Diabetes
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Beth Duff-Brown
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Non-communicable diseases such as heart and respiratory disease, cancer, obesity and diabetes are now responsible for some two-thirds of premature deaths around the world. And most of those are in low- and middle-income countries.

The United Nations has estimated that on top of the social and psychological burdens of chronic disease, the cumulative loss to the global economy could reach $47 trillion by 2030 if things remain status quo.

“That was a big whopper of a number and got a lot of attention, and that was good because it raised awareness,” said Rachel Nugent, vice president for global non-communicable diseases (NDCs) at the research institute RTI International.

“It’s an issue that is driven by a lot of different factors, “ she said. “And understanding how the larger social and economic factors affect NDCs, at a policy level, very little progress has been made — there’s been very little collaboration.”

Nugent was addressing the fourth annual Global Health Economics Colloquium at University of California San Francisco, with health experts, policymakers, students and researchers from Stanford, Berkeley and UCSF who gather every year to take a deep dive into the economics of a global health issue. More than 200 experts from 10 universities and public health departments attended the conference.

The daylong gathering focused on recent developments in the economics of NDCs, looking at case studies from around the world, and new guidelines for cost-effectiveness analysis and the role of economics in reducing health inequality.

“The donors are not convinced that there are cost-effective things that we can do in these countries; a lot of them are very skeptical that this is affecting the poor,” said Nugent, a member of the World Health Organization’s expert advisory panel on the management of NCDs.

In India, for example, much of the population still defecates outdoors, contaminating water sources and agricultural products, which can lead to malnutrition and physical and cognitive disorders. Many donors would rather see funds go to building latrines as they can see tangible results; NDC prevention is a long-term slog.

“But I don’t think we should necessarily think of NDCs as either-or,” said Nugent.  “I think that integration of services and programming is very much at the forefront of what is the right way to go.”

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Cost-effectiveness Analyses

Nugent’s research has shown five cost-effective interventions would avert more than 5 million premature deaths from NCDs by 2030, or a reduction of 28.5 percent in projected mortality from chronic disease around the world. And the average benefit-cost ratio is 9:1, at a global cost of $8.5 billion a year.

The interventions are raising the price of tobacco products by 125 percent through taxation; providing aspirin to 75 percent of those suffering from acute myocardial infarction; reducing salt intake by 30 percent; reducing the prevalence of high blood pressure with low-cost hypertension medication; and providing preventive drug therapy to 70 percent of those at high risk of heart disease.

Gillian Sanders-Schmidler, a professor of medicine at Duke University Medical Center and former assistant professor of medicine at Stanford Health Policy’s Center for Primary Care and Outcomes Research, addressed the colloquium about recommendations of the Second Panel on Cost-Effectiveness in Health and Medicine.

“There is a continued emphasis on transparency and comparability across analyses,” said Sanders-Schmidler. “And of course the big changes are that we’re now asking for a second reference case and using an ‘impact inventory’ table to clarify the scope of the findings.”

The independent panel of non-government scientists and scholars, which also included Stanford Health Policy’s Douglas K. Owens, focused on new ways to deliver health care effectively, yet with a focus on efficiency, as health care spending in the United States has reached 18 percent of GDP, much greater than the global average of 10 percent.

The first panel that convened in 1996 recommended that all cost-effectiveness analyses of health interventions include a reference case that uses standard methodological practices to improve comparability and quality. The second panel, which published its findings in September, now recommends that in addition to the societal perspective recommended by the original panel, that CEAs include a second reference case that looks at the health-care sector impact of an intervention. Additional guidance was given on what to include in the societal perspective reference case.

The panel wrote in its JAMA “special communication” that these societal reference cases should include medical costs “borne by third-party payers and paid out-of-pocket by patients, time costs of patients in seeking and receiving care, time costs of informal (unpaid) caregivers, transportation costs, effects on future productivity and consumption, and other costs and effects outside the health-care sector.”

They found most countries, including the United States, give greater weight to clinical evidence in their cost-effectiveness analyses. The panel now recommends an “impact inventory” that helps analysts and end-users of cost effectiveness analyses look at the impact of interventions beyond the formal health-care sector.

“We’re trying to ask people to be explicit,” said Owens, director of the Center of Primary Care and Outcomes Research and Center for Health Policy at Stanford.

“We want them to look at how to value outcomes in a societal perspective, not just the health-care sector, to look at all these other sectors such as productivity consumption, criminal justice, education, housing and the environment,” he said.

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Case Studies

Several case studies presented at the colloquium indicated that policy changes, government intervention and social factors are key to preventing obesity and diabetes and other NCDs.

Kristine Madsen, an associate professor of public health at UC Berkeley who focuses on childhood obesity, spoke about the nation’s first “soda tax” on sugar-sweetened beverages, which was implemented in Berkeley in March 2015.

The city has seen a 21 percent decline in the drinking of soda and other sugary drinks in low-income neighborhoods after the city levied a penny-per-ounce tax on sodas and sugary drinks. At the same time, according to a study in the American Journal of Public Health, neighboring San Francisco — where a similar soda-tax measure was defeated — and Oakland saw a 4 percent increase in the purchase of sweetened beverages.

“This decline of 21 percent in Berkeley represents the largest public health impact in an intervention that I have ever seen,” said Madsen.

Sergio Bautista of the Mexico National Institute of Public Health and UC Berkeley, said that Mexico’s sugary drinks tax implemented in January 2014 is expected to lead to a 10 percent reduction in sugary drinks consumption and prevent an estimated 189,300 cases of diabetes in a country famed for its sugary bottled cola.

William Dow, a professor of health policy management at UC Berkeley, shared his research on Costa Rica, where on average people live longer than Americans, despite the several times higher income and 10 times higher health expenditures in the United States.

Costa Rican men have a life expectancy of 77 and the women typically live until age 82; in Americans the numbers are 76 and 81, respectively. Obesity is low among Costa Rican men and few of their women smoke. Lung cancer mortality in the United States is four times higher among men and six times higher among women.

“It’s remarkable in so many ways,” Dow said, noting that deaths in the Central American country are due predominantly to infectious disease. “Does Costa Rica have any unique effective programs to emulate, or is there something going on upstream driving those health outcomes?”

He believes Costa Rica’s national health insurance and excellent access to primary care for nearly all its people are key. Having this guaranteed lifetime access to health care also reduces the stress and depression that can so badly harm physical health.

“And I would argue that probably diet is one of the most important things going on here,” said Dow, noting their diets are healthy.

Costa Ricans eat mostly unprocessed foods such as rice and black beans, corn tortilla, yam and squash, with little meat and plenty of fresh fruit.

“They also have the highest remaining life expectancy at age 80 of any country in the world, he said. “What we have learned in Costa Rica would be helpful in many other countries.”

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Nearly 100 health economists from across the United States signed a pledge urging U.S. presidential candidates to make chronic disease a policy priority. Karen Eggleston, a scholar of comparative healthcare systems and director of Stanford’s Asia Health Policy Program, is one of the signatories. 

The pledge calls upon the candidates to reset the national healthcare agenda to better address chronic disease, which causes seven out of 10 deaths in America and affects the economy through lost productivity and disability.

Read the pledge below.

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David Studdert and colleagues explore how to balance public health, individual freedom, and good government when it comes to sugar-sweetened drinks. Over the last decade, many national, state, and local governments have introduced laws aimed at curbing consumption of sugar-sweetened beverages (SSBs), especially by children. The main regulatory approaches are taxes, restrictions on the availability of SSBs in schools, restrictions on advertising and marketing, labeling requirements, and government procurement and benefits standards. Efforts to regulate in this area often encounter stiff opposition, including claims that the laws are inequitable, do not achieve their goals, and have negative economic effects. Several lessons can be drawn from the international experience with SSB regulation to date, which may inform future design and implementation of legal interventions to combat noncommunicable disease.

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PLOs
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David Studdert
David Studdert
Michelle Mello
Michelle M. Mello
Jordan Flanders
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7

Advanced Registration for this conference is required.  For more information and to register, please click here.

 

Overview

 This conference focuses on economic aspects of diabetes and its complications.

 

 A major focal point of the conference will be a comparison of health economic diabetes models both in terms of their structure and performance. This conference builds on six previous diabetes simulation modelling conferences that have been held since 1999. A write-up of a past conference can found by here.

 

A particular theme of the 2014 challenge will be how to generalise diabetes simulation models for different populations and over time. To what degree are existing models able to adjust for differences risk due to ethnic and socio-economic differences as well as any secular improvements in diabetes care?"

The conference will also have open sessions on all aspects of the health economics of diabetes.

Following previous Mount Hood Challenges, the emphasis will be on comparing model projections to real world or clinical trial outcomes, and explanation and discussion of differences seen between each model and the real world results.

 

Abstract submissions are invited on the following themes

(1) Modelling diabetes disease progression and its complications

(2) Effect of diabetes on society – its impact on life and work

(3) Economic approaches to measuring quality of life

(4) Quantifying the cost of diabetes and its complications

(5) Methodological aspects of diabetes modelling

 

Abstract Submission Requirements

 

ALL ABSTRACTS ARE TO BE SUBMITTED via email mthood2014@gmail.com

 

SUBMISSION DEADLINE: Friday 28th March 2014

 

ALL ABSTRACT SUBMISSIONS AND PRESENTATIONS MUST BE IN ENGLISH.

Conference registration is required for all presenters. Note if the abstract is not accepted for presentation, participants that have registered can withdraw from the conference prior to end of April 2014 without financial penalty.

 

The presenters of research are required to disclose financial support. Abstract review will NOT be based on this information.

 

The research abstracts, EXCLUDING title and author information, should be no longer than 300 words.

 

The use of tables, graphs and figures in your research abstract submission are not allowed.

 

Generic names should be used for technologies (drugs, devices), not trade names.

 

Research that has been published at any national or international meeting prior to this Conference is discouraged.

 

MULTIPLE ABSTRACTS ON THE SAME STUDY ARE DISCOURAGED.

Abstracts will be reviewed by the steering committee and notification of acceptance or rejection will be made by 15th April 2014

 

Bechtel Conference Center

Conferences
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Erin Digitale
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Instilling healthy eating and exercise habits in children may help prevent obesity later in life. But which kids most need such obesity-prevention efforts? A recent study by Jeremy Goldhaber-Fiebert and colleagues at Stanford's School of Medicine showed that this question is harder to answer than it seems. The study, published earlier this year in Medical Decision Making, found that targeting obesity prevention to small children who are overweight might not be effective. That's because a higher-than-normal weight at age 5 provides an accurate predictor of adult obesity only 50 percent of the time.

Goldhaber-Fiebert, an assistant professor of medicine and core faculty member of Stanford Health Policy, discusses the problem.

What does your paper tell us about the recent focus on childhood and adolescent obesity measurements?

Our study has two take-home messages. First, while childhood obesity is an important problem, solving childhood obesity alone will not solve future adult obesity problems. Second, addressing future adult obesity will require broader societal measures — not simply interventions focused on obese children.

It used to be that no one worried much if a small child was chubby; the doctor might say, "It's baby fat, he'll grow out of it." How has that changed?

In fact, our data show that many children still do "grow out of it." But our findings suggest that it is difficult to predict whether this will happen for a specific child. Consequently, efforts to help obese children must be connected to broader efforts to create healthy diets and habits for all children.

Childhood obesity is concerning both because it presents increased health risks for individuals while they are children and also because of the fear that it will translate into serious adult obesity-related health issues. Our analyses show that targeting children who are already obese is unlikely to be sufficient in addressing broader public health challenges of obesity in later childhood, adolescence and adulthood.

Are there other more promising screening criteria for chronic adult obesity instead of using a child's weight?

It really depends on the purpose of screening. Researchers have identified a variety of characteristics to predict a child's future obesity status — for example, easily observed measures like the weight of a child's parent as well as more complex measures such as their size at birth and the rapidity with which they subsequently grew and gained weight.

The challenge is to have a measure that both does not miss a substantial fraction of those who become obese later on and also does not falsely predict obesity for a large number of those who do not become obese as adults. The trade-off between these two types of errors depends on the seriousness of health implications of obesity and the costs of treating health conditions once they arise, as well as the health and economic costs of delivering preventive interventions to people who are identified as being at risk of becoming obese regardless of whether they become obese in the future.

What are some of the best potential approaches for reducing childhood obesity if the entire population is being targeted?

Given that many health-related habits are developed in childhood, efforts to create healthy eating and exercise habits in children would seem to be beneficial. But for most potential interventions, we lack evidence of their widespread effectiveness over a long period of time. Do reductions in obesity persist from childhood into adulthood? Do they lead to measurable improvements in health outcomes? We do not have answers to these key questions.

Food, beverage or sugar taxes and other manipulations to food prices or availability may be effective, but may also have unintended harms and certainly come at the cost of curtailing personal choice. Re-engineering the built environment or nudging people with various behavioral/economic mechanisms have garnered attention though, again, widely generalizable evidence on them is lacking. The problem deserves continued creativity and ongoing evaluation and testing.

Your paper focuses on which obese children will become obese adults, yet we are seeing a growing number of children experiencing type-2 diabetes and other negative health consequences of being overweight before they're even out of their teen years. Is adult obesity the best endpoint to focus on?

Obesity-related conditions of childhood clearly should not be ignored. What we are concerned about is the sense that people were conflating good care for children to deal with their shorter-term health needs (i.e., childhood obesity management to deal with childhood health issues) and the belief that such an approach might largely solve the broader adult obesity issues. Addressing childhood obesity is still important even if it does not fix adult obesity and its deleterious health consequences.

Erin Digitale is the pediatrics writer for Stanford School of Medicine's Office of Communication and Public Affairs.

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OBJECTIVE To assess the individual financial impact of having diabetes in developing countries, whether diabetic individuals possess appropriate medications, and the extent to which health insurance may protect diabetic individuals by increasing medication possession or decreasing the risk of catastrophic spending.

RESEARCH DESIGN AND METHODS Using 2002–2003 World Health Survey data (n = 121,051 individuals; 35 low- and middle-income countries), we examined possession of medications to treat diabetes and estimated the relationship between out-of-pocket medical spending (2005 international dollars), catastrophic medical spending, and diabetes. We assessed whether health insurance modified these relationships.

RESULTS Diabetic individuals experience differentially higher out-of-pocket medical spending, particularly among individuals with high levels of spending (excess spending of $157 per year [95% CI 130–184] at the 95th percentile), and a greater chance of incurring catastrophic medical spending (17.8 vs. 13.9%; difference 3.9% [95% CI 0.2–7.7]) compared with otherwise similar individuals without diabetes. Diabetic individuals with insurance do not have significantly lower risks of catastrophic medical spending (18.6 vs. 17.7%; difference not significant), nor were they significantly more likely to possess diabetes medications (22.8 vs. 20.6%; difference not significant) than those who were otherwise similar but without insurance. These effects were more pronounced and significant in lower-income countries.

CONCLUSIONS In low-income countries, despite insurance, diabetic individuals are more likely to experience catastrophic medical spending and often do not possess appropriate medications to treat diabetes. Research into why policies in these countries may not adequately protect people from catastrophic spending or enhance possession of critical medications is urgently needed.

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Diabetes Care
Authors
Crystal Smith-Spangler
Crystal Smith-Spangler
Jay Bhattacharya
Jay Bhattacharya
Jeremy Goldhaber-Fiebert
Jeremy Goldhaber-Fiebert
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Background: High childhood obesity prevalence has raised concerns about future adult health, generating calls for obesity screening of young children. 

Objective: To estimate how well childhood obesity predicts adult obesity and to forecast obesity-related health of future US adults. 

Design: Longitudinal statistical analyses; microsimulations combining multiple data sets. 

Data Sources: National Longitudinal Survey of Youth, Population Study of Income Dynamics, and National Health and Nutrition Evaluation Surveys.

Methods: The authors estimated test characteristics and predictive values of childhood body mass index to identify 2-, 5-, 10-, and 15 year-olds who will become obese adults. The authors constructed models relating childhood body mass index to obesity-related diseases through middle age stratified by sex and race.

Results: Twelve percent of 18-year-olds were obese. While screening at age 5 would miss 50% of those who become obese adults, screening at age 15 would miss 9%. The predictive value of obesity screening below age 10 was low even when maternal obesity was included as a predictor. Obesity at age 5 was a substantially worse predictor of health in middle age than was obesity at age 15. For example, the relative risk of developing diabetes as adults for obese white male 15-year-olds was 4.5 versus otherwise similar nonobese 15-year-olds. For obese 5-year-olds, the relative risk was 1.6. 

Limitation: Main results do not include Hispanics due to sample size. Past relationships between childhood and adult obesity and health may change in the future. 

Conclusion: Early childhood obesity assessment adds limited information to later childhood assessment. Targeted later childhood approaches or universal strategies to prevent unhealthy weight gain should be considered.

 

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Medical Decision Making
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Jeremy Goldhaber-Fiebert
Jeremy Goldhaber-Fiebert
Rachel Rubinfeld
Jay Bhattacharya
Jay Bhattacharya
Thomas N. Robinson
Thomas N. Robinson
Paul H. Wise
Paul H. Wise
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0272989X12447240
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Douglas Owens, director of the Center for Health Policy at FSI and the Center for Primary Care and Outcomes Research in the Department of Medicine and School of Medicine, has been appointed to the U.S. Preventive Services Task Force.

The task force is an independent, volunteer panel of 16 experts in prevention and evidence-based medicine that makes recommendations and develops clinical guidelines for preventive services. They focus on issues including screening for breast cancer, colon cancer, prostate cancer, cervical cancer, diabetes, drug and alcohol misuse, and hepatitis C.

“These guidelines are used widely, and they address important issues for our veterans, and for the nation at large,” said Owens, the associate director of the Center for Health Care Evaluation at the VA Palo Alto Health Care System and the Henry J. Kaiser Jr. Professor at Stanford.

“I look forward to working with the Task Force.”

 

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To address growing concerns over childhood obesity, the United States Preventive Services Task Force (USPSTF) recently recommended that children undergo obesity screening beginning at age 6. An Expert Committee recommends starting at age 2. Analysis is needed to assess these recommendations and investigate whether there are better alternatives. We model the age- and sex-specific population-wide distribution of BMI through age 18 using National Longitudinal Survey of Youth (NLSY) data. The impact of treatment on BMI is estimated using the targeted systematic review performed to aid the USPSTF. The prevalence of hypertension and diabetes at age 40 are estimated from the Panel Study of Income Dynamics (PSID). We fix the screening interval at 2 years, and derive the age- and sex-dependent BMI thresholds that minimize adult disease prevalence, subject to referring a specified percentage of children for treatment yearly. We compare this optimal biennial policy to biennial versions of the USPSTF and Expert Committee recommendations. Compared to the USPSTF recommendation, the optimal policy reduces adult disease prevalence by 3% in relative terms (the absolute reductions are <1%) at the same treatment referral rate, or achieves the same disease prevalence at a 28% reduction in treatment referral rate. If compared to the Expert Committee recommendation, the reductions change to 6 and 40%, respectively. The optimal policy treats mostly 16-year olds and few children under age 14. Our results suggest that adult disease is minimized by focusing childhood obesity screening and treatment on older adolescents.

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Obesity
Authors
Wein, L.M
Yang, Y.
Jeremy Goldhaber-Fiebert
Jeremy Goldhaber-Fiebert
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