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Health Policy

Health Disparities, Health Policy

A quiz on the social determinants of health

Given the topic of today’s SMS-Unplugged entry, during which Moises Humberto Gallegos discusses how things like housing insecurity and financial hardship can contribute to poor health, I was interested to come across this Covering Health quiz on the social determinants of health. Writer Joe Rojas-Burke asks 10 true-or-false questions, and I think some of the answers may surprise you. For example:

Expanding health insurance coverage and access to medical care (the focus of the federal Affordable Care Act) is unlikely to reverse the health disparities caused by the social determinants of health.

TRUE: In countries that established universal health coverage decades ago, lower social status still correlates with worse health and shorter lives. The research on social determinants suggests that progress is likely to require broader social changes, such as improving access to education, boosting economic opportunity and making disadvantaged neighborhoods safer and and more vital.

And:

Food deserts – neighborhoods with few or no grocery stores selling fresh, affordable produce – are a well-defined root cause of obesity and other health problems in disadvantaged communities.

FALSE: There is evidence showing that low-income and minority Americans are more likely to live in food deserts. But it’s not at all clear to what extent the lack of supermarkets and grocery stores contributes to obesity or other health outcomes.

Previously: In medicine, showing empathy isn’t enough, Should the lack of access to good food be blamed for America’s poor eating habits? and Hopkins researchers find place, rather than race, may be greater determinant of health

Ethics, Events, Health Policy, Stanford News, Transplants

How can we end the donor organ shortage?

How can we end the donor organ shortage?

organ donorOur country’s organ shortage is an issue of critical importance – especially to the more than 100,000 Americans currently waiting for an organ transplant. In the words of Stanford’s Keith Humphreys, PhD, “Everyone agrees that 18 people dying each day on transplant waiting lists is unacceptable, but there is fierce disagreement about what to do about it.”

Next week, Humphreys will moderate a panel discussion that delves into the issue. He’ll be joined by three experts – including Stanford bioethicist David Magnus, PhD – who will discuss the effect of the organ donation on our country’s overall health and debate the ethical and practical aspects of proposals to solve the problem. Among the most controversial proposed approach and something that will be vigorously debated: paying people to donate their organs.

The event, part of Stanford’s Health Policy Forum series, will be held on July 28 at 11 AM at the Li Ka Shing Center for Learning and Knowledge, in room LK130. For those local readers: It’s free and open to the public, but space is limited. More information can be found on the forum website.

Previously: Students launch Stanford Life Savers initiative to boost organ donation, Full-length video available for Stanford’s Health Policy Forum on serious mental illness, Stanford forum on the future of health care in America posted online and Stanford Health Policy Forum focuses on America’s methamphetamine epidemic
Photo by Mika Marttila

Addiction, FDA, Health Policy, otolaryngology, Public Health

How e-cigarettes are sparking a new wave of tobacco marketing

e-cig tip - smallFollowing the FDA’s announcement earlier this spring that it would regulate the sale – but not marketing – of electronic cigarettes, debate has continued on the safety of using e-cigarettes and the ethics of advertising them.

In case you missed it, today’s New York Times delves into the issue and highlights how Big Tobacco is now rolling into the world of e-cigarettes, which writer Matt Richtel calls an “overnight sensation.” A subsidiary of Reynolds American plans to begin distributing its Vuse e-cigarette line nationwide on June 23 with a campaign that includes television ads (forbidden for cigarettes) in major markets, and other tobacco companies have similar entries in the works. Questions about the potentially far-reaching effects advertising of e-cigarettes, including promoting smoking tobacco and reaching child audiences, concern public-health advocates and other critics – and a U.S. Senate hearing is planned for Wednesday.

From the article:

Matthew L. Myers, [JD,] president of the Campaign for Tobacco-Free Kids, who is scheduled to testify at the Senate hearing, said the fact that the F.D.A. did not limit marketing allowed tobacco companies to return to the airwaves with ads that make e-cigarettes sexy, rebellious, glamorous — “exactly the same themes we saw work with kids in the U.S. for decades with cigarettes.”

In the absence of marketing regulation, “they will set the agenda,” Mr. Myers said of the tobacco companies. “They will drive the evolution of the product in a way that serves their interests and not public health, and that’s exactly what’s happening.”

Robert Jackler, MD, chair of otolaryngology at Stanford Medicine, is an expert on tobacco marketing who studies it through his center, the Stanford Research Into the Impact of Tobacco Advertising. Like Myers, he has vocalized his concerns about e-cigarettes and tobacco companies’ aggressive marketing tactics – especially those targeted toward teens – and you can hear more about his views and research in this recent podcast.

Previously: E-cigarettes and the FDA: A conversation with a tobacco-marketing researcherE-Cigarettes: The explosion of vaping is about to be regulatedStanford chair of otolaryngology discusses federal court’s ruling on graphic cigarette labels and What’s being done about the way tobacco companies market and manufacture products
Photo by Li Tsin Soon

Health Policy, Media, Public Health, Research, Technology

Lack of adoption of social media among health-policy researchers = missed opportunity

Lack of adoption of social media among health-policy researchers = missed opportunity

Despite the opportunity for connecting directly with the public and policy makers, health-policy researchers have yet to rapidly adopt social media-tools in communicating news about their work, according to a study recently published in Health Affairs.

The survey of more than 200 health and health-policy researchers (primarily MDs and PhDs) found that 14 percent of participants reported using Twitter and an estimated 21 percent used blogs or Facebook in the past year to discuss their findings. However, 65 percent of individuals utilized press releases, media interviews or other traditional media channels. Lead author David Grande, MD, MPA, said in a release that the low adoption of social media among these experts “could be a significant missed opportunity to expose a larger audience to important health news and findings.”

Grande and colleagues identified four factors preventing researchers from participating in social media: the belief that the culture of social media is frequently at odds with that of research, perceived professional risk, low confidence in ability to use social media, and uncertainties about how effective the tools are at disseminating research. Educating researchers about how to use social media and best practices could alleviate these concerns and increase adoption, said the authors. They concluded:

Public investments in research on health and health care are substantial. It is essential to maximize the returns on those investments by making research a key component of the process of developing, implementing, and refining health policies. Historically, the communication gap between researchers and policy makers has been large. Social media are a new and relatively untested tool, but they have the potential to create new communication channels between researchers and policy makers that can help narrow that gap. Determining how health researchers can best use and adapt this new technology to communicate evidence to policy makers should be a priority for universities, research funders, and scientists.

Previously: More reasons for doctors and researchers to take the social-media plunge, A reminder to young physicians that when it comes to social media, “it’s no longer about you”, How using Twitter can benefit researchers and How can physicians manage their online persona? KevinMD offers guidance
Via PsychCentral

Chronic Disease, Health Costs, Health Policy, Nutrition, Obesity, Stanford News

Study shows banning soda purchases using food stamps would reduce obesity and type-2 diabetes

Study shows banning soda purchases using food stamps would reduce obesity and type-2 diabetes

soda

In the late 1800s and early 1900s, carbonated beverages such as Coca-Cola, Dr Pepper and 7UP were sold as nerve tonics and health drinks. But, we now know that sugary sodas contribute to obesity, type-2 diabetes and cavities. Still, most Americans drink more soda than they like to admit.

Even though sugar-laden soft drinks have no nutritional value, they are still eligible for food stamps. Nutrition researchers and some politicians have advocated for a ban on buying sugar-sweetened drinks with food stamps but the U.S. Department of Agriculture, which runs the program, is under tremendous pressure from beverage company lobbyists to keep the existing regulations.

Sugary drinks are especially concerning because too many liquid calories put consumers at a higher risk of developing type-2 diabetes. Some nutrition experts are concerned that taxpayers are subsidizing an unhealthy diet, which will result in higher medical costs for Medicare and Medicaid down the road, when food stamp recipients experience the health problems associated with obesity and diabetes.

In a new study (subscription required) published in this month’s Health Affairs, Sanjay Basu, MD, PhD, an assistant professor of medicine at the Stanford Prevention Research Center, and his colleagues created a computer model to simulate the effects of a soda ban on the health of food stamp recipients. They found that obesity would drop by 1.12 percent for adults, and by 0.41 percent for children, affecting about 281,000 adults and 141,000 children. Type-2 diabetes would also drop by 2.3 percent.

The researchers also calculated the effects of reimbursing participants 30-cents for each dollar spent on fruits and vegetables. The subsidy did not affect obesity or diabetes rates, but doubled the number of people who ate the recommended number of fruits and vegetables each day. A county in Massachusetts tried the same reimbursement system as part of the USDA’s Healthy Incentives pilot study, and saw a similar increase in the fruit and vegetable purchases of food stamp recipients.

“It’s really hard to get people to eat their broccoli,” said Basu in a press release. “You have to make it really cheap, and even then, sometimes people don’t know what to do with it.” But, with one in seven Americans receiving food stamps, he points out that these small changes can have wide-ranging effects.

“It’s very rare that we can reach that many people with one policy change and just one program.”

Patricia Waldron is a science writing intern in the medical school’s Office of Communication & Public Affairs.

Previously: Food stamps and sodas: Stanford pediatrician weighs inCan food stamps help lighten America’s obesity epidemic? and Stanford’s Sanjay Basu named a Top Global Thinker of 2013
Photo by Andy Schultz

Aging, Health Policy, Medicine and Society, Podcasts, Research, Stanford News

More on doctors and end-of-life directives

More on doctors and end-of-life directives

Earlier this week, my colleague wrote about a study showing that the majority of doctors surveyed said they would forgo aggressive end-of-life care for themselves. Now, in the latest 1:2:1 podcast, researcher VJ Periyakoil, MD, director of palliative care education and training at the medical school, talks in depth about the study and why doctors appear to want one thing for themselves at the end of life and quite another for their patients.

Previously: Study: Doctors would choose less aggressive end-of-life care for themselves

Aging, Health Policy, In the News, Public Health, Research, Stanford News

Study: Doctors would choose less aggressive end-of-life care for themselves

Study: Doctors would choose less aggressive end-of-life care for themselves

DNR bindersWhy do physicians continue to provide high-intensity care for terminally ill patients but choose to forgo such care for themselves at the end of life? That’s the question raised by a new Stanford study published in PLOS ONE today.

An overwhelming percentage of doctors surveyed for the study in 2013 – 88.3 percent to be exact – said they would choose “no-code” or do-not-resuscitate orders for themselves. And though other studies have shown that most other Americans would choose to die gently and naturally at home, that’s not what’s happening. As I describe in a release:

“A big disparity exists between what Americans say they want at the end of life and the care they actually received,” the study says. “More than 80 percent of patients say that they wish to avoid hospitalizations and high-intensity care at the end of life, but their wishes are often overridden.”

In fact, the type of treatments they receive depends not on the patients’ care preferences or on their advance directives, but rather on the local health-care system variables, such as institutional capacity and individual doctors’ practice style, according to the study.

The study involved two sets of subjects – 1081 physicians in 2013 and 790 physicians in 1989 – which both completed the same 14-question survey on their attitudes concerning advanced directives. Stanford researchers hypothesized that attitudes would have changed in the 24-years since the passage of the Self-Determination Act in 1990, a law designed to give patients more control over end-of-life care decisions and requires health care organizations to inform patients that they have the option to fill out such directives.

Surprisingly, despite the law, physicians attitudes have not changed, said VJ Periyakoil, MD, an expert in palliative care and lead author of the study. More from the release:

As a geriatrics and palliative care physician who sits at the bedside of sick patients herself, Periyakoil said she understands the disconnect between the type of care doctors want for themselves at the end of life and what they actually do for their patients. It’s not because doctors are trying to make more money or because they are intentionally insensitive to their patients’ desires. At the core of the problem is a biomedical system that rewards doctors for taking action, not for talking with their patients.

“Our current default is ‘doing,’ but in any serious illness there comes a tipping point where the high-intensity treatment becomes more of a burden than the disease itself,” said Periyakoil, who trains physicians in palliative medicine. “It’s tricky, but physicians don’t have to figure it out by themselves. They can talk to the patients and their families and to the other interdisciplinary team members, and it becomes much easier.

“But we don’t train doctors to talk or reward them for talking. We train them to do and reward them for doing. The system needs to be changed.”

A touching first-person essay on this topic by Ken Murray, MD, a retired family practitioner has been popping up recently on various blogs and other internet sites. It describes how doctors don’t want to experience the kind of suffering that they see their patients go through. In the piece, titled “How doctors die: It’s not like the rest of us, but it should be,” the author mentions that he has even seen one medical professional with a “Do not Resuscitate” tattoo.

Previously: Communicating with terminally ill patients: a physician’s perspective, Asking the hardest questions: Talking with doctors while terminally ill, On a mission to transform end-of-life care, The importance of patient/doctor end-of-life discussions and A Stanford nurse shares her experience in talking to her aging mother about end-of-life decisions
Photo by Frank DiBona

Aging, Health and Fitness, Health Policy, Public Health, Stanford News

Moderate exercise program for older adults reduces mobility disability, study shows

Moderate exercise program for older adults reduces mobility disability, study shows

senior_dog_walk

A 20-minute walk each day could help older adults stay on their feet and out of wheelchairs longer, according to a multicenter study published in the Journal of the American Medical Association today and coordinated by the University of Florida.

Researchers showed that a daily program of moderate physical activity reduced the risk of mobility disability in older adults by 18 percent compared to those who did not exercise. They also found a 28-percent reduction in the permanent loss of the ability to walk unaided.

Mobility, defined in this study as the ability to walk without assistance for at least 400 meters or about a quarter mile, is critical for aging seniors to function independently. Loss of mobility can lead to higher hospitalization and institutionalization costs, and even early death.

“These results suggest the potential for structured physical activity as a feasible and effective intervention to reduce the burden of disability among vulnerable older persons, in spite of some functional decline in late life,” wrote the researchers.

“While people are aware of the benefits of physical activity, this study is the largest and longest duration randomized trial evaluating the effects of physical activity on mobility disability in older adults. It will provide the hard evidence needed to change health policy,” said Abby King, PhD, the lead investigator for the Stanford field center and a professor of health research and policy and of medicine.

For this study, 1,635 sedentary men and women, age 70 to 89, were recruited by eight field centers across the United States and followed for an average of 2.6 years. All participants were able to walk a quarter mile within 15 minutes but were at risk for losing that ability.

“These are the patients who physicians see every day. This is why this study is so important: It includes a population that is typically understudied,” said principal investigator Marco Pahor, MD, director of the University of Florida’s Institute on Aging.

During the study, participants were randomly assigned to one of two groups. The first group walked 150 minutes per week and did strength, flexibility and balance training. They were encouraged to stay on track with the program through weekly participation in two in-person exercise classes and several home-based physical activity sessions. The second group attended health education classes, including low-intensity stretching exercises.

King said one of the most important takeaways from the study was this: “It’s never too late to gain important benefits from increased physical activity.”

Study results are summarized in this JAMA Report video.

Previously: AAMC’s Health Equity Research Snapshot features Stanford project on virtual health advisers, Help from a virtual friend goes a long way in boosting older adults’ physical activity, Computer-generated phone calls shown to help inactive adults get – and keep – moving
Photo by hartcreations/iStock

Health Policy, Pediatrics, Research, Stanford News

Less burnout, better safety culture in hospitals with hands-on executives, new study shows

Less burnout, better safety culture in hospitals with hands-on executives, new study shows

walkroundsA specific method for fostering interaction between hospital executives and front-line health-care workers can reduce burnout and improve a hospital’s safety culture, new research from Stanford and other institutions has found.

“Caregiver burnout is a huge problem for health care,” said Stanford’s Jochen Profit, MD, in a conversation with me about the new study, which he led. Profit is also a neonatologist at Lucile Packard Children’s Hospital Stanford. “Across the industry, a third to half of our staff are burned out. How do you maintain quality and safety in that environment?”

The method that Profit’s team evaluated holds an answer. Called executive walk-rounds, it consists of regular, safety-focused visits by hospital executives to the units where patients receive care. The study, published last week in BMJ Quality & Safety, evaluated the effects of walk-rounds on the staff of neonatal intensive care units, the nurseries that care for the sickest newborns. Walk-rounds provide doctors, nurses and other caregivers with an opportunity to point out safety problems, and, ideally, also give executives a chance to tell staff about resolutions used for the problems they’ve raised.

The study surveyed worker engagement and safety culture in 44 NICUs during a quality improvement project led by the California Perinatal Quality Care Collaborative. The surveys asked workers if walk-rounds were used at their institution and whether they had participated in the process. They also asked about caregivers’ levels of burnout, the hospital’s overall culture of safety and about feedback returned from hospital leadership to front-line caregivers to follow up on suggestions made during walk-rounds.

“Walk-rounds are a way for organizations to make sure they make the lines of communication open,” Profit said. “It can help show that they care for the people in the trenches.” Walk-rounds might help clear up confusion about the hospital’s chain of command or resolve difficulties with getting equipment or supplies in a timely fashion, to name a few anecdotal examples from the study.

Follow-up was the key to successful walk-rounds, the study showed. About 30 percent of the hospitals surveyed used walk-rounds, and these differed in the extent to which staff said they received feedback on how the safety suggestions they identified were resolved. Staff at hospitals with the highest levels of follow-up said they had lower rates of burnout, better communication about errors, and better teamwork and safety climates.

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

Microbial mushroom cloud: How real is the threat of bioterrorism? (Very)

Microbial mushroom cloud: How real is the threat of bioterrorism? (Very)

Dr. Milana Trounce, M.D. teaches a class on the the risks of bioterror at the Stanford School of Medicine. Photo taken on Monday, April 21, 2014. ( Norbert von der Groeben/ Stanford School of Medicine )

“What if nuclear bombs could reproduce? Get your hands on one today, and in a week’s time you’ve got a few dozen.”

That’s the lead sentence of a feature article I just wrote for Inside Stanford Medicine. The answer is, bombs can’t reproduce. But something just as potentially deadly – and a whole lot easier to come by – can, and does.

What I learned in the course of writing the feature, titled “How contagious pathogens could lead to nuke-level casualties” (I encourage you to take a whack at it), was bracing. Stanford surgeon Milana Trounce, MD, who specializes in emergency medicine, has been teaching a course that pulls together students, faculty and outside experts from government, industry and academia. Her goal is to raise awareness and inspire collaborations on the thorny multidisciplinary problems posed by the very real prospect that somebody, somewhere, could very easily be producing enough killer germs to wipe out huge numbers of people – numbers every bit as large as those we’ve come to fear in the event of a nuclear attack.

Among those I quote in the article are infectious-disease expert David Relman, MD, and biologist/applied physicist Steven Block, PhD, both of whom have sat in on enough closed-door meetings to know that bioterrorism is something we need to take seriously.

Not only do nukes not reproduce. They don’t leap from stranger to stranger, or lurk motionless in midair or on fingertips. Nor can they be fished from soil and streams or cheaply conjured up in a clandestine lab in someone’s basement or backyard.  One teaspoon of the toxin produced by the naturally occurring bacterial pathogen Clostridium botulinum is enough to kill several hundreds of thousands of people. That’s particularly scary when you consider that this toxin – better known by the nickname “Botox” -  is already produced commercially for sale to physicians who inject it into their patients’ eyebrows.

As retired Rear Adm. Ken Bernard, MD, a former special assistant on biosecurity matters to Presidents Bill Clinton and George W. Bush and a guest speaker for Trounce’s Stanford course, put it: “Who can be sure there’s no off-site, illegal production? Suppose a stranger were to say, ‘I want 5 grams — here’s $500,000’?

That’s five grams, as in one teaspoon. As I just mentioned, we’re talking hundreds of thousands of people killed, if this spoonful were to, say, find its way into just the right point in the milk supply chain (the point where loads of milk from numerous scattered farms get stored in huge holding tanks before being parsed out to myriad delivery trucks). That’s pretty stiff competition for a hydrogen bomb. For striking terror into our hearts, the only thing bioweapons lack is branding – nothing tops that mushroom-cloud logo.

Previously: Stanford bioterrorism experts comments on new review of anthrax case and Show explores scientific questions surrounding 2001 anthrax attacks
Photo of Milana Trounce by Norbert von der Groeben

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