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Global Health, Health Disparities, Health Policy, In the News, Medicine and Society

Why millions lack access to surgery: A conversation with Stanford surgeon Thomas Weiser

Why millions lack access to surgery: A conversation with Stanford surgeon Thomas Weiser

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In the United States, many routine surgeries are just that: routine. They may or may not correct the condition, but the likelihood of death or of life-changing complications are minimal.

But if you live in a poorer nation, surgery — even a cesarean birth — is quite risky and hard to procure. For as many as 5 billion people, these basic procedures are out of reach, according to a recent report by the Lancet Commission, the focus of a recent Scope post and many other news articles.

There are numerous reasons for this surgical gap, as Stanford surgeon Thomas Weiser, MD, who contributed to the report, explains in an Inside Stanford Medicine Q&A.

First, surgery “requires a strong and continuous supply chain, highly technical skills and ongoing training, and intensive management to organize such services,” Weiser said. In addition, most aid programs focus on a specific disease, while surgery is a therapy, leaving it outside the bounds of most international development programs, he said.

So what does the future hold? Weiser is optimistic:

I hope that these findings and the new data presented in the commission report will increase attention and awareness of the vital role surgical care plays in a health system. Ideally, we will see increased leadership from organizations like the WHO and the World Bank in the form of attempts to standardize data collection, identify high-performing health systems, publicize successful programs and promote their adoption and replication in other health settings, and support improved investments in surgical capacity and quality improvement as a way to strengthen the health system more generally.

Previously: Billions lack surgical care; report calls for change, Stanford Medicine magazine opens up the world of surgery and Global health expert: Economic growth provides opportunity to close the “global health gap”
Photo by skeeze

Events, Global Health, Health Policy, Pediatrics, Stanford News, Videos

Rajiv Shah discusses efforts to end preventable child deaths worldwide at Childx

Rajiv Shah discusses efforts to end preventable child deaths worldwide at Childx

The inaugural Childx conference was held here this month, and video interviews featuring keynote speakers, panelists and moderators are now on the Stanford YouTube channel. To continue the discussion of driving innovation in maternal and child health, we’ll be featuring a selection of the videos this month on Scope.

More than six million children under the age of five die from preventable diseases each year. During this year’s Childx conference, Rajiv Shah, MD, the former administrator of USAID, told the crowd, “I do think it’s possible to end preventable child death.”

In the video above, he explains how innovations in drug development, diagnostics and vaccines are among the solutions that are effectively reducing child mortality rates around the world. But there is still more that can be done. Using global health data to see in real-time where children are dying because of a lack of vaccines and places children are suffering as a result of poor health care, Shah said, could assist in more efficiently directing resources to these areas and other pockets of need. Watch the full interview with Shah to hear more about why he thinks ending preventable child death is achievable in the next 20 years.

Previously: Childx speaker Matthew Gillman discusses obesity prevention, Pediatric health expert Alan Guttmacher outlines key issues facing children’s health today, “It’s not just science fiction anymore”: Childx speakers talk stem cell and gene therapy and Global health and precision medicine: Highlights from day two of Stanford’s Childx conference

Addiction, Health Policy, Pain, Public Health

Unmet expectations: Testifying before Congress on the opioid abuse epidemic

Unmet expectations: Testifying before Congress on the opioid abuse epidemic

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My recent trip to Washington D.C. to speak before a congressional subcommittee on the problem of opioid misuse was all about unmet expectations.

First of all, I never expected to get invited to testify for the U.S. Congress. A 2012 article I wrote in the New England Journal of Medicine on the problem of doctors over-prescribing opioids to patients was picked up by Washington Post journalist Charles Lane in a piece he did, “The legal drug epidemic,” which was subsequently read by Alan Slobodin, chief investigative counsel for the House Committee on Energy and Commerce. Slobodin then sent a message to my in-box asking to “discuss the opioid abuse problem.” I almost deleted it as a hoax. But Keith Humphreys, PhD, my mentor and chief of the mental health policy section in our department, assured me it was real.

Second, not really understanding how government works beyond what I learned from the animated musical cartoon “I’m Just a Bill” when I was seven years old, and being a regular reader of the New York Times, which has almost convinced me that everyone in Washington is against everyone else and nothing ever gets done, I prepared myself for the possibility that various members of the committee might just be looking for sound bites to support their pre-ordained opinions. I was wrong.

Slobodin and his staff were curious, earnest, intelligent, and dedicated to understanding the opioid problem at the deepest level. At the hearing itself, where I and other experts testified on the problem of opioid misuse, overdose, and addiction, Congressman Tim Murphy (R-PA), and Congresswoman Diana DeGette  (D-CO) didn’t go for each other’s jugular like a couple of vampires out of Twilight, which I thought might happen. Instead, they were courteous, collegial, and again, struck me as truly dedicated to ameliorating the problem of addiction in this country.

Third and finally, I didn’t imagine that my testimony would make much of a difference, yet some of my suggestions were picked up by members of the committee, including Bridgette DeHart, a senior policy advisor for Congresswoman Yvette D. Clarke (D-NY). DeHart is a whip-smart young woman who in ten minutes of conversation conveyed to me her sophisticated understanding of the opioid epidemic. She talked about incorporating one of my suggestions – mandating physician education on the use of Prescription Drug Monitoring Databases (PDMDs) at the time of DEA-licensure – into a larger bill that Clarke and her team are working on.

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Global Health, Health Disparities, Health Policy, Patient Care, Public Health, Surgery

Billions lack surgical care; report calls for change

Billions lack surgical care; report calls for change

In this country, we take it for granted that we will have access to needed surgeries, whether it’s the repair of a broken leg or an operation to remove an infected appendix or a malignant tumor. But for as many as 5 billion people – or two-thirds of the world’s population – these basic procedures are out of reach.

A major new report by the Lancet Commission sheds light on this enormous surgery gap and argues that building surgical infrastructure in low- and middle-income countries is critical both from an economic, as well as a human, perspective.

“Surgery hasn’t been part of the dialogue with respect to health system strengthening. It’s been a hugely neglected item,” said Stanford trauma surgeon Thomas Weiser, MD, who contributed to the 58-page report. The commission includes 25 leading experts from the fields of surgery and anesthesia, with contributions from more than 110 countries.

In its report, the commission notes that in 2010, nearly one-third of all deaths (16.9 million) were attributable to conditions readily treated by surgery, such as appendicitis, hernia, fractures, obstructed labor, congenital abnormalities and breast and cervical cancer. That is more than the number of deaths from HIV/AIDS, tuberculosis and malaria combined. And although there have been many gains in global health in the last 25 years, the quality and availability of surgical services in many regions have stagnated or declined, while the demand for surgery continues to rise.

“The global community cannot continue to ignore this problem – millions of people are already dying unnecessarily, and the need for equitable and affordable access to surgical services is projected to increase in the coming decades, as many of the worst affected countries face rising rates of cancer, cardiovascular disease and road accidents,” said Lars Hagander, MD, of Lund University in Sweden and one of the lead authors.

Weiser and his colleagues provide new estimates of the global shortfall, calculating that some 143 million additional surgeries are needed to save lives and prevent disability, with the largest number of neglected patients living in South Asia (57.8 million), East Asia (27.9 million) and southern sub-Saharan Africa (18.9 million).

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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

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