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Health Policy, Mental Health, Patient Care, Pediatrics, Stanford News

Stanford expert on new treatment guidelines for teens’ eating disorders

Stanford expert on new treatment guidelines for teens' eating disorders

eatingdisorder-plateEating disorders often begin in the teenage years, but, surprisingly, the medical community long lacked a teen-specific set of guidelines for treating these serious illnesses.

That changed in May with the publication of a set of practice parameters co-authored by Stanford eating disorder expert James Lock, MD, PhD, who also directs the Comprehensive Eating Disorders Program at Lucile Packard Children’s Hospital Stanford. The parameters were based on an extensive review of the current scientific evidence around eating-disorder treatment, including recent studies by Lock and his colleagues that show that teens’ parents can play an active role in helping their children recover from anorexia nervosa. That’s a big shift from traditional thinking about eating disorders, which held that young patients’ families should be shut out of treatment.

In a new Q&A, I talked with Lock about why the parameters were needed. He told me:

There have never been practice parameters that address eating disorders in children and adolescents, and expertise in treating these disorders has been sort of sequestered. Yet eating disorders are so prevalent and are such a severe problem: Lifetime prevalence in adolescent girls is around 1 percent, and the disorders have among the highest fatality rates of all mental illnesses.

Teens need treatment approaches that account for their level of physical and emotional development, the fact that their parents generally want and need to be involved in their recovery, and the fact that they have not usually had eating disorders for as long as adult patients with the same diagnoses.

Lock also discusses how he hopes the new guidelines will improve training of psychiatrists, how recent changes to eating disorder diagnostic criteria are making it easier for doctors to get their patients the help they need, and why outpatient treatment is the new front line for young people with eating disorders.

Previously: Patient tells how social media helped her overcome the “shame” of her eating disorder, Incorporating family into helping teens overcome eating disorders and Story highlights need to change the way we view and diagnose eating disorders in men
Photo by Darren Tunnicliff

Chronic Disease, Global Health, Health Policy, Public Health, Research, Stanford News

Finding the sweet spot in public health law to regulate sugary drinks

Finding the sweet spot in public health law to regulate sugary drinks

lemonade-155663_1280Two Stanford public health law experts say one of the biggest culprits of the obesity epidemic – on top of fast foods and sedentary lifestyles – is sugary drinks. And they believe the sweet spot for public health law in curbing the adverse effects of sugar-sweetened beverages (SSBs) lies in the strategic use of measures such as higher SSB taxes, limits on advertisements targeting kids, and restrictions on soft drinks and sugar-sweetened teas and sports drinks in government institutions, such as public schools.

“Enough is already known about the promise of some legal interventions to curb SSB consumption – significant tax hikes and advertising restrictions are two good examples – to be fairly confident that they would make a difference,” says David Studdert, MD, a professor in the medical and law schools and a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research.

Studdert is the lead author of a review paper, “Searching for Public Health Law’s Sweet Spot: The Regulation of Sugar-Sweetened Beverages,” which was published today in PLoS Medicine.

Studdert and senior author Michelle Mello, MD, also a professor in the medical and law schools, and co-author Jordan Flanders, a former Stanford Law School student, argue that sugary drinks are a substantial, yet preventable contributor to the global burden of obesity and associated health conditions.

A recent study in the journal Circulation linked the consumption of sugary drinks to an estimated 184,000 adult deaths each year, with more than 25,000 of those Americans. While Americans’ consumption of sugary drinks has plateaued, according to the research, about three-fourths of the deaths due to SSBs are now in developing countries. Mexico leads with 24,000 total deaths. The United States still ranks fourth, however, just behind South Africa and Morocco.

The Stanford researchers say the evidence shows that sugary drinks are contributors to the global obesity epidemic, but the appropriate reach of regulation to curtail SSB consumptions remains highly contested.

“Finding public health law’s sweet spot requires regulatory approaches that are capable both of achieving measurable improvements to public health and of winning victories in courts of law and public opinion,” they wrote.

That’s often difficult.

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

On King v. Burwell and the survival of the Affordable Care Act (and an unexpected birthday present)

On King v. Burwell and the survival of the Affordable Care Act (and an unexpected birthday present)

5362318849_dd1527d632_zToday is my birthday – and the Supreme Court (or, at least, two-thirds of it) just gave me, most people who follow health policy, and millions of now still-insured Americans a present: King v. Burwell.

There’s a lot to say about this decision, but I want to focus on three things: the strength of the conflicting substantive arguments, the possible internal Court dynamics that resulted in the majority and dissenting opinion, and a guess at some deeper meanings of the case for the future of health care in America.

On the substance, this is a case that really could have gone either way. The idea that the Court should apply the words as written, no matter how silly, has precedent in the Court’s history; so does the idea that the Court should try to interpret laws in ways that make them work as intended. The majority — at the end, Chief Justice John Roberts’s opinion — does recognize this conflict; the dissent, from the more textualist end of the Court, rejects the idea of a tension. The majority has it right in the sense that sometimes the Court applies the words as written, sometimes it requires interpretation, and that both are legitimate responses to cases – both are within the culture of legal interpretation that the Court has included over the last two-and-a-quarter centuries.

I do think the Court could have legitimately gone the other way, though I think it would have been foolish and harmful, to the country and even to the conservatives who will now bemoan this outcome. I am glad they did not. I prefer judges who try, when the law – or more accurately its interpretative culture – will allow them to, to make things work in a sensible way. The dissent’s position would have upended a major government program and harmed millions of people for a technicality – like a ticky-tack penalty or foul call deciding the Super Bowl or the World Cup. The Court could have done that, but it would have been wrong.

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

Supreme Court upholds Affordable Care Act with a 6-3 vote

Supreme Court upholds Affordable Care Act with a 6-3 vote

Supreme Court picUpdated 4:07 PM: “Obamacare lives to fight another day,” writes David Studdert, ScD, a core faculty member at CHP/PCOR and an expert in health law, in a Stanford Law School blog post. In his piece, he offers more legal details of the ruling.

***

Updated 1:51 PM: Stanford law professor Hank Greely, JD, has this to say:

Today is my birthday – and the Supreme Court (or, at least, two-thirds of it) just gave me, most people who follow health policy, and millions of now still-insured Americans a present: King v. Burwell

I do think the Court could have legitimately gone the other way, though I think it would have been foolish and harmful to the country and even to the conservatives who will now bemoan this outcome. I am glad they did not. I prefer judges who try, when the law – or more accurately its interpretative culture – will allow them to, to make things work in a sensible way. The dissent’s position would have upended a major government program and harmed millions of people for a technicality – like a… foul call deciding the Super Bowl or the World Cup.  The Court could have done that, but it would have been wrong…

What does it mean about the future of Obamacare? Well, I think it means the Supreme Court is done with it, at least with its fundamental, life or death issues.

Greely will expand on these thoughts in a longer piece on Scope later today.

***

Updated 12:45: Mello goes into detail on the ruling in a just-published Stanford Law School blog post.

***

Updated 11:51 AM: Stanford’s Laurence Baker, PhD, who has done extensive research on the economic performance of the U.S. health-care system, has also weighed in, saying, “This ruling, affirming the intent of the Affordable Care Act, is a relief for millions of Americans who have gained coverage under the law. It also provides important stability for insurers and the health-care system more broadly, avoiding what would have been tumultuous disruption in health-insurance markets in many states. We can now turn full attention back to the important work of improving health-insurance markets and expanding coverage, from which this court case was such a distraction.”

***

Updated 11:04 AM: Some thoughts now from Stanford health economist Jay Bhattacharya, MD, PhD, a core faculty member at the Center for Health Policy and the Center for Primary Care and Outcomes Research (CHP/PCOR):

Today’s Supreme Court ruling preserves the Obama administration’s implementation of the ACA’s subsidy scheme to all qualified people (between 133 and 400 percent of the poverty line). The Supreme Court essentially ruled for the status quo.

Had the plaintiffs won the case, such subsidies would only have been legal in states, like California, that have established their own insurance exchange (or marketplace). The immediate effect of the ruling, then, would have been to eliminate federal subsidies for the people living in states without a state-established insurance exchange. Families with income between 133 and 400 percentof the poverty line in such states who purchased their insurance through a federally-established exchange would have had to pay the full costs of their insurance premiums. This would have made insurance unaffordable for many of these families.

The ruling would not have directly affected people who get insurance through their employers or through the government in some other way, such as through Medicare (health insurance for the elderly and disabled) or through Medicaid (health insurance for the poor).

It is difficult to imagine, had the ruling gone the other way, that it would be a stable political equilibrium for people in one state to be eligible for federal subsidies, while similar people in another state to be not eligible. There would have been a lot of pressure on Democrats and Republicans at both state and federal levels to reform Obamacare, and either reestablish the subsidies or make some other arrangement to make insurance affordable. With the Supreme Court ruling the way it did, there will be substantially less impetus or desire for the reform of Obamacare, especially on the Democratic side.

***

Updated 10:45 AM: Stanford’s Michelle Mello, JD, PhD, professor of law and of health research and policy, has just provided her insight on the ruling, which she said offered strong claims by both sides:

The Court was profoundly influenced by its desire to avoid an interpretation of the law that would defeat Congress’s purpose in passing it. That purpose was to create a functional market through which individuals could buy insurance… The Court found it “implausible” that Congress intended for States that opted not to set up their own Exchanges to suffer the foreseeable, well-understood consequence of a “death spiral.”

The spiral occurs because without the tax credits, a very large proportion of the people who would otherwise be required to buy insurance get exempted from the individual mandate because the insurance cost exceeds a set amount of their income. That means too few people — and in particular, too few healthy people — buying insurance now… People know they can buy insurance later when they get sick. Their decisions to do so push premiums up for everyone, and the adverse selection makes the market unsustainable…

The trio writing in dissent could hardly have shown greater disgust with the majority’s approach. They disputed the majority’s threshold claim that the four little words were ambiguous — and everything that followed from it. The length and complexity of the majority’s justification for its holding, they claimed, is just proof that (once again) the justices are contorting the law in order to achieve a political objective — upholding the Affordable Care Act…

But on balance, I think the majority got it right in pointing to the well-understood consequences of withholding tax credits as evidence that Congress didn’t intend the reading the challengers urged. The decision is on firm legal ground, and to public-health advocates, is an enormous relief.

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Global Health, Health Disparities, Health Policy, Stanford News

Rosenkranz Prize winners devoted to innovative health care in developing countries

Rosenkranz Prize winners devoted to innovative health care in developing countries

African girls studyingMarcella Alsan, MD, PhD, knows that the division of labor among men and women starts at a young age in the developing world.

“Anecdotally, girls must sacrifice their education to help out with domestic tasks, including taking care of children, a job that becomes more onerous if their younger siblings are ill,” Alsan, a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research (CHP/PCOR) within the Freeman Spogli Institute of International Studies, recently told me.

More than 100 million girls worldwide fail to complete secondary school, despite research that shows a mother’s literacy is the most robust predictor of child survival. So Alsan is analyzing whether medical interventions in children under 5 tend to lead their older sisters back to school. She’ll compile data from more than 100 Demographic and Health Surveys covering nearly 4 million children living in low- and middle-income countries. The surveys ask about episodes of diarrhea, pneumonia and fever in children under 5 and record data on literacy and school enrollment for every child in the household.

“My proposed work lays the foundation for a more comprehensive understanding of how illness in households and early child health interventions impact a critical determinant of human development: an older girl’s education,” Alsan, the only infectious-disease trained economist in the United States, said.

Alsan is one of two winners of this year’s Rosenkranz Prize for Health Care Research in Developing Countries, awarded by CHP/PCOR. Her Department of Medicine colleague, Jason Andrews, MD, is the other recipient of the $100,000 prize, which is given to young Stanford researchers to investigate ways to improve access to health care in developing countries.

In the current scientific climate, most National Institutes of Health grants go to established researchers. The Rosenkranz Prize aims to stimulate the work of Stanford’s bright young stars – researchers who have the desire to improve health care in the developing world, but lack the resources.

While Alsan is researching how older girls in poorer countries are impacted by the health of their younger siblings, Andrews is focusing his attention on cheap, effective diagnostic tools for infectious diseases.

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Global Health, Health Policy, Medicine and Society, Public Health, Stanford News

The battle against big tobacco hits the classroom

The battle against big tobacco hits the classroom

4822770407_f1a230b06c_bIn Malawi, children as young as five years old work in tobacco fields. Here, in the Silicon Valley, five-year-olds compete to attend top preschools. Stanford communications major Minkee Sohn highlighted that dramatic contrast with a parody video, “Fresh Recruits,” for a new Stanford anthropology class. Taught by Matthew Kohrman, PhD, the class, “Smoke and Mirrors in Global Health,” aimed to raise awareness about the global tobacco industry and was the subject of a recent Stanford News article.

Simply acknowledging that “smoking is bad for you” is no longer enough to halt tobacco’s spread. As noted in the piece, the tobacco industry remains a powerful global force and produces three times as many cigarettes as it did during the smoking heyday in America in the 1960s; it’s also the source of millions of preventable deaths. Kohrman encouraged his students to develop original communication strategies and to take on hard-hitting issues, such as the use of underage labor.

For their final projects, Kohrman’s class presented a slew of web-based videos, exposés and written critiques exploring little known facets of the global tobacco industry, including:

  • Chinese academia’s involvement in the tobacco industry
  • Philip Morris’ use of child labor in Africa
  • South Korea’s flawed approaches to tobacco control

Overall, Kohrman, an associate professor of anthropology, deemed his experimental class a “great success.” The course uncovered many little-known aspects of global tobacco, and taught students to “understand the sociocultural means by which something highly dangerous to health such as the cigarette is made both politically contentious and inert.”

Alex Giacomini is an English literature major at UC Berkeley and a writing and social media intern in the medical school’s Office of Communication and Public Affairs.  

Previously: A call to stop tobacco marketing, Cigarettes and chronographs: How tobacco industry marketing targeted racing enthusiasts and How e-cigarettes are sparking a new wave of tobacco marketing 
Photo by Jo Naylor

Health Costs, Health Policy, Medicine and Society, Orthopedics, Research, Stanford News

When physicians work together, costs can rise

When physicians work together, costs can rise

97187153_16040f08b7_zOnce upon a time, patients received care from a local doctor, who usually worked alone or with a few partners. Now, most physicians belong to large practices, which have standardized procedures and costs.

These mergers have been greeted warmly by regulators and the public, who believe that larger groups can take advantage of economies of scale. But these alignments could also give physicians greater bargaining power with insurers, a move that could push costs up, according to a new study by Stanford researchers.

Eric Sun, MD, an instructor of anesthesiology, perioperative and pain medicine, working with senior author Laurence Baker, PhD, investigated the fees charged by orthopedic surgeons for knee replacements between 2001 and 2010. They also ranked how concentrated physicians’ health-care markets scored on a commonly used index.

They found that physicians’ fees in markets with a high concentration of physician groups rose $168 compared to fees in the least concentrated markets — a jump of 7 percent.

The research has implications for the Affordable Care Act, which encourages physicians to join alliances. “The point is not to say that consolidation is a bad thing,” Sun concluded in our press release on the study. “But as we think about encouraging these kinds of mergers, we really want to weigh the costs against the benefits.”

The study appears in the June issue of Health Affairs.

Previously: Health-care policy expert Arnold Milstein weighs in on Medicare’s plan to prioritize “value over volume”, Steven Brill’s Bitter Pill and What’s the going rate? Examining variations in private payments to physicians
Photo by Waldo Jaquith

Health Disparities, Health Policy, In the News, Medicine and Society, Women's Health

Report: Health-care industry needs to focus on women

Report: Health-care industry needs to focus on women

16755600997_ca15a76fcf_zThe health-care industry needs to pay much more attention to women. That’s the argument laid out in a recent piece on MedCity News, which shared findings of a survey (.pdf) from the Center for Talent Innovation. That report shows that women make the majority of health-care decisions but are inadequately equipped to do so, and it calls on health-care companies, which are increasingly oriented towards consumers, to bridge that gap.

According to the survey, which included more than 9,200 respondents from the U.S., U.K., Germany, Japan, and Brazil, 94 percent of women make decisions for themselves and 59 percent make decisions for others; when working moms are considered separately, 94 percent make decisions for others. And yet, 58 percent of these decision makers lack confidence in their decision making.

The report says this is due to “three profound famines”: lack of time, lack of knowledge, and lack of trust. Seventy-seven percent of women don’t know what they need to do to stay healthy; 62 percent lack the time. Only 38 percent of working mothers passed a “health literacy quiz,” and the report showed that women are unlikely to trust online information (31 percent), their insurance companies (22 percent), or pharmaceutical companies (17 percent).

The report suggests that health-care companies need to understand women in the context of their family and career responsibilities, which is quite different from standard male-based “life stage analysis.” Moreover, they need to understand that women think about health more broadly than freedom from illness and health risks. Fully 79 percent said that health means “having spiritual and emotional wellbeing,” while 77 percent called it “being physically fit and well rested.”

An excellent place to start change is the management structure of health-care companies, the report suggests. Despite being the “CMOs” (Chief Medical Officers) for their families, women are underrepresented in other “C-level” roles in these companies:

We find that, while the health-care industry employs a large number of female professionals, their ideas, insights, and capabilities haven’t been fully supported, endorsed, and promoted. Without women in power, women’s ideas don’t get the audience they deserve, because… leaders only see value in ideas they personally relate to or see a need for.

MedCity news writer Nina Ruhe sums up another area for improvement. “Doctors, insurance companies and pharmaceutical companies can start instilling trust in women again by letting them know exactly what they should know in regards to their personal health and the health of their families,” she writes.

Health Policy, In the News, Patient Care, Stanford News, Technology

Exploring electronic health reminders’ effect on quality of care

Exploring electronic health reminders' effect on quality of care

It’s not every day that the director of the National Institutes of Health blogs about your research. But that’s the day that David Chan, MD, PhD, assistant professor of medicine, recently had when NIH Director Francis Collins, MD, PhD, highlighted his work.

Chan, a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research, is exploring the impact of electronic health record reminders on the quality of primary care. He received an NIH Early Independence Award last year for his work in this area.

Collins writes:

Is 5 too few and 40 too many? That’s one of many questions that… Chan is asking about the clinical reminders embedded into those electronic health record (EHR) systems increasingly used at your doctor’s office or local hospital. Electronic reminders, which are similar to the popups that appear when installing software on your computer, flag items for healthcare professionals to consider when they are seeing patients. Depending on the type of reminder used in the EHR—and there are many types—these timely messages may range from a simple prompt to write a prescription to complex recommendations for follow-up testing and specialist referrals.

More details on Chan’s work can be found in the full post.

Beth Duff-Brown is communications manager for the Center for Health Policy and Center for Primary and Outcomes Research.

Previously: A new tool for tracking harm in hospitalized childrenAutomated safety checklists prevent hospital-acquired infections, Stanford team finds and Can sharing patient records among hospitals eliminate duplicate tests and cut costs?

Cancer, Dermatology, FDA, Health Policy, In the News, Public Health

Experts call on FDA for a “tanning prevention policy”

Experts call on FDA for a "tanning prevention policy"

6635416457_a62bfeb09d_zIndoor UV tanning beds are known carcinogens that are responsible for many cases of skin cancer, which is the most commonly diagnosed form of cancer in the U.S. A recently issued Call to Action to Prevent Skin Cancer from the U.S. Surgeon General states that “more than 400,000 cases of skin cancer [8% of the total], about 6,000 of which are melanomas, are estimated to be related to indoor tanning in the U.S. each year” while “nearly 1 out of every 3 young white women engages in indoor tanning each year,” making indoor tanning a serious public health issue.

In a JAMA opinion piece published yesterday, Darren Mays, PhD, MPH, from the Georgetown University Medical Center‘s Department of Oncology, and John Kraemer, JD, MPH, from Georgetown’s School of Nursing and Health Studies, argued that the FDA needs to step up its regulatory approach and restrict access to this technology – due to its limited therapeutic benefits and known damaging effects.

In 2011, California was the first state to ban access to indoor UV tanning beds to minors. The authors assert that “state-level policies restricting a minor’s access to indoor tanning devices are effectively reducing the prevalence of this cancer risk behavior among youth,” but argue that regulation at the federal level is in order:

Like tobacco products, a national regulatory framework designed to prevent and reduce indoor tanning could reduce public health burden and financial costs of skin cancer. …from a public health perspective the indoor tanning device regulations are not commensurate to those of other regulated products that are known carcinogens with very little or no therapeutic benefit.

However, the likelihood of this regulation taking place is questionable:

FDA did not leverage its authority last year to put a broader regulatory framework in place, which could have included a national minimum age requirement and stronger indoor tanning device warning labels… Critical factors seem to be aligning for such policy change to take place, but additional momentum is needed to promote change at a national scale. The US national political environment makes more expansive regulation by either FDA or Congress seem unlikely in the near future.

The authors concluded with a call for organizations other than governments to help build momentum on toward a “national indoor tanning prevention policy.” For example, they said, universities could implement “tan-free” campus policies similar to the “tobacco-free” campaign.

Previously: More evidence on the link between indoor tanning and cancers, Medical experts question the safety of spray-on tanning productsTime for teens to stop tanning?, Senator Ted Lieu weighs in on tanning bed legislation and A push to keep minors away from tanning beds
Photo by leyla.a

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