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Addiction, Health Policy, In the News

Stanford addiction expert: “The country needs to spring into action” on heroin epidemic

Stanford addiction expert: "The country needs to spring into action" on heroin epidemic

What’s underlying today’s heroin epidemic and what can be done about it? That was the focus of the opening hour of KQED’s Forum yesterday morning, and Stanford addiction expert Keith Humphreys, PhD, was one of the panelists who weighed in on the issues. He talked about the connection between painkiller addiction and heroin use, the differences between heroin addicts these days versus those in the 1970s, and the use of Naloxone, which can reverse the effects of opioids. Noting that California recently passed a bill that makes this medication available at pharmacies, he said, “I would encourage anyone who is at risk for overdose, or loves someone who is at risk for overdose to get Naloxone.”

Humphreys also referenced the relative lack of resources that goes into studying the heroin epidemic: “We don’t seem to have the will to take this problem on the way we need to… The country really needs to spring into action. We did on AIDS, and we are not doing it here.”

Previously: Heroin: The national epidemic and A focus on addiction, the country’s leading cause of accidental deathIncreasing access to an anti-overdose drug and A reminder that addiction is a chronic disease

Health Costs, Health Policy, Research, Stanford News

Stanford study: Medical procedures more expensive where physicians cluster in large medical practices

Stanford study: Medical procedures more expensive where physicians cluster in large medical practices

doctors shaking handsAs more physicians move from solo and small practices, a dozen common medical procedures are becoming more expensive in areas where physicians are clustered into large medical practices, according to new research appearing in Health Affairs.

The study assessed the relationships between physician competition and prices paid by private organizations in 2010 for 15 common, high-cost procedures to determine whether high concentrations of physician practices and accompanying increased market power were associated with higher prices for services.

They found that prices were indeed 8 to 26 percent higher in the thousands of counties analyzed, with the highest average physician concentration compared to counties with the lowest. This was for 12 of the 15 procedures they examined, including colonoscopy with lesion removal, vasectomy, laparoscopic appendectomy and knee replacement surgery.

“Our findings are consistent with the hypothesis that greater market power allows physicians to bargain for higher prices from insurers,” wrote Dan Austin, MD, a graduate of Stanford’s medical school and a resident physician at the University of California, San Francisco, and Laurence Baker, PhD, chair of health research and policy at Stanford and a core faculty member at the Center for Health Policy and Center for Primary and Outcomes Research.

“We concluded that physician competition is frequently associated with prices,” they said. “Policies that would influence physician practice organization should take this into consideration.”

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Emergency Medicine, Global Health, Health Policy, Stanford News, Videos

A look at “India’s medical miracle,” the largest ambulance service in the world

A look at "India's medical miracle," the largest ambulance service in the world

A patient in shock arrives via ambulance at Gandhi Hospital in Hyderabad, India with a gaping wound in his right hand, blood spattered on his blue jeans and T-shirt. Emergency medical technicians wheel him into a dark room in the government-run hospital, where clinicians move quickly to irrigate the wound and pump fluids into the man, who appears to be in his 20s.

With luck, the patient might survive. Ten years ago, he would not have had a chance.

Thanks to some passionate philanthropists, businessmen and medical experts, India today has what we have long taken for granted in the United States: a modern, emergency 911-type system and a cadre of trained emergency responders who have helped save an estimated 1.4 million lives. Begun in 2005, it is now the largest ambulance service in the world and serves more than 750 million people in cities and villages across the Indian sub-continent.

I saw the system in action first-hand in August when I traveled to India, together with about 10 other faculty and staff from Stanford’s School of Medicine, including Dean Lloyd Minor, MD, to celebrate its 10th anniversary amid much color and fanfare. I was there to write a story about the new system for Stanford Medicine magazine.

Begun in August 2005 in the south Indian metropolis of Hyderabad, the service, known as GVK EMRI (Emergency Management and Research Institute), is operated as a public-private partnership, providing its services free of charge, mostly to the very poor. It is a remarkable achievement, given the diversity of India, with its 29 states and more than 120 major languages, and the bureaucracy and corruption that can sometimes impede progress in this vast country of 1.2 billion souls.

“It’s hard to fathom what this system has done in 10 years,” S.V. Mahadevan, MD, interim chair of Stanford’s Department of Emergency Medicine, told me while stationed in one of EMRI’s ambulances. “It could be regarded as one of the most important advances in global medicine in the world today.”

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Emergency Medicine, Health Policy, Patient Care

Improving patient satisfaction and turn-around time in an emergency department

Improving patient satisfaction and turn-around time in an emergency department

Emergency Room SignWhat could a manufacturing philosophy concocted by a car maker have to offer a beleaguered emergency department staff? More than you would expect.

“Lean manufacturing” is a method used in the 1960s and 1970s by Toyota to improve quality on its assembly lines. The idea was to empower all the workers to have the authority and confidence to stop the line and address quality and efficiency issues. In the decades since, it’s made its way to other industries beyond manufacturing, including software development.

When Amir Dan Rubin, MHSA, MBA, came on board four years ago as president and CEO of Stanford Hospitals and Clinics, he brought the lean management mentality with him.

Marlena Kane, MPH, executive director for performance excellence & medicine services at Stanford Hospital described the process as “looking at things from the patient’s perspective and getting people to talk to each other.”

The hospital’s emergency department implemented the lean methodology, and a year later, wait times dropped dramatically and patient satisfaction shot up. Kane, along with David Pickham, PhD, director of research at Stanford Hospital, and their colleagues reported their experience in a paper in the Journal of Nursing Administration last month. And Rubin spoke about the changes they’ve implemented at this year’s Medicine X conference.

The median length of stay in the ED fell by 17 percent, despite a 7 percent increase in patients. And there was virtually no increase in the cost of running the department. “We all want the same thing, to take care of patients well,” Kane said.

The main change the department made was to teach front-line staff to solve problems as they cropped up. Those front-line staffers were able to have discussions with other groups when they noticed inefficiencies or slow-downs. This required several teams to work together to find solutions – from nurses and residents to transporters, housekeepers and translator services.

Training the teams on the new approach was no small feat. For the day-long trainings, additional staff had to be called in to back-fill staff members who would be away from the emergency department.

She pointed out that the lean approach has to have leadership buy-in and commitment to work. “You have to start with the executive team,” she said. “They have to be invested and give time to let staff do it. It can’t be grass roots.” When the lean approach fails at an organization, it’s often because the leadership team isn’t fully invested in the process.

Kane noted that handing the power to solve problems to front-liners frees up leadership staff to tackle long-term problems. “If we keep solving problems for our teams, they won’t be empowered,” she said. “We are always fire-fighting, not thinking strategically.”

Previously: Speed it up: Two programs help reduce length of stay for emergency-room visitorsStanford’s “time banking” program helps emergency room physicians avoid burnout, and An emergency medicine physician’s take on honoring your emotions
Photo by KOMUnews

Global Health, Health Costs, Health Policy, Stanford News

Pharmaceutical adventures in India

Pharmaceutical adventures in India

medication in IndiaIn the course of a recent trip to India, I developed some minor health problems and found myself doing what many locals do: consulting with a pharmacist. India’s cities are peppered with these modest little storefronts, some the size of a large closet, which sit along the street, the pharmacists stationed on a stool behind a counter awaiting customers.

The pharmacies are stocked floor-to-ceiling with a plethora of remedies for whatever ails the human body and spirit. My husband and I sought treatment for an affliction common both to travelers and local Indians, caused by contamination in food and water: diarrhea. Despite our best food precautions, we managed to contract a case of the runs after eating at a very elegant restaurant in Jaipur in the northern province of Rajasthan. When a dose of Lomotil did not prove entirely effective, we decided to turn to a pharmacist for advice, as my experience traveling abroad is that local practitioners often know best how to treat common local problems.

The pharmacist asked us several questions in perfect English: Did we have a fever? Any vomiting? Any stomach cramps? No to the first two, yes to the last. He radiated a sense of confidence. He then produced two sets of pills in silver and green packages. We were advised to take these twice a day. He also gave us an electrolyte replacement solution, to be mixed with purified water and consumed twice daily as well. The pills had names I did not recognize, so I largely took them on faith, explicitly following his directions. The total cost for both of us: the equivalent of $2.50.

“You actually behaved in many ways like a many locals would – like a person who doesn’t have easy access to a health-care provider,” Nomita Divi, program manager of the Stanford India Health Policy Initiative, told me recently when I related my experiences.

Divi took a group of Stanford students – one med student, one masters and two undergraduates – to India for 8 weeks this summer to study this very phenomenon: the role of pharmacists in healthcare delivery in India, where a dire shortage of physicians, particularly primary care physicians, severely limits access to care. These pharmacists often serve as first-line providers, she said. Some have formal training, but many do not and operate on the basis of experience, as the students observed this summer, she said.

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Health Policy, NIH, Research, Science Policy, Stanford News

NIH tries to reduce the gray in the grant pool

NIH tries to reduce the gray in the grant pool

This 45-second animation vividly illustrates the funding crisis that young scientists face as they work to launch their research careers: For the last three decades, large NIH grants have increasingly been awarded to older investigators.

“The average age of first-time, R01-funded investigators who have PhDs remains 42, even after seven years of policies at NIH to increase the numbers of new and early-stage investigators,” said Robin Barr, director of the NIH’s Division of Extramural Activities, in a recent editorial on the NIH website.

But there is hope on the horizon, as the NIH rolls out a series of funding mechanisms that aim to give new investigators a leg up. I recently wrote about one such program, the KL2 mentored career development award, and an inspirational Stanford physician-researcher, Rita Hamad, MD, MPH, who is taking full advantage of it.

Hamad is interested in studying the cause-and-effect relationships between poverty and health. The KL2 program helps Hamad’s research through salary support, mentoring, pilot grants and tuition subsidies. In just two years, she has produced actionable data that can be used by policymakers and by health-care providers to improve the overall health of populations, including a study exploring the impact of the earned-income tax credit on child health in the United States. It will be published this fall in the American Journal of Epidemiology.

Previously:NIH funding mechanism “totally broken,” says Stanford researcher, NIH director on scaring young scientists with budget cuts: “If they go away, they won’t come back” and Sequestration hits the NIH – fewer new grants, smaller budgets
Animation by the NIH

Big data, Events, Health Costs, Health Policy, Medicine X

Peter Bach on drug pricing: “A system so broken even a child could manipulate it”

Peter Bach on drug pricing: “A system so broken even a child could manipulate it”

Peter Bach at MedX

The U.S. medical system is like a New England toll road: It’s designed to extract tolls from patients all along their health-care journeys, with a callous disregard for whether or not these travelers arrive at their desired destination, a place of better health.

This was the angry message delivered by Peter Bach, MD, director of Memorial Sloan Kettering’s Center for Health Policy and Outcomes, who was the keynote speaker at today’s Medicine X conference.

Dr. Bach is a physician, an epidemiologist, a researcher and a respected health-care policy expert whose work focuses on the cost and value of anti-cancer drugs. He was also a caregiver who has traveled down the patient side of the system as his wife died of cancer.

In his talk, Bach discussed three of the major toll takers in the system — pharmaceutical companies, hospitals and researchers — and how the public’s wielding of a growing body of health-care data could be used to reign in a process that is driven more by profit than health outcomes.

This week no discussion on escalating health-care costs could pass without mentioning Martin Shkreli, the 32-year-old hedge fund manager whose drug company raised the price of a decades-old anti-parasite drug by more than 5,400 percent. “He made it clear that the system is so broken even a child could manipulate it,” said Bach.

But Bach went on to show some promising quality improvement projects that are helping to bring accountability into the health-care system.

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FDA, Health Policy, Nutrition, Pediatrics, Public Health, Research, Stanford News

How much Bisphenol A is okay?

How much Bisphenol A is okay?


A new study came out this week that happened to remind me of one of my pet peeves about certain biomedical studies — choosing an “outcome” measure that doesn’t tell you what you really want to know. The study, which was led by Stanford postdoctoral fellow Jennifer Hartle, DrPH, and estimated the amount of BPA a child is exposed to in the course of a normal school day, was great. But her description of EPA safety tests on the plastics component Bisphenol A, or BPA — done back in the 1980s — made me think back to earlier work by University of California, Berkeley biologist Tyrone Hayes, PhD.

In the 1990s, the agricultural herbicide atrazine was safety tested by exposing frogs to low doses of atrazine as they developed from eggs to tadpoles to frogs. The adult frogs didn’t die or show obvious deformities such as extra legs, so the pesticide was deemed safe. But Hayes took a closer look and, in 2002, found that even at very low levels of atrazine exposure, male frogs were producing eggs instead of sperm.

So no gross deformities if you just looked at the frogs for 30 seconds. But in fact the animals had experienced a dramatic change in their health and biology. The lesson is that, in biology, sometimes the right outcome measure is something you have to really look for. There is a lot more to the Hayes-atrazine story.

But back to the current study: Hartle and her colleagues turned their attention to national school breakfast and lunch programs, which provide nutritious meals to 30 million kids every year but also deliver small amounts of BPA, an estrogen mimic that messes with hormones. Children’s meals are disproportionately packaged in tiny one-meal containers. Those tiny packages of apple sauce and juice have a greater BPA-emitting surface area than a big carton or can for the amount of food. And school kids often eat meals off plastic trays with plastic forks and spoons. For children who eat a lot of meals at school, it can add up.

According to Hartle’s paper, appearing today in the Journal of Exposure Science and Environmental Epidemiology, the question isn’t whether the kids are getting BPA in their meals — they are — but whether any of them are getting doses of BPA that could affect their long-term health. Based on those 1980s studies, the EPA estimates that BPA is safe at chronic exposure levels below 50 μg per kilogram of body weight per day. Happily, Hartle and her colleagues found that children are getting far less than that — as little as 0.0021 μg for a low-BPA breakfast to 0.17 μg for a high-BPA lunch. Everything should be hunky-dory, right?

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Global Health, Health Policy, Stanford News, Videos

Stanford journalist returns to old post in India – and finds health care still lagging

Stanford journalist returns to old post in India - and finds health care still lagging

Three Stanford seniors and a second-year School of Medicine student spent their summer investigating India’s complicated health-care system — and I got to go along for part of the ride.

It had been a decade since I’d been back to India. I was the South Asia bureau chief for The Associated Press from 2000 to 2005, based in New Delhi. It was among the best assignments of my life.

The posting took me from the Himalayas to the valley of Kashmir, from the deserts of Rajasthan to the lush tea plantations of Sri Lanka. I traveled across Bangladesh with the director of the CDC to document the world’s last push against polio. I wrote about the medical horrors that still plagued those in Bhopal who had been poisoned by gas 20 years before.

And now I was back, this time as a journalist for Stanford Health Policy, comprised of the Center for Health Policy/Center for Primary Care and Outcomes Research and the Department of Medicine.

As I wrote in this story about the student’s research among the poor communities on the outskirts of Mumbai: India is a land of extremes.

I found that little had changed, on the surface, for the rich and the poor. The wealthy still live lavishly, which the students saw for themselves as they looked up at a billion-dollar home in the heart of Mumbai. And the poor remain among the unhealthiest in the world, as witnessed by the students who spent seven weeks in Mumbai’s surrounding slums.

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Big data, Cardiovascular Medicine, Health Policy, NIH, Precision health, Public Health

The diagnostic odyssey

The diagnostic odyssey

Sick-girl-christian-krohg-1881Imagine developing some odd symptoms, like a rash and an ache. You go to the doctor and she shrugs it off and says they are probably unrelated and to come back if the rash doesn’t go away. Two months later, the rash is gone but the ache is worse. You go back and she sends you to physical therapy and suggests a specialist. A month later, neither has identified a problem. The physical therapist suspects you aren’t doing the exercises and the specialist suggests you see a psychiatrist about depression. The rash is back, too. And you are tired all the time.

For some people this frustrating and scary lack of diagnosis and care can go on for years. Sometimes, doctors have overlooked a common disease that just manifests oddly. But often, the patient has a rare disease their doctors have never heard of, let alone seen.

Yesterday, NIH launched a new Undiagnosed Diseases Network, consisting of seven major medical centers where select patients with no diagnosis can go — at no cost — for the best diagnostic facilities available. Together, the seven centers, one of which is at Stanford Medicine, magnify that network of expertise to consider patients’ cases.

Euan Ashley, MRCP, DPhil, associate professor of cardiovascular medicine and of genetics at Stanford Medicine, is co-chair of the UDN steering committee. Recently, he spoke to me for a Q&A about the new network, which is open for business. And more information on the Stanford Center for Undiagnosed Diseases can be found here.

Previously: NIH network designed to diagnose, develop possible treatments for rare, unidentified diseases and Using crowdsourcing to diagnose medical mysteries
Photo by Christian Krohg, 1881, from Wikimedia Commons

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