Health Policy

The World Heath Organization today issued revised recommendations for women who are at high risk for HIV/AIDS and who are using injectable hormonal contraceptives. The new recommendations come on the heels of a study published last October in The Lancet Infectious Diseases, which found that women using these contraceptives, which are particularly popular in eastern and southern Africa, were at twice the risk of contracting HIV, although the absolute rate of infection was relatively low. HIV-positive women using the contraceptives also were found to be more likely to infect their partners.

The widely publicized study generated considerable concern, as millions of women are using these progesterone-only contraceptives in Africa, where HIV rates are among the highest in the world. The results prompted the WHO in January to convene a group of 75 experts from around the world to review the issue. The group found that the evidence wasn’t conclusive – as some studies didn’t find the same association and many of the studies were limited in their design.

The panel concluded that there should continue to be no restrictions on use of these contraceptives but it added a clarification to these recommendations, strongly advising HIV-positive women or those at risk of HIV to use condoms and other forms of protection.

Paul Blumenthal, MD, a professor of obstetrics and gynecology at Stanford who served on the panel, said the group sought to re-emphasize the importance of dual protection to minimize the risk of HIV transmission. He told me today:

It is also important to note that decreases in use of hormonal contraceptives, perhaps as a result of concern about HIV risk, may result in increased rates of unintended pregnancy, which, especially in areas where HIV risk is high, also carries increased risks associated with unsafe abortion and high maternal mortality. Thus, the revised recommendations represent an important balancing of the complex relationships between contraception, HIV risks and pregnancy-related risks.

A study in today’s new issue of Archives of Pediatrics & Adolescent Medicine takes a close look at food for sale in more than 3,800 public and private elementary schools across the U.S. between 2006 and 2010. The findings are discouraging: During a period when school menus have generated lots of attention as contributors to childhood obesity, kids’ access to sugary foods at school remained high, while healthy options remained less available.

Not surprisingly, the authors suggest that schools should take a hard look at the foods kids can buy on campus and provide more healthy options while removing unhealthy choices.

But an accompanying editorial by Packard Children’s Hospital’s Thomas Robinson, MD, a nationally-recognized childhood obesity researcher asks: “How do we know that those changes would make a dent in childhood obesity rates?”

Unless we conduct studies that compare different health policies head-to-head in rigorously designed experiments, we can’t be sure what actually works, Robinson writes. He proposes implementing randomized controlled trials that make use of existing state and national health-surveillance programs (21 states already have laws that mandate measuring children’s body mass index in school, for instance) and that assign schools to different proposed health-policy changes so that the policies’ effects can be evaluated.

If this idea sounds daunting, Robinson has prepared an answer for potential critics:

Too difficult? Too expensive? Not when compared with the unrecoverable costs of getting policies wrong. [...] Federal, state and local governments and nongovernmental organizations are already spending many hundreds of millions of dollars per year to implement policy interventions that may or may not have any impact on childhood obesity. If evaluated at all, it is usually with nonexperimental designs. It would be a terrible lost opportunity if we learned several decades from now that most of these dollars produced no health benefits.

The entire editorial is definitely worth a read.

From redesigning food labels to eliminating urban “food deserts,” researchers and policy-makers have proposed a number of solutions aimed at encouraging Americans to eat healthier. But recent data from the Share Our Strength’s Cooking Matters program suggests that difficulties in understanding nutrition facts and lack of access to good food may not be solely to blame for America’s poor eating habits.

As the Atlantic’s Jane Black explains today, the report (.pdf) hints that the greater obstacles to healthy meals may be planning skills, time and the price of food:

• Although families are largely satisfied with the variety (61 percent) and quality (64 percent) of healthy grocery items available to them, only 30 percent are satisfied with price
• Time is a barrier for some, especially families where the food decision maker works full time. This demographic has a significantly lower average number of healthy or made-from-scratch dinners in a typical week
• Low-income families that regularly plan meals, write grocery lists and budget for food make healthy meals from scratch more often (5+ times a week) than those who don’t. Unfortunately, 55 percent of families don’t regularly plan meals before going to the store, and 34% don’t regularly use a written grocery list

In her piece, Black goes on to weigh in on the findings:

The data reflects what my husband, Brent Cunningham, and I saw while reporting for six months in Huntington, West Virginia. Among the families we followed, the very poorest was the one most likely to cook healthy meals at home. But it required intense planning and basic cooking skills. The families least likely to eat well were the ones who, frankly, didn’t have to. They had enough money to swing by Burger King for dinner on the way home instead of cooking family meals and eating leftovers… They shopped impulsively, instead of methodically, at the grocery store, which meant their carts were filled with frozen pizzas, chips, and snacks.

Previously: When it comes to nutritional value, debating “organic” vs. “conventionally grown” may be beyond the point, Living near fast food restaurants influences California teens’ eating habits, CDC calls for improving kids’ access to healthy food and Mapping out our country’s “food deserts”
Photo by jessica mullen

In a Canadian Medical Association Journal editorial published today, a Canadian physician argues that the gender of a baby shouldn’t be revealed to the parents-to-be until after the 30-week mark. (This information is usually made available ten or more weeks earlier.) I was shocked by the reason that he says such action is needed, and you may be, too. Booster Shots has the story.

We’ve written in the past about the country’s growing problem with oxycodone abuse; Kentucky, Florida and West Virginia are three states that have been particularly hard-hit. Now comes a concerning report on the dramatic increase in painkiller use in our third-most populous state. From a New York Attorney General report (.pdf):

In New York, the number of prescriptions for all narcotic painkillers has increased from 16.6 million in 2007 to nearly 22.5 million in 2010 – prescriptions for hydrocodone have increased 16.7 percent, while those for oxycodone have increased an astonishing 82 percent. In New York City, the rate of prescription pain medication misuse among those age 12 or older increased by 40 percent from 2002 to 2009, with nearly 900,000 oxycodone prescriptions and more than 825,000 hydrocodone prescriptions filled in 2009.

The report goes on to outline the problems attached to these numbers – overdoses, addiction-related violence, increased government spending – and advocates for the establishment of  a controlled substance reporting system. The ultimate goal would be to ensure these drugs are given to people “who truly need them.”

Previously: Governors to Congress: Help us fight prescription-drug abuse, Florida’s prescription-drug problem, The Florida Governor’s questionable actions on drugs and How to combat prescription-drug abuse
Via Daily Intel

Smith as Dean Philip Pizzo

Anna Deavere Smith’s one-woman theatrical performances are so brilliantly drawn, so carefully textured that watching her onstage is always a rich and rewarding experience. Her artistry has been saluted all over the country since the ‘90s, when she captured American theater critics and audiences with two noted theatrical events: Twilight Los Angeles, about the LA riots following the trial of Rodney King, and Fires in the Mirror, about the Crown Heights civil disturbances.

Now another solo performance by Smith, Let Me Down Easy, has become a national theatrical sensation. The play premiered at New York’s Second Stage in the fall of 2009 (“Woman of 1,000 Faces Considers the Body” was headline of the New York Times review) and a national tour followed. PBS recorded it at Washington’s Arena Stage, and Let Me Down Easy will debut on PBS’s Great Performances next Friday, Jan. 13 at 9 p.m.

From the PBS press release:

Conceived, written and performed by Smith in her signature one person performance style, the play examines the miracle of human resilience through the lens of our current national debate on health care. Smith interviewed more than 300 people during her research and traveled to three continents.

Smith, a former Stanford professor, performed Let Me Down Easy in workshop at Stanford in 2006 as she was fine-tuning the piece. She also talked with a range of the medical school’s faculty about medicine, patient care and biomedical research. Philip Pizzo, MD, dean of the school, is one of the characters Smith performs in the play. She found his warning that we are in danger of slipping into a health-care system that “resembles that of a developing nation… unless it’s changed dramatically,” an apt description for the current tumult in U.S. health care.

I did a podcast about Let Me Down Easy with Smith in 2009, and I’ve seen Let Me Down Easy countless times. Each time it stirs me. A different character becomes richer, words are deeper and more meaningful or actions more affecting. You watch as a careful portrait is being drawn on stage. You realize a meticulous artist is at work. Each character is pulling a thread weaving a larger vision. You feel the human clock ticking. As the lives of the characters unfold, you consider too your own – the sorrows and joys of the human experience. Treasure the moment and live with grace. Is that the lesson here? Then a final word. A Buddist monk appears and is bathed in light. He lifts a tea cup and gently pours the water into his open hand. Finished!

Previously: How a med school dean became part of Anna Deavere Smith’s hit play, Playwright takes healthcare to the stage and Let me down easy
Photo by Joseph Sinnott / WNET

There is a thought-provoking essay by Donald Barr, MD, PhD, associate professor of pediatrics, in the Boston Review today discussing how rapidly rising health-care costs combined with expanding unemployment rates have left millions of families in the United States exposed to potential economic crisis in the event of an illness or injury.

The piece includes a number of alarming statistics on the inequities in the cost of health care and health insurance in America but, as Barr explains, this data only tells part of the story. He writes:

Economic inequality brings with it inequality in health outcomes, independently of access to health care. A 25-year-old American with income more than four times the poverty level will live, on average, five years longer than a 25 year old with income less than twice the poverty line.⁵ Those with a college education are three times as likely to report excellent or very good health status as those who did not finish high school.⁶ Those with less than a high school degree are twice as likely to experience coronary heart disease as those of the same age who have graduated from college.⁷ Money and education secure not just more life but a healthier one as well.

Barr is one of several Stanford faculty members, students and community leaders who are facilitating discussions on a range of topics, including disparities in education and health care, population growth and environmental sustainability, at tomorrow’s Occupy the Future event.

Also among the group is Mark Cullen, MD, professor of general medical disciplines, who is leading a teach-in session on health equity and inequity. Cullen said his talk will examine how “the underlying social and economic disparities are the root cause of health disparities. [How] these are compounded by high disparate access and quality of care, [which] are now made even worse by the increased shifting of the costs of care to those who can afford it least – working Americans.”

Previously: Occupy the Future awareness event to take place at Stanford tomorrow and Study shows increase in health disparities among young Americans

A series of teach-in style sessions inspired by the Occupy protests are being held on the Stanford campus tomorrow in an effort to increase awareness about social inequality, the erosion of American democracy and the link between unrestrained growth and the current environmental crisis.

The half-day forum was developed by a coalition of Stanford faculty, students and staff who united under the name Occupy the Future. During the event, faculty, students and community leaders will facilitate discussions on a range of topics including disparities in education and health care, population growth and environmental sustainability. Organizers’ outlined three main reasons for creating the forum in a statement (.pdf). The first is:

… the deep and growing division between the have and have-nots. Across multiple areas of life–health, education, income, housing–we see the greatest inequalities the U.S. has known since at least the Great Depression. “We are the 99 percent” is not a mere rhetorical device. It’s consistent with data showing that over the past decade only the top one percent of wage earners have seen their incomes rise. The next two to five percent has experienced flat wages, and everyone else has experienced a drop in earnings. The general trend toward increasing inequality has been going on for 30 years, but has now reached unprecedented levels. The top one percent has claimed nearly all of the growth in personal income over the past 20 years, with most of that accruing to the top .1 percent. Consider this staggering fact: in 2009 the net worth of the 400 wealthiest households in the United States exceeds that of the bottom 50 percent of all American households; 400 families have more than 155 million Americans.

The event includes concurrent teach-in sessions from noon-1:15 pm; a public rally from 1:30-3 pm at White Plaza; and an open forum at 3:30 pm in the Oak Room, Tresidder Union. Three of the sessions have a health-care focus. These talks include: Mark Cullen, MD, professor of general medical disciplines on health equity and inequity; Donald Barr, MD, PhD, associate professor of pediatrics, on the impact of economic inequality on health care and health status; and Michele Barry, MD, Stanford’s director of global health initiatives.

Stanford nutrition researcher Jennifer Otten and some of the promotional items given away with children's meals.

Do ordinances that restrict the ability of restaurants to give away toys with unhealthy kids’ meals have an impact? A new Stanford study looks at what happened in Santa Clara County in the months after the nation’s first such policy was enacted.

The study, published today in the American Journal of Preventive Medicine, examines the actions taken by a small number restaurants immediately after Santa Clara’s ordinance took effect in August 2010.

Although none of the restaurants in the study added healthier offerings for children, two of the restaurants removed toy marketing posters and two offered toys separately at an additional cost. One restaurant singled out the children’s meals that met the ordinance criteria as “promoting good nutrition” on its menu boards.

“Before, parents had no idea which meals met the nutritional criteria. After the law was implemented, one restaurant made it clear which ones did,” said lead researcher Jennifer Otten. “In addition, there was a clear decrease in toy marketing and advertising at some of the affected restaurants.”

With an increasing number of communities looking at ways to curb the rising rates of childhood obesity, Otten and her team want to gather objective data on the effects of policies like the one in Santa Clara County. “This ordinance gave us the opportunity to study a real-world example of a private-sector response to a public health policy,” she said.

But the effort won’t end there. The researchers surveyed almost 900 families before and after the ordinance took effect to determine whether it affected their fast-food purchases. The team is also collecting data from families and fast-food restaurants in San Francisco, where a similar law took effect on Dec. 1. They plan to publish the findings related to the family surveys and the longer-term restaurant responses in future papers.

Previously: Toying with Happy Meals and Are Happy Meals illegal? A public health lawyer says, yes
Photo by Norbert von der Groeben

I’m a few days late to this, but I still think it’s worth commenting on a story from Stanford’s Freeman Spogli Institute for International Studies about the use of research by economist Scott Rozelle, PhD, to improve school lunches in China.

In a series of studies conducted in 2008 and 2009, Rozelle’s research team found that nearly 40 percent of Chinese primary-school children suffered iron-deficiency anemia — no surprise given that their diets consisted mostly of rice and noodles, with very few servings of the iron-rich veggies (think spinach or broccoli) or red meat that could have alleviated the problem. The anemic children had worse school performance than non-anemic kids, a problem that could have significant detrimental effects for China’s economic modernization:

“For 5,000 years it was OK to be anemic if you’re never going to leave the farm,” said Rozelle… who is still experimenting with ways to improve children’s health in rural China and get the government to adopt the most effective methods.

“But we’re looking 20 years into the future where there are much fewer farms and you need at least a high school education to make a living in the city,” Rozelle said. “If you are sick with anemia, it is going to affect your cognitive ability, educational performance and ultimately your chances of going on in school.”

The problems with school performance were reversed when children received better diets and iron supplements, the Stanford researchers showed. After assessing Rozelle’s work, the Chinese government has pledged $2.5 billion a year for the next nine years to make elementary and middle-school lunches more nutritious. Wow!

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With rising health care costs threatening to implode the U.S. economy if we don’t act quickly, the Department of Health and Human Services announced yesterday that it will award up to $1 billion dollars for innovative projects that test creative ways to deliver high quality medical care and save money.

Funded by the Affordable Care Act, the Health Care Innovation Challenge will offer grants of $1 million to $30 million to applicants who come up with most compelling new health care delivery ideas. Priority will be given to proposals that expand health care sector jobs.

Anxious to defuse the ticking time bomb of rising U.S. health-care spending, the White House issued a “We Can’t Wait” memo on this initiative. Government experts estimate that annual costs will reach more than $4 trillion by 2017, accounting for $1 out of every $5 the nation spends.

Award “letters of intent” are due December 19, so there’s no time to waste. Which begs the question, what would resourceful, cool-headed, bomb-diffusing TV hero MacGyver do to solve the health-care crisis?

Stanford’s own MacGyver, Arnold Milstein, MD, who oversees a health-care reform ‘SWAT’ team at the university, thinks this initiative might help do the trick, telling me:

With the new health-care law about to expand coverage to millions of Americans, we don’t have the luxury of time. This award will unlock clinician creativity in the design of innovated care models that both curb health spending growth and improve clinical outcomes.

As director of the Stanford’s Clinical Excellence Research Center, Milstein is one of the architects of the “intensified care model,” which strengthens up-front primary care services for patients suffering from severe chronic illnesses, so that downstream expenses like emergency room visits and hospitalizations are reduced. This approach offloads overworked primary care physicians, while creating new jobs for nurses, physical therapists, pharmacists, nutritionists, psychologists, and lay health coaches.

Previously: New Stanford center to address inefficient health care delivery, Innovative Stanford clinic to support chronic care patients, Community-based workshops help patients manage chronic illness and Free self-management program offered to people with chronic illness
Photo by Designs 4601/iStock

While the health benefits of medical research are easily observed in our everyday lives -through stories of patient survival, biomedical discoveries and prevention strategies – the economic rewards often go unnoticed.

To help the public better understand the far-reaching impact of medical schools and teaching hospitals, the Association of American Medical Colleges released a new report today quantifying the importance of publicly funded health-care advancements for the fiscal health of the nation. According to the analysis (.pdf), which was conducted by economic consulting firm Tripp Umbach:

Federal- and state-funded research received by medical schools and teaching hospitals in 2009 added close to $45 billion to the U.S. economy. To put this in perspective, the National Institute of Health (NIH), the largest federal funding agency of medical research, invested approximately $28.5 billion in fiscal year 2009 for extramural research conducted across the nation, including American Recovery and Reinvestment Act (ARRA) funding. Of those funds, about 55 percent (or about $15.6 billion) went to medical schools and teaching hospitals, a particularly productive research environment where physicians and scientists deliver care to patients, help train the next generation of physicians and researchers, and conduct vital medical research. While NIH funding is critical, the data show that for every dollar invested in research at medical school and teaching hospitals, $2.60 of economic activity occurs.

In the report, a comparison of the total economic and employment impact for the top 24 states and the District of Columbia with AAMC-member medical schools and teaching hospitals showed that California ranked No.1.

Previously: Economic impact of human genome sequencing, Report: NIH investments created $68 billion in economic activity last year, Academic medical centers bring billions to the economy and New initiatives show how federal stimulus dollars advance scientific and medical research

Although smoking rates in California have steadily declined since 1998, nearly 2.5 million children in the state are still at risk of secondhand smoke, according to a recent report from the UCLA Center for Health Policy Research.

In the report (.pdf), researchers analyzed data from several cycles of the California Health Interview Survey. Results showed that an estimated 561,000 children are directly exposed to secondhand smoke in the home and another 1.9 million are at risk because a family member at home is a smoker. Additional findings include:

• African-American children have the highest level of exposure—12.6%. This rate is statistically higher than that of all other racial/ethnic groups and particularly striking at triple the rate of all other groups
• A clear relationship between income level and children at risk for exposure to secondhand smoke. The lower a household’s income the more likely it is that the household has an adult or teen smoker.  Children living in households at or above 300% FPL (2.4%) were far less likely to be exposed to secondhand smoke than children
• The proportions of households where children are at risk for exposure range from 19.4% in the Northern/Sierra region to 9.5% along the Central Coast.  The highest rates are in the San Joaquin Valley (4.8%) and Northern/Sierra regions (4.5%), where close to 5% of young children live in homes that permit smoking indoors

Study authors hope the data will be useful in identifying communities that would benefit form targeted messages about the negative health effects of secondhand smoke. Among their recommendations is for public health officials to develop a comprehensive media and outreach campaign using tailored, culturally-competent approaches to reduce children’s exposure to secondhand smoke.

Previously: Study shows anti-tobacco programs targeting adults also curb teen smoking, Study shows secondhand smoke a serious health threat to casino workers, patrons and Study shows smoking bans decrease kids’ exposure to secondhand smoke
Photo by Jesslee Cuizon

For some eye-popping facts on U.S. health-care spending compared to that of other nations, check out a post from Ezekiel Emanuel, MD, PhD, on The New York Times’ Opinionator blog. Emanuel acknowledges that we’ve heard gloomy statistics about health-care costs many times before but adds that “few people really understand how much we spend on health care, how much we need to spend to provide quality care, and the difference between the two.”

He asks, “Do we spend too much? Would cutting costs require rationing, or worse, death panels?” And his answers aren’t pretty.

If you suffer from hypertension, I advise you to read no further. For the rest of us, here goes: Noting that the Unites States spent $2.6 trillion on health care in 2010, Emanuel writes:

If we stacked single dollar bills on top of one another, $2.6 trillion would reach more than 170,000 miles — nearly three-quarters of the way to the moon. Or, compare our spending to that of other countries. France has the fifth largest economy in the world, with a gross domestic product of nearly $2.6 trillion. The United States spends on health care alone what the 65 million people in France spend on everything: education, defense, the environment, scientific research, vacations, food, housing, cars, clothes and health care.

And we’re not getting better care, either:

Almost no matter how we measure it — whether by life expectancy or by survival for specific diseases like asthma, heart disease or some cancers; by the rate of medical errors; or simply by satisfaction with health services — the United States is actually doing worse than a number of countries, like France and Germany, that spend considerably less.

But it was the following statements that reduced me to a state of head-cradling doom:

The fact is that when it comes to health care, the United States is on another planet. The United States spends around 40 percent more per person than the next highest-spending countries, Switzerland and Norway.

Previously: U.S. health-care costs rising faster than abroad
Photo by Veeyawn

The National Institutes of Health recently finalized new rules aimed at reducing financial conflicts of interest and industry influence among federally funded researchers.

Starting on August 24, 2012, the new regulations will require the disclosure of many financial conflicts of interest previously hidden from view, including industry-sponsored travel reimbursements, a wider array of consulting agreements, and authorship fees from medical societies and foundations.

As the dust settles on this 144-page regulation, Harry Greenberg, MD, senior associate dean for research at the School of Medicine, discussed the reasons behind these rules and the effect they’ll have on universities and academic medical centers in today’s Inside Stanford Medicine.

Most significantly, the new rules will require that universities more carefully review and mitigate researcher financial conflicts that could potentially bias medical research. Greenberg summed up the net effect of the regulations in this way: “Overall, many more researcher-industry interactions will be subject to evaluation of financial conflicts and their effect on the research.”

In the spirit of transparency, new financial conflicts of interest must be publicly disclosed on a research institution’s website within 30 days or mailed to requestors within five business days. The Stanford article includes a table summarizing the regulation’s other major changes – and you can read the entire regulation and a new FAQ document on the NIH’s conflicts-of-interest website.

Previously: AAMC issues conflict-of-interest guidelines for teaching hospitals, Medical groups beefing up conflict-of-interest policies, Stanford’s medical school expands its policy to limit industry access, Faculty consulting work: now on public view and Let the sun shine
Photo by Andriy Solovyov