Stanford Health Policy is a joint effort of the Freeman Spogli Institute for International Studies and the Stanford School of Medicine
This compendium of articles provides a clear view of the factors affecting the health of Americans and the role of public health, medical care, and the community in ensuring the nation's health. The Seventh Edition continues the emphasis of earlier editions on the health of the population, the determinants of health, women's health, long term care, and the precarious set of circumstances faced by the nation's public health and health care systems as we begin the 21st century.
New issues, particularly related to bioterrorism and community health are addressed in this edition. This volume also includes coverage of tobacco, immunizations, HIV/AIDS, environmental health, dietary guidelines, physical activity, and food safety. In addition, a major new feature is an article on community problem solving, emphasizing a multidisciplinary approach to collaborative practice and research to improve community health.
As policymakers consider expanding insurance coverage for the human immunodeficiency virus (HIV+) population, it is useful to ask whether insurance has any effect on health outcomes, and, if so, whether public insurance is as efficacious as private insurance in preventing premature death. Using data from a nationally representative cohort of HIV-infected persons receiving regular medical care, we estimate the impact of different types of insurance on mortality in this population. Our main findings are that (1) ignoring observed and unobserved health status misleads one to conclude that insurance may not be protective for HIV patients, (2) after accounting for observed and unobserved heterogeneity, insurance does protect against premature death, and (3) private insurance is more effective than public insurance. The better performance of private insurance can be explained in part by more restrictive Medicaid prescription drug policies that limit access to highly efficacious treatment.
The second half of the 20th century witnessed spectacular advances in health care. Innovations such as magnetic resonance imaging, genetically engineered growth factors, and highly effective drugs for the treatment of depression, gastroesophageal reflux, high blood cholesterol, and HIV disease greatly improved the detection and treatment of both rare and common diseases. The advances greatly improved the outcomes of complex procedures such as organ transplantation, coronary artery bypass surgery, and high-dose chemotherapy (bone marrow transplantation) for acute myeloid leukemia and multiple myeloma. As the 21st century opens, technological progress in medicine is continuing and may be accelerating. It is a source of hope for the prevention, effective treatment, and cure of disease.
Technological innovation is also the major source of increases in real per capita medical spending in the United States. If medical advances continue to be adopted as rapidly as they have been, they will pose knotty economic, political, and ethical challenges for health care policy at a time when spending on health care in the United States has once again begun to surge after a mid-1990s pause and the number of Americans without health insurance has once again begun growing.
Background: Policy and clinical decisions regarding children's nutrition are often based on dietary intake estimates from self-reports. The accuracy of these estimates depends on memory of both the type of food eaten and the amount consumed. Although children's self-reports of food intake are widely used, there is little research on their ability to estimate food portions.
Objective: To assess the validity of children's estimates of the food portions they consume by means of 2 types of measurement aids: standard 2-dimensional food portion visuals and manipulative props.
Design: Randomized controlled trial.
Participants: Fifty-four African American girls aged 8 to 12 years.
Main Outcome Measures: Girls were served a standard meal and actual intake was assessed by weighing food portions before and after the meal. On completion of the meal, dietitians collected food recalls and portion size estimates from the girls by means of both manipulative props and 2-dimensional food portion visuals, administered in a randomized order.
Results: Absolute value percentage differences between actual and estimated grams of food consumed averaged 58.0% (SD, 102.7%) for manipulative props and 32.8% (SD, 72.8%) for 2-dimensional food portion visuals. Spearman correlations between actual and estimated intakes with both portion size measurement aids were high (range, r = 0.56 to 0.79; all P.001), with the exception of bread intake (r = 0.16, P =.43). Correlations with actual intakes did not differ significantly between the 2 methods.
Conclusions: Children's self-reported portion size estimates are appropriate for ranking children's relative intakes, but they result in sizable errors in quantitative estimates of food and energy intakes. Caution should be used in interpreting quantitative dietary intake estimates derived from children's self-reports.
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Douglas K. Owens is the Henry J. Kaiser, Jr. Professor, Chair of the Department of Health Policy in the Stanford University School of Medicine and Director of the Center for Health Policy (CHP) in the Freeman Spogli Institute for International Studies (FSI). He is a general internist, a Professor of Management Science and Engineering (by courtesy), at Stanford University; and a Senior Fellow at the Freeman Spogli Institute for International Studies.
Owens' research includes the application of decision theory to clinical and health policy problems; clinical decision making; methods for developing clinical guidelines; decision support; comparative effectiveness; modeling substance use and infectious diseases; cardiovascular disease; patient-centered decision making; assessing the value of health care services, including cost-effectiveness analysis; quality of care; and evidence synthesis.
Owens chaired the Clinical Guidelines Committee of the American College of Physicians for four years. The guideline committee develops clinical guidelines that are used widely and are published regularly in the Annals of Internal Medicine. He was a member and then Vice-Chair and Chair of the U.S. Preventive Services Task Force, which develops national guidelines on preventive care, including guidelines for screening for breast, colorectal, prostate, and lung cancer. He has helped lead the development of more than 50 national guidelines on treatment and prevention. He also was a member of the Second Panel on Cost Effectiveness in Health and Medicine, which developed guidelines for the conduct of cost-effectiveness analyses.
Owens also directed the Stanford-UCSF Evidence-based Practice Center. He co-directs the Stanford Health Services Research Program, and previously directed the VA Physician Fellowship in Health Services Research, and the VA Postdoctoral Informatics Fellowship Program.
Owens received a BS and an MS from Stanford University, and an MD from the University of California-San Francisco. He completed a residency in internal medicine at the University of Pennsylvania and a fellowship in health research and policy at Stanford. Owens is a past-President of the Society for Medical Decision Making. He received the VA Undersecretary’s Award for Outstanding Achievement in Health Services Research, and the Eisenberg Award for Leadership in Medical Decision Making from the Society for Medical Decision Making. Owens also received a MERIT award from the National Institutes on Drug Abuse to study HIV, HCV, and the opioid epidemic. He was elected to the American Society for Clinical Investigation (ASCI) and the Association of American Physicians (AAP.)
How successful are HIV prevention programs? Which HIV prevention programs are most cost effective? Which programs are worth expanding and which should be abandoned altogether? This book addresses the quantitative evaluation of HIV prevention programs, assessing for the first time several different quantitative methods of evaluation.
The authors of the book include behavioral scientists, biologists, economists, epidemiologists, health service researchers, operations researchers, policy makers, and statisticians. They present a wide variety of perspectives on the subject, including an overview of HIV prevention programs in developing countries, economic analyses that address questions of cost effectiveness and resource allocation, case studies such as Israel's ban on Ethiopian blood donors, and descriptions of new methodologies and problems.
OBJECTIVES: This study determined the cost-effectiveness of expanding methadone maintenance treatment for heroin addiction, particularly its effect on the HIV epidemic.
METHODS: We developed a dynamic epidemic model to study the effects of increased methadone maintenance capacity on health care costs and survival, measured as quality-adjusted life-years (QALYs). We considered communities with HIV prevalence among injection drug users of 5% and 40%.
RESULTS: Additional methadone maintenance capacity costs $8200 per QALY gained in the high-prevalence community and $10,900 per QALY gained in the low-prevalence community. More than half of the benefits are gained by individuals who do not inject drugs. Even if the benefits realized by treated and untreated injection drug users are ignored, methadone maintenance expansion costs between $14,100 and $15,200 per QALY gained. Additional capacity remains cost-effective even if it is twice as expensive and half as effective as current methadone maintenance slots.
CONCLUSIONS: Expansion of methadone maintenance is cost-effective on the basis of commonly accepted criteria for medical interventions. Barriers to methadone maintenance deny injection drug users access to a cost-effective intervention that generates significant health benefits for the general population.