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Health Policy, Public Health, Stanford News

Defining a “public-health emergency” in an age of complex health threats

Defining a “public-health emergency” in an age of complex health threats

MHE_-_KBH_Brandvaesen_-_HAZMAT_3aWhen chemicals used in coal mining were spilled into the Elk River in West Virginia in January, the governor declared a state of emergency the same day. When the H1N1 influenza virus was discovered in 2009, President Obama declared a national public-health emergency. In both cases, people were willing to comply with government orders (don’t drink the water, speed up vaccine production) in order to get an impending health threat under control.

But what happens when the health threat isn’t imminent? Or if it has no clear end-point? In a perspective piece in the most recent issue of the New England Journal of Medicine, Stanford public-health law scholar Michelle Mello, PhD, JD, and her co-authors delve into just such questions. They describe Massachusetts Governor Deval Patrick’s unusual step in March to declare a public-health emergency in order to control the state’s recent opioid-addiction epidemic – 40 people had died from heroin overdoses in four months. The move allowed public-health authorities to take several steps to address the problem, including monitoring prescription use and release funds for addiction treatment. Few states have taken such drastic steps to control drug use problems, though, and it raises questions about what exactly constitutes a public health emergency. In the piece, the authors write:

Patrick’s unusual invocation of emergency public health powers, which are traditionally reserved for infectious disease outbreaks, natural disasters, or acts of terrorism, offers an opportunity to consider some important questions. Should widespread injuries, such as those caused by opiates or motor vehicle crashes, be viewed as public health emergencies? Should chronic health conditions such as hypertension or obesity be similarly categorized? When should normal lawmaking processes, and the typical rights afforded to individuals and entities, be suspended to protect public health?

Although there may be benefits – drawing public attention to an important problem, access to critical funding sources, even mustering military personnel (for example, the National Guard was deployed to deal with the Elk River chemical spill) – there are drawbacks as well. Emergency powers give the government unprecedented leeway, as the authors note, they “sit largely outside the ordinary structures of checks and balances.” The authors go on to describe some of the pitfalls of declaring public-health emergencies:

Most important, concerns about due process are amplified when emergency orders restrict individual freedoms and property rights. The notion that highly coercive measures such as mandatory blood tests, quarantines, or property seizures could be imposed for common threats without democratic procedures and full due process offends our constitutional values. The lack of clear triggering thresholds for terminating emergency powers is particularly troubling, creating the possibility that critical legal protections might be suspended indefinitely.

Government officials rarely invoke public health emergencies, partly due to their out-sized power. The authors note, though that Patrick’s invocation “sets a troubling precedent” for a power that should be used with caution.

Photo by hebster

Emergency Medicine, Health Policy, In the News, Patient Care, Research, Stanford News

Exploring how the Affordable Care Act has affected number of young adults visiting the ER

Exploring how the Affordable Care Act has affected number of young adults visiting the ER

ER sign - 560

One of the earliest – and most popular – parts of the Affordable Care Act allowed young adults to stay on their parents insurance until their 26th birthday. This week, Stanford researchers led by Tina Hernandez-Boussard, PhD, published a paper in the journal Health Affairs that tracked emergency room visits in California, New York and Florida for two age groups: 19 to 25 year olds – the group affected by the new requirement -  and 26 to 31 year olds for comparison. The researchers examined ER visits for the two years prior to the ACA requirement (2009 and 2010) and one year after the requirement went into effect (2011). Their findings showed that in 2011, 19- to 25-year-olds had slightly fewer ER visits – 2.7 per 1,000 people -compared to the older group.

The researchers calculated that the drop in ER use means more than 60,000 fewer visits for 19- to 26-year-olds across the three states  in 2011. They also found that the  largest relative decreases in ER use were among women and blacks.

post on Washington Post‘s Wonkblog covered the study and discussed further findings:

The researchers had another finding that seems just as important. While the total number of ER visits among the under-26 group was down, about the same number of people still went to the ER. The distinction here is that young adults with chronic conditions, who have greater care needs, probably now had better access to non-ER care settings, so their number of visits to the ER decreased. But the finding also suggests that healthy young adults, who might have shunned health insurance before, still continued to see the ER as a place for seeking out routine care, according to the study. Further, insurance likely makes those ER visits cheaper, which could actually increase how much people use the ER, the researchers wrote.

Hernandez-Boussard and her colleagues concluded in their paper, “As EDs face capacity challenges, it is important to consider how to meet the broad underlying needs of young adults through other channels and ensure the needed availability of these alternative health services.”

Previously: Abraham Verghese on health-law battle: “We’ve worried so much about the process, not the patient”
Photo by Eric Staszczak/KOMU

Podcasts, Public Safety, Science, Science Policy, Stanford News

The risks of tinkering with dangerous pathogens

The risks of tinkering with dangerous pathogens

In an effort to understand new and rare infectious diseases, researchers often use recombinant DNA technology to create novel strains in the lab. In 2012, researchers did just that, creating strains of the H5N1 influenza virus that were transmissible between mammals, setting off a debate about the ethics of creating viruses that were potentially more dangerous than those that occurred naturally.

Earlier this year, in July, a group called the Cambridge Working Group convened to continue discussing these questions. David Relman, MD, a biosecurity expert at Stanford, is a member of the group and spoke to Paul Costello about the risks and benefits of lab-created pathogens. Highlights of their conversation are in a piece in the most recent issue of Inside Stanford Medicine, where Relman notes:

My greatest fear is that someone will create a highly contagious and highly pathogenic infectious agent that does not currently exist in nature, publish its genetic blueprint, allow it to escape the laboratory by accident, or else enable a malevolent person or persons to synthesize the agent with the intention of releasing it in a deliberate manner. Although these may be unlikely scenarios, they could have catastrophic consequences, which is why I and others feel that we need to sensitize everyone to these possibilities and decide how to manage these risks ahead of time. I want to be clear: I am not opposed to laboratory work on dangerous pathogens, especially if they are known to exist in nature. Rather, I am opposed to high-risk experiments and, in particular, those that seek to create novel, dangerous pathogens that cannot be justified by well-founded expectations of near-term, critical benefits for public health — benefits that clearly outweigh the risks, and benefits that cannot be achieved through other means.

But not all researchers advocate the same level of caution. A few weeks after the Cambridge Working Group formed, another group called Scientists for Science to advocate in favor of using recombinant versions of pathogens in order to understand them better. Relman says that the two groups are probably not as far apart as they appear. He says he fully supports studying disease-causing bacteria, but:

The place where we may disagree is on whether we are willing to acknowledge that there may be experiments — probably few and far between — that perhaps ought not to be undertaken because of an unusual degree of risk. Just because a scientist can think up an experiment doesn’t mean it should be performed.

Relman elaborates on these topics in the 1:2:1 podcast with Costello above.

Previously:  How-to manual for making bioweapons found on captured Islamic State computer, Microbial mushroom cloud: How real is the threat of bioterrorism? (Very) and Stanford bioterrorism expert comments on new review of anthrax case

Cardiovascular Medicine, Patient Care, Pediatrics, Stanford News

A nurse puts heart into her work at Adult Congenital Heart Program

A nurse puts heart into her work at Adult Congenital Heart Program

heart_sillman_560A few decades ago, if a child was diagnosed a serious heart defect it was essentially a death sentence, but thanks to recent advances in neonatal heart surgery, most patients now live well into adulthood. And at least one of them has gone on to care for other people with congenital heart defects.

Christy Sillman, RN, is the nurse coordinator for Stanford’s Adult Congenital Heart Program and is profiled in the most recent issue of Inside Stanford Medicine. Although most people who were treated for heart defects as children don’t require continued surgical interventions as adults, doctors now know that they have other challenges that require ongoing care. Sillman went through this firsthand. After being told as a teenager that she was “cured” and going a decade without care, she learned she was suffering from cardiomyopathy, a deterioration of the heart muscle. From the article:

“At that point, my frustration with the medical care of people with congenital heart defects was elevated,” Sillman recalled. “I wouldn’t have been in such bad shape had I gotten the right care earlier. This motivated me to get more involved.”

That involvement was huge. Sillman talked with many people who shared similar stories, which inspired her to become an advocate for patients like herself. When a position was available with the program at Stanford in 2013, Sillman jumped at the chance and was hired.

“I don’t want any teenager to go through what I went through,” Sillman said. “Being told you’re cured and finding out that’s not really true? That should never happen.”

Sillman’s personal experiences are not unusual for a congenital cardiac patient of her generation, but it influenced her professional choices and now, she says, she enjoys bringing “a patient’s perspective” to her work.

Previously: Patient is “living to live instead of living to survive,” thanks to heart repair surgery
Photo by Norbert von der Groeben

Big data, Research, Stanford News

Stanford researchers use data mining to show safety of peripheral artery disease treatment

Stanford researchers use data mining to show safety of peripheral artery disease treatment

Every day, doctors across the country take down reams of information about their patients. Those notes are a treasure trove of information about preventive treatments, side effects of drugs and drug interactions. But most of this information has been hard to access - until now.

In the past, researchers who really wanted the data have combed through individual records - which can be hundreds of pages - manually. When I worked as an epidemiologist at the California Department of Public Health, for example, I worked on a large study that looked at prenatal hospital records for infectious disease lab testing – and our team of a dozen researchers took months to go through a few hundred records. It’s not an efficient approach for most diseases medical researchers might want to study. Recently launched national efforts also recognize this limitation and call for turning data from regular doctor visits into data points to figure out what is best for patients.

So when I learned that Nigam Shah, MBBS, PhD, a biomedical informatics professor at Stanford, has been looking at ways to pull out information electronically from clinical notes, my ears perked up.

In a paper published today in the journal PLOS ONE, Shah and co-authors Nicholas Leeper, MD, a Stanford cardiologist and vascular medicine specialist, and Anna Bauer-Mehren, PhD, an informaticist who recently moved from Stanford to Roche Germany, used a new methodology to answer a nagging question about the safety of Cilostazol, the only drug with the American Heart Association’s highest effectiveness rating – Class 1A - for treating the symptoms of peripheral arterial disease, a condition that affects millions of Americans. Regulators fear the drug might have side effects on the cardiovascular system that could lead to death, so the drug has historically carried a “black-box warning.” As a result, the use of this drug has been limited.

Looking at a specialized system that includes health-research data from millions of patients seen at Stanford Hospital over 18 years, the researchers found no evidence that patients with peripheral arterial disease who took Cilostazol suffered the side effects about which doctors were worried, compared with patients who didn’t receive the drug. By querying these records, the researchers identified a subset of patients they felt were at highest risk – a group which is often excluded from company-sponsored trials – and found no evidence of the side effects.

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