History
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For forty years, the Tuskegee Study of Untreated Syphilis in the Negro Male passively monitored hundreds of adult black males with syphilis despite the availability of effective treatment. The study's methods have become synonymous with exploitation and mistreatment by the medical community. We find that the historical disclosure of the study in 1972 is correlated with increases in medical mistrust and mortality and decreases in both outpatient and inpatient physician interactions for older black men. Our estimates imply life expectancy at age 45 for black men fell by up to 1.4 years in response to the disclosure, accounting for approximately 35% of the 1980 life expectancy gap between black and white men.

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Journal Articles
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Journal Publisher
The Quarterly Journal of Economics
Authors
Marcella Alsan
Marianne Wanamaker
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Abstract

OBJECTIVE:

To examine the frequency and predictors of out-of-home placement in a 30-month follow-up for a nationally representative sample of children investigated for a report of maltreatment who remained in their homes following the index child welfare report.

METHODS:

Data came from the National Survey of Child and Adolescent Well-being (NSCAW), a 3-year longitudinal study of 5,501 youth 0-14 years old referred to child welfare agencies for potential maltreatment between 10/1999 and 12/2000. These analyses focused on the children who had not been placed out-of-home at the baseline interview and examined child, family and case characteristics as predictors of subsequent out-of-home placement. Weighted logistic regression models were used to determine which baseline characteristics were related to out-of-home placement in the follow-up.

RESULTS:

For the total study sample, predictors of placement in the 30-month follow-up period included elevated Conflict Tactics Scale scores, prior history of child welfare involvement, high family risk scores and caseworkers' assessment of likelihood of re-report without receipt of services. Higher family income was protective. For children without any prior child welfare history (incident cases), younger children, low family income and a high family risk score were strongly related to subsequent placement but receipt of services and case workers' assessments were not. CONCLUSIONS/PRACTICE IMPLICATIONS: Family risk variables are strongly related to out-of-home placement in a 30-month follow-up, but receipt of child welfare services is not related to further placements. Considering family risk factors and income, 25% of the children who lived in poor families, with high family risk scores, were subsequently placed out-of-home, even among children in families who received child welfare services. Given that relevant evidence-based interventions are available for these families, more widespread tests of their use should be explored to understand whether their use could make a substantial difference in the lives of vulnerable children.

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Journal Articles
Publication Date
Journal Publisher
Child Abuse and Neglect
Authors
Sarah (Sally) M. Horwitz
Hurlburt, M. S.
Cohen, S. D.
Zhang, J.
Landsverk, J.
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Abstract

The diabetic Charcot foot syndrome is a serious and potentially limb-threatening lower-extremity complication of diabetes. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners. Now considered an inflammatory syndrome, the diabetic Charcot foot is characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism. An international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this entity.

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Journal Articles
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Journal of the American Podiatric Medical Association
Authors
Rogers LC
Frykberg RG
Armstrong DG
Boulton AJ
Edmonds M
Van GH
Hartemann A
Game F
Jeffcoate W
Jirkovska A
Jude E
Morbach S
Morrison WB
Pinzur M
Pitocco D
Lee M. Sanders
Lee Sanders
Wukich DK
Uccioli L

Encina Commons Room 210,
615 Crothers Way,
Stanford, CA 94305-6006

(650) 723-1919
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Professor, Pediatrics
Professor, Health Policy
Professor, Epidemiology & Population Health (by courtesy)
sanders_photo_20153.jpg
MD, MPH

Dr. Lee Sanders is a general pediatrician and Professor of Pediatrics at the Stanford University School of Medicine, where he is Chief of the Division of General Pediatrics. He holds a joint appointment in the Center for Health Policy in the Freeman Spogli Institute for International Studies, where he is a co-director of the Center for Policy, Outcomes and Prevention (CPOP).

An author of numerous peer-reviewed articles addressing child health disparities, Dr. Sanders is a nationally recognized scholar in the fields of health literacy and child chronic-illness care.  Dr. Sanders was named a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar for his leadership on the role of maternal health literacy and English-language proficiency in addressing child health disparities.  Aiming to make the US health system more navigable for the one in 4 families with limited health literacy, he has served as an advisor to the Institute of Medicine, the Centers for Disease Control and Prevention, the Food and Drug Administration, the American Academy of Pediatrics, the Academic Pediatric Association, and the American Cancer Society.  Dr. Sanders leads a multi-disciplinary CPOP research team that provides analytic guidance to national and state policies affecting children with complex chronic illness – with a focus on the special health-system requirements that arise from the unique epidemiology, care-use patterns, and health-care costs for this population.  He leads another CPOP/PCOR-based research team that applies family-centered approaches to new technologies that aim to improve care coordination for children with medical complexity.    Dr. Sanders is also principal investigator on two NIH-funded studies that address health literacy in the pediatric context: one aims to assess the efficacy of a low-literacy, early-childhood intervention designed to prevent early childhood obesity; the other aims to provide the FDA with guidance on improved labeling of pediatric liquid medication.  Research settings for this work include state and regional health departments, primary-care and subspecialty-care clinics, community-health centers, WIC offices, federally subsidized child-care centers, and family advocacy centers.

Dr. Sanders received a BA in History and Science from Harvard University, an MD from Stanford University, and a MPH from the University of California, Berkeley.  Between 2006 and 2011, Dr. Sanders served as Medical Director of Children’s Medical Services South Florida, a Florida state agency that coordinates care for more than 10,000 low-income children with special health care needs.  He was also Medical Director for Reach Out and Read Florida, a pediatric-clinic-based program that provides books and early-literacy promotion to more than 200,000 underserved children.  At the University of Miami, Dr. Sanders directed the Jay Weiss Center for Social Medicine and Health Equity, which fosters a scholarly community committed to addressing global health inequities through community-based participatory research.  At Stanford University, Dr. Sanders served as co-medical director of the Family Advocacy Program, which provides free legal assistance to help address social determinants of child health.

Fluent in Spanish, Dr. Sanders is co-director of the Complex Primary Care Clinic at Stanford Children’s Health, which provides multi-disciplinary team care for children with complex chronic conditions.  Dr. Sanders is also the father of two daughters, aged 11 and 14 years, who make sure he practices talking less and listening more.

Co-Director, Center for Policy, Outcomes & Prevention (CPOP)
Chief, Division of General Pediatrics, School of Medicine
CV
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Prior studies suggest patient self-testing (PST) of prothrombin time (PT) can improve the quality of anticoagulation (AC) and reduce complications (e.g., bleeding and thromboembolic events). "The Home INR Study" (THINRS) compared AC management with frequent PST using a home monitoring device to high-quality AC management (HQACM) with clinic-based monitoring on major health outcomes. A key clinical and policy question is whether and which patients can successfully use such devices. We report the results of Part 1 of THINRS in which patients and caregivers were evaluated for their ability to perform PST. Study-eligible patients (n = 3643) were trained to use the home monitoring device and evaluated after 2-4 weeks for PST competency. Information about demographics, medical history, warfarin use, medications, plus measures of numeracy, literacy, cognition, dexterity, and satisfaction with AC were collected. Approximately 80% (2931 of 3643) of patients trained on PST demonstrated competency; of these, 8% (238) required caregiver assistance. Testers who were not competent to perform PST had higher numbers of practice attempts, higher cuvette wastage, and were less able to perform a fingerstick or obtain blood for the cuvette in a timely fashion. Factors associated with failure to pass PST training included increased age, previous stroke history, poor cognition, and poor manual dexterity. A majority of patients were able to perform PST. Successful home monitoring of PT with a PST device required adequate levels of cognition and manual dexterity. Training a caregiver modestly increased the proportion of patients who can perform PST.

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Journal Articles
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Journal Publisher
Journal of Thrombosis and Thrombolysis
Authors
Dolor RJ
Ruybalid RL
Uyeda L
Edson RG
Ciaran S. Phibbs
Ciaran S. Phibbs
Vertrees JE
Shih MC
Jacobson AK
Matchar DB
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Background: Sodium consumption raises blood pressure, increasing the risk for heart attack and stroke. Several countries, including the United States, are considering strategies to decrease population sodium intake.

Objective: To assess the cost-effectiveness of 2 population strategies to reduce sodium intake: government collaboration with food manufacturers to voluntarily cut sodium in processed foods, modeled on the United Kingdom experience, and a sodium tax.

Design: A Markov model was constructed with 4 health states: well, acute myocardial infarction (MI), acute stroke, and history of MI or stroke.

Data Sources: Medical Panel Expenditure Survey (2006), Framingham Heart Study (1980 to 2003), Dietary Approaches to Stop Hypertension trial, and other published data.

Target Population: U.S. adults aged 40 to 85 years.

Time Horizon: Lifetime.

Perspective: Societal.

Outcome Measures: Incremental costs (2008 U.S. dollars), quality-adjusted life-years (QALYs), and MIs and strokes averted.

Results of Base-case Analysis: Collaboration with industry that decreases mean population sodium intake by 9.5% averts 513 885 strokes and 480 358 MIs over the lifetime of adults aged 40 to 85 years who are alive today compared with the status quo, increasing QALYs by 2.1 million and saving $32.1 billion in medical costs. A tax on sodium that decreases population sodium intake by 6% increases QALYs by 1.3 million and saves $22.4 billion over the same period.

Results of Sensitivity Analysis: Results are sensitive to the assumption that consumers have no disutility with modest reductions in sodium intake.

Limitation: Efforts to reduce population sodium intake could result in other dietary changes that are difficult to predict.

Conclusion: Strategies to reduce sodium intake on a population level in the United States are likely to substantially reduce stroke and MI incidence, which would save billions of dollars in medical expenses.

Primary Funding Source: Department of Veterans Affairs, Stanford University, and the National Science Foundation.

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Publication Type
Journal Articles
Publication Date
Journal Publisher
Annals of Internal Medicine
Authors
Crystal Smith-Spangler
Jessie L. Juusola
Eva A. Enns
Douglas K. Owens
Douglas Owens
Alan Garber
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Background: Sodium consumption raises blood pressure, increasing the risk for heart attack and stroke. Several countries, including the United States, are considering strategies to decrease population sodium intake.

Objective: To assess the cost-effectiveness of 2 population strategies to reduce sodium intake: government collaboration with food manufacturers to voluntarily cut sodium in processed foods, modeled on the United Kingdom experience, and a sodium tax.

Design: A Markov model was constructed with 4 health states: well, acute myocardial infarction (MI), acute stroke, and history of MI or stroke.

Data Sources: Medical Panel Expenditure Survey (2006), Framingham Heart Study (1980 to 2003), Dietary Approaches to Stop Hypertension trial, and other published data.

Target Population: U.S. adults aged 40 to 85 years.

Time Horizon: Lifetime.

Perspective: Societal.

Outcome Measures: Incremental costs (2008 U.S. dollars), quality-adjusted life-years (QALYs), and MIs and strokes averted.

Results of Base-case Analysis: Collaboration with industry that decreases mean population sodium intake by 9.5% averts 513 885 strokes and 480 358 MIs over the lifetime of adults aged 40 to 85 years who are alive today compared with the status quo, increasing QALYs by 2.1 million and saving $32.1 billion in medical costs. A tax on sodium that decreases population sodium intake by 6% increases QALYs by 1.3 million and saves $22.4 billion over the same period.

Results of Sensitivity Analysis: Results are sensitive to the assumption that consumers have no disutility with modest reductions in sodium intake.

Limitation: Efforts to reduce population sodium intake could result in other dietary changes that are difficult to predict.

Conclusion: Strategies to reduce sodium intake on a population level in the United States are likely to substantially reduce stroke and MI incidence, which would save billions of dollars in medical expenses.

Primary Funding Source: Department of Veterans Affairs, Stanford University, and the National Science Foundation.

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1
Publication Type
Journal Articles
Publication Date
Journal Publisher
Annals of Internal Medicine
Authors
Crystal Smith-Spangler
Juusola JL
Enns EA
Douglas K. Owens
Douglas Owens
Alan Garber
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As academic fields and professions go, health services research is relatively young. Whether one dates the beginning of this field to the first National Institutes of Health study section on health services research in 1960, the passage of Medicare and Medicaid in 1965 and the accompanying drive to develop the conceptual and analytic tools to manage them, or the founding of this journal by the Health Research and Educational Trust with a grant from the U.S. Public Health Service in 1966, its history is much shorter than that of many other disciplines. The field gained its own professional organization only as recently as 1981 with the establishment of the Association of Health Services Research (now called AcademyHealth).

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Journal Articles
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Journal Publisher
Health Services Research
Authors
Colby DC
Laurence C. Baker
Laurence Baker
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OBJECTIVE: To examine developmental and behavioral status of children in child welfare (CW) over time, by intensity of CW involvement using a national probability sample.

METHODS: As part of the National Survey of Child and Adolescent Well-being (NSCAW), data were collected on 1,049 children 12-47 months old investigated by CW agencies for possible abuse or neglect. Analyses used descriptive statistics to characterize developmental and behavioral status across four domains (developmental/cognitive, language, adaptive functioning, and behavior) by intensity of CW involvement (in-home with CW services, in-home with no CW services or out-of-home care) over time. Multivariate analyses were used to examine the relationship between independent variables (age, gender, home environment, race/ethnicity, maltreatment history, intensity of CW involvement) and follow-up domain scores.

RESULTS: On average, children improved in developmental/cognitive, communication/language status over time, but these improvements did not differ by intensity of CW involvement. Analyses revealed a positive relationship between the home environment and change in language and adaptive behavior standard scores over time, and few predictors of change in behavioral status. An interaction between intensity of CW involvement and initial developmental/cognitive status was present.

CONCLUSIONS: Across domains, intensity of CW involvement does not appear to have a significant effect on change in developmental and behavioral status, although out-of-home care does have differential relationships with children's developmental/cognitive status for those with very low initial cognitive/developmental status. Facilitating development in children in CW may require supportive, enriched care environments both for children remaining at home and those in foster care. P

RACTICE IMPLICATIONS: Toddler and preschool age children known to child welfare are likely to have difficulties with development whether they are removed from their homes or not. It would be helpful if child welfare workers were trained to screen for developmental, language, adaptive behavior and behavioral difficulties in children in foster care, and those remaining at home. Additional support for biological, foster, and kinship caregivers in encouraging development is important for the attainment of critical developmental skills, especially for children with developmental difficulties.

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1
Publication Type
Journal Articles
Publication Date
Journal Publisher
Child Abuse and Nelect
Authors
Stahmer AC
Hurlburt M
Sarah (Sally) M. Horwitz
Landsverk J
Zhang J
Leslie LK
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