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Global Health, Health Policy, Infectious Disease, Research, Stanford News

Building the case for a national hepatitis B treatment program in China

Building the case for a national hepatitis B treatment program in China

An estimated 100 million people in China are living with chronic hepatitis B infection, making it the most prevalent life threatening disease in the country. If left untreated, hepatitis B can lead to serious liver damage and is the leading cause of liver-related cancer and deaths in China. Despite the availability of effective therapies, there is no national policy in place to cover hepatitis B treatment and many patients, particularly those with rural health plans, can’t afford it.

Now, in the first comprehensive, independent study of its kind, researchers at Stanford and the University of Michigan have published a cost-effective analysis of all available treatments – branded and generic – for chronic hepatitis B in China. The analysis, published today in PLOS ONE, quantifies the economic value and potential life-saving benefits of implementing a national treatment strategy in China.

If China can successfully treat hepatitis B, the rest of the world will follow

The paper is also the first to provide cost thresholds, meaning the specific price point at which a particular drug would be cost-effective or offer cost-savings.

“Health insurance programs in China don’t always cover the most effective medications,” said Stanford research associate Mehlika Toy, PhD, lead author of the study. “In comparing the potential cost-effectiveness of all available treatments, we aim to provide policy-makers in China with the evidence to support the development and implementation of a viral hepatitis treatment program, and information to help support drug pricing negotiations.”

In their analysis, the researchers compared eight different treatment strategies using a statistical model to simulate disease progression and long-term health outcomes. The analysis evaluated chronic hepatitis B patients who had not received prior treatment, but would be eligible for treatment under current international and World Health Organization guidelines.

Costs were determined based on estimated medical management and related costs associated with disease complications, such as cirrhosis (scarring of the liver) and liver cancer, as well as generic and brand drug costs.

The findings showed that certain therapies performed better than others and that not treating at all resulted in the highest health care costs and the worst health outcomes, compared to other strategies. For example, it was shown that 65 percent of non-cirrhotic patients with active hepatitis associated with high virus concentrations (HBeAg positive) would die of hepatitis B-related liver disease in their lifetime if not treated. Alternately, approximately 60 percent of those deaths could be averted if treated with one of two highly potent, low-resistance drugs, entecavir and tenofovir.

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Events, Global Health, Health Policy, Public Health, Stanford News

Using innovation to improve health in the developing world

Using innovation to improve health in the developing world

Ramano RaoHow can Silicon Valley-style know-how help improve health and lift up the lives of the poor in the developing world? That question was the focus of a panel discussion among four distinguished speakers last week at a Stanford conference on global development and poverty.

Panelist Ramana Rao, MD, described one technologically-based solution he helped develop with colleagues in Hyderabad, India:  a 911-type emergency care system which now serves some 750 million people across the South Asian country.

Though the system, users can call a single number – 108 – to summon an ambulance and team of skilled providers who can provide treatment en route to the nearest hospital.  The system, a public-private partnership known as GVK EMRI (Emergency Management and Research Institute), uses advanced call center technology, in which trained operators typically respond to calls within the first ring and relay them immediately to paramedics and emergency medical technicians on ambulances in the field, Rao told an audience of more than 200 people at the Stanford Graduate School of Business.

The system uses Google maps to help quickly locate patients. And the designers have introduced a mobile device app, which can be easily downloaded to call the service and which can be used to track the location of a caller during the first hour, the critical “golden hour” for treating trauma patients, he said.

Panel moderator Paul Yock, MD, PhD, noted the system is far more effective than the fragmented, 911 emergency system in the United States. “It’s a marvelous example of technology leap-frogging what we do here in this country,” said Yock, founder and director of Stanford Biodesign.

The Indian system was made possible in part by the soaring popularity of cell phones in India, used by 950 million people, including the poor.

“The mobile phone has been the most transformational technological advance in the developing world in the last 15 years,” noted panelist Rajiv Shah, MD, administrator of the U.S. Agency for International Development.

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Global Health, Health Costs, Health Policy, Research, Stanford News

A new framework for expanding treatment guidelines for parasitic worm diseases

A new framework for expanding treatment guidelines for parasitic worm diseases

Schistosomiasis outbreakA new health economics evaluation unveiled last week shows historical World Health Organization treatment guidelines for the two most common parasitic worm diseases are far too restrictive, and it provides a framework for the necessary expansion of global treatment programs.

The findings were presented by Nathan Lo, a third-year Stanford medical student, at the American Society of Tropical Medicine and Hygiene Annual Meeting in Philadelphia, which convened infectious disease experts from around the world to share the latest scientific advances in tropical medicine and global health.

These diseases – schistosomiasis and soil-transmitted helminthiasis – are caused by tiny worms found in water and soil that can cause severe discomfort and even death after coming into contact with humans. Together, they infect some 1.5 billion people in the developing world.

The medications to treat these diseases are cheap and highly effective, but there’s a large unmet need in treatment. Under the current WHO guidelines, treatment is focused upon school-aged children living in high prevalence areas. These guidelines have been largely unchanged for nearly a decade and leave many infected people untreated.

“The prevalence thresholds that have defined mass drug administration for nearly a decade were developed based upon expert opinion, but they are not based on rigorous scientific evidence,” said Lo. “We are urging the WHO to consider lowering the current thresholds and expanding global treatment programs.”

Stanford’s Jason Andrews, MD, the senior author of the study, Lo and colleagues have proposed a new framework for determining the optimal treatment strategy – who to treat, how often, and with what medicines – based on prevalence thresholds in a specific community using economic modeling. The findings show that expanding mass drug administration in communities with much lower disease prevalence would not only be cost-effective, but would result in improved quality of life, reduce re-infection rates and lower disease intensity. If adopted, this would result in a five-fold increase in the number of people who would receive treatment in sub-Saharan Africa alone.

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Addiction, Cancer, Events, Health Policy, Medicine and Society, Public Health

The devil you know: Experts discuss the public-health consequences of e-cigarettes

The devil you know: Experts discuss the public-health consequences of e-cigarettes

e-cigarettesHow do we reduce health risk in the face of harm that can’t be eradicated completely? That’s the question that the medical school’s dean, Lloyd Minor, MD, presented to the audience at Monday’s Health Policy Forum on e-cigarettes — a topic about which he said “intelligent and reasonable people can disagree.”

E-cigarettes are a heavily contested subject in the public-health community. Panelists at this event debated whether the recently developed devices hold promise to help long-time smokers move away from combustible cigarettes, or whether they carry the worrisome potential to re-normalize smoking.

All panelists agreed that those under 21 shouldn’t be using any nicotine delivery devices, and they shared a goal of minimizing general use of harmful health products. They disagreed, however, on what the advent of e-cigarettes means to the accomplishment of those goals.

David Abrams, PhD, a Johns Hopkins clinical psychologist specializing in health psychology, addictions, and tobacco-use behavior, described himself as a harm reductionist. He argued that as an alternative mode of nicotine delivery, e-cigarettes pave the way for saving lives by helping addicted smokers not use traditional cigarettes.

“I do think the evidence is very solid that they are dramatically less harmful than cigarettes…because they absolutely have very low, almost undetectable levels or trace amounts of the top eight carcinogens that are found in cigarettes and they have no carbon monoxide,” he explained.

But a lack of extensive research makes Stanford’s Robert Jackler, MD, and Bonnie Halpern-Felsher, PhD, question whether vaping is actually safe — and a prevalence of candy-flavored e-liquids leaves them concerned for the potential for harm to youth.

“Let me point out that you can smoke [combustible cigarettes] for many years before you get chronic destructive lung disease,” said Jackler, who leads a Stanford research team studying the impact of tobacco advertising, marketing, and promotion. “So while I agree… that they are safer, the presumption that they are safe for teenagers to adopt as opposed to combustible tobacco, we won’t know that for decades.”

In the meantime, he worries that “we’re experimenting with the lungs of teens.”

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Health Policy, Obesity, Public Health, Stanford News

“We should act now”: Stanford expert calls for more targeted anti-obesity policies

"We should act now": Stanford expert calls for more targeted anti-obesity policies

U. S. Department of Agriculture's Food Nutrition Service (FNS) helps educate shoppers about the value of food labeling in December 1975. Photo courtesy National Archives and Records Administration.

Reality TV shows like “The Biggest Loser” are popular in part because the audience can relate to the participants — more than two-thirds of adults and about one-third of children and adolescents are obese or overweight in the U.S. The Surgeon General and the Centers for Disease Control and Prevention have declared obesity to be a national epidemic and a major contributor to leading causes of death, including heart disease, stroke, diabetes and some types of cancer.

Although our country is committed to finding solutions to the increase in obesity, public policies have fallen short, according to Deborah Rhode, JD, a Stanford law professor and legal ethics scholar. In a recent journal article, she wrote:

Many policy responses have proven controversial, and those most often recommended have frequently faced an uphill battle at the federal, state, and local level. At the same time that obesity rates have been rising sharply, many jurisdictions have resisted, or rolled back, strategies such as soda taxes or regulation of advertising directed at children.

In the article, Rhode goes on to evaluate anti-obesity policies, including calorie disclosure requirements, taxes or bans on sugar-sweetened beverages, food stamp modifications, zoning regulations, children’s marketing restrictions, physical activities initiatives, food policies and education. She suggests that a more targeted approach is needed to combat obesity. For instance, Rhode recommends creative zoning regulations that restrict the location of fast-food restaurants near schools while encouraging healthy food retailers in underserved neighborhoods.

In a Stanford news release, Rhode noted that the first lady Michelle Obama’s “Let’s Move!” campaign against childhood obesity applies to politics as well as physical activity. Rhode summarized, “Although we need more evaluation of policy strategies, we know enough about what works to chart a course of reform. We should act now on what we know.”

Jennifer Huber, PhD, is a science writer with extensive technical communications experience as an academic research scientist, freelance science journalist, and writing instructor.

Previously: Finding the sweet spot in public health law to regulate sugary drinksStudy shows banning soda purchase using food stamps would reduce obesity and type-2 diabetesCapturing the metabolic signature of obesity and How to combat childhood obesity? Try everything
Photo by U.S. Department of Agriculture

Big data, Clinical Trials, Health Policy, Precision health, Research

Push-button personalized treatment guidance for patients not covered by clinical-trial results

green buttonA pediatrician, a cardiologist and a biomedical informaticist walk into a pharmacy. They all look as if they could use some strong medicine. “We want a Green Button,” they tell the pharmacist in unison.

“Green Button? Hmmm. I can’t say I know how to compound that prescription,” the puzzled pharmacist replies. “But if all three of you are ordering it, maybe I should. Can you tell me what, specifically, goes into a Green Button?”

“A lot of patients,” reply the three thirsty health experts.

“OK, I’ll play along,” says the pharmacist, beginning to lose his patience. “What comes out?”

“If we knew the answer to that, we wouldn’t need a Green Button.”

Actually, that punch line is no joke. The “Green Button” signifies a profound, potentially pervasive approach that could revolutionize medical practice. In a just-published feature in Inside Stanford Medicine, I report on a futuristic (but not too futuristic) vision of a “learning health-care system” outlined in a 2014 Health Affairs paper by three Stanford experts: pediatric specialist Chris Longhurst, MD, cardiologist Bob Harrington, MD, and biomedical informaticist Nigam Shah, MBBS, PhD.

As I noted in that feature:

The randomized clinical trial is considered the gold standard of medical research. In a randomized clinical trial… participants are randomly assigned to one of two – or sometimes more – groups. One group gets the drug or the procedure being tested; the other is given a placebo or undergoes a sham procedure. … Once the trial’s active phase ends, rigorous statistical analysis determines whether the hypothesis, spelled out in advance of the trial, was fulfilled.

There’s one problem: Clinical trials select only a small, artificial subset of the real population. The rest of us are kind of out of luck.

“Clinical trials are designed to prove one thing,” Shah told me. “And you’re testing it on people with just one thing: type 2 diabetes, eczema, whatever. But most real-life people don’t have just one thing. They have three or four or five things.”

Enter the Green Button. Suppose you’re a clinician facing a patient for whom no clear clinical guidelines exist. Instead, according to the scheme depicted by Longhurst, Harrington and Shah, you press a virtual “green button” on a computer screen displaying your patient’s electronic medical record. This triggers a real-time search of millions, or tens or millions, of other electronic records. In a matter of minutes, up pops a succinct composite summary of the outcomes of 25 or 100 or perhaps 1,000 patients very similar to the one in front of you – same race, same height, same age, same symptoms, similar medical histories, lookalike lab-test results – who were given various medications or procedures for the condition you’re hoping to treat. Those “lookalikes,” it turns out, respond much better to one treatment than to the others – something you’d have been hard put to guess on your own.

That’s all very nice, you say. Now I get your “artisanal faux-joke” lead. But, you ask, why does the button have to be green? And I answer: It doesn’t. But the other good colors were already taken.

Previously: Widely prescribed heartburn drugs may heighten heart-attack risk, New research scrutinizes off-label drug use and A new view of patient data: Using electronic medical records to guide treatment
Photo by Green Mamba :)–<

Health Costs, Health Policy, Public Health, Research

Is it time to compensate kidney donors?

Is it time to compensate kidney donors?

7272346858_ce4d2c871d_o_flickr_Tareq_560x372SalahuddinA recent New York Times blog entry editorialized on the worldwide shortage of transplant kidneys, raising the question of whether it’s time to compensate kidney donors to meet the growing need. The blog echoed the debate that is emerging in the United States among some doctors, medical societies, and groups that oversee organ transplants.

Taboos against paying for transplant organs are powerful. But these may be overcome by necessity, since the demand for transplant kidneys is growing at an alarming rate largely due to kidney failure from diabetes, high blood pressure and obesity-related diseases. According to the National Kidney Foundation, 450,000 Americans are on dialysis and the severe shortage of transplant kidneys in the U.S. results in 12 patient deaths each day.

In sum, having the government compensate kidney donors would be a win-win-win situation

Laying the groundwork for change, a collaboration of nephrology and finance experts, including Philip J. Held, PhD, a Stanford consulting professor of nephrology, performed a comprehensive cost-benefit analysis of a proposed government program for kidney donor compensation. In a study published last week in the American Journal of Transplantation, the authors estimate the shortage of transplant kidneys would be eliminated within five years if the government compensates living kidney donors $45,000 and the estates of deceased donors $10,000. The proposed compensation would also include an insurance policy against any health problems that might result from the donation.

The authors’ analysis shows that the benefits of a donor compensation program would greatly exceed the costs for society in general and taxpayers in particular. The researchers calculate the monetary value of a longer and healthier life for each kidney recipient at $1.3 million, with the added bonus of saving $1.5 million for not needing expensive dialysis treatments. After subtracting from these benefits the cost of transplants, society would enjoy a net welfare gain of $1.9 million over the lifetime of each kidney recipient. Since taxpayers currently pay about 75 percent of the cost of both dialysis and kidney transplants, this represents a taxpayer savings of about $400,000 per kidney recipient.

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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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