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Global Health, Health Policy, Stanford News

E-cigarettes a growing cause for concern in the developing world

E-cigarettes a growing cause for concern in the developing world

11505926173_7be7ca343b_zIt is a common misconception that e-cigarettes are a problem only in wealthy nations, say two Stanford global health researchers in a commentary published today in the Journal of the American Medical Association. In the piece, co-authors Michele Barry, MD, FACP and Andrew Chang, MD, call attention to the widespread availability of e-cigarettes in the developing world and a growing concern over the potential health implications unique to low- and middle-income countries.

Chang, an internal medicine resident in Stanford’s Global Health track planning to specialize in cardiology, has been closely tracking the conversation around global tobacco control, but noticed e-cigarettes have been largely absent from the discussion. With support from Barry, director of the Center for Innovation in Global Health, Chang dug deeper and found that while U.S. health officials and researchers have been grappling with uncertainties around e-cigarette regulation and health impacts, the rise of e-cigarettes has in fact become a global threat.

The authors point to a 2014 survey from the World Health Organization suggesting that already, more than half of the world’s population is living in countries where e-cigarettes – or electronic nicotine delivery systems (ENDS) – are available. Public awareness in many of these countries is high and the devices are cheap.

But in some parts of the world, notably Africa and South Asia, there is little to no data on e-cigarette awareness and usage trends. This is of particular concern, say Barry and Chang, as regions like Africa and South Asia represent vast potential markets and are likely to be hit hardest by the growth of e-cigarettes.

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Global Health, Health Costs, Health Policy, Medicine and Society, Research

Chinese clinicians use inpatient visits to compensate for drug revenue loss

Chinese clinicians use inpatient visits to compensate for drug revenue loss

For decades, many doctors in rural China boosted their incomes by both recommending and selling drugs, often at steep markups. With mounting evidence of overprescription, in 2009 the Chinese national government largely banned markups, undermining doctors’ financial incentive to over-provide them. Instead, the government provided physicians with a subsidy to compensate for the loss in profits.

Since then, a number of scholars have examined the effects of the policy. But no one has looked at the unintended consequences — until now.

In a study published today in Health Affairs, a team of researchers found the policy had the unintended consequence of boosting hospitalizations and the provision of inpatient care.

“When you have a regulation that affects pricing, it’s like pushing a balloon in in one place — then it pops out in another,” said Grant Miller, PhD, director of the Stanford Center for International Development, senior fellow at the Freeman Spogli Institute for International Studies and an associate professor of medicine. The first author is Hongmei Yi, PhD, program manager of FSI’s Rural Education Action Program in China.

The team, which also includes Scott Rozelle, a senior fellow at FSI, examined data from rural Chinese clinics between 2007 and 2011. They found clinics that were most heavily reliant on drug revenues before the policy change more than doubled their provision of inpatient services when compared with the clinics least reliant on drug revenues before the change. These centers also experienced little change in revenue, which indicates they were able to offset the losses of drug revenue with income from inpatient stays.

Based on their analysis, the team also believes that this increase is not driven by demand for inpatient services, Miller said.

By also surveying and conducting follow-up phone interviews with patients, the researchers also found some evidence that clinics may be artificially boosting their inpatient tallies to increase their compensation from the government.

He said he was not surprised the policy had unexpected ramifications. “Humans are adaptive creatures and doctors are not categorically different than the rest of us. If you take away a source of livelihood, it’s not surprising they found another way to make it up.”

Rural primary care doctors in China “are also not at the top of the economic pyramid,” Miller said.

Health-care reform is on the national agenda in China and it’s possible that this study could inform future policies, Miller said. “It raises a much broader set of questions about how you design in a more holistic way a proper set of incentives for providers,” he said.

Previously: Seeking solutions to childhood anemia in China, Better school lunches — in China and Stanford India Health Policy Initiative fellows are in Mumbai — come follow along

Health Policy, Pediatrics, Research, Sleep

Rethinking middle and high-school success: strategies for creating healthier students

Rethinking middle and high-school success: strategies for creating healthier students

512px-Sleeping_while_studyingMy daughters are still years away from college or even high school, but I’m not looking forward to the high-pressure arena that they look to be from afar. The stress and lack of sleep has to take a toll on students’ health. I was curious, then, to hear about a program developed by researchers from Stanford’s Graduate School of Education called Challenge Success. The program helps parents and schools develop a more even-keeled approach to the high-pressure world that many college-bound middle- and high-schoolers find themselves in.

Last week, the program released Overloaded and Underprepared: Strategies for Stronger Schools and Healthy, Successful Kids, a book that gathers what researchers at Challenge Success have learned in the dozen years the program has been in place. The GSE’s website features a Q&A with two of the book’s authors: Denise Pope, PhD, EdM, a Stanford GSE lecturer and co-founder of Challenge Success, and Maureen Brown, Challenge Success Executive Director.

Below are some highlights of the interview, which is worth reading all the way through:

How are students overloaded today?

Pope: People assume with the new standards and requirements for college admission, that teachers need to cover more topics in class and that kids need to take more courses and do more activities in school and after school to meet expectations for success. This is a confusion between rigor and load. Rigor is real depth of understanding, mastery of the subject matter. That’s what we want. Load is how much work is assigned. Many educators and many parents assume that the more work you assign and the more work students do, the better they will understand it. That is not necessarily the case. For example, we have teachers who teach AP classes and cut their homework load in half, and the kids end up doing as well on the exam. You don’t have to do four hours of homework in order to learn something in depth or to retain it. But four hours of homework can be incredibly damaging physically and emotionally.

. . .

Who should read this book?

Pope: We started writing it for educators, to give a guide to those schools that couldn’t physically partner with us at Challenge Success. The goal was to compile our best practices. But after a little bit of writing, I handed it to my husband (who isn’t an educator) just to see if it made sense. He came back and said, ‘You know, I was really interested as a parent as to why a school would use a block schedule or why so many kids are cheating or what is the purpose of taking an Advanced Placement course.’ So we realized it was actually a book for a much broader audience of people who were interested in the research on some of these practices.

Brown: For example, if parents don’t understand the ‘why’ for certain policies or practices, they can’t help advocate for real systemic change. The book gives parents the ability to ask the right questions at their schools to understand why their school is going down a certain path.

Previously: Excessive homework for high-performing high schoolers could be harmful, study findsWith school bells ringing, parents should ensure their children are doing enough sleeping, Stanford expert: Students shouldn’t sacrifice sleep and Stanford researchers to study effectiveness of yoga-based wellness program at local schools
Photo by Psy3330 W10

Aging, Health Costs, Health Policy, Patient Care

A look back at Medicare’s 50 years

Hand in HandOn Friday, KQED’s Forum offered a look at Medicare and Medicaid to mark the programs’ 50-year anniversary. Stanford health policy researcher Laurence Baker, PhD, participated in the discussion, which covered issues such as how the programs drive the way prices for care are negotiated with medical providers, how the large population of Baby Boomers will affect the system, and how reimbursement rates affect the kind of care Medicare and Medicaid patients receive.

The panel also discussed the gaps in coverage — services like dental care are not covered by Medicare — and the challenges they create. Medicare coverage has grown from the narrow set of conditions it first covered, and Baker thinks the conditions are right to begin a new national conversation about expanding coverage:

One of the things that’s really ripe for discussion is how this country is going to handle the long-term care issues. Medicare’s got to be at the center of that. And it almost feels like the time is coming that we’re going to have to think about that much more seriously.

And when host Mina Kim asked Baker the question that’s on a lot of people’s mind — Is Medicare sustainable for the long term? — Baker noted:

The program is pretty important; it’s clearly something the country values across the political spectrum. Lots of people want to see it sustained. It may not be a pretty process. It might not be fun to watch the politics of how we work all this out, but there are lots of ways to keep the program solvent, so I’m optimistic.

Previously: Competition keeps health-care costs low, Stanford study findsWhat’s the going rate? Examining variations in private payments to physiciansCheck the map – medical procedure rates vary widely across CaliforniaMedicare payment reform shown to cut costs and improve patient care and KQED health program focuses on baby boomers and the future of Medicare
Photo by Garry Knight

Health Policy, In the News, Medicine and Society, Pediatrics, Stanford News

Stanford researchers analyze California’s new vaccine law

Stanford researchers analyze California's new vaccine law

CA vaccine photoWhat do California, West Virginia and Mississippi have in common? Stumped?

Thanks to a recent law signed by California Gov. Jerry Brown, these three states now have strict vaccine policies that require children to be vaccinated before entering school, unless they have a medical exemption. The new requirements eliminate religious and philosophical exemptions.

Stanford’s Michelle Mello, JD, PhD, and David Studdert, LLB, ScD, (along with co-author Wendy Parmet, JD) heralded the change in a New England Journal of Medicine commentary published this week. From a Stanford News release:

“The move represents a stunning victory for public health that affects not only California schoolchildren, but the prospects for strengthening vaccination requirements nationwide,” they wrote.

The new laws come in the wake of a measles outbreak that started at Disneyland last year. It fueled a nationwide debate about the merits of vaccines, and of the large number of children unvaccinated due to parental objections.

The new California law requires all children enrolled in private and public schools and day-care facilities to be vaccinated against measles, whooping cough and several other diseases.

Yet the law is sure to face challenges, particularly from opponents who say it violates their religious rights. In addition, a lack of enforcement may weaken the law’s ability to ensure widespread protection.

Nonetheless, California’s new law is worth celebrating, they say:

“Although California politics may be distinctive, its experience with SB277 teaches us that even strong opposition can be overcome with the right combination of astute public education, political strategy and legislative fortitude,” they wrote. “Fewer vaccination exemptions and vaccine-preventable illnesses would be accomplishments that other states would find difficult to ignore.”

Previously: A discussion of vaccines, “the single most life-saving innovation ever in the history of medicine”, Science Friday-style podcast explains work toward a universal flu vaccine and Side effects of childhood vaccines are extremely rare, new study finds
Image by Niyazz

Cancer, Health Policy, NIH, Public Health

Draining the cancer swamp

Draining the cancer swamp

4011473415_46405053bd_zThere’s an old adage that applies to many difficult situations that we face in life: When you’re up to your armpits in alligators, it’s difficult to remind yourself that you should have drained the swamp.

I’ve come to view cancer as a vicious predator lurking in dark waters, eager to attack one out of two of us in our lifetimes. Cancer is the second most common cause of death in the United States.

Looking at the current national funding model for cancer research, I wonder if society has lost track of a vital goal: preventing cancer, not just treating it. Wouldn’t it be better if we prevented cancer in the first place? Cancer prevention would reduce the devastating physical, psychological, emotional, social and economic burden placed on patients, their families and their friends.

As he stepped down from the role of Director of the National Cancer Institute, Harold Varmus, MD, spoke about the deep complexity of cancer and the tremendous amount of basic research that needs to be done. While recognizing the need for clinical testing, he also called for more pioneering discoveries into who gets cancer, where and why.

The financial constraints facing scientific research force us to make difficult choices. Right now, our current health-care model prioritizes “identifiable individuals” over “statistical individuals.” Identifiable individuals are those real persons in distress who have been diagnosed with cancer. They need treatment, and we are highly motivated to help cure them. The cost of doing so, however, is high: The average monthly cost of cancer treatment has more than doubled to $10,000 over the last decade. Of course, we are willing to pay the costs – these victims are our mothers, our fathers, our sons and our daughters.

Statistical individuals are those who may be at risk, but they may not know it. They may never know that scientific research “rescued” them from a devastating disease. Through prevention measures enacted by individuals themselves (e.g., getting more exercise, avoiding tobacco use) or by society (e.g., limiting chemical exposures in the environment, banning the use of tanning beds for minors), these individuals may be able to escape the scourge of cancer.

When making choices about where to invest limited dollars, it is so much easier to say “no” to statistical people rather than real people.

I don’t advocate taking money away from cancer treatment, but I do advocate a greater investment of federal dollars in research that leads to reducing the incidence of cancer in the healthy population. By tracking and analyzing patterns and trends of cancer, we can identify potential risk factors and inform individuals and communities about positive changes they can make toward living cancer-free lives.

It is estimated that over 50 percent of the 585,720 cancer deaths in the U.S. in 2014 were related to preventable causes. As such, federal dollars directed toward statistical individuals will save both money and lives.

We need to drain the swamp. Our ultimate societal goal shouldn’t be to treat cancer more effectively, but to prevent it altogether. We need to intervene as early as possible in the trajectory of cancer. By doing so, we will greatly reduce the extent and depth of human suffering.

Donna Randall, PhD, is chief executive officer of the Cancer Prevention Institute of California.

Photo by William Warby

Global Health, Health Policy, Stanford News

Stanford India Health Policy Initiative fellows are in Mumbai – come follow along

Stanford India Health Policy Initiative fellows are in Mumbai - come follow along

India Health Policy students

Today, I’m on my way to India to join the 2015 Stanford India Health Policy Initiative fellows. These fellows are part of a program that designs and conducts collaborative student projects focused on generating new, on-the-ground insight into the factors that distinguish health-delivery success and failure. This summer, the four fellows are Mark Walsh, a rising senior who is majoring in economics; Pooja Makhijani, a second-year medical student; and Lina Vadlamani and Hadley Reid, both rising seniors who are majoring in human biology.

The students are spending seven weeks investigating the pharmaceutical networks in urban Mumbai in an effort to understand how informal providers interface with these networks and whether it impacts how providers practice, prescribe and dispense medication. The fellows are traveling house to house to investigate community preferences for medications.

We’ll be updating this Storify page with stories on their time there, and we’ll be tweeting from @StanfordHP (and using the hashtag#StanfordHealthIndia) over the next few weeks. I hope you’ll follow along.

Beth Duff-Brown is communications manager for the Center for Health Policy and Center for Primary and Outcomes Research (CHP/PCOR).

Photo, of Walsh, Makhijani and Vadlamani, courtesy of CHP/PCOR

Health Policy, Research, Stanford News

Exploring the link between patient-record fees and doctor switching

Exploring the link between patient-record fees and doctor switching

HCCH-medical_recordsWho owns your medical records – you or your doctor? If you answered that you do, you’re like most patients, according to a recent survey. But you would be wrong.

Legally, the doctors or hospitals who create medical records own them. Although federal law states they have to provide records to patients who request them at a reasonable cost, the definition of “reasonable” varies quite a bit. And that cost also has some surprising repercussions.

Three Stanford researchers – health economist Kate Bundorf, PhD, Laurence Baker, PhD, chief of health services research, and health and political economist Daniel Kessler, PhD, JD – examined the issue in a recent study in the American Journal of Health Economics. They compared rates of doctor-switching between states that have caps on medical-record copying fees and those that don’t.

The team found that patient record charges decreased the number of patients who switched doctors and that when there were caps on copying fees, more providers switched to electronic medical records. A Stanford GSB article described the findings in detail:

In states that imposed caps on fees for medical records, patients changed their primary doctors 11% more frequently and their specialty doctors 13% more frequently. In addition, the researchers found that health care providers were about 12% more likely to establish electronic medical records in states that imposed caps on copying fees.

The fact that more than 1 in 10 people would switch doctors if their records were easier to get means that copying fees matter. In addition, other research suggests that adoption of electronic medical records can significantly reduce mortality in complicated cases; to the extent this is correct, caps on copying fees not only enhance patient convenience but also save lives.

Kessler says the study suggests there is a good case for regulating the fees charged for medical records: “You can’t make it impossible for people to switch doctors. We know that can’t be the right direction.”

Baker agrees, telling me, “No one should have to feel like they’re stuck with a doctor when they’d like to switch. Policies that help people get reasonable access to their medical records look like they can help.”

Previously: Can sharing patient records among hospitals eliminate duplicate tests and cut costs?U.S. Olympic team switches to electronic health recordsA new view of patient data: Using electronic medical records to guide treatment and Do electronic health records improve health? It’s complicated
Image by Jackhsiao

Global Health, Health Policy, Research, Stanford News

Health aid may be allocated efficiently, but not always optimally

Health aid may be allocated efficiently, but not always optimally

malaria bed net

Foreign aid to the public-health sectors of developing countries often appears to be allocated backwards: The global burden of non-communicable diseases such as diabetes or heart disease is enormous – yet these disorders receive little health aid.

By comparison, the global burden of HIV is much smaller, yet it receives more health aid than any other single disease.

An alignment in health aid could best be improved by focusing on malaria and TB, especially where addressing those diseases is highly cost effective

So will a wholesale reversal in health aid priorities improve global health? The answer, according to a new study by Stanford researchers, is that if the goal is to maximize the health benefits from each donor dollar, health aid is actually allocated pretty well.

Still, reallocating foreign aid to step up the fight against malaria and tuberculosis (TB) could lead to greater overall health improvements in developing nations. And it could be done without spending more money, the researchers show.

For their work, Eran Bendavid, MD, an assistant professor in the Department of Medicine and a core faculty member at the Center for Health Policy and Center for Primary Care and Outcomes Research, and three researchers focused on 20 countries that received the greatest total amount of aid between 2008 and 2011, a period of historically unprecedented growth in health aid. The 20 countries – from Afghanistan to Zambia – received $58 billion out of the $103.2 billion in recorded health aid disbursements to 170 countries between 2001 and 2011.

“What we found, somewhat to our surprise, is that in nearly all countries, more aid was flowing to finance priorities with more cost-effective options,” Bendavid, said in an interview. “That is partly because more aid was flowing to the treatment and prevention of infectious diseases such as HIV and malaria, and their management can be relatively inexpensive.”

Bendavid, an infectious disease physician, added: “Even though the burden of non-communicable diseases is high and growing, addressing chronic conditions such as diabetes and heart disease is, broadly, more costly than the unfinished infectious disease agenda.”

In their paper, Bendavid and his co-authors write that the “data suggest that [an alignment in health aid] could best be improved by focusing on malaria and TB, especially where addressing those diseases is highly cost effective.” Gains would come from taking some aid earmarked for HIV or maternal, newborn or child health, and putting it toward programs to treat these two disorders, they say.

But it’s also crucial, they conclude, to further study the consequences of realignment of donor funds.

This paper appears in the July issue of Health Affairs.

Beth Duff-Brown is communications manager for the Center for Health Policy and Center for Primary and Outcomes Research.

Previously: Foreign health care aid delivers the goods and Foreign aid for health extends life, saves children, Stanford study finds
Photo, of a mother and son under an insecticide-treated bed net in Tanzania, by the Gates Foundation

Health Policy, In the News, Medicine and Society

Medicare to pay for end-of-life conversations with patients

Medicare to pay for end-of-life conversations with patients

800px-Doctor_and_couple_talking_(1)Remember “death panels?” In the summer of 2009, in the midst of the debate about the Affordable Care Act, aka Obamacare, a small item in the legislation allowing Medicare to reimburse physicians for end-of-life conversations with patients unleashed a tsunami of criticism. Opponents charged that so-called “death panels” – anonymous Washington bureaucrats – would be making decisions about rationing health care and ultimately deciding who would live and who would die. As foolish as that charge was, the Obama administration choose not to fight the opposition and the payment proposal was dropped.

Now, the Centers for Medicare and Medicaid Services has announced a new policy. Beginning January 1, 2016, the government will reimburse voluntary end-of-life conversations that Medicare physicians have with their patients.

We asked Stanford’s VJ Periyakoil, MD, a nationally recognized leader in palliative care, for comment, and she said, “Medicare’s proposal to reimburse doctors to have a conversation with the patient about their values and preferences for care is a quantum leap forward towards the lofty goal of improving quality of care for all Americans at the end-of-life.” But she emphasized that this is just one part of the solution:

Advance care planning is not an event but a process. The key is having conversations in plural, over time as patients’ goals of care change as their illness progresses.

Early in the illness, most patients prefer to have a trial of high-intensity treatments including life support, and this is a very reasonable thing to do. However, there is a tipping point in the illness trajectory where we go from prolonging life with quality to prolonging the dying process. Beyond this tipping point, most patients, if given a choice, prefer to die gently and naturally at home minimizing the burden to their loved ones. But in order for this to happen, we need doctors who are well trained and highly skilled at conducting end-of-life conversations with their patients. We need to ensure that patients and their proxy decision makers are well supported to make end of life decisions. Finally, it takes significant support of both the patient and caregiver by a skilled team of clinicians to ensure a gentle and peaceful death at home.

Unless we have all these components in place, we can’t expect to see major and sustained improvements in end-of-life care.

Previously: “Everybody dies – just discuss it and agree on what you want”In honor of National Healthcare Decisions Day: A reminder for patients to address end-of-life issuesA call to “improve quality and honor individual preferences at the end of life”Study: Doctors would choose less aggressive end-of-life care for themselves and On a mission to transform end-of-life care
Photo by National Cancer Institute

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