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Events, Health Policy, Pediatrics, Stanford News

Innovating for kids’ health: More from first day of Stanford’s Childx

Innovating for kids' health: More from first day of Stanford's Childx

Childx table“We are at the precipice of massive change in health care.”

That was the message from pediatrician Alan Greene, MD, speaking during a Thursday afternoon session on accelerating innovation in child and maternal health at Stanford’s inaugural Childx conference. (The conference continues today and will be live tweeted from @StanfordMed.)

Greene, a practicing pediatrician who in 1995 launched one of the very first websites to provide patients with health information, knows a thing or two about innovating in health care. “Patients are the biggest underused resource in medicine, and moms and their kids are the biggest underused resource in pediatrics,” he said, noting that the idea for his website came from the parents of his patients.

The kind of innovation he anticipates in medicine is happening elsewhere in society first, Greene said. Car service Uber and accommodation website Airbnb have rapidly become global leaders not because they own fleets of cars or chains of hotels but because “they have used people, existing resources, data and software to create this magic that just sprung out of nowhere, seemingly,” he said. Now, we’re on the verge of parallel changes in crowd-sourced medicine, for instance with patients now able to contribute their data to research through the quantified-self movement and with user-oriented collaborative medicine, which will allow patients not just to participate in research but also to help shape the research questions.

After Greene’s presentation, three Stanford scientists spoke about their approaches to innovation. Daria Mochly-Rosen, PhD, described Stanford’s SPARK program, now in its ninth year, that she launched to help scientists take their medical innovations past the “valley of death” – the gap between research and clinical use that kills many good ideas before they help patients. To date, the program has moved an impressive 57 percent of its projects to companies for clinical trials or pre-clinical trial work, or to clinical trials that are being conducted at Stanford itself.

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Events, Health Policy, Pediatrics, Public Health, Research, Stanford News

“What we’re really talking about is changing the arc of children’s lives”: Stanford’s Childx kicks off

"What we're really talking about is changing the arc of children's lives": Stanford's Childx kicks off

Childx Guttmacher

Stanford’s Childx conference got off to a great start today. Shortly after Lloyd Minor, dean of the medical school, welcomed the attendees, keynote speaker Alan Guttmacher, MD, director of the Eunice Kennedy Shriver National Institute of Child Health and Development, took the stage to talk about how scientific research needs to evolve to continue to advance children’s health.

Pediatric research has reached an inflection point, Guttmacher said. “I really believe the fundamental questions we need to ask are different,” he said. “This isn’t about health in a narrowly defined way. What we’re really talking about is changing the arc of children’s lives, and the medical model is useful but not sufficient.”

He mentioned several successes from the history of pediatric medicine, including large reductions in infectious disease, better care for preterm babies, and the “Back to Sleep” public health campaign that cut newborn deaths from SIDS by more than half. But he also highlighted several areas where children’s health now needs research that goes beyond a strictly medical approach to integrate social and environmental factors, such as learning how to prevent preterm birth, help children with autism and intellectual and developmental disabilities participate more fully in society, understand how children’s lives are changed by cyberbullying, and make medical and ethical decisions about the possible use of newborns’ genomic data.

He anticipates that this type of research will bring new strength to pediatricians’ interactions with patients and their families. “I would hope that the pediatric practice of the future, in terms of anticipatory guidance, won’t be about the next six weeks, six months or even six years of [the child’s] life; it’ll be about the next six decades,” he said.

“We need to be a society that values children,” Guttmacher concluded, adding that we should view children as a shared societal responsibility and also a shared societal investment. He challenged the audience of pediatric researchers to ask themselves, “What do we need to do to … change the nature of research that would make real change, not just small blips, in the lives, especially of kids in the United States and globally?”

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Addiction, Events, Health Policy, Stanford News

Stanford Health Policy Forum to focus on balancing benefits and costs of prescription opioids

Stanford Health Policy Forum to focus on balancing benefits and costs of prescription opioids

6284740462_c1d824cbb7_zNationwide deaths from drug overdose have been steadily increasing since 1990 and are a leading cause of injury death. More than half of drug overdose deaths in the United States are related to pharmaceuticals and 71 percent of these involve prescription painkillers, according to the latest figures from the Centers for Disease Control and Prevention.

In California, the number of deaths involving opioid prescription medications has risen almost 17 percent in the past nine years. As a result, policymakers are struggling to develop methods to reduce the risk of such medications while making sure patients that rely on them for pain management have access.

On April 9, the School of Medicine will host a forum examining the challenges of balancing the benefits and costs of prescription opioids and discussing potential solutions. The event is part of the Stanford Health Policy Forum series and will be moderated by Paul Costello, the medical school’s chief communications officer. Stanford addiction medicine expert Anna Lembke, MD, and pain medicine expert Sean Mackey, MD, PhD, will participate in the forum.

For our local readers: The event, which is free and open to the public, will run from 12:30-2 p.m. in Berg Hall at the Li Ka Shing Center for Learning and Knowledge.

Previously: Stanford addiction expert: It’s often a “subtle journey” from prescription-drug use to abuse, Why doctors prescribe opioids to patients they know are abusing them, Do opium and opioids increase mortality risk? and How to combat prescription-drug abuse
Photo by Erin DeMay

Aging, Chronic Disease, Events, Health Policy, Neuroscience, Public Health, Women's Health

Alzheimer’s forum with Rep. Jackie Speier spurs conversation, activism

Alzheimer's forum with Rep. Jackie Speier spurs conversation, activism

10776927963_3dd8d244da_zWhat happens when you bring together a woman with Alzheimer’s, a congresswoman, a policy expert and two doctors? No, this isn’t a joke – but an intro to an informative and wide-ranging discussion on Alzheimer’s disease and its effects on women.

“I was pretty ignorant until fairly recently,” said Rep. Jackie Speier (D-CA), who organized the forum Alzheimer’s: A women’s health issue held in San Mateo, Calif. yesterday. She also penned an opinion piece published recently in the San Francisco Chronicle. “I had no idea that two out of three people diagnosed with Alzheimer’s are women.”

Although it’s the fifth leading cause of death in California, Alzheimer’s receives much less federal money than many other major diseases, she said.

To spur conversation and provide information, Speier invited Cynthia Ortiz Guzman, a former nurse who suffers from Alzheimer’s; Ruth Gay, director of public policy and advocacy for the Alzheimer’s Association; Elizabeth Landsverk, MD, medical director of ElderConsult, and Stanford’s Michael Greicius, MD, MPH, an associate professor of neurology and neurology and medical director of the Stanford Center for Memory Disorders. Greicius has done research on women’s risk of the disease.

Nearly all of the 150-plus people who attended the forum had a loved one who suffered from Alzheimer’s. “We still have a good life, but there is so much that needs to be done,” Guzman told them.

Greicius and Landsverk fielded questions about how to diagnose and treat Alzheimer’s as well as promising directions of research.

At Stanford, Greicius said a person with memory impairment would meet with a neurologist, take a several hour neuropsychological exam, have bloods tests and a brain scan, and meet with social workers and nurses. He emphasized that this is far above the level of care available in more community medical centers. Sometimes physicians are able to find biomarkers that signal Alzheimer’s presence more than a decade before symptoms appear he said.

Greicius urged attendees to find out if they’re eligible for a neurological research trial at Stanford and to consider donating their brains and the brains of their loved ones to use for research. He also thanked Speier for focusing attention on Alzheimer’s.

“We’ve got to get the attention of policymakers to address this issue,” Speier said, adding that she might try to secure federal funds as part of the defense budget.

Gay, who recently traveled to Washington, D.C. to advocate for the disease, agreed. “We know that today we need a game changer – we need people to step forward and speak out about this disease,” she said.

Previously: Science Friday explores women’s heightened risk for Alzheimer’s, The state of Alzheimer’s research: A conversation with Stanford neurologist Michael Greicius and The toll of Alzheimer’s on caretakers 
Photo by Marjan Lazarevski

Health Costs, Health Policy, In the News, Patient Care, Public Health

Health-care policy expert Arnold Milstein weighs in on Medicare’s plan to prioritize “value over volume”

Health-care policy expert Arnold Milstein weighs in on Medicare's plan to prioritize "value over volume"

8266476742_4967a82707_zAmerican health-care spending is the highest in the world, yet some question whether that money really leads to improved patient outcomes. But significant reforms taking place within Medicare, the US’s biggest healthcare payer, over the next few years aim to quell these concerns and reduce costs while improving quality of care.

Health policy experts explained the context of these changes last week in a webinar hosted by Reporting on Health and supported by the NIH’s Health Care Management Foundation. The panel featured Stanford’s Arnold Milstein, MD, MPH, director of the Clinical Excellence Research Center, as well as health economist Austin Frakt, PhD, professor at Boston University School of Medicine, and Jordan Rau, a correspondent for Kaiser Health News.

Health-care’s dominant “fee for service” (FFS) model has been around “since doctors were getting paid in chickens,” said Rau in the webinar, but it has no link whatsoever to quality. Many think this model needs to be changed because it incentivizes physicians to do more (and more expensive) procedures, regardless of the effect they have on patient outcomes. “Better, less expensive care is a national imperative,” said Milstein. “The cost to society of inefficiently delivered care is creating enormous opportunity cost.”

Starting in 2011, Medicare began to tie payments to quality: Doctors get paid 2 percent more if quality goes up, and 6 percent less when it goes down, based on patient ratings and rates of readmission and infection. In 2014, quality-linked FFS accounted for around 80 percent of care, of which around 20 percent featured some more radical change. The new plan is that 50 percent of payments will be non-FFS by 2018.

Options to reform this model could include bundled fees (a flat rate per “episode” that includes all complications and follow-up care), accountable care organizations (ACOs) that take responsibility for all patient needs and costs, incentives for cross-provider cooperation, and population-based payment in which doctors receive a set fee for any patient (currently being pioneered in Maryland).

How will we know which changes to push? Milstein used a graph to indicate “positive value outliers,” institutions with high quality and low cost, whose strategies and techniques will be emulated to see if they can be effective elsewhere. He explained what researchers found makes them different:

[Positive value outliers] tended to have deeper, more personal relationship with their patients; their patients trusted that if they called these doctors on nights and weekends, someone who knew something about them would be rapidly responsive. Doctors’ vision of their responsibility to their patients extended far beyond producing a perfect office visit; it really meant being a steward for their patients’ best interests as their patients traversed emergency room doctors, hospitalists and medical specialists. And lastly, these doctors were not trying to be solo heroes – they did a wonderful job hiring and training medical assistants and taking advantage of a team… and it was associated with a substantial improvement in value. Our next step is to splice this DNA into average performing primary care practices and verify that this is indeed the right stuff.

Some other ideas for achieving the targets were mentioned, such as sending physicians to homes so patients don’t get admitted, or in the longer term, having an intensive-care unit (ICU) “airline control tower” with more perspective than those on the “frontline” of critical care, an idea Milstein said was studied across 56 American ICUs and resulted in a 25 percent mortality reduction.

Milstein said such approaches could lower baseline health-care costs by 30 percent, but moreover could slow the rate at which health-care spending outgrows the economy, which is the real measure of success. Innovators in this area, he said, will need to draw from behavioral and computer science to think about problems differently.

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Events, Global Health, Health Costs, Health Disparities, Health Policy, Stanford News

Global health expert: Economic growth provides opportunity to close the “global health gap”

Yamey talkStanford’s Center for Innovation in Global Health hosted a recent seminar for Stanford students and faculty with global health-policy expert Gavin Yamey, MD, MPH. The discussion focused on the disparity in heath care between higher- and lower-income countries and how economic growth in lower-income countries could set the stage for big improvements in global health.

During the talk, Yamey explained that millions of lives could be saved if economic gains in low- and lower-middle-income countries were invested in health care. “I can’t think of any other investment on the planet that could improve human welfare in such a huge way,” Yamey told the audience.

As described in an online story on the event, Yamey cited Rwanda – a country that rebuilt its economy and healthcare after the 1994 genocide – as an example of how this scenario could play out elsewhere:

Over the past decade, Rwanda has experienced significant drops in mortality associated with HIV, malaria and maternal death, and achieved the greatest drop in child mortality rates in recorded history. While scholars acknowledge several factors that contributed to such an extraordinary rebound, government spending on public health, the smart use of aid, and economic growth were all integral to the equation.

“We have an extraordinary opportunity to bring down maternal, newborn and infectious disease deaths to universally low levels everywhere,” Yamey said. “But for that to happen, we need an aggressive scale up of existing tools and interventions, investment in new tools and a build-up of delivery systems.”

Previously: Minimum wage: More than an economic principle, a driver of healthHealth care in Haiti: “At risk of regressing”Child-mortality gap narrows in developing countries and Stanford general surgeon discusses the importance of surgery in global health care
Photo, of Gavin Yamey (left) and moderator Paul Costello, courtesy of the Center for Innovation in Global Health

Health Costs, Health Policy, In the News, Medicine and Society

“From volume to value:” Stanford expert to discuss Medicare reform in free webinar

Big changes are ahead for Medicare, the largest payer in the U.S. health-care system. By 2018, Medicare aims to tie at least half of all payments to the quality or value of care received, not the quantity of services rendered. Many critics of the existing system claim that it incentivizes doctors to do more procedures, which do not in the end improve health.

A panel of experts will discuss changes in how we pay for care, and whether payment reforms can improve quality while lowering costs, in a free public webinar this Thursday at 10 AM Pacific time. Heading the panel is Stanford’s Arnold Milstein, MD, MPH, director of the Clinical Excellence Research Center. That center focuses on new methods of health-care delivery that substantially reduce health spending while improving outcomes.

More details, including the link to register, can be found on the Reporting on Health website. The webinar is free and made possible by the National Institute for Health Care Management Foundation.

Previously: Medicare reforms cut costs and improve patient careExperts discuss high costs of healthcare and what it will take to improve the systemAnalysis: the Supreme Court upholds the health reform act (really) and Views on costs and reform from the “dean of American health economists” and New Stanford center to address inefficient health care delivery

Addiction, FDA, Health Policy, Pediatrics, Public Health

Raising the age for tobacco access would benefit health, says new Institute of Medicine report

Raising the age for tobacco access would benefit health, says new Institute of Medicine report

cigarette packToday, the Institute of Medicine released a new report evaluating the public health effects of reducing teenagers’ access to cigarettes and other tobacco products. Right now, in most places in the United States, you must be 18 years old to buy cigarettes and other tobacco products. But a few states and cities have higher minimums, and in 2013, the IOM convened a committee, at the request of the U.S. Food and Drug Administration, to examine the potential effects of a higher minimum legal age for tobacco access across the country.

The committee, which was led by Richard Bonnie of the University of Virginia and included Stanford adolescent medicine expert Bonnie Halpern-Felsher, PhD, reviewed the existing scientific literature on tobacco use in teens. They also devised mathematical models to predict what would happen if the federal minimum legal age were 19, 21 or 25.

The report brief (.pdf) says, in part:

Based on its review of the literature, the committee concludes that overall, increasing the MLA [minimum legal age] for tobacco products will likely prevent or delay  initiation of tobacco use by adolescents and young adults. The age group most impacted will be those age 15 to 17 years. The committee also concludes that the impact of raising the MLA to 21 will likely be substantially higher than raising it to 19. However, the added effect of raising the MLA from 21  to 25 will likely be considerably less.

The parts of the brain most responsible for decision making, impulse control, sensation seeking, and susceptibility to peer pressure  continue to develop and change through young adulthood, and adolescent brains are uniquely vulnerable to the effects of nicotine. In  addition, the majority of underage users rely on social sources—like family and friends—to get tobacco. Raising the MLA to 19 will therefore not have much of an effect on reducing the social sources of those in high school. Raising the MLA to 21 will mean that those who can legally obtain tobacco are less likely to be in the same social networks as high school students.

Although it can take time to fully realize the benefits of reduced smoking, since heart disease, lung cancer and other diseases linked to smoking take decades to develop, the payoff would ultimately be significant, the report adds:

…if the MLA were raised now to 21 nationwide, there would be approximately 223,000 fewer premature deaths, 50,000 fewer deaths from lung  cancer, and 4.2 million fewer years of life lost for those born between 2000 and 2019.

Previously: How e-cigarettes are sparking a new wave of tobacco marketing, To protect teens’ health, marijuana should not be legalized, says American Academy of Pediatrics and UN’s top health official: Anti-tobacco efforts can lead to better health “in every corner of the world”
Photo by Thomas Lieser

Addiction, FDA, Health Policy, Medicine and Society, Public Health, Public Safety

To keep edibles away from kids, marijuana policies must be “fully baked”

To keep edibles away from kids, marijuana policies must be "fully baked"

sanfran031606_fig1_highresDepending on your position, legal marijuana might raise images of stoners on every street corner or of users enjoying a private puff in their backyards. However you probably don’t picture a child munching on a pot-laden brownie she found in her kitchen cupboard.

But as Stanford legal experts Robert MacCoun, PhD, and Michelle Mello, JD, PhD, point out in a commentary published today in the New England Journal of Medicine, the loose state regulation of marijuana edibles creates some unnecessarily and potentially serious public health risks that should concern everyone.

Packaged in brightly colored wrappers, edibles often mimic popular sweets, but they contain a powerful dollop of tetrahydrocannabinol (THC), the chemical responsible for marijuana’s psychoactive effects. Some edibles contain multiple “servings” of THC per package.

Both Colorado and Washington — the two states with legal recreational marijuana — require “child-resistant” packaging and a warning to “keep out of the reach of children.” But edibles remain quite attractive to children, who may confuse them with regular candies and snacks, and potentially deceptive to adults, who may assume one bar is a just one serving. “I look at these packages and I get hungry just looking at them,” MacCoun said.

The edibles are not regulated as either a food or a drug by the U.S. Food and Drug Administration, because the federal government considers marijuana illegal. Legalizing states have been slow to fill the gap, and have done so incompletely, Mello said. “This is sort of a weird space that’s betwixt and between federal and state oversight,” she said.

It’s time for the medical community to get involved, MacCoun said. “Most people don’t understand the brain metabolizes chemicals ingested by mouth differently than those smoked.”

Ingested marijuana offers a delayed high, so people keep eating thinking they are fine. The intoxication lasts longer and is associated with more hallucinations and perceptual distortions, he said. “It’s almost like a different drug.”

For now, the issue is most pressing in Colorado and Washington, but many other states are considering legalizing recreational marijuana, including California, MacCoun said.

“We’re not taking some strong position these products should be banned. Sensible and fairly modest regulations would reduce the risk without greatly restricting people’s freedom to consume these products,” MacCoun said.

Previously: Discussing the American Academy of Pediatrics’ call to put the brakes on marijuana legalization, To protect teens’ health, marijuana should not be legalized, says American Academy of Pediatrics and Medical marijuana not safe for kids, Packard Children’s doc says
Photo by DEA

Global Health, Health Policy, Infectious Disease

“Made-in-India” vaccine could save thousands of children

"Made-in-India" vaccine could save thousands of children

5559524166_510ebb57a0_zIndia reached a milestone this week with the introduction of a novel rotavirus vaccine, the first vaccine designed entirely in the developing world. The vaccine is not only safe and effective, but also affordable; the manufacturer, Bharat Biotech, has pledged to make it available for $1 to governments in low-income countries.

The vaccine, known as ROTAVAC, will be used to fight a disease that kills 80,000 children a year in India alone. On a global scale, rotavirus, which causes severe diarrheal disease, is responsible for some 450,000 childhood deaths and 2 million hospitalizations.

The vaccine was developed through a unique partnership supported by the Indo-U.S. Vaccine Action Program, which was chaired until recently by Harry Greenberg, MD, senior associate dean for research at the School of Medicine. Greenberg was a lead inventor of the first-generation vaccine for rotavirus.

“The ROTAVAC project is a beautiful example of the great power of team science,” Greenberg told me. “The vaccine is a culmination of a very large and disparate group of people and organizations, all working together for a common goal: to produce a safe, effective and affordable vaccine to prevent severe, rotavirus-associated diarrhea in Indian children.”

During a three-day visit to India in January, U.S. President Barack Obama and Indian Prime Minister Narendra Modi had praised the “highly successful collaboration” that lead to the development of the vaccine. Prime Minister Modi was on hand for ceremonies Monday announcing the launch of the vaccine, which the Indian government will make available in public clinics across the country.

The vaccine originated from a weakened strain of rotavirus that was isolated from an Indian child in the mid-1980s. It went through a long development process which included investigators from 13 institutions and culminated in a randomized, double-blind clinical trial involving nearly 6,800 infants in India. The results, published in the Lancet in 2014, showed it was as effective as two other licensed, commercial oral rotavirus vaccines.

The vaccine was developed with support from the National Institutes of Health and the U.S. Centers for Disease Control and Prevention, among others.

“The impact of this vaccine to improve child survival is enormous,” said Roger Glass, MD, PhD, director of the Fogarty International Center at the NIH. “Our groups at the CDC and NIH are proud to be an integral part of this longstanding and enormously successful collaboration with our Indian colleagues.”

Previously: President Obama and Indian Prime Minister praise partnership that led to rotavirus vaccine, Life-saving dollar-a-dose rotavirus vaccine attains clinical success in advanced India trial and Trials, and tribulations, of a rotavirus vaccine
Photo by The Bill and Melinda Gates Foundation

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