Health policy

700 Welch Road Suite #225
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(650) 736-0629 (650) 497-8465
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Professor of Pediatrics, Stanford University School of Medicine
Medical Director at the Center for Quality and Clinical Effectiveness at Lucile Packard Children’s Hospital Stanford
Chief Clinical Patient Safety Officer at Lucile Packard Children’s Hospital Stanford
Sharek_Paul10-08-08.jpg MD, MPH

Paul graduated from Columbia University Medical School in New York, completed residency and chief residency in pediatrics at the University of California, San Francisco, received a Masters of Public Health from University of California, Berkeley and completed a fellowship in health services research at Stanford University.

Paul is presently a Professor of Pediatrics at Stanford University, a pediatric hospitalist, and is the creator and Medical Director of the LPCH Center for Quality and Clinical Effectiveness and Chief Clinical Patient Safety Officer at Lucile Packard Children’s Hospital. Paul is presently the Director of Quality Improvement for the California Perinatal Quality of Care Collaborative (CPQCC), is a founding and current member of the Solutions for Patient Safety Clinical Steering Committee, and is on the Strategic Planning Committee for Quality and Patient Safety for CHA (Children’s Hospital Association). In 2013, Paul was awarded the inaugural Paul V. Miles Fellow in Quality Improvement from the American Board of Pediatrics, an Award bestowed on individuals who have “dedicated themselves to quality improvement and demonstrated accomplishments leading to better healthcare for children”. Paul is presently an investigator or co-investigator on numerous grants focused on pediatric patient safety. Most recently, Paul has dedicated his research and administrative efforts to translating the tenets of high reliability organization theory into healthcare, and is partnering with human factors engineers to translate “design thinking” into the healthcare industry to accelerate patient safety and quality improvement. Paul has given a substantial number of presentations at national and international academic meetings related to quality of care and patient safety and is a faculty member of the Institute for Healthcare Improvement (IHI). Paul has been a visiting professor on quality/patient safety at numerous children’s hospitals across the world including Great Ormond Street Hospital for Children in London, The Hospital for Sick Kids in Toronto, The Children’s Hospital of Eastern Ontario in Ottawa, and several national children’s hospitals including, Children’s National Hospital in Washington DC, Morgan Stanley Children’s Hospital of Columbia University, Children’s Hospital of Los Angeles, Children’s Hospital of Colorado, St Louis Children’s Hospital, Nationwide Children’s Hospital, and St Jude Children’s Research Hospital. Paul has published extensively on the topics of pediatric quality of care and patient safety, including a Nov 2007 study correlating a Rapid Response Team intervention with decreased mortality in JAMA, and a Nov 2010 study on adverse events over time in the New England Journal of Medicine, and is recognized internationally as a thought leader in the area of pediatric quality and patient safety.

Stanford Health Policy Associate
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Landau Economics Bldg, Room 230
Stanford, CA 94305-6015

(650) 725-1870
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Assistant Professor of Economics
CHP/PCOR Affiliate
CDDRL Affiliated Faculty

Seema Jayachandran is an assistant professor in the Department of Economics at Stanford University. She is also a Faculty Research Fellow at the National Bureau of Economic Research (NBER) and a Research Affiliate of the Bureau for Research and Economic Analysis of Development (BREAD), Centre for Economic Policy Research (CEPR), and Stanford Center for International Development (SCID).

Her research focuses on microeconomic issues in developing countries, including health, education, labor markets, and political economy. Her work has been published in the American Economic Review ("Odious Debt," on sovereign debt incurred by dictators), Journal of Political Economy ("Selling Labor Low," on labor market risk in India), and the Quarterly Journal of Economics ("Life Expectancy and Human Capital Investments," on increased education caused by declines in maternal mortality in Sri Lanka), and other journals. Her current projects are based in India, Nepal, and Zimbabwe.

She also works on social issues in the United States. Previously she was a Robert Wood Johnson Scholar in Health Policy Research at the University of California, Berkeley. She also worked as a management consultant with McKinsey & Company in San Francisco. She earned a PhD and master's degree from Harvard University, a master's degree from the University of Oxford where she was a Marshall Scholar, and a bachelor's degree from MIT.

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Background: Although the number of infected people receiving highly active anti-retroviral therapy (HAART) in low- and middle- income countries increased dramatically, optimal disease management is not well defined.

Methods: We developed a model to compare the costs and benefits of three types of Human Immunodeficiency Virus monitoring strategies: symptom-based strategies, CD4-based strategies, and CD4 plus viral load strategies for starting, switching, and stopping HAART. We used clinical and cost data from southern Africa and performed a cost-effectiveness analysis. All assumptions were tested in sensitivity analyses.

Results: Compared to the symptom-based approaches, monitoring CD4 every 6 months and starting treatment at a threshold of 200 cells/μl was associated with a life expectancy gain of 6.5 months (61.9 vs. 68.4) and a discounted lifetime cost savings of $464 per person (4,069 vs. 3,605 discounted 2007 USD). CD4-based strategies where treatment was started at the higher threshold of 350 cells/μl provided an additional life expectancy gain of 5.3 months at a cost effectiveness of $107 per life-year gained compared to a threshold of 200 cells/μl. Monitoring viral load with CD4 was more expensive than monitoring CD4 alone, added 2.0 months of life, and had an incremental cost-effectiveness ratio of $5,414/life-year gained relative to monitoring CD4 counts. In sensitivity analyses, the cost-savings from CD4 monitoring compared to symptom-based approaches was sensitive to cost of inpatient care, and the cost-effectiveness of viral load monitoring was influenced by the per-test costs and rates of virologic failure.

Conclusions: Use of CD4 monitoring and early HAART initiation in southern Africa provides large health benefits relative to symptom-based approaches for HAART management. In southern African countries with relatively high costs of hospitalization, CD4 monitoring would likely reduce total health care expenditures. The cost-effectiveness of viral load monitoring depends on test prices and rates of virologic failure.

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Publication Type
Journal Articles
Publication Date
Journal Publisher
Archives of Internal Medicine
Authors
Eran Bendavid
Douglas K. Owens
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