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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

Chronic Disease, Health Policy, In the News, Medicine and Society, Medicine X

Patients with “invisible illnesses” speak out about challenges in their communities and workplaces

3477601702_765d0c9504_zWhat does a patient with chronic disease look like? Sometimes they look like everyone else, as many diagnosed with “invisible illnesses” are pointing out. In a recent NPR story, Carly Medosch, a former ePatient scholar at Stanford’s Medicine X, speaks about discrimination in the workplace for those whose health challenges are not immediately obvious. Medosch has been living with Crohn’s disease for 20 years and fibromyalgia for one year.

From NPR’s write-up:

For Medosch and others who struggle with an invisible disability, occasional hospital stays and surgeries are not the hard part. Mundane, everyday activities can be more difficult… Walking to the subway or even bending down to pick something up can take a lot out of her. But that isn’t apparent from the outside.

“I kind of call it being able to pass,” she says. “So I can pass as a normal, healthy, average person, which is great and definitely helps ease my everyday life — especially in interactions with strangers, getting your foot in the door in a situation like a job interview.”

But a foot in the door doesn’t mean people are sympathetic: Wayne Connell, who founded the Invisible Disabilities Association after his wife was diagnosed with Lyme disease and multiple sclerosis, is also quoted in the piece:

We’d park in disabled parking and she didn’t use a wheelchair or a cane, and so people would always give us dirty looks and scream at us… When they see someone in a wheelchair, OK, they get that they’re in a wheelchair. But what if they have chronic pain, what if they have PTSD — anything from cancer to peripheral neuropathy to autism?

Perhaps more importantly, disabled people have legal rights that are being ignored. Joyce Smithey, a lawyer who specializes in labor and employment, says it’s not uncommon for employers to say “We don’t do that as a policy” when people with invisible disabilities request accommodations. Smithy says:

And that’s a problem, because that person is not asking to partake of a benefit that’s offered in a policy; that person is asking for an accommodation they’re entitled to under the law.

Previously: When you say nothing at all: Living with an invisible illness, and How to cope with an “invisible illness”
Photo by Hugo Chisholm

Health Disparities, Health Policy, SMS Unplugged

Minimum wage: More than an economic principle, a driver of health

Minimum wage: More than an economic principle, a driver of health

SMS (“Stanford Medical School”) Unplugged was recently launched as 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.

Gallegos minimum wage sketchI admittedly don’t understand much about the intricacies of economics. But I don’t have to in order to recognize the significance behind Wal-Mart’s decision to raise the minimum pay for its lowest paid hourly employees. In the week following the company’s announcement, plenty has been written about the impact that such a move will have on the company’s success and on local economies. It goes beyond that, however. What I see is the impact that an increase in income can have on the health of working individuals making a minimum wage.

Let’s do some quick math. Current guidelines list the poverty level at $24,250 for a household of four. Federal minimum wage is $7.25/hr. A full-time employee earning minimum wage therefore brings home $15,080. The working class individual, whose spouse stays home to care for their two children since childcare is unaffordable, incredibly falls $9,170 below the recognized poverty level.

This April, Wal-Mart will increase hourly pay to $9.00 and follow this with an increase to $10.00/hr in February 2016. Even then, a family of four with only one working parent will still fall more than $3,000 below the federal poverty level. Yet, the true hardship of poverty can’t be quantified so easily.

What can’t be measured is the stress that surrounds a working family’s paycheck – especially in matters of health. The difficult decision that my patient makes to skip work in order to bring their sick child to clinic, sacrificing a day’s pay, and – worse – their job security. Weighing feelings of worry for their ailing child against the stress of providing financially for the family. Or my patient who struggled through an upset stomach because she couldn’t afford both the medication and the food that she should be taking it with. Choosing health while enduring hunger.

A raise in minimum wage has direct impacts on health. It means the ability to deal with an unexpected expense without risking basic living standards like food, shelter, and transportation. It means having the luxury of buying fresh peaches instead of canned fruit. It means having a warm coat and shoes for winter. It means buying that prescription that’s been pending for months. It means securing the monthly bus pass to get you to work in the first place. For many, however, even the near 38 percent raise announced by Wal-Mart will not lift their families above the federal poverty line. In a situation where pennies and dimes add up, there will still be a significant deficit that will continue to make it improbable (read: impossible) to earn a way out of poverty.

Countless articles can be found online and in print about the need to increase minimum wage. Recently in the political sphere was a push for a $10.10 minimum wage under the Harkin-Miller Bill (Fair Minimum Wage Act). Unfortunately, the bill didn’t pass the Senate. While the bill may not have represented the necessary increase, it was an acknowledgement by some of the direction we need to take- and not just for economic purposes. We must recognize that reductions in financial hardship through fair wages provide a pathway for addressing health disparities and improving health outcomes.

Moises Gallegos is a fourth-year medical student. He’ll be going into emergency medicine, and he’s interested in public-health topics such as health education, health promotion and global health.

Sketch by Moises Gallegos

Chronic Disease, Health Policy, Public Health, Public Safety, Stanford News

New uses for old polymers: Stanford Engineering team uses surgical glove material to make air filters

New uses for old polymers: Stanford Engineering team uses surgical glove material to make air filters

After visiting China and enduring the stifling air pollution, Stanford engineering professor Yi Cui, PhD, wanted to explore solutions to the problem. This week, his team published a paper in the scientific journal Nature Communications, detailing a new kind of highly effective air filter made out of polyacrylonitrile, a synthetic polymer that is used to make surgical gloves.

The researchers used a relatively new technique called electrospinning, or drawing out microscopically thin threads from a liquid to make a lightweight and fairly transparent filter out of PAN. The filter attracts particles from the air, especially those around 2.5 microns – or PM2.5 – which are among the most dangerous for the human respiratory tract.

The researchers make the case for the new PAN air filter pretty eloquently in a press release:

“It was mostly by luck, but we found that PAN had the characteristics we were looking for, and it is breathtakingly strong,” said Po-Chun Hsu, co-author on the study and a graduate student in Cui’s lab.

. . .

“The fiber just keeps accumulating particles, and can collect 10 times its own weight,” said Chong Liu, lead author on the paper and a graduate student in Cui’s lab. “The lifespan of its effectiveness depends on application, but in its current form, our tests suggest it collects particles for probably a week.”

The material collects 99 percent of air particles for up to a week, but is still 70 percent transparent, so it could be used as a window covering. “It might be the first time in years that people in Beijing can open their window and let in a fresh breeze,” Cui said in the statement.

Previously: The high cost of pollution on kids’ healthStudy shows air pollution may increase heart attack risk more than drug useContinuing pollution restrictions used during Beijing Olympics could reduce cancer rates and New insight into asthma-air pollution link
Video by Kurt Hickman

Chronic Disease, Health Policy, In the News, Pediatrics, Public Health, Sleep

Talking about teens’ “great sleep recession”

Talking about teens' "great sleep recession"

Sleepy Teen Student

We all understand, at some level, that sleep is critical to our health. But there’s a cultural undercurrent that belies that understanding: We tend to glorify the go-getters who can survive on four or five hours of sleep, lauding their productivity and drive. Numerous studies have shown that Americans of all ages – kids, teens, and adults – are not getting enough sleep.

More and more, researchers are warning that lack of sleep can damage our long-term health. Just yesterday, Rafael Pelayo, MD, with the Stanford Center for Sleep Sciences and Medicine, was on KQED’s Forum radio program to discuss a new study looking at some alarming trends in teen sleep habits. The study, titled “The Great Sleep Recession” was published this week in the scientific journal Pediatrics. It showed that over the past 20 years, teens have been getting less sleep. Girls, minority teens, teens in urban areas and of low socioeconomic status were less likely to get at least seven hours of sleep than male, white teens. What’s more, minority teens and low SES teens were likely to report they thought they got enough sleep.

During the show, Pelayo spoke about our relationship with sleep and the challenges of sticking to a “sleep budget”:

When I read the title [of the study] it made me think of Bill Dement, who talks – at Stanford – about a sleep debt and not having enough total sleep. And a sleep debt has been growing and accumulating in people who have used sleep as something as optional in their lives. These students are… modeling after their parents, who are not getting enough sleep… But in the kids, it’s a particularly hard problem for them, they feel pressure to not get enough sleep.

Pelayo went on to say that parents and teens tend to prioritize other things, like homework, over sleep – but what they should be doing is setting aside a certain amount of time for sleep. “If the homework doesn’t get done, it doesn’t get done. They can’t make homework more important than sleep,” he said.

That last statement is a pretty radical suggestion, but if we are to avoid the fall-out from our bad sleep habits, radical changes may be the only solution.

Previously: With school bells ringing, parents should ensure their children are doing enough sleeping, Stanford docs discuss all things sleep, Study shows poor sleep habits as a teenager can “stack the deck against you for obesity later in life” and What are the consequences of sleep deprivation?
Photo by Alberto Vacarro

Health Policy, Medical Education, Public Health, Public Safety

Why I never walked to school: the impact of the built environment on health

Why I never walked to school: the impact of the built environment on health

SMS (“Stanford Medical School”) Unplugged was recently launched as 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.

kids walking to schoolMy California-acclimated body was a little shocked by the 15-degree weather I encountered while visiting my Kentucky hometown over winter break, but I was still determined to bundle up most days and to get outside for long walks with my mom and daughter. One day as we were struggling to catch an opening in traffic to cross the blindly curving road leading out of our subdivision, it occurred to me that the cold was the least of our barriers to getting a little exercise.

“I don’t think I could design a more dangerous place to walk if I tried,” I observed in frustration. Another car whizzed by within a couple feet of my daughter’s stroller. “This town was definitely built for cars, not people.”

For most of my childhood, my family lived right in the middle of town, within about a mile of many of the places a young family might visit on a daily basis. Grocery stores, school, church, the public library, restaurants, the park where I played softball, and my grandmother’s house were all close enough that they should have been an easy walk. But that one mile might as well have been twenty, and I can count on one hand the times I walked to those destinations. I tried a few times, but to get there on foot I’d have to navigate roads lined by steep hills or ditches with no sidewalks or crosswalks. There is one underpass that would require a pedestrian to climb onto a narrow strip of gravel and inch along the wall, close enough to the fast-moving traffic to be unbalanced by gusts from each passing car.

Because of these real physical barriers, the local cultural wisdom took it as self-evident that cars were the only reasonable way to get around. Walking and biking were recreational activities to be done in endless circles around the cul-de-sac, not viable modes of transportation. The risk of walking wasn’t just a theoretical one: Our roads were decorated with a couple of makeshift roadside altars made by the families of teenagers who had died while trying to cross the street. More recently, I was disappointed to read an article confirming my suspicions that cycling in the Southeastern U.S. is drastically more dangerous than in other regions.

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Aging, Health Policy, Patient Care, Stanford News

A call to “improve quality and honor individual preferences at the end of life”

A call to "improve quality and honor individual preferences at the end of life"

ICU IllustrationThis week’s New England Journal of Medicine featured a perspective piece co-authored by Philip Pizzo, MD, former dean of Stanford’s School of Medicine, and David M. Walker discussing recommendations for how U.S. physicians can approach the issue of end-of-life care. Pizzo and Walker co-chaired an Institute of Medicine (IOM) committee on the issue that culminated in a report that we wrote about last September.

In a recent survey, most physician respondents said they “would forgo high-intensity end-of-life treatment” for themselves. Yet many patients in their care are subjected to aggressive treatments that prolong the dying process unnecessarily. The editorial outlines the challenges that we face as a nation regarding end-of-life care and notes that the aging population of the country will soon make end-of-life care a critical issue. The authors recommend, among other things, adding end-of-life care to physician training, incorporating end-of-life conversations into patient care, even before they become terminally ill, and incorporating end-of-life decisions into health care delivery and payment programs.

In an email, Pizzo discussed why fixing our end-of-life care predicament is so important, telling me:

Unfortunately, all too frequently, individual preferences are not honored at the end of life – with many individuals experiencing more invasive interventions than they wished at the end of their life. It is important that we value the quality of life throughout the life journey, including at the end of life. As a nation, our current health-care system fails in end of life care – which has an enormous impact on individuals, their families and loved ones, and our community and nation.

The situation is complicated by politics. In 2009, end-of-life care became a hot-button issue when critics of the Affordable Care Act claimed that a provision to reimburse physicians for advising patients on living wills or advance directives would lead to “death panels.” Pizzo said of the debate:

Having conversations with our families and physicians about the end of life that allow us to express our personal preferences should not be seen as controversial… Sadly, what has made this issue controversial is egregious political rhetoric. The suggestion that health-care reform would result in “death panels” was wrong and highly destructive, frightening many Americans unnecessarily. When such hyperbole and soundbites become the story they have highly negative consequences. That is why the IOM committee underscored the importance of a more accurate and fact based public discussion about end of life care that made it clear that our intentions, as a society, must be to improve quality and honor individual preferences at the end of life.

Previously: No one wants to talk about dying, but we all need to, Study: Doctors would choose less aggressive end-of-life care for themselves, Former School of Medicine dean named to expert panel to reform end-of-life care in America, Communicating with terminally ill patients: A physician’s perspective and On a mission to transform end-of-life care
Image, “A portrait of death in modern America,” by Neils Olson

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