Published by
Stanford Medicine

Category

Health Policy

CDC, Chronic Disease, Health Policy, In the News, Infectious Disease, Public Health

To screen or not to screen for hepatitis C

Hep CIn the past few years, newer, more effective treatments have been introduced for hepatitis C – a disease that can lead to chronic liver problems and in the worst cases, liver cancer. In 2012, the Centers for Disease Control and Prevention recommended screening for the disease in anyone born between 1945-1965, since about three-quarters of cases occur in this age group, the Baby Boomers. Last year, the World Health Organization also called for more screening for the disease.

But in a recent analysis piece in The BMJ (formerly the British Medical Journal), several scientists, including Stanford epidemiologist John Ioannidis, MD, DSc, lay out the case that universal screening in this age group may not be warranted. A story in the San Francisco Chronicle today quotes Ioannidis:

“The question is whether these aggressive screening policies are justified and whether they would result in more benefit than harm,” said Dr. John Ioannidis...“We know very little about the potential harms of these drugs, especially in the long-term. And we don’t know how they will translate into long-term benefits.”

Ioannidis and his colleagues suggest that instead of rolling out widespread screening programs, researchers, as soon as possible, start a randomized trial to test the usefulness of screening and who may benefit from it.

On top of the medical uncertainties of the new treatments, they’re expensive, costing about $84,000 for the 12-week treatment. But they’ve been shown to cure patients of their hepatitis C infections at the end of that 12 week stint. Not all people who contract the disease will develop chronic infections, but a majority – two-thirds -will. Twenty percent of those cases will go on to develop severe liver disease.

Advocates of universal screening say that the new screening strategy could identify many people who don’t know they’re sick – symptoms from hepatitis C chronic infections can take years to manifest. But Ioannidis and his colleagues note that many people will get unnecessary treatment and that the long-term uncertainties of the treatment should be taken into consideration.

Previously: Despite steep price tag, use of hepatitis C drug among prisoners could save money overallA primer on hepatitis CFor patients with advanced hepatitis C, benefits of new drugs outweigh costsDrugs offer new hope for hepatitis C and Program examines hepatitis C, the “silent epidemic”
Photo of hepatitis C virus by AJ Cann

Aging, Chronic Disease, Ethics, Health Policy

Exploring the value of longevity with bioethicist Ezekiel Emanuel

baby hand in old hand - big

In a popular article in the Atlantic published this past fall, Ezekiel Emanuel, MD, bioethicist and prominent federal policy adviser, made a controversial case against longevity. Just before the recent holidays, the USC Annenberg School for Communication & Journalism sponsored a webinar during which Emanuel explained and elaborated on his message. It’s not that he “hopes to die at 75,” as the title chosen by the Atlantic suggested, but he wants a life at 75 focused on living, not on living longer.

Emanuel essentially argues for quality of life over quantity of years, and he claims that American society is becoming obsessed by the latter. I listened in on his December talk, which began with an ad from the AARP that glorifies “going on forever” – a value he says is reflected in both the medical system and our contemporary culture.

He directed his scientific criticism against the idea of the “compression of morbidity” – the belief that with enough medical advances, disabilities will go away and people will live in good health until, more or less suddenly, they die. He calls this the “rectangularization” of life: falling off a cliff instead of rolling down a gradual decline. The idea is immensely popular and money-making, but while some research claims to prove it, far more proves the opposite. There is, in fact, an expansion of morbidity as people live longer, an elongated and more gradual decline with more disabilities and less and less creativity.

Given this, Emanuel’s hope and recommendation is two-fold: that people will consider what makes their life meaningful and spend their energy cultivating that, and that medical resources will be redirected from prolonging life to improving its quality at the outset – by reducing the country’s exceptionally high rate of premature births, for example.

American life expectancy is at an all-time high at nearly 80 years, but are octogenarians living meaningfully? Last month in the New York Times, David Brooks argued against Emanuel’s earlier piece by saying that the “happiest people” are ages 82-85; in the webinar, Emanuel says this misses the point. It’s much easier to measure happiness than meaningfulness, yet the latter is the real aim of life (and, furthermore, Brooks didn’t account for the perspectives of those in nursing homes, assisted living, or suffering from dementia). Emanuel talked of patients who say cancer was “the best thing that happened to me” because it made them focus on what was meaningful in their life. The end of life is important to think about, as it helps us see what we want from life now.

“Contorting life around living as long as possible seems to me to be counter-productive,” he said. “What we should be focusing our life on is what’s meaningful, how we enrich other people and contribute to our families and society.”

Continue Reading »

Ethics, Health Policy, In the News, Medicine and Society, Research

Watching your spouse die on a TV reality show: De-identification as a myth, in death and life

Watching your spouse die on a TV reality show: De-identification as a myth, in death and life

Much biomedical research relies on the idea of “de-identification.” The Common Rule, the federal regulation on human subjects research, applies, as a general matter, if the researchers make some kind of intervention with the research subject or if they use “identifiable private information” about the research subject. But the “Private information must be individually identifiable (i.e., the identity of the subject is or may readily be ascertained by the investigator or associated with the information) in order for obtaining the information to constitute research involving human subjects.”

De-identification doesn’t mean that no one will recognize the research subjects’ identity. Federal regulation says the researchers must not be able to ascertain it readily.

If the private information was not collected by the researcher (it comes from someone’s medical record or was collected as part of someone else’s research) and the research subject’s identity is not known to and cannot “readily be ascertained” by the researcher, it doesn’t count. No consent is required, no IRB review is required – it isn’t “human subjects research.”

And why should it be? If no one knows it is you, you cannot be hurt, or so the argument goes.

[Last Friday], the New York Times published an extraordinary article entitled “Dying in the E.R., and on TV Without His Family’s Consent” by Charles Ornstein, a reporter for ProPublica. It recounted how Anita Chanko, a 75-year-old widow, watching an ABC reality television show, NYMed, suddenly realized that she was watching her husband’s death in the emergency room. More than a year earlier, the 83-year-old man had been hit by a garbage truck while crossing the street and had died in the NewYork-Presbyterian hospital. The televised version blurred his face, but not the face of the surgeon, the description of the accident, or the sound of her late husband’s voice, asking “Does my wife know I’m here?”

At no time were any of the family told  that Mr. Chanko’s treatment was being filmed or asked their consent to its use on television.

The dead man’s widow and children were traumatized. One of their sons wrote in a complaint “I had to unnecessarily relive my father’s death at your hospital a second time, while knowing that the public at large was able to — and continues to be able to — watch my father’s passing, for the purposes of what can only be described as drive-by voyeuristic ‘entertainment.’ ”

Continue Reading »

Health Policy, SMS Unplugged

A student’s reflections on the American Medical Association

A student's reflections on the American Medical Association

SMS (“Stanford Medical School”) Unplugged is a forum for students to chronicle their experiences in medical school. The student-penned entries appear on Scope once a week; the entire blog series can be found in the SMS Unplugged category.

AMA picLast month, I had the opportunity to attend the American Medical Association’s interim meeting in Dallas, one of two annual conferences held by the organization. I went to the meeting to present at a research symposium, but I stuck around for a few extra days because I was curious about the inner workings of organized medicine. As someone interested in health-care systems and the delivery of medical care, I was aware of the AMA but wanted to learn more about its purpose and process. (Plus, I had heard they throw great conferences. They didn’t disappoint – among other things, I got to practice my lassoing skills).

To provide some background, the AMA is the oldest and largest physician organization in the United States and has historically played an important role in the development of American health-care policy. While membership has ticked upwards in recent years, the AMA has been struggling with a decades-long trend of declining involvement and fading physician interest.

There are a number of possible reasons for this decline. Some commentators cite an overarching shift in social norms, arguing that people today are simply less likely to join groups. Others attribute it to the changing needs of physicians. Physicians are now more likely to work for a hospital system rather than opening a private practice. Given that the AMA’s advocacy has traditionally focused on the interests of independent doctors, employed physicians may feel disengaged. Finally, the proliferation of local, state, and other national physician organizations have likely drawn members away from the AMA.

Such issues have brought up questions about the sustained relevance of the AMA. Going into the conference, I’ll admit I was somewhat skeptical about its continued impact. However, I came away feeling like participation in the AMA is highly worthwhile.

With reform underway and a health-care system in flux, it’s more important than ever for health-care providers to understand how policy approaches influence patient care. The AMA offers a forum that serves two major roles. First, it gives medical students and doctors a way to learn about issues in health care. Topics like payment reform, the implementation of new health-care technology, and organ-transplant restrictions don’t come up in medical school in any significant way, but they have a huge impact on what we can do for patients. Every medical specialty has its share of conferences to make sure providers stay up to date on the latest developments in that field. The AMA helps people stay informed about the big-picture issues.

Second, conferences like the one I attended allow students and doctors to not only learn, but also to develop and exchange their own ideas on how to address issues in health care. The policy sessions at the conference often featured lively debates. While some physicians feel like the AMA doesn’t represent their views (it certainly didn’t represent some of mine), the best way to change that is to participate in these debates rather than disengaging. The AMA remains the single most important physician voice in policy discussions. If individuals don’t contribute to that voice, policymakers will no longer take the physician perspective into account when making decisions on health care.

The AMA is by no means a perfect organization. Like any political group, it comes with quite a bit of bureaucracy and the self-importance was occasionally irritating. Regardless, it serves as one of the best ways for medical students and physicians to become aware of the issues that affect our profession, and come up with solutions.

Akhilesh Pathipati is a second-year medical student at Stanford. He is interested in issues in health-care delivery.

Photo courtesy of Akhilesh Pathipati

Health Costs, Health Policy, Patient Care, Research

Medicare payment reform shown to cut costs and improve patient care

Medicare payment reform shown to cut costs and improve patient care

PT got Margie practicing on crutches, including going up and down a step.A few years back, the Centers for Medicare and Medicaid Services (CMS) made a straightforward change: No longer would it pay for easily preventable conditions that develop in the hospital. A care-team fails to help ambulate a patient following a hip or knee surgery and the patient develops deep-vein thrombosis? Unfortunate for the patient and unfortunate for the hospita, which now has to absorb the cost of that care.

It seems obvious, yet slightly disturbing, that this approach would be successful. In my idealized worldview, all patients are treated the same, regardless of who’s picking up the tab.

But when you change the financial incentives, change happens. Stanford health economist Jay Bhattacharya, MD, PhD, and health economist Risha Gidwani,DrPH, who is affiliated with the VA and Stanford, found the prevalence of two preventable conditions – deep-vein thrombosis and pulmonary embolisms – for patients with a recent hip or knee surgery dropped after Medicare stopped paying. The study was published today in the Journal of General Internal Medicine.

From our press release on the work:

When CMS stopped paying for treating deep-vein thromboses and pulmonary embolisms, the incidence of those conditions after hip or knee replacement surgery dropped 35 percent in the Medicare population, Gidwani said. In the younger, non-Medicare population, the incidence of these two conditions increased, although they also decreased in the patients over age 65 who had private insurers. There are more than 1 million hip or knee replacements performed in the United States each year, and over 60 percent of them are paid for by Medicare.

“We have a win-win,” Gidwani told me. “We have patients who are avoiding adverse events while Medicare saves money.”

Previously: Beyond Berwick brouhaha: Medicare chief another step to health-care reform, Experts discuss high costs of health-care — and what it will take to change the system and Competition keeps health-care costs low, Stanford study finds
Photo by Dave & Margie Hill

Health Costs, Health Policy, Patient Care, Research

Spotting stellar primary care practices, Stanford study identifies 10 practices that lead to excellence

Spotting stellar primary care practices, Stanford study identifies 10 practices that lead to excellence

crutches-538883_1280Many of us know first-hand that expensive, substandard health care abounds in America. The problem has been analyzed and bemoaned, measured and critiqued. Solutions, bright spots and success stories are less abundant—in fact they are downright rare. That’s why recent findings from a partnership between Stanford’s Clinical Excellence Research Center and the Peterson Center on Healthcare, a new organization that aims to improve health care in the United States, are so exciting. Bucking current theories, researchers found that independent, primary care medical practices can provide superior care while saving money. And, they identified 10 principles these practices embrace, which distinguish them from their peers.

I had the chance to speak with CERC Director Arnold Milstein, MD, about the Stanford-based project:

What exactly did you do?

We examined the performance of more than 15,000 primary care practices looking for “positive outliers” or practices that provide excellent care at a lower cost. This is the first  systematic comparison of its kind and we weren’t sure we’d be able to discern any differences. But we did. We found a substantial difference in measures of quality and the total annual amount of health care spending between sites. Then, we arranged for  observers (independent physicians) to visit these offices to understand what was different about care delivery at sites associated with less spending and high quality scores.  They discovered 10 distinguishing features of successful health-care practices that were present much more frequently in these positive outlier practices than in other offices. There are some major differences in how they deliver care.

What were some these features? Did any surprise you?

About two-thirds align with current national initiatives such as Choosing Wisely and the Patient Centered Medical Home, but about one-third are new ideas.

The 10 features are not abstract ideas, they are tangible and therefore more easily transferable. For example, the higher-performing sites are ‘always on’ — patients can reach the care team quickly 24/7. I use the word ‘care teams’ because I’m not referring to physicians only. These teams include nurses, nurse practitioners, medical assistants and/or office managers, developed  to the highest of their abilities. These teams often treat conditions in a gray zone between primary care and specialist care. They follow up with their patients when a case is referred to a specialist. They check in with patients to ensure they are able to follow self-care recommendations.  Their work station is shared, so they can learn from each other. These teams adhere to systems to deliver care — choosing individual tests and treatments carefully. Distribution of revenues among physicians is not  solely based on service volume. Finally, these practices invest much less in office rent and costly testing hardware.

 

Continue Reading »

Chronic Disease, Health Disparities, Health Policy, Public Health, Research

Study shows former foster kids face higher risk of future health problems

Study shows former foster kids face higher risk of future health problems

2411929600_da793593b2_zAccording to a new study from the journal Pediatrics, adults who were raised in the foster-care system are more likely to have chronic-health problems than those not from foster backgrounds, even after controlling for economic security.

It has long been recognized that foster kids have high rates of health problems as children, but this study is the first to ask what happens when those kids reach adulthood. It considered cardiovascular risk factors and other chronic problems, and it compared three groups of young adults: those formerly in foster care, those from the general public with economically insecure backgrounds, and those from the general public with economically secure backgrounds. The results were graduated among the three groups, from foster care, to economic insecurity, to economic security.

In the paper, the authors explain why their findings are not surprising:

Foster youth are often exposed to poverty and many other adverse childhood experiences including abuse, neglect, domestic violence, and parental substance use, and many undergo frequent placement and school changes while in foster care. Several theories exist regarding the effects of chronic and early exposures to adversity, all of which suggest that the more stressors to which one is exposed, the higher the likelihood of a chronic physical or mental health condition later in life.

However, because these theories regarding adversity haven’t yet been adequately investigated, this study has important implications. Scientific evidence could influence policy-makers to address this problem, perhaps by continuing Medicaid access for former foster kids or granting it to those far below the poverty line, or by offering continued support from the foster-care system into young adulthood. Provisions for the first two changes were made in the Affordable Care Act, and the federal government does offer incentives for states to continue foster care until age 21, but due to technicalities and state-level laws, these benefits are not widely accessible.

Continue Reading »

Health Policy, In the News, Public Safety, Rural Health

The Navajo-Native Nexus: A chance to make history and improve health

The Navajo-Native Nexus: A chance to make history and improve health

Navajo kids

For the sake of history in the making, not another Tobacco Settlement disaster, please.

A month ago, the Obama Administration released the $554 million of “no-strings-attached” money to the Navajo Nation — the largest settlement to a tribe in history — as part of the resolution to a long-running land dispute. The Navajo Nation, with its size and political connections, is perfectly poised to demonstrate best practices for how tribes can leverage such funds after years of inadequate support. I know I’m not someone who’s in the place to suggest what would be best for the Navajo Nation, but I hope to see this community benefit from settlement money catalyzing positive change.

I write as a first-year medical student who lived on the Navajo reservation in Sanders, Arizona for the past two years as a high-school teacher. In Sanders, I’ve seen how access to preventive services, behavioral health services, and assistance navigating health-care service provision can have life or death implications. In our small school, every few weeks at least one of my students would miss class because of a funeral that could have been avoided. The 2014 report on a proposed Medicaid expansion for the Navajo Nation cites that for Navajos on the reservation, 60 percent have no phones, 32 percent live without plumbing, 28 percent without kitchen facilities, and many without electricity. Seventy-eight percent of roads are unpaved, so air emergency transport is used, and there is no accredited residential substance abuse treatment program. The Navajo Nation mortality rate is 31 percent higher than in the U.S.

If the Navajo Nation wants a lesson in what not to do with the money, it can look at the poor outcomes of another historic settlement for the U.S. back in 1998: The Tobacco Master Settlement Agreement. Recent reports indicate several states chose to invest in bonds when using settlement money from the tobacco industry, though the funds were intended to fuel prevention initiatives. Only 1.9 percent of funding per year was devoted to preventive services; unsurprisingly, today preventable tobacco-related deaths remain high in the U.S. Tempting as it may be for the Navajo Nation to use this money for miscellaneous expenses, this is a chance for the Navajo to set the precedent for other indigenous groups who might find themselves similarly empowered with a large sum of unmarked money.

Navajos are in the spotlight and could seize this timely chance to show how spending on one focused initiative implemented with outside partnerships could positively affect outcomes of societal welfare. Using settlement funds to more seamlessly integrate services that are starting to be provided by other health resources (like from a new potential Navajo Medicaid) into a navigable health infrastructure could enhance an entire sector of life on the Navajo Nation in measurable ways.

Continue Reading »

Ethics, Health Policy, In the News, Medicine and Society, Transplants

Moving the needle on organ donation

Moving the needle on organ donation

For the thousands of people on organ donation lists, news of an available heart, or lungs, or liver can’t come soon enough. But many don’t get that call in time. According to a new feature on The Atlantic’s website, 21 people die waiting for a transplant every day. That works out to more than 7,600 patients every year.

Unfortunately unless you’re personally touched by the issue… you don’t really think about it

Although many people say they support organ donation, in many countries, only a minority actually register as organ donors. (“Unfortunately unless you’re personally touched by the issue, unless you have a child that gets a virus and suddenly needs a new heart, you don’t really think about it,” one expert says in the piece.) It’s a paradox many people in the field are trying to unravel. The reasons they’ve uncovered so far include mistrust of medical professionals: Some people believe that if a medical team finds out that you’re an organ donor, they won’t work as hard to save your life, in order to harvest your organs. And how much TV a person watches can influence how much he or she trusts doctors. One study found that people who watched more of the TV series Grey’s Anatomy were more likely to mistrust doctors and nurses.

Religion also influences the picture, probably because of concepts of bodily integrity in the afterlife. Catholics are less likely to donate their organs, even though the Vatican officially supports organ donation.

So what can be done about the organ shortage? Some groups are working on solutions, as highlighted in the piece:

“What we’re trying to do in New York is move the cultural needle on the issue,” says Aisha Tator, executive director of the New York Alliance for Donation. “Organized tissue donation should be a cultural norm like we did with bike helmet and seatbelt interventions.” Her organization isn’t the only one. Throughout the United States there have been a smattering of recent educational campaigns and studies on their efficacy. Campaigns have targeted the young, the oldnursesDMV employees, and ethnic minorities who tend to donate less than white Americans or white Brits.

Another, more drastic change is to shift the U.S.’s current opt-in system to one that requires people to opt-out. Many experts point to Spain, which has an opt-out system – and one of the highest rates of organ donation. But the logistics of such a system would probably be difficult, best, to implement.

Continue Reading »

Health Costs, Health Policy, Patient Care, Stanford News

A call for medical malpractice reform

Golden Lady Justice, Bruges, BelgiumA new report in the Journal of the American Medical Association offers a look at the current decline in medical malpractice suits and makes some predictions about their future. The authors include two Stanford faculty, Michelle Mello, JD, PhD, and David Studdert, LLB, ScD, who both have joint appointments at the School of Medicine and the School of Law.

Using national databases, the researchers found that the paid claims against doctors decreased between 2002 and 2013. Rates decreased by an average of 6.3 percent for medical doctors (MDs) and 5.3 percent for doctors of osteopathy (DOs). The amount of an average paid claim peaked in 2007 at $218,400, but had gone down a bit as of 2013. A post on the Stanford Law School’s blog explains why this may be a good time for policy-makers to consider reforms in the medical liability system:

“After years of turbulence, the medical liability environment has calmed,” said Mello. “Although many aspects of the malpractice system are dysfunctional, causing angst for physicians, the cost of malpractice claims and insurance have been stable for the last few years and the number of claims has been declining.”

She added, “Usually, attention is only focused on reform during ‘malpractice crises,’ but highly charged political environments are not conducive to cool-headed policy decisions. This current period of calm is a good time to be thinking about reforms that could improve our medical liability system.”

In their piece, the authors describe seven different novel approaches to medical malpractice reform, including one that encourages medical institutions and providers to communicate with complaining patients and find resolutions that might include payouts to patients before they file suit.

The paper also includes some predictions about the trends that will be important for medical liability policy in the coming decade. The authors assert that traditional tort reforms “will never deliver,” but the previously mentioned communication-and-resolution programs are likely to expand, as will “safe harbor” laws that protect clinicians and their institutions if they can show they are following a prescribed course of clinical treatment. Other trends include the increasing consolidation of health care within hospitals and large health systems. These large entities are likely to use their growing size to influence the liability system.

More ominously, authors note that liability insurance crises have happened in regular cycles since the system was expanded in the 1960s, and warn that another is imminent. They conclude their report by saying:

Action now to reduce the amplitude of the next medical liability cycle is both prudent and feasible. Further testing of nontraditional reforms, followed by wider implementation of those that work, holds the most promise. Prospects for permanent improvement in the medical liability climate depend on it.

Photo by Emmanuel Hybrechts

Stanford Medicine Resources: