transparency, and Access e10672.4.6. Recommendations: Social Justice and Racism e10692.4.7. Caveats e10702.5. Task Force 5: Modern Healthcare Delivery: Challenges Related to New Care Delivery Systems e10712.5.1. Addressing Potential COIs When Designing and Engaging in New Models and Venues of Cardiovascular Care Delivery e10722.5.2. Medical Professionalism for the Employed Clinician e10732.5.3. Ethical Challenges and Professionalism Related to Billing, Coding, Documentation, and EHRs e10752.5.4. Quadruple Aim: Does an Ethical and Professional Perspective Enhance or Obstruct Patient Satisfaction, Outcomes and Quality, Cost, and Clinician Satisfaction? e10762.5.5. Conclusions e1076References e1077Appendix 1. Author Relationships With Industry and Other Entities (Comprehensive) e1082Appendix 2. Reviewer Relationships With Industry and Other Entities (Comprehensive) e10871. INTRODUCTIONIvor J. Benjamin, MD, FAHA, FACCWilliam J. Oetgen, MD, MBA, MACCKatherine A. Sheehan, PhDC. Michael Valentine, MD, MACC, FAHAThe 2020 American Heart Association and American College of Cardiology Consensus Conference on Professionalism and Ethics (2020 Consensus Conference) comes at a time even more fraught than the eras of the 3 previous meetings on the same topics. A virulent pathogen has challenged the physical and economic health of the entire country; a series of tragedies have awakened a sense of social justice previously unexpressed nationally; and the political climate rivals the divisiveness seen at the birth of the nation.1 Arguably, there could be no better time to review and take a fresh perspective on medical ethics and professionalism in the light of established norms and current stressors. In addition, the American Heart Association (AHA) and the American College of Cardiology (ACC) recognize that this important assessment should be undertaken on a more regular basis. There should be no more 16-year gaps.Building on a solid understanding of previous similar efforts and with a firm appreciation of the obligations of medicine's social contract, the tenets of medical ethics, and the principles and commitments of medical professionalism, the ACC and the AHA sponsored a conference on medical professionalism and ethics on October 19 to 20, 2020. Multiple medical professional organizations provided valuable input. The purpose of the present 2020 Consensus Conference is to address the practical management of professional and ethical behavior of cardiovascular clinicians and scientists and to make specific recommendations in light of contemporary issues of professionalism and ethics. The consensus committee reviewed previously published documents and current materials to formulate their recommendations.1.1. Historical Perspective and Current PlanThe AHA and the ACC have long individual and collective histories of formally addressing issues of medical ethics and medical professionalism. The 21st Bethesda Conference (Ethics in Cardiovascular Medicine) was held in October 19892; the 29th Bethesda Conference (Ethics in Cardiovascular Medicine [1997]) was held in October 19973; and the collaborative effort (ACC/AHA Consensus Conference on Professionalism and Ethics) was held in June 2004.4 The specific major topics and subtopics discussed in these conferences reflect the ethical and professional issues extant at the time of the assemblies.The 21st Bethesda Conference2 was devoted to discussions of ethical decision making in medicine; the relation of cardiovascular specialists to patients, other physicians, and physician-owned organizations; the allocation of limited resources in cardiovascular medicine; scientific responsibility and integrity in medical research; and the relation of cardiovascular specialists to industry, institutions, and organizations.Subtopics included in the 21st Bethesda Conference discussion were the following: acting in the patient's interest; respecting the patient's preferences; distributive justice; physician responsibilities to society; medical decision making; end-of-life decisions; AIDS and the cardiovascular physician; conflicts of interest (COIs) and ethics in medical education; resource limitations and distribution; end-of-life care; cost and efficacy of medical technology; the welfare of the individual patient and the welfare of society; responsibilities of clinical investigators, research objectivity, credibility, and COIs; specific physician relationships with industry (RWIs); physician ownership of healthcare facilities; and physicians' relationships to institutions and organizations.The 29th Bethesda Conference3 discussed external influences on the practice of cardiology, application of medical and surgical intervention near the end of life, and clinical research in a molecular era and the need to expand its ethical imperatives.Subtopics discussed in the 29th Bethesda Conference included managed care and the reinterpretations of ethical standards and the concept of professionalism; the relationship of medical ethics and business ethics; the application of medical and surgical interventions in elderly patients; palliative care; futile care; forgoing treatment and advance care planning; physician-assisted suicide; ethical considerations in the conduct of clinical trials; the ethical, legal, and social implications of the Human Genome Project; data confidentiality; and genetic information and its implications for medical insurance.The ACC/AHA Consensus Conference4 dwelt on codes of conduct in human subjects research (HSR); investigator participation in clinical research; disclosure of relationships with commercial interests and policies for educational activities and publications; appropriate clinical care and issues of self-referral; expert testimony and opinions; and a code of conduct for organizational staff and volunteer leadership.Subtopics treated in the ACC/AHA Consensus Conference were COIs and proper disclosure; formal scrutiny of research involving human subjects; confidentiality in research activities; indemnification of research activities; avoidance of bias in clinical trials; physician self-referral; direct-to-consumer advertising; cardiovascular specialty hospitals and physician financial COIs; antikickback statutes; Stark laws; expert testimony in professional liability, class action litigation, and patent issues; and nonprofit organizational governance, management, and potential COIs.For the 3 prior ACC or ACC/AHA ethics and professionalism conferences, there were 164 unique attendees; 11.6% were identified as women, and 2.4% were identified as Black. Twenty of the 164 attendees were present at 2 or 3 of the conferences. Of the 164 attendees, 20 were past, present, or future ACC presidents, and 13 were past, present, or future AHA presidents. No attendees were identified as early career or fellows-in-training.In the 2020 Consensus Conference, of the 61 participating attendees, 41.2% were women, 7.9% were Black, and 4.8% were Hispanic. Three of the 61 were present at the prior conference in 2004; 6 were past, present, or future ACC presidents; and 4 were past, present, or future AHA presidents. Two 2020 Consensus Conference attendees were identified as early career, and 4 were fellows-in-training. Figure 1 shows comparative attendee demographic data for the combined earlier conferences and for the 2020 Consensus Conference.Download figureDownload PowerPointFigure 1. American Heart Association (AHA)/American College of Cardiology (ACC) conferences on professionalism and ethics: attendee demographics.Figure 2 shows the academic degrees and professional representations of the attendees at the current conference and at each of the 3 previous conferences. It is important to note that for the purpose of the current conference, the ascendancy of the team care paradigm in 21st century cardiovascular medicine is recognized, and references to physicians in prior publications, by extension, include all members of the healthcare team. In this document, the terms clinician, practitioner, and medical professional will be used in lieu of the term provider.Download figureDownload PowerPointFigure 2. American Heart Association (AHA)/American College of Cardiology (ACC) Conferences on Professionalism and Ethics: attendee academic and professional representation. Mean conference attendance=63.This document is a comprehensive summary of the deliberations of the 5 task forces that made up the 2020 Consensus Conference. Throughout the preparation of this report, efforts were made to be as concise as reasonably possible; however, because this is envisioned to be a reference document, essential detail was deliberately not euthanized for the sake of brevity.1.2. Context FramingThese conferences have reinforced the notion that the operative underpinning for the practice of medicine in the United States is a set of principles of medical ethics. These principles also form the basis for medical professionalism and what has become known in more recent years as medicine's social contract. Ethical medical practice is an a priori assumption of medicine's social contract, and the principles of ethics shape that contract, giving rise to the concept of professionalism and the rules by which that contract is implemented from the perspective of the medical professional.5,6The American College of Physicians7 and the American Medical Association (AMA)8 have codes of ethics for physicians. The American College of Physicians' Ethics Manual provides context, for example, in reviewing the principles of medical ethics and reminding us thatMedicine is not, as Francis Peabody said, "a trade to be learned, but a profession to be entered." A profession is characterized by a specialized body of knowledge that its members must teach and expand; by a code of ethics and a duty of service that, in medicine, puts patient care above self-interest; and by the privilege of self-regulation granted by society. Physicians must individually and collectively fulfill the duties of the profession.7The tenets of medical ethics, the principles and commitments of medical professionalism, and the specific obligations of medicine's social contract form the basis of this joint AHA/ACC study of medical ethics and professionalism in the 21st century. By way of creating a common ground of understanding, in this introduction, each of these 3 sets of elements is reviewed.1.3. The Tenets of Medical EthicsThe classic ethical principles of medical practice are duties based in respect for autonomy, beneficence, nonmaleficence, and justice.7,9Respect for autonomy. The duty to protect and foster a patient's free, uncoerced choices.Beneficence. The duty to promote good and to act in the best interest of the patient.Nonmaleficence. The duty to do no harm in every interaction with patients.Justice. There should be fairness and equity in health care.1.4. The Principles and Commitments of Medical ProfessionalismThe Physician Charter on Medical Professionalism was published in 2002 as a collaboration between the American Board of Internal Medicine Foundation, the American College of Physicians–American Society of Internal Medicine Foundation, and the European Federation of Internal Medicine.10 Both the ACC and the AHA have officially endorsed the charter, as have >100 other medical professional organizations across the world.11 The charter contains eloquent, succinct, and actionable expressions of the principles and commitments of medical professionalism. Its descriptors are reproduced here with permission.101.4.1. Principles of ProfessionalismPrimacy of patient welfare. This principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.Patient autonomy. Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients' decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.Social justice. The medical profession must promote justice in the healthcare system, including the fair distribution of healthcare resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, sex, socioeconomic status, ethnicity, religion, or any other social category.1.4.2. Commitments of ProfessionalismProfessional competence. Physicians must be committed to lifelong learning and be responsible for maintaining the medical knowledge and clinical and team skills necessary for the provision of quality care. More broadly, the profession as a whole must strive to see that all of its members are competent and must ensure that appropriate mechanisms are available for physicians to accomplish this goal.Honesty with patients. Physicians must ensure that patients are completely and honestly informed before the patient has consented to treatment and after treatment has occurred. This expectation does not mean that patients should be involved in every minute decision about medical care; rather, they must be empowered to decide on the course of therapy. Physicians should also acknowledge that in health care, medical errors that injure patients sometimes do occur. Whenever patients are injured as a consequence of medical care, patients should be informed promptly because failure to do so seriously compromises patient and societal trust. Reporting and analyzing medical mistakes provide the basis for appropriate prevention and improvement strategies and for appropriate compensation to injured parties.Patient confidentiality. Earning the trust and confidence of patients requires that appropriate confidentiality safeguards be applied to disclosure of patient information. This commitment extends to discussions with individuals acting on a patient's behalf when obtaining the patient's own consent is not feasible. Fulfilling the commitment to confidentiality is more pressing now than ever before, given the widespread use of electronic information systems for compiling patient data and an increasing availability of genetic information. Physicians recognize, however, that their commitment to patient confidentiality must occasionally yield to overriding considerations in the public interest (for example, when patients endanger others).Maintaining appropriate relations with patients. Given the inherent vulnerability and dependency of patients, certain relationships between physicians and patients must be avoided. In particular, physicians should never exploit patients for any sexual advantage, personal financial gain, or other private purpose.Improving quality of care. Physicians must be dedicated to continuous improvement in the quality of health care. This commitment entails not only maintaining clinical competence but also working collaboratively with other professionals to reduce medical error, to increase patient safety, to minimize overuse of healthcare resources, and to optimize the outcomes of care. Physicians must actively participate in the development of better measures of quality of care and the application of quality measures to routinely assess the performance of all individuals, institutions, and systems responsible for healthcare delivery. Physicians, both individually and through their professional associations, must take responsibility for assisting in the creation and implementation of mechanisms designed to encourage continuous improvement in the quality of care.Improving access to care. Medical professionalism demands that the objective of all healthcare systems be the availability of a uniform and adequate standard of care. Physicians must individually and collectively strive to reduce barriers to equitable health care. Within each system, the physician should work to eliminate barriers to access based on education, laws, finances, geography, and social discrimination. A commitment to equity entails the promotion of public health and preventive medicine, as well as public advocacy on the part of each physician, without concern for the self-interest of the physician or the profession.A just distribution of limited finite resources. While meeting the needs of individual patients, physicians are required to provide health care that is based on the wise and cost-effective management of limited resources. They should be committed to working with other physicians, hospitals, and payers to develop guidelines for cost-effective care.Scientific knowledge. Much of medicine's contract with society is based on the integrity and appropriate use of scientific knowledge and technology. Physicians have a duty to uphold scientific standards, to promote research, and to create new knowledge and ensure its appropriate use. The profession is responsible for the integrity of this knowledge, which is based on scientific evidence and physician experience.Maintaining trust by managing COIs. Medical professionals and their organizations have many opportunities to compromise their professional responsibilities by pursuing private gain or personal advantage. Such compromises are especially threatening in the pursuit of personal or organizational interactions with for-profit industries, including medical equipment manufacturers, insurance companies, and pharmaceutical firms. Physicians have an obligation to recognize, to disclose to the general public, and to deal with COIs that arise in the course of their professional duties and activities. Relationships between industry and opinion leaders should be disclosed, especially when the latter determine the criteria for conducting and reporting clinical trials, writing editorials or therapeutic guidelines, or serving as editors of scientific journals.Professional responsibilities. As members of a profession, physicians are expected to work collaboratively to maximize patient care, to be respectful of one another, and to participate in the processes of self-regulation, including remediation and discipline of members who have failed to meet professional standards. The profession should also define and organize the educational and standard-setting process for current and future members. Physicians have both individual and collective obligations to participate in these processes. These obligations include engaging in internal assessment and accepting external scrutiny of all aspects of their professional performance.1.5. The Obligations of Medicine's Social ContractMedicine's social contract is an agreement between 2 parties: society as a whole and medical practitioners.12,13 Some elements of the contract are tacit, and some are codified in the laws and regulations governing the practice of medicine. Examples of the latter are laws establishing the healthcare system, educational requirements, and licensure. The tacit elements are behaviors and attitudes expressed by practitioners such as honesty, commitment, compassion, and altruism, none of which are concepts suitable for legislative or regulatory actions. Contracts—tacit or written—document the obligations agreed to by the parties involved. The obligations of the healthcare social contract, as delineated by Cruess and Cruess,14 are as follows:1.5.1. Medical Practitioners Agree to:Fulfill the role of the healer. The healer is an elemental and well-defined role in all human societies. Attributes of the healer include caring and compassion; insight and self-awareness; openness; respect for the healing function; respect for patient dignity and autonomy; being fully present and without distraction for the patient; and accompanying the patient through the journey of healing.15Achieve and maintain proficiency in the knowledge of their area of practice. At the basic level for initial licensure, all US states require an allopathic or osteopathic medical degree, successful completion of a licensure examination, and between 1 and 3 years of postgraduate training.16 For license renewal, all US states except Colorado and South Dakota require continuing medical education.17 At the higher clinical functioning level, all boards require postgraduate training in an approved program and successful completion of a comprehensive examination for specialty certification. All specialty boards provide time-limited certification, and all require participation in a maintenance of certification program for recent diplomates.18Achieve and maintain a high level of skill in their area of practice. At the level of the medical student, clinical skills are assessed by Step 2 (Clinical Skills) of the United States Medical Licensing Examination process.19 The Accreditation Council for Graduate Medical Education (ACGME) sets skill standards for residents and fellows-in-training.20 For the practicing physician, fulfillment of this obligation of the social contract is aspirational. There is no formal organization or process for assessing and documenting clinical skills beyond clinical training, although hospital medical staff quality committees have the responsibility of monitoring procedural outcomes across a variety of specialties.Provide for the patient's needs ahead of their own. This is the fundamental expression of altruism, which is a basic tenet of all descriptions of professionalism. The modern concept of altruism is that it is not an inherent, fixed personality trait; rather, it can be objectively measured and increased by education, practice, role modeling, and reinforcement.21Provide access to needed care. Five steps have recently been highlighted with which physicians can advocate or act to improve access to care for the most vulnerable of our fellow Americans:– Ensure adequate funding of the Children's Health Insurance Program and retain Medicaid expansion and implement expansion in more states.– Stabilize individual insurance marketplaces and retain Affordable Care Act market reforms.– Address physician clinical workforce shortages.– Expand telehealth and remote patient monitoring.– Increase the efficiency of the existing workforce by instituting common-sense medical liability reforms and reducing government and insurance industry regulatory burdens such as prior authorization that detract from patient care and increase costs.22Behave with morality, integrity, and honesty within a delineated code of ethics. Both the ACC23 and the AHA24 have established codes of ethics that define the values and behaviors required of their respective members.Be trustworthy. Patients must be confident that physicians will act not in self-interest but in the interests of their patients. Avoidance of even the appearance of a COI is the responsibility of each physician and is a corollary to the fundamental altruistic obligation to put the patient's needs ahead of the physician's own needs.25Show respect for patient dignity and autonomy. Respect for the dignity and autonomy of the patient is foundational to the pract

The American Heart Association (AHA) is the largest not-for-profit funder of cardiovascular and cerebrovascular disease research in the United States. It has supported research of independent scientists for 7 decades with the goal of finding novel discoveries that will reduce death and disability from these diseases and ultimately improve overall health. In 2014, the AHA approved a pilot initiative to include lay stakeholders (patients, caregivers, and passionate advocates) in its research and science operations. The initiative was based on the premise that lay stakeholders would add a unique and necessary perspective that would improve decisions concerning research funding, research direction, and scientific guidelines. The AHA developed a framework for the initiative that defined lay stakeholder, created a volunteer recruitment and training program, established policies for incorporating lay stakeholders into science operations, and set metrics for evaluating the initiative over time. It has instituted creative ways to engage lay volunteers and to foster lay and scientist cooperation. Program assessments have been consistently positive and have identified needed future improvements. The benefits of lay/scientist collaboration have far exceeded the AHA's expectations. The AHA will continue to strengthen lay volunteer engagement throughout its science and research operations; to focus on developing a larger, diverse group of qualified lay stakeholders; to educate scientists on how to communicate research effectively to the public and donors; and to retain the respect of donors for the rigors of its research funding, scientific statements, and clinical guidelines.

A Love-wave device and a PDMS microfluidic chip have been developed in order to measure immunoreactions in liquid media, operating in dynamic mode (continuous flow-through). The obtained results with the above system for the detection of rabbit immunoglobulin by means of an antibody of goat anti-rabbit have been compared with those obtained by the most used acoustic wave device, the quartz crystal microbalance (QCM), which has worked in static mode. It has been demonstrated once again that QCM is an excellent tool as an immunosensor, although the Love-wave device is a good alternative due to its higher sensitivity.The dynamic mode improves the response time and the limit of detection. In addition, the use of microchannels has allowed working with a small sample volume for a long period of time in dynamic mode.On the other hand, a secondary antibody conjugated with gold nanoparticles has been used as a different method to measure the desired concentrations of antigens, obtaining in this case, a greater frequency shift.

September 13, 2016 Circulation. 2016;134:e198–e225. DOI: 10.1161/CIR.0000000000000438 e198 Lynne T. Braun, PhD, CNP, FAHA, Chair Kathleen L. Grady, PhD, MS, RN, FAHA, Co-Chair Jean S. Kutner, MD, MSPH, Co-Chair Eric Adler, MD Nancy Berlinger, PhD Renee Boss, MD Javed Butler, MD, MPH, MBA, FAHA Susan Enguidanos, PhD, MPH Sarah Friebert, MD Timothy J. Gardner, MD, FAHA Phil Higgins, PhD, LICSW Robert Holloway, MD Madeleine Konig, MPH Diane Meier, MD Mary Beth Morrissey, PhD, MPH, JD Tammie E. Quest, MD Debra L. Wiegand, PhD, RN, FAHA Barbara Coombs-Lee, PA, FNP, JD George Fitchett, DMin, PhD Charu Gupta, MD William H. Roach, Jr, JD On behalf of the American Heart Association Advocacy Coordinating Committee AbstrAct: The mission of the American Heart Association/American Stroke Association includes increasing access to high-quality, evidencebased care that improves patient outcomes such as health-related quality of life and is consistent with the patients’ values, preferences, and goals. Awareness of and access to palliative care interventions align with the American Heart Association/American Stroke Association mission. The purposes of this policy statement are to provide background on the importance of palliative care as it pertains to patients with advanced cardiovascular disease and stroke and their families and to make recommendations for policy decisions. Palliative care, defined as patientand family-centered care that optimizes health-related quality of life by anticipating, preventing, and treating suffering, should be integrated into the care of all patients with advanced cardiovascular disease and stroke early in the disease trajectory. Palliative care focuses on communication, shared decision making about treatment options, advance care planning, and attention to physical, emotional, spiritual, and psychological distress with inclusion of the patient’s family and care system. Our policy recommendations address the following: reimbursement for comprehensive delivery of palliative care services for patients with advanced cardiovascular disease and stroke; strong payerprovider relationships that involve data sharing to identify patients in need of palliative care, identification of better care and payment models, and establishment of quality standards and outcome measurements; healthcare system policies for the provision of comprehensive palliative care services during hospitalization, including goals of care, treatment decisions, needs of family caregivers, and transition to other care settings; and health professional education in palliative care as part of licensure requirements. Palliative Care and Cardiovascular Disease and Stroke

The mission of the American Heart Association/American Stroke Association includes increasing access to high-quality, evidence-based care that improves patient outcomes such as health-related quality of life and is consistent with the patients’ values, preferences, and goals. Awareness of and access to palliative care interventions align with the American Heart Association/American Stroke Association mission. The purposes of this policy statement are to provide background on the importance of palliative care as it pertains to patients with advanced cardiovascular disease and stroke and their families and to make recommendations for policy decisions. Palliative care, defined as patient- and family-centered care that optimizes health-related quality of life by anticipating, preventing, and treating suffering, should be integrated into the care of all patients with advanced cardiovascular disease and stroke early in the disease trajectory. Palliative care focuses on communication, shared decision making about treatment options, advance care planning, and attention to physical, emotional, spiritual, and psychological distress with inclusion of the patient’s family and care system. Our policy recommendations address the following: reimbursement for comprehensive delivery of palliative care services for patients with advanced cardiovascular disease and stroke; strong payer-provider relationships that involve data sharing to identify patients in need of palliative care, identification of better care and payment models, and establishment of quality standards and outcome measurements; healthcare system policies for the provision of comprehensive palliative care services during hospitalization, including goals of care, treatment decisions, needs of family caregivers, and transition to other care settings; and health professional education in palliative care as part of licensure requirements.

Circulation. 2016;134:00–00. DOI: 10.1161/CIR.0000000000000438 September 13, 2016 e1 Plicy Satem entS Lynne T. Braun, PhD, CNP, FAHA, Chair Kathleen L. Grady, PhD, MS, RN, FAHA, Co-Chair Jean S. Kutner, MD, MSPH, Co-Chair Eric Adler, MD Nancy Berlinger, PhD Renee Boss, MD Javed Butler, MD, MPH, MBA, FAHA Susan Enguidanos, PhD, MPH Sarah Friebert, MD Timothy J. Gardner, MD, FAHA Phil Higgins, PhD, LICSW Robert Holloway, MD Madeleine Konig, MPH Diane Meier, MD Mary Beth Morrissey, PhD, MPH, JD Tammie E. Quest, MD Debra L. Wiegand, PhD, RN, FAHA Barbara Coombs-Lee, PA, FNP, JD George Fitchett, DMin, PhD Charu Gupta, MD William H. Roach, Jr, JD On behalf of the American Heart Association Advocacy Coordinating Committee AbstrAct: The mission of the American Heart Association/American Stroke Association includes increasing access to high-quality, evidencebased care that improves patient outcomes such as health-related quality of life and is consistent with the patients’ values, preferences, and goals. Awareness of and access to palliative care interventions align with the American Heart Association/American Stroke Association mission. The purposes of this policy statement are to provide background on the importance of palliative care as it pertains to patients with advanced cardiovascular disease and stroke and their families and to make recommendations for policy decisions. Palliative care, defined as patientand family-centered care that optimizes health-related quality of life by anticipating, preventing, and treating suffering, should be integrated into the care of all patients with advanced cardiovascular disease and stroke early in the disease trajectory. Palliative care focuses on communication, shared decision making about treatment options, advance care planning, and attention to physical, emotional, spiritual, and psychological distress with inclusion of the patient’s family and care system. Our policy recommendations address the following: reimbursement for comprehensive delivery of palliative care services for patients with advanced cardiovascular disease and stroke; strong payerprovider relationships that involve data sharing to identify patients in need of palliative care, identification of better care and payment models, and establishment of quality standards and outcome measurements; healthcare system policies for the provision of comprehensive palliative care services during hospitalization, including goals of care, treatment decisions, needs of family caregivers, and transition to other care settings; and health professional education in palliative care as part of licensure requirements. Palliative care and cardiovascular Disease and Stroke

HomeCirculationVol. 130, No. 8The Role of Worksite Health Screening Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBThe Role of Worksite Health ScreeningA Policy Statement From the American Heart Association Ross Arena, PhD, PT, FAHA, Donna K. Arnett, PhD, FAHA, Paul E. Terry, PhD, Suihui Li, PhD, Fikry Isaac, MD, Lori Mosca, MD, MPH, PhD, Lynne Braun, PhD, CNP, FAHA, William H. RoachJr, Esq, Russell R. Pate, PhD, Eduardo Sanchez, MD, MPH, Mercedes Carnethon, PhD and Laurie P. Whitsel, PhD Ross ArenaRoss Arena , Donna K. ArnettDonna K. Arnett , Paul E. TerryPaul E. Terry , Suihui LiSuihui Li , Fikry IsaacFikry Isaac , Lori MoscaLori Mosca , Lynne BraunLynne Braun , William H. RoachJrWilliam H. RoachJr , Russell R. PateRussell R. Pate , Eduardo SanchezEduardo Sanchez , Mercedes CarnethonMercedes Carnethon and Laurie P. WhitselLaurie P. Whitsel Originally published10 Jul 2014https://doi.org/10.1161/CIR.0000000000000079Circulation. 2014;130:719–734Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2014: Previous Version 1 IntroductionThe healthcare system in the United States is undergoing a paradigm shift that will result in a greater focus on the early identification and management of risk factors known to be associated with a higher risk for noncommunicable diseases, in particular, cardiovascular disease (CVD). Healthcare delivery must move beyond the clinical environment by partnering with employers, schools, community-based organizations, and public health agencies to reach large segments of the population and address the problems that contribute to poor health.1,2 Justification for this transformation in US healthcare delivery can be made from several perspectives, namely the renewed focus on prevention. However, one of the most compelling arguments in the current economic environment is the financial benefit of shifting the focus towards prevention. Direct medical costs associated with CVD in the United States are projected to increase from $273 billion in 2010 to $818 billion in 2030. Indirect costs associated with CVD secondary to lost productivity will increase from $172 billion to $276 billion over this same timeframe.3 Clearly, to avoid these disconcerting economic forecasts, the change in healthcare delivery and emphasis on primary and primordial prevention must happen quickly.Modifiable risk factors that portend a higher likelihood of initial CVD development, or subsequent events if a diagnosis has been established, have been known for several decades: excess body weight, hyperglycemia and diabetes mellitus, physical inactivity/low cardiorespiratory fitness (CRF), high blood pressure, tobacco use, and poor diet. Improved identification and management of these risk factors is essential to altering future healthcare projections of worsening health coupled with higher costs.The workplace is an ideal environment to initiate the shift towards prevention. Biometric screening is defined by the Centers of Disease Control and Prevention as "the measurement of physical characteristics such as height, weight, body mass index, blood pressure, blood cholesterol, blood glucose, and aerobic fitness tests that can be taken at the worksite and used as part of a workplace health assessment to benchmark and evaluate changes in employee health status over time."4 Biometric screening is often combined with a Health Risk Assessment tool (eg, questionnaire to assess current and future health risks),5 and combined they are defined as health screening in the workplace.There is consensus that conducting health screenings in the workplace is a promising strategy for early detection of established risk factors with the hopes of preventing the development of noncommunicable diseases, or, if an individual has already been diagnosed with a noncommunicable disease, managing this condition and preventing subsequent events.6–8 Screenings may be even more effective at identifying risk factors and providing better return on investment (ROI) if they are targeted toward higher risk individuals.9–13 Health screenings serve as a catalyst to further clinical health assessments for those who were not aware of their risk factors14 as well as a first step in a workplace health and wellness promotion process where awareness of personal health risks can lead to participation in lifestyle change or tailoring of disease management programs (eg, structured exercise, dietary, or psychosocial interventions).15–17 Increasingly, based on provisions in the Patient Protection and Affordable Care Act (ACA), health screenings will be associated with monitoring progress toward the achievement of health standards and, often, screening results will be connected to incentives that encourage employee participation in worksite health and wellness programs.18 Research suggests that the healthcare costs avoided from delaying or preventing the onset of noncommunicable diseases justify the upfront investments made in identifying and reducing existing health risks.19 Whether through prevention or risk reduction, currently available studies indicate that employers can achieve a positive ROI when employee health screening is offered in concert with a well designed comprehensive health and wellness program.20–22Although the implementation of worksite health screening seems highly reasonable and advantageous on the surface, there are numerous nuances and logistical considerations that require discussion. This American Heart Association (AHA) policy statement will provide considerations for and guidance on worksite health screening, with particular implications for subsequent health and wellness programming, in the context of a rapidly changing US healthcare landscape.Review of Available Evidence Related to Worksite Health Screening and Health and Wellness ProgramsEffectiveness of Health Screenings for Behavior Change and Health OutcomesThe rationale for hypothesizing that health screenings would be effective independent of additional behavioral change programming is that employees who are aware of their health status may be motivated to make behavioral changes on their own, identify other sources of support for making behavioral changes, or seek follow-up medical care.23 From the perspective of the employer, offering health screenings that are not coupled with additional programming can be cost effective if their employees have the individual resources required to change their behaviors (eg, memberships to athletic training facilities, resources within the community) and are sufficiently motivated to do so. However, given that participation in health screening programs is commonly voluntary, employees who are willing to complete the health screening may be systematically different from nonparticipants; at least 1 study suggests that healthier employees are more likely to participate.24 Other studies suggest that employees whose self-reported health is poorer are more likely to change their behaviors,25 possibly because they may be further along the behavior change continuum that ranges from precontemplation to action and, ultimately, maintenance.26 A handful of studies have evaluated the effectiveness of health screenings for encouraging participation in health and wellness programming, promoting health behavior changes and modifying health outcomes.In a 2010 systematic review, Soler et al27 evaluated the effectiveness of health screening with and without feedback on health outcomes based on 86 studies published between 1980 and 2005. In the subset of 37 studies that evaluated health risks and provided feedback, there were favorable changes in health behaviors relevant to CVD, including self-reported increases in fruit and vegetable intake with a concomitant decrease in saturated fat intake, increased physical activity, and modest improvements in smoking cessation rates. Overall, the behavioral changes were modest, and most study designs were before–after analyses that did not include a comparison group. The effectiveness of health screening with feedback on healthcare services use demonstrated promising findings in relation to decreases in physician visits per year. Not surprisingly, the effectiveness of health screening on each of the behavioral and biometric measures was stronger when the screening was followed by offering a comprehensive health and wellness program. Based on the evidence, the authors concluded that although many of the studies did suggest that health screenings were effective, the study designs were flawed. Stronger evidence could be determined from studies that, at a minimum, included a control arm, and at best, randomized employees to the intervention or control.Three additional studies that were either published since the review or were not included in the review evaluated the effectiveness of worksite health screenings and warrant some discussion. In 1 Dutch company, 368 employees volunteered to complete an internet-based health screening that included an evaluation of height, weight, waist circumference, blood pressure, a blood collection to determine lipids and glucose, and a urine sample for albumin and creatinine.28 Employees were offered a health counseling session and tailored motivational and educational health advice. There was a significant improvement in the Framingham Risk Score (−4.9%, P=0.02) and even more substantial improvements among employees who were at the highest risk at baseline; among the 21 employees whose baseline Framingham Risk Score was ≥20%, CVD risk declined by 17.9% (P<0.001). Although the findings from this study were notable, the study design suffers a number of limitations including the reliance on a volunteer sample of participants who represented only 8% of all employees (n=2149) at the company. Further, of the 368 who participated in the program, fewer than half (48%) returned for the follow-up assessment. It is plausible that those who returned for repeated assessment did so because of the changes they observed in their CVD risk.Blue Cross–Blue Shield of Kansas City evaluated the effectiveness of their comprehensive worksite health and wellness programming on 15 employee groups that included 4230 employees.29 All program participants underwent a health screening after which they met with a health and wellness program counselor to review screening results and discuss programming options to support their behavior changes. The majority of employees (86%) who were low-risk at baseline remained so at follow-up. Nearly half (49%) of high-risk employees improved their risk status, and 40% of the moderate-risk employees improved. Thus, this study, which integrated health screening with subsequent health and wellness programs, including telephone coaching, smoking cessation, and exercise campaigns, showed promising results.More than 5000 employees from 15 employee groups representing a range of industries across the United States underwent health screenings as part of the myhealthIQ program (www.myhealthiq.com).30 Health status was categorized as higher risk versus lower risk at baseline and on follow-up, which took place 7 to 12 months later. For each of the cholesterol metrics and smoking category, the proportion of employees classified as high-risk declined significantly (total cholesterol: −4.6%, P<0.01; HDL cholesterol: −3.9%, P<0.01; LDL cholesterol: −6.1%, P<0.01; smoking: −2.5%, P<0.01). The decrease in the proportion of employees initially classified as high risk according to systolic blood pressure group was not statistically significant (−0.7%, P=0.30), whereas the −3.4% decrease in diastolic blood pressure was significant (P<0.01). There was no change in the proportion of employees in the high-risk body mass index (BMI) category (0%, P=0.96). Based on these findings and on a significant improvement in their summary score, the investigators concluded that education about health risks could motivate behavior changes in employees.In 1 study that used a rigorous trial design, university employees who had CVD risk factors were randomly assigned to complete a health screening plus targeted disease management or a health screening with counseling and environmental support for behavior change to determine which was most effective in changing the Framingham Risk Score over 1 year.31 The Framingham Risk Score decreased 22.6% in the disease management arm, but went up 4.2% in the counseling arm (P=0.02), suggesting that health screenings are only effective when coupled with targeted interventions.In summary, the body of currently available evidence indicates health screening in the workplace is a promising strategy for initiating behavioral changes in employees that can ultimately lead to improvements in established CVD risk factors and maintenance of cardiovascular health. However, most evidence evaluating the effectiveness of worksite health screening demonstrates that the most effective model is one that combines screening with encouragement to participate in some type of health and wellness program.Return on Investment: Health Screening as a Facilitator for Health InterventionsOnce modifiable risk factors are identified via worksite health screenings, they must be improved on for optimal impact on employee health. Some literature suggests there is a favorable ROI through participation in a worksite health and wellness program. For most studied worksite health and wellness programs, a health screening was incorporated as an essential first step in identifying known risk factors for individual employees. The health screening information was used to prioritize interventions to improve health, tailor programs to individual needs, and potentially refer employees to their healthcare providers. For example, it was estimated that worksite weight management interventions achieving a 5% weight loss would reduce the total annual medical and absenteeism costs by $90 per overweight or obese employee.32 Overall, previous analyses have reported a wide variability in ROI through worksite health and wellness programs; namely, that every dollar invested in a worksite health and wellness program could generate between $2.50 and $10.00 in savings attributable to both reduced absenteeism and medical costs.23 A recent meta-analysis reported that an average worksite health and wellness program would lead to $358 in annual savings per employee, with an up-front cost of $144 per employee per year.33 Such investment projections typically consider the costs of administering the health screening, maintaining onsite exercise equipment, organizing health education programming, and providing bonuses and reimbursements to motivate participation.A number of randomized, controlled trials found that worksite health screenings alone offered little ROI benefit, whereas an assessment followed by behavioral counseling and incentives achieved favorable cost savings.34,35 Naydeck et al36 studied the ROI of a worksite health and wellness program offered by Highmark Inc. between 2002 and 2005. The program was launched with a health screening that included cholesterol, glucose, and blood pressure measurements. Participants were then provided with free nutrition classes, smoking cessation classes, and access to fitness centers. The researchers used longitudinal medical claims data to create a matching pool of nonparticipants who were similar to participants in their preintervention medical expenditures and health profiles. Multivariate analysis showed that in comparison with nonparticipants, program participants experienced a $176 reduction in health expenditures per person per year. It is important to note, however, that employees simply completing the health screening with no follow-up behavioral interventions did not experience cost savings.Considerations for Health Screening and Biometric MeasuresTraditional Biometric MeasuresThere are 7 established, traditional biometric measures related to cardiovascular health that are captured within the worksite health screening, ideally obtained as an initial component of a worksite health and wellness program. These include blood pressure, glucose, cholesterol, physical activity, diet, body habitus (ie, BMI), and tobacco use.7,23,37–41 For its 2020 goals for cardiovascular health, the AHA has defined poor, intermediate, and ideal health categories based on these biometric measures, as listed in Table 1.42Table 1. Definitions of Poor, Intermediate, and Ideal Cardiovascular Health for Each Metric in the AHA 2020 Goals for Adults Aged ≥20 YearsLevel of Health for Each MetricPoorIntermediateIdealCurrent smokingYesFormer ≤12 monthsNever or quit >12 monthsNever tried; never smoked whole cigaretteBMI*≥30 kg/m225–29.9 kg/m218.5–25 kg/m2PA†None1–149 min/week moderateor1–74 min/wk vigorous1–149 min/wk moderate + 2× vigorous>0 min <60 min of moderate or vigorous every day≥150 min/wk moderateor≥75 min/wk vigorous≥150 min/wk moderate + 2× vigorous≥60 min of moderate or vigorous every dayHealthy diet pattern, number of components‡0–12–34–5Total cholesterol≥240 mg/dL200–239 mg/dL or treated to goal<200 mg/dLBlood pressureSBP ≥140 mm HgorDBP ≥90 mm HgSBP 120–139 mm HgorDBP 80–89 mm Hgortreated to goal<120 mm Hg/<80 mm HgFasting plasma glucose≥126 mg/dL100–125 mg/dL<100 mg/dLAHA indicates American Heart Association; BMI, body mass index; DBP, diastolic blood pressure; PA, physical activity; and SBP, systolic blood pressure.*Represents appropriate energy balance (ie, appropriate dietary quantity and PA to maintain normal body weight).†Proposed questions to assess PA: (1) "On average, how many days per week do you engage in moderate to strenuous exercise (like a brisk walk)?" and (2) "On average, how many minutes do you engage in exercise at this level?"38 Other options for assessing PA available.41‡In the context of a healthy dietary pattern that is consistent with a Dietary Approaches to Stop Hypertension (DASH)–type eating pattern, to consume ≥4.5 cups/d of fruits and vegetables, ≥2 servings/wk of fish, and ≥3 servings/d of whole grains and no more than 36 oz/wk of sugar-sweetened beverages and 1500 mg/d of sodium.Employers should consider using this biometric measure categorization model for worksite health screenings to help illustrate current health status to employees, individualize health and wellness programming, and establish goals for improvement or health maintenance. In addition, the recently released AHA/American College of Cardiology cholesterol screening guidelines,43 the Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure,44 and the 2013 AHA/ American College of Cardiology/Centers for Disease Control and Prevention science advisory, "An Effective Approach to Blood Pressure Control,"45 should also be considered when assessing biometric measurement results during a worksite health screening.In assessing BMI, the AHA recommends adding waist circumference because the accuracy of BMI for diagnosing obesity is especially limited for individuals in the intermediate BMI ranges, in men, and in the elderly.46 Also, abdominal adiposity and visceral fat provide a more refined health indicator of the risk for cardiovascular death than BMI, especially in middle-aged adults.47–50For tobacco use, it is important to determine how "use" will be assessed (self-report vs. cotinine test), what tobacco products will be included in the definition (cigarette, cigar, smokeless tobacco product, e-cigarette, etc.), and the amount of tobacco use that meets the threshold for use. The goal of defining tobacco use should be to provide a simple and precise assessment of the consumer's tobacco use status that minimizes misunderstandings or potential false reporting and accounts for changing trends in tobacco products and uses. Employers should include not only combustible products like cigarettes and cigars in their screening, but also the new electronic nicotine delivery systems (e-cigarettes), hookah products, smokeless tobacco, and dissolvable products that are in the marketplace. Employers should also offer access to a comprehensive cessation program that includes both pharmacological treatment and cessation counseling as part of their screening and wellness programs.Lastly, as a standard practice, the writing group currently recommends having physical activity patterns quantified in a standardized fashion using 1 of several accepted methods (ie, questionnaire, diary/log, pedometers, or accelerometers)38,41,51 as opposed to directly measuring CRF during worksite health screenings. Admittedly, CRF is a more objective assessment compared with quantifying physical activity patterns and, as such, the former approach is potentially more reflective of the health status of relevant physiologic systems (ie, cardiovascular, pulmonary, and skeletal muscle). Moreover, evidence demonstrating the importance of actual CRF to overall health, functional independence, and longevity, beyond self-reported physical activity patterns, is irrefutable.52–54 As such, when recent (ie, ≈6 months or less) CRF data are available from a reliable and valid source outside of the worksite health screening event for a given employee (eg, stress test results conducted by the employee's physician), and the employee is willing to share this information, it should be considered when biometric measurements are assessed in totality. Moreover, the writing group finds no reason to dissuade employers from implementing an actual CRF assessment in a worksite screening if this is deemed important and feasible by a given organization.Nontraditional/Novel Biometric Measures as Part of Worksite Health ScreeningDespite the increased availability of nontraditional/novel biometric measurements and investigations in their role in the assessment of risk of CVD, there is currently insufficient evidence to support their inclusion in worksite health screening. Examples of nontraditional/novel biometric measurements include the following: (1) C-reactive protein, (2) coronary artery calcium score, (3) arterial stiffness, (4) lipoprotein(a) level, (5) lipoprotein-associated phospholipase A2, (6) homocysteine level, and (7) carotid intima-media thickness. A recent AHA guideline for assessment of CVD risk in asymptomatic adults also suggests there is no definitive benefit to screening with these nontraditional/novel biometric measurements and there may be harm in several situations.55 Rather, the AHA has suggested further evaluation on the clinical utility, impact on clinical outcomes, and cost-effectiveness of nontraditional/novel biometric measurements before considering their implementation to improve clinical management.56 The US Preventative Services Task Force shares the opinion that there is insufficient evidence to recommend routine screening for novel nontraditional/novel biometric measurements in the assessment of risk of CVD among asymptomatic men and women.57 In summary, it is currently recommended that current worksite health screenings entail the evaluation of biometric measurements related to traditional risk factors, as described earlier, intended to aid in recommendations for further assessment and lifestyle modifications to reduce risk.Logistical Issues Surrounding Worksite Health ScreeningsWho Should Administer the Worksite Health Screening?Ideally, health professionals who regularly deliver wellness or medical services should perform the worksite health screening to ensure continuity and sustainability. If this resource is not available within the organization offering the worksite health screening, depending on local regulations and resources, contracted external vendors, qualified health professionals and technicians, or appropriately trained wellness screeners could be utilized. Considerations for an employer in selecting an external vendor are listed in Table 2.6Table 2. Factors to Consider When Selecting an External Vendor to Deliver Worksite Health Screening and Health and Wellness Programs•Vendor able to demonstrate sufficient history in delivering worksite health screening and health and wellness programs•Ensure that the healthcare professionals employed by the vendor are licensed or properly credentialed•Portfolio of current and past customers —Vendor provides contact list to discuss services provided•Vendors proposed biometric measurements for health screenings follow current scientific guidelines/consensus statements —New/novel biomarkers, not supported by current evidence, should not be included as part of vendor services•Vendor rigorously collects outcomes data; demonstrating effectiveness of services —Able to summarize benefits from employee biometric screening including return on investment or cost-effectiveness•Cost of services by vendor are reasonable and favorable in relation to potential return on investment•Vendor has established processes for the following: —Obtaining informed consent from employees —Managing protected health information and assuring employees of the privacy of their data —Individual result reporting with the employee and ideally with the employee's provider and aggregate reporting to the employer —Management of data, quality assessment of data, systems to monitor data turnaround times —Training and managing staff and staff development —Updating written policies and procedures and mechanisms for communicating same to staff•Vendor demonstrates services are in compliance with all state and federal laws relevant to worksite health screening and health and wellness programs•Vendor has obtained relevant certifications and accreditations —Centers for Medicare and Medicaid Services CLIA certification —NCQA Wellness and Health Promotion Accreditation•Vendor employs health and wellness professionals who are able to proficiently deliver worksite health screenings and health and wellness programs•Vendor able to meet needs of employer worksite health screening and health and wellness programs —Flexibility in scheduling —Ability to provide services to given number of employees•Vendor demonstrates an ability to capitalize on currently available technology in delivering services —Smart phone applications —Web-based servicesCLIA indicates Clinical Laboratory Improvement Amendments; and NCQA, National Committee for Quality Assurance.FrequencyThe frequency of worksite health screenings should consider a number of factors; they should be frequent enough to become a routine which conditions employees to participate but not so frequent as to make employees' become bored or frustrated because their biometric measurements change slowly over time. The logistics of measuring a given variable (eg, blood lipids versus physical activity status) may impact assessment frequency. Moreover, when a variable indicates "increased health risk," the timing and frequency of follow-up assessments should also be considered.Generally, organizations will adopt a 1- or 2-year cycle for conducting health screenings. Funds available to cover resources required to implement a worksite health screening (eg, external vendor contracts, healthcare professionals, space, cost of blood work, or biometric measure assessment tools) will impact the frequency of screening. Another influencing factor is the allotted time needed for employees to participate in the health screening and the workplace environment, the latter of which can be a particular logistical challenge in larger organizations or manufacturing environments. Employee demographic issues that influence assessment frequency are age and existing health risks of the employee population. Lastly, labor and employment agreements may also affect an employer's ability to schedule and conduct health screenings.TimingTiming of worksite health screening is important to consider in an effort to optimize employee participation. Employers should consider a "blitz" type event, so all employees are scheduled over a defined period, which makes it easier to promote and encourage participation. If there are multiple work shifts each day, having several screening sessions would be advantageous. Additionally, if relevant, employers should also take advantage of annual events, such as sales meetings, when field employees are together in 1 place to complete the health screening.Blood tests, when incorporated into worksite health screening, serve as another example as to why timing is important. The gold standard for measuring blood glucose and lipid profiles is a fasting sample, which requires timing considerations for the collection of these data. Nonfasting blood samples can also provide valuable information and allows for more flexibility in timing of measurement. However, compared with fasting samples, values differ for certain cholesterol measurements as well as blood glucose, requiring consideration of different thresholds to define abnormal values and higher risk.58–60 With respect to assessment of blood glucose levels, measurement of hemoglobin A1C may be considered, if possible, when a nonfasting blood sample is going to be obtained during the worksite health screen.58 With respect to screening for diabetes mellitus, if fasting is required, it may be advantageous for the employer to offer appointments early in the morning.Associated CostWorksite health screenings do carry up-front costs to the employer. Health and wellness professionals, used to conduct the health screening, interpret results, discuss appropriate wellness interventions, or facilitate referrals to employees' personal physicians if a significant health risk is identified, can range in price according to their level of experience and whethe

### Background The American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA) have jointly engaged in the development of clinical practice guidelines (CPGs) for nearly 3 decades, based on the shared vision of their responsibility to provide guidance to cardiovascular healthcare professionals and the patients they serve by translating the best available evidence into clinical practice. The ACCF/AHA Task Force on Practice Guidelines (Task Force) oversees and directs the CPG development process and methodology that have been the foundation of our documents and responsible for their widespread recognition. In brief, once a topic is selected for a new, revised, or updated CPG, selected organizations and professional societies with similar interests and expertise are invited …

719 T he healthcare system in the United States is undergoing a paradigm shift that will result in a greater focus on the early identification and management of risk factors known to be associated with a higher risk for noncommunicable diseases, in particular, cardiovascular disease (CVD). Healthcare delivery must move beyond the clinical environment by partnering with employers, schools, community-based organizations, and public health agencies to reach large segments of the population and address the problems that contribute to poor health. Justification for this transformation in US healthcare delivery can be made from several perspectives, namely the renewed focus on prevention. However, one of the most compelling arguments in the current economic environment is the financial benefit of shifting the focus towards prevention. Direct medical costs associated with CVD in the United States are projected to increase from $273 billion in 2010 to $818 billion in 2030. Indirect costs associated with CVD secondary to lost productivity will increase from $172 billion to $276 billion over this same timeframe. 3 Clearly, to avoid these disconcerting economic forecasts, the change in healthcare delivery and emphasis on primary and primordial prevention must happen quickly. Modifiable risk factors that portend a higher likelihood of initial CVD development, or subsequent events if a diagnosis has been established, have been known for several decades: excess body weight, hyperglycemia and diabetes mellitus, physical inactivity/low cardiorespiratory fitness (CRF), high blood pressure, tobacco use, and poor diet. Improved identification and management of these risk factors is essential to altering future healthcare projections of worsening health coupled with higher costs. The workplace is an ideal environment to initiate the shift towards prevention. Biometric screening is defined by the Centers of Disease Control and Prevention as " the measurement of physical characteristics such as height, weight, body mass index, blood pressure, blood cholesterol, blood glucose, and aerobic fitness tests that can be taken at the worksite and used as part of a workplace health assessment to benchmark and evaluate changes in employee health status over time. " 4 Biometric screening is often combined with a Health Risk Assessment tool (eg, questionnaire to assess current and future health risks), 5 and combined they are defined as health screening in the workplace. There is consensus that conducting health screenings in the workplace is a promising strategy for early detection of established risk factors with the hopes of preventing the development of noncommunicable diseases, …