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Ethics, Health Policy, Patient Care

Small number of physicians account for many malpractice claims

Small number of physicians account for many malpractice claims

gavel01-lgA small number of physicians account for a disproportionately large number of malpractice claims in the United States, Stanford medical and law researchers found after examining 10 years of medical data.

The ability to identify these claim-prone physicians early would be invaluable, the researchers write in a paper published today in The New England Journal of Medicine.

David Studdert, ScD, professor of law and of medicine, and Michelle Mello, JD, PhD, professor of law and of health research and policy — who are also core faculty members of Stanford Health Policy — conducted the study in collaboration with researchers from the University of Melbourne, Australia.

The team found that just 1 percent of practicing physicians accounted for 32 percent of paid malpractice claims over a decade. The study also found that claim-prone physicians had a number of distinctive characteristics. Studdert, lead author of the study, explains:

The degree to which the claims were concentrated among a small group of physicians was really striking. But the fact that these frequent flyers looked quite different from their colleagues — in terms of specialty, gender, age, and several other characteristics — was the most exciting finding. It suggests that it may be possible to identify problem physicians before they accumulate troubling track records, and then do something to stop that happening.

Male physicians had a 35 percent higher risk of recurring claims than female physicians, and the risk of recurrence among physicians younger than 35 years old was about one-third the risk among their older colleagues, the study found.

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Global Health, Health Policy, In the News, Pediatrics, Pregnancy, Women's Health

Ending preventable stillbirth: A Q&A with Stanford global-health expert Gary Darmstadt

Ending preventable stillbirth: A Q&A with Stanford global-health expert Gary Darmstadt

Today, prominent medical journal The Lancet publishes “Ending Preventable Stillbirth,” a series of articles calling for global efforts to greatly reduce fetal deaths that occur late in pregnancy or during labor. The series brings much-needed attention to a medical and societal problem that often goes ignored.

“Millions of women and families around the world have suffered the pain of stillbirth in silence,” said series adviser Gary Darmstadt, MD, a Stanford global-health expert who studies how to improve medical care for pregnant women, infants and children in developing countries.

Darmstadt recently answered my questions about why we should break the silence and work to lower stillbirth rates. “Many of the interventions that avert stillbirths also avert deaths of mothers and newborns,” he said. An edited version of his responses is below.

What’s the biggest misconception about stillbirth?

Perhaps the biggest misconception is that stillbirths don’t matter. There is a tradition of social stigma and lack of awareness of stillbirths that makes it easy to keep them out of sight and out of mind. But an estimated 1.2 million women around the world every year have an intrapartum stillbirth: They enter into labor after a normal pregnancy, with great expectations for a healthy baby and one of the most joyous experiences of a lifetime, only to face sudden devastation when the baby dies during birth. Their experiences matter.

A related misconception is that nothing much can be done to prevent stillbirth, or that prevention will divert scarce resources from other important issues. In fact, three fourths of intrapartum stillbirths around the world could be prevented through means that we take for granted in high income societies — such as skilled medical care before and during delivery — and that also benefit mothers, surviving newborns and children.

Why did the scientists involved in The Lancet’s new series think it was important to break the common pattern of silence, stigma and fatalism around stillbirth?

Stillbirth is a taboo topic in many societies, or worse yet, mothers are blamed for failing to deliver a healthy baby and feel intense social pressure to keep quiet about stillbirth. Their sense of loss and isolation may lead to depression, which in turn has many adverse consequences, including for subsequent pregnancies. On the other hand, many women who have the opportunity to talk about their experience with stillbirth and work through their grief express great relief and renewed hope. When the last Lancet stillbirth series came out five years ago, and women shared their experiences online or in parent support groups — often the first time they had ever shared their experience with stillbirth with anyone — many found this to be immensely healing and empowering. Thus, it was both the science showing the adverse effects of unexpressed and unresolved grief, and the testimonials of women who had experienced the benefits of breaking the silence that I believe influenced the scientists involved in The Lancet series to highlight this issue.

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Health Policy, In the News, Women's Health

Breast screening recommendations — finalized?

Breast screening recommendations — finalized?

mammogramThe simmering national debate over how often and at what age women should get mammograms has come to a full boil once again.

This week, the U.S. Preventive Services Task Force reaffirmed its 2009 guidelines that said women in their 40s with an average risk of breast cancer should discuss mammography with their clinicians and make individual decisions about whether to have the screening.

The panel members said their final recommendation is that women 50 and older only get the screening every other year.

This has provoked an outcry from some medical associations and cancer-awareness advocates who fear the advice would lead some women to delay having mammograms and put them at greater risk of death. A task force editorial explains:

In 2015, contentious discussions about breast cancer screening and prevention continued, with physicians, advocates, lawmakers, and scientists all lending their voices to the debate.

Many of these stakeholders focused on the need for women to be able to make more informed health care choices about when to start screening without having to worry about the cost of an insurance copayment.

Douglas Owens, MD, director of the Center for Health Policy and the Center for Primary Care and Outcomes Research, is a member of the task force.

The task force determined that while screening mammography in women aged 40 to 49 may reduce the risk for breast cancer death, the number of deaths averted is smaller than that in older women and the number of false-positive results and unnecessary biopsies is larger.

The balance of benefits and harms is likely to improve as women move from their early to late 40s, the task force said.

Breast cancer is the second-leading cause of cancer death among women in the United States, according to the National Cancer Institute. In 2015, an estimated 232,000 women were diagnosed with the disease and 40,000 women died.

Previously: A new way of reaching women who need mammograms, Education reduces anxiety about mammography and Screening could slash number of breast cancer cases
Photo by Getty iStock

Health Costs, Health Policy, Stanford News

Improving care for the frailest, elderly patients

Improving care for the frailest, elderly patients

6193352974_7f7e6ff120_zCaring for the oldest, frailest patients isn’t easy. They can bounce in and out of the hospital with less-than-ideal outcomes. They see handfuls of specialists, who each look at just a slice of the patient: their heart, or eyes, or knees.

Arnold Milstein, MD, director of Stanford’s Clinical Excellence Research Center, laid out the problem for me in a recent email:

Care-delivery methods are in a constant state of evolution as poorly met patient needs become widely apparent, though the pace quickened after the enactment of the Affordable Care Act.

As a cumulative tsunami of NIH-catalyzed new medical treatments triggered narrower and narrower medical specialization, adverse health and financial consequences from coordination failures grew especially severe for medically fragile patients with multiple conditions.

With Harvard MD-MBA student Brian Powers and Sachin Jain, MD, a consulting professor of medicine at Stanford, Milstein presents two potential fixes in a recent study in the Journal of the American Medical Association.

One model, called the comprehensive care model, is based on a University of Chicago Health System program that matches Medicare patients with one hospitalization in the previous year with a “comprehensive care physician” who leads both inpatient and outpatient team-based care. These physicians meet with outpatients in clinics in the morning and are paged when one of their assigned patients is admitted to the emergency room, where they can help direct care and potentially avoid unnecessary hospitalizations.

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Health Policy, In the News, Medicine and Society, Precision health

Aim higher: Dean Lloyd Minor calls for widespread embrace of precision health

Aim higher: Dean Lloyd Minor calls for widespread embrace of precision health

cycling-655565_1280Dean Lloyd Minor, MD, calls for President Barack Obama to use next week’s State of the Union to embrace precision health. He lays out his thoughts and Stanford’s vision in a commentary published today on Forbes:

If the amazing scientific advances of recent years can help us more effectively treat disease based on individual factors, shouldn’t we also put them to work by helping us keep people from getting sick in the first place?

…Instead of a frantic race to cure disease after the fact, we can increasingly focus on preventing disease before it strikes. By focusing on health and wellness, we can also have a meaningful impact in reducing healthcare costs. At Stanford, we call this idea Precision Health, where we focus on helping individuals thrive based on all the factors that are unique to their lives, from their genetics to their environment.

Precision health marries the advances of data science, biotechnology and genetic analysis with the old-school passion for patients as people, people who can now partner with their physicians to manage, and maximize, their well-being. It aims higher, he says.

“Because when it comes to health, we must think as big as we can – not just about treating disease, but about making and keeping people healthy,” Minor writes.

Previously: Lloyd Minor shares his vision for Stanford Medicine, talks about its “paradigm-shifting advances”, How Stanford Medicine will “develop, define and lead the field of precision health” and A conversation on the promises and challenges of precision health 
Photo by skeeze

Health Policy, Infectious Disease, Microbiology, Public Health, Research, Stanford News

Excessive antibiotic use in flu season contributes to resistance

Excessive antibiotic use in flu season contributes to resistance

addiction-71573_1280The cold and flu season is upon us — and with that comes the potential overuse of antibiotics. All too often, physicians prescribe antibiotics for viral infections, which typically is ineffectual and can even be dangerous for elderly Medicare patients.

An estimated 2 million Americans are infected with drug-resistant organisms each year, resulting in 23,000 deaths and more than $20 billion in excess costs, according to the Centers for Disease Control and Prevention.

Excessive antibiotic use in cold and flu season is not only costly, but it also contributes to antibiotic resistance, writes Marcella Alsan, MD, PhD, and her co-authors in a study published in the December edition of Medical Care. The study’s objective was to develop an index of excessive antibiotic use in cold and flu season and determine its correlation with other indicators of clinically appropriate or inappropriate prescribing.

Alsan, a core faculty member at Stanford Health Policy, and senior author, Dartmouth economist Jonathan Skinner, PhD, concluded that flu-related antibiotic use was correlated with prescribing high-risk medications to the elderly.

“These findings suggest that excessive antibiotic use reflects low-quality prescribing,” the authors wrote. “They imply that practice and policy solutions should go beyond narrow, antibiotic specific, approaches to encourage evidence-based prescribing for the elderly Medicare population.”

To better understand patterns of antibiotic overuse and whether such patterns reflect prescribing quality, the authors developed a measure that isolates antibiotic prescribing in response to state-by-state influenza activity. They focused on the elderly, as national data on antibiotic use are readily available and because the interactions between multiple prescriptions are particularly important for this population.

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Global Health, Health Policy, Pregnancy, Stanford News, Women's Health

C-section rates up to 19 percent help save women and their newborns, global study finds

C-section rates up to 19 percent help save women and their newborns, global study finds

321699721_9002c5cebd_zCesarean sections are the most commonly performed operations around the world. But just how effective are these procedures, which have their own risks and complications, in saving the lives of women and their newborns?

To help answer that question, researchers at Stanford and Harvard’s Ariadne Labs examined C-section delivery rates in 2012 for 194 countries – all the member states of the World Health Organization. In that year, an estimated 22.9 million C-sections were performed in these countries.

The researchers found that maternal and child deaths declined when the C-section rate was up to 19 percent. When the number of C-sections was higher than that, there was no reduction in these mortality rates, the researchers report today in the online issue of the Journal of the American Medical Association.

Those numbers are higher than current WHO guidelines, which recommend that national C-section rates be no greater than 10 to 15 percent of deliveries. Worldwide, the number of C-sections varies widely from region to region, from .6 percent (South Sudan) to 56.6 percent (Brazil). In the United States, the C-section rate is roughly 30 percent.

Stanford surgeon Tom Weiser, MD, MPH, co-lead author, said the study “certainly presents a compelling argument for improved surgical capacity,” particularly in poor countries where there is limited capacity for surgical care. In parts of the developing world, women routinely die of obstructed labor and other pregnancy-related complications because there is no surgical infrastructure and personnel to provide advanced care, including C-section deliveries, he said.

Weiser and his co-authors argue for improving access to these potentially life-saving procedures, which could have many spillover effects, including improved facility infrastructure such as clean water and electricity – both needed for a functioning operating room – as well as improvements in healthcare systems as a whole.

“All the things you need to do to build up surgical capacity, like personnel training, improving supply chains, providing clean water and sterile environments, all contribute to general strengthening of health-care systems,” said Weiser, an assistant professor of surgery. “If you were to build a strong and robust surgical capacity, you’d have a health-care system more resilient and more resistant to catastrophic events, including Ebola or other infectious outbreaks.”

He noted, however, that new surgical services have to be provided within a safe environment to avoid potentially fatal complications, such as infection and bleeding.

“We cannot just advocate for increased access, as services have to be safe and they have to adhere to basic standards of surgical care,” he said.

Previously: Stanford microbiome research offers new clues to the mystery of preterm birth, From womb to world: Stanford Medicine magazine explores new work on having a baby and Study shows women prefer less-intense pain at the cost of a prolonged labor
Photo by Bonbon

Addiction, Ask Stanford Med, Health Policy, Public Health, Stanford News

Is a proposed ban on smoking in public housing fair?

Is a proposed ban on smoking in public housing fair?

smoking ban sign - 560

Cigarette smoking kills nearly half a million Americans each year, making it the leading preventable cause of death in the United States.

So the Department of Housing and Urban Development thinks it’s time to ban cigarette smoking from some 1.2 million subsidized households across the nation.

HUD Secretary Julián Castro unveiled a proposal last week intended to protect residents from secondhand smoke in their homes, common areas and administrative offices on public housing property.

“We have a responsibility to protect public housing residents from the harmful effects of secondhand smoke, especially the elderly and children who suffer from asthma and other respiratory diseases,” Castro said, adding the proposed rule would help public housing agencies save $153 million every year in health-care, repairs and preventable fires.

Stanford Law School professor Michelle Mello, PhD, JD, who is a core faculty member with Stanford Health Policy, has researched and written about this issue extensively, including in a 2010 article in The New England Journal of Medicine.

In a piece published yesterday, I asked Mello about her views on the federal smoking ban proposal. A sampling of the Q&A:

What would be the greatest benefit to banning smoking in public housing?

There are lots of benefits, but to me the greatest benefit is to the 760,000 children living in public housing. Although everyone knows that secondhand smoke exposure is extremely toxic, not everyone knows how much children in multiunit housing are exposed — even when no one in their household smokes. Research shows that smoke travels along ducts, hallways, elevator shafts, and other passages, undercutting parents’ efforts to maintain smoke-free homes. Also, chemicals from cigarette smoke linger in carpets and curtains, creating hazardous “third-hand smoke” exposure that especially affects babies and small children.

Beth Duff-Brown is communications manager for Stanford Health Policy.

Photo by Getty Images iStock

Clinical Trials, Ethics, Health Policy, Public Health, Stanford News

Using social media in clinical research: Case studies address ethical gray areas

Using social media in clinical research: Case studies address ethical gray areas

decisions

If a public-health researcher is reviewing Facebook profiles of 14-year-old males for firearm references and discovers photos or words referencing a potentially threatening situation, should the researcher intervene? What levels of privacy should these children expect in the online world?

These are the kinds of difficult questions that ethics consultants are faced with as they attempt to provide moral and legal guidance to researchers gathering health-related data from the Internet.

To help researchers with these nascent ethics issues, the Clinical Research Ethics Consultation Collaborative, a group of almost 50 bioethicists who provide free or low-cost ethics consultations across the United States, has begun publishing case studies on its most ethically challenging cases. Thus far they’ve posted 40 case studies in the categories of behavioral/social science research, clinical trials, genetics, pediatrics, research misconduct and surrogate decision making. The site also includes information on how to participate in educational webinars and collaborative case discussions.

This effort is being led by Benjamin Wilfond, MD, at Seattle Children’s Research Institute and University of Washington, and Mildred Cho, PhD, at the Stanford Center for Biomedical Ethics.

“Our bioethics consortium has learned a great deal from the complex ethics consultations that we’ve been providing since 2005,” said Cho. “Now we have a strategy for sharing these best practices with others, to provide moral and legal guidance to researchers across the country and to better inform policymakers on evolving ethical gray areas.”

More information on the collaborative or to request a consult can be found on this website.

Previously: The challenge – and opportunity – of regulating new ideas in science and technologySocial media brings up questions, ethical unknowns for doctorsBuild it (an easy way to join research studies) and the volunteers will come
Photo by NLshop/Shutterstock

Events, Global Health, Health Disparities, Health Policy, Podcasts

An optimist’s approach to improving global child health

An optimist’s approach to improving global child health

Globally, more than six million children die before their fifth birthday each year, most having been born into poverty. While great strides have been made over the last few decades in reducing global child mortality, some countries, like Pakistan, have lagged behind. Today, Pakistan has the third-highest infant mortality rate in the world and some of the worst child health and social indicators in the world.

In a new 1:2:1 podcast, Paul Costello, chief communications officer for the medical school, talks with Anita Zaidi, MD, an internationally renowned pediatrician and director of the Enteric and Diarrheal Diseases Program at the Bill & Melinda Gates Foundation, about the state of child health in her home country of Pakistan and what it takes to lift a nation up. The conversation was adapted from a recent global health seminar sponsored by the Center for Innovation in Global Health.

In speaking to an audience of Stanford students and faculty prior to her talk with Costello, Zaidi described herself as a “relentless optimist” who always takes the “glass half full” perspective. In looking back from 1990 to now, she said Pakistan has made some progress in reducing child mortality, but not as much as what it could have achieved.

Perhaps the biggest barrier to Pakistan’s progress stems from gender inequalities and the poor status of maternal health.

“Women are very marginalized in Pakistan, which affects their health and child mortality,” said Zaidi. “Unless we address those issues, [child health] is a tough problem to take care of… The citizens of Pakistan have a very big role to play.”

In 2013, Zaidi became the inaugural recipient of the $1 million Caplow Children’s Prize for her work in one of Karachi’s poverty stricken fishing communities, Rehri Goth, to save children’s lives. Through her work in Rehri Goth, she saw first hand the complex issues that impact whether a child will live to age five or not. In areas of extreme poverty, like Rehri Goth, improving primary healthcare is not enough.

“There’s no source of income. There are more than 10 kids in a family. Even if their newborn isn’t dying, the child dies at two or three months of age because there’s nothing to eat,” said Zaidi. “You realize there is this sub-population of extremely high-risk individuals, who need more than primary healthcare…They actually need some poverty alleviation types of interventions, food subsidies, to get them out of that.”

So, what does it take to lift a nation up? For Zaidi: “Girls getting educated will change the world, and more and more girls are getting education. We know that [education] one of the strongest predictors of improving child health outcomes.”

Rachel Leslie is the communications officer at Stanford’s Center for Innovation in Global Health.

Previously: Pediatric health expert Alan Guttmacher outlines key issues facing children’s health todayCountdown to Childx: Global health expert Gary Darmstadt on improving newborn survival and Training program helps dramatically reduce stillborn rates in developing countries

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