Stanford Health Policy’s newest faculty member, Joshua Salomon, believes that one urgent need in global health research is to improve forecasts of the patterns and trends that are the major causes of death and disease.

Salomon, who is leaving leaving his position as professor of global health at the Harvard T.H. Chan School of Public Health to join Stanford on Aug. 1, works on modeling of infectious and chronic diseases and their associated intervention strategies, as well as methods for economic evaluation of public health programs and ways to measure the global burden of disease.

And he looks at the potential impact and cost effectiveness of new health technologies.

“Projections of future trends in health are crucial to formulating policy,” said Salomon, who has a PhD from Harvard. “To think strategically about the technologies and policies that would make the biggest impact on health over the next 20 to 50 years, we really need to start by understanding the range of likely trends in major health challenges over the coming decades.”

Stanford, he said, offers him a “rich collaborative environment” to better learn from advances in forecasting across a range of other disciplines, such as economics, political science, and environmental science.

“With a better picture of what the world is likely to look like over the next 50 years — and what are going to be the most pressing health problems — we can invest wisely and put ourselves in a position to respond more effectively.”

Salomon is also the director of the Prevention Policy Modeling Lab, which is funded by a five-year award from the Centers for Disease Control and Prevention. The consortium represents the collaborative research of experts from Massachusetts General Hospital, Boston Medical Center, Dana Farber Cancer Institute, Yale School of Public Health, Brown University School of Public Health, and the Massachusetts Department of Public Health and.

He will continue directing the lab from Stanford and intends to bring in new research threads from his colleagues here on the Farm. The lab works on a wide range of projects dealing with policy analysis for hepatitis, sexually transmitted infections and diseases such as HIV, and tuberculosis.

“It’s a rewarding grant for me to work on because, unlike a lot of modeling projects, the work that we do really starts from urgent public health questions that policymakers have,” he said. “All of the questions that we are working on are questions that originated directly from discussions with CDC and other public health partners.”

With Salomon’s move to Stanford, the university gains a dynamic duo.

Grace Lee joins Stanford as the Associate Chief Medical Officer at Lucile Packard Children's Hospital in the fall, 2017.

His wife, Grace Lee, MD, MPH, joins in the fall as the Associate Chief Medical Officer at Lucile Packard Children’s Hospital. As a professor of population medicine at Harvard Pilgrim Health Care Institute & Harvard Medical School, Lee has led research in vaccine safety in the FDA-funded Post-licensure Rapid Immunization Safety Monitoring (PRISM) program and the CDC-funded Vaccine Safety Datalink, which monitors the safety of vaccines and studies rare and adverse reactions from immunizations.

She has also examined the impact of financial penalties on rates of healthcare-associated infections, as the principal investigator of an AHRQ-funded study, as well as developed novel surveillance definitions for ventilator-related events in neonates and children.

While at Stanford, Lee said, she intends “to find opportunities to enhance the learning health system approach to improve patient outcomes and population health.”

Salomon has spent his entire career as a collaborator on the Global Burden of Disease project, the world’s most comprehensive epidemiological study commissioned by the World Bank in 1990, which tracks mortality and morbidity from major diseases, injuries and risks factors.

“The study has made a major contribution to global public health because before this study we just didn’t have a comprehensive, systematic understanding of the things that cause death and disability in low- and middle-income countries. But now we do,” he said. “It’s hugely ambitious and very sweeping in scope — and a lot of my work is around providing the evidence we need to inform policy.”

Much of Salomon’s work is global in nature. He’s most recently focused on older adults in one rural South African community, which has a high prevalence of HIV and one of the world’s highest levels of hypertension. His research there aims to inform urgent prevention initiatives tailored to older adults where HIV and cardiovascular risks are moderate or high, as in similar communities in sub-Saharan Africa.

“People don’t expect a high level of ongoing HIV transmission in older adults,” he said. “The double burden that we find, with a very high level of HIV, as well as the high prevalence of diabetes and heart disease, creates enormous strains on the health-care system.”

Fewer girls in low-and-middle-income countries finish secondary school, resulting in poorer health and economic outcomes for their own children — and perpetuating the vicious cycle of gender inequality worldwide.

According to The World Bank, in Sub-Saharan and South Asia, boys are 1.5 times more likely to complete secondary education than girls. Many are forced to stay at home and help their mothers with housework and childcare, particularly if a younger sibling is sick.

Yet the potential gains from increased participation of women in the global workforce over the next decade are estimated at $12 trillion. Studies show that women’s equal participation in the workforce could boost some countries’ GDP by up to 20 percent.

Stanford Health Policy’s Marcella Alsan, a physician and economist, argues in a new study in the journal Pediatrics, that identifying contributors to education disparities and making investments in early childhood health could significantly advance global health and development.

“There are so many advantages to girls staying in school,” Alsan, an assistant professor of medicine at Stanford Medicine, said in an interview. “For one thing, the longer they’re in school, the less likely they are to become young mothers or contract HIV. And the more educated the mother, their own children have better chances of survival.”

So what are some of the biggest barriers to girls completing secondary school in less developed countries?

Alsan and her co-authors found the gender gap is compounded by illness among young children in the household since adolescent girls are often tasked with childcare and domestic chores. The problem is exacerbated if the mother works outside the household.

Follow the Numbers

Along with SHP research data analyst Anlu Xing, Alsan and her team used Demographic and Health Surveys on 41,821 households in 38 low-and-middle-income countries. The surveys asked about illnesses in children under 5 in the last two weeks, and then asked the adolescent boys and girls if they had been in school in the same period.

As expected, more girls remained at home than boys. When no young children in the household are ill, adolescent girls are on average 6 percent less likely to attend school than adolescent boys within the same household.

But the gap increases to 7.8 percent if the household reports one illness episode among an under-5 child, and up to 8.5 percent if there are two or more episodes of illness.

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In other words, the authors write, “The gender gap in adolescent school attendance increased by around 50 percent when young children in the household became ill.”

The education gap between adolescent boys and girls jumps to 10.06 percent if the younger child has two or more episodes of illness — and the mother is working outside the home or in the fields.

“Policies that strengthen family and community supports for challenges such as sick child care will prove essential,” the authors write, “particularly as women move increasingly into the workforce outside the home.”

Alsan’s co-authors are Eran Bendavid, assistant professor of medicine and core faculty member at Stanford Health Policy; Gary Darmstadt, a professor of pediatrics and associate dean for maternal and child health at Stanford Medicine; and Paul Wise, another core faculty member at SHP and professor of pediatrics.

Vaccines Also Key

Alsan and her team also examined data on the gender gap in adolescent education in association with national vaccine rates, using the same country-year surveys.

They found that in countries where about 70 percent of all the boys and girls had the same series of eight vaccines — including polio, diphtheria, tetanus and measles — the gender gap in education approaches zero.

“We hypothesize that countries with high rates of childhood vaccination will experience lower rates of young child illness, thereby decreasing the need for adolescent girls’ to devote time to caring for sick children,” the authors write.

Given the long-term benefits of secondary school for women’s health and economic outcomes, the authors believe their study underscores the societal benefits of keeping girls in school. A combination of vaccines and early childhood interventions to keep toddlers healthy and their older sisters in school are paramount.

“The international community agrees that educating girls through secondary school has plenty of societal benefits — we show that health interventions targeting young kids are an important way to do just that,” says Alsan. “Not only the targeted little kids benefit but also their older sisters — a double dividend.”

The first time Devin cooked an opioid, it wasn’t to ease a back injury or chronic headaches. In an interview with NPR, he said he saw other people injecting, and it seemed like they were having a good time. He figured, why not?

He didn’t know his Indiana town of 4,500 people was in the midst of an HIV epidemic, so it never occurred to him to worry about sharing needles.

Over the past decade, the opioid epidemic in the United States has doubled the number of people injecting heroin, making the health risks associated with injection drug use a public health crisis.

During the same time period, the incidence of HIV has gone down, but as people like Devin share needles to inject drugs — particularly opioids — Stanford researchers are concerned that increased HIV transmission could be on the horizon.

Cora Bernard, a PhD student in Management Science and Engineering, led a study on prevention programs that could head off a resurgence of HIV and perhaps lessen the effects of the opioid crisis.

“There’s a real public health crisis associated with injecting,” said Bernard. “We think it’s important to understand what investments give highest value because HIV prevention programs, and especially programs that reduce the prevalence of injection drug use, can have outsized, positive impact on individuals, families and public safety.”

In July of 2016, Bernard and her co-authors published a different study examining pre-exposure prophylaxis (PrEP), a pill that reduces a person’s risk of infection when they come into contact with the HIV virus. They found that PrEP was effective, but expensive.

The new study examines alternatives that also reduce the risk of HIV infection but are more cost-effective. They created a model to determine how many quality-adjusted life years — a metric that incorporates both life expectancy and quality of life — a person could gain from four HIV prevention programs, and what those years would cost.

“The dynamics of HIV prevention and treatment are complex,” said Margaret Brandeau, PhD, the senior author of the study and a professor of Management Science and Engineering. “Our model allows us to evaluate the costs and effects of the interventions, singly and in combination, to determine what programs would be effective and cost-effective in preventing the spread of HIV among persons who inject drugs.”

Of the prevention programs simulated in the model, the authors found that opioid agonist therapy (OAT) was the most cost-effective. OAT replaces drugs like heroin with a prescription that provides similar effects under safer conditions.

Needle-syringe exchange programs (NSP) — in which people swap their dirty needles for clean ones — were the next most cost-effective option. This was followed by test-and-treat programs, which identify people with a high risk of contracting HIV, test them for the virus and treat them before the disease has much chance to spread — both within their own bodies and to others who are exposed.

The study estimated that PrEP can also successfully reduce HIV, but not in a cost-effective way. The authors write that the other three techniques could all cost less than $50,000 for each quality life year gained by individuals. PrEP would likely cost more than $600,000.

The prevention programs were most effective when used in combination. The authors project that combining OAT and NSP could avert up to 40,000 HIV infections over 20 years for people who inject drugs, not to mention preventing downstream sexual transmission of HIV to others.

According to Bernard, one of the benefits of OAT is that in addition to reducing the risk of HIV, it can also help people stop injecting drugs. The authors project that expanding OAT access could decrease the size of the injection population as much as 37 percent over 20 years.

“We started out thinking about this as an HIV problem, but we realized that the majority of health benefit actually comes from reducing injection drug use and improving quality of life for drug users,” said Bernard. “This is why we found OAT to be the highest-value investment.”

Bernard and her co-authors believe that employing techniques like OAT could help reduce the effects of the opioid crisis.

“Our study aims to help policy makers and clinicians understand how a variety of interventions can help improve health outcomes and prevent HIV,” said Douglas Owens, MD, an author of the study, a professor of medicine and an internist at the VA Palo Alto Health Care System. “We hope our analyses help show how to use limited resources efficiently to prevent the devastating consequences of substance use.”

End-stage renal disease makes up 7.2 percent of Medicare spending, even though those patients represent less than 1 percent of the Medicare population, according to a database that tracks chronic kidney disease.

Despite the gnashing of teeth about the runaway costs of Medicare spending, the national health-care system for the elderly, younger people with certain disabilities and chronic kidney disease appears to have found one way to lower costs.

Congress established the end-stage renal disease (ESRD) Prospective Payment System in 2008, as part of the Medicare Improvement for Patients and Providers Act. It mandated that ESRD Medicare patients treat themselves at home if able.

The new payment system introduced two incentives to increase home dialysis use: bundling injectable medications into a single payment for treatment and paying for training for patients to give themselves injections and treatment at home.

A new study by Stanford researchers shows home dialysis treatment among Medicare patients increased by 5.8 percent from January 2006 through August 2013. The researchers also found that non-Medicare patients covered by other forms of health insurance also turned to home dialysis by a jump of 4.1 percent.

“These spillover effects suggest that major payment changes in Medicare can affect all patients with end-stage renal disease,” the authors wrote in the study published in the latest edition of the Journal of the American Society of Nephrology. “One of the stated goals of the PPS payment reform was to incentivize an increase in-home dialysis use, and it appears that it has succeeded in this stated goal.”

Eugene Lin, a postdoctoral fellow in nephrology at the Stanford School of Medicine and lead author of the study, told me that most nephrologists believe the trend toward home dialysis is good for the taxpayers and for the patients.

People going through this phase of chronic kidney disease — when dialysis or a kidney transplant are the only chance of survival  — cost less to take care of at home and have similar outcomes to in-center hemodialysis patients.

“It’s hard to say if one therapy is definitively better than the other,” Lin said, “though home dialysis generally offers patients more independence and potentially better quality of life.”

Lin explained the difference between in-center hemodialysis and home treatment: At a center, blood is filtered through a machine, whereas home dialysis entails either having a hemodialysis machine at home (and having a caregiver help with the treatments) or performing peritoneal dialysis.

The latter is the most commonly used at-home treatment and involves using the abdominal compartment as a filter. The toxins in the blood get filtered through the abdominal membranes into clean fluid, which is then removed and discarded.

Similar drugs are used both in centers and at home, but they’re easier to give in the hemodialysis setting, so had a higher likelihood of overuse prior to payment reform.

“Once they bundled the drug reimbursement with the treatment, we saw dramatic decreases in the use of these drugs and a concurrent increase in home dialysis use,” Lin said.

The researchers, including senior author Jay Bhattacharya of Stanford Health Policy, noted that home dialysis remained stagnant at around 11 percent from 1983 to 1992 and steadily declined until 2008.

“While the cause of this decline is unknown, several policies made home dialysis less favorable than in-center hemodialysis economically,” they wrote.

First, the federal Centers for Medicare & Medicaid Services in 1991 revised its reimbursement policy for the erythropoietin-stimulating agent needed for functioning kidneys, making it the most profitable component of in-centers hemodialysis. Then, CMS introduced a tiered fee-for-service physician payment in 2004, providing the potential for enhanced revenues with in-center dialysis.

But the PPS bundling shifted erythropoietin from the profit side to the cost side, so it was no longer advantageous to use high doses common with in-center hemodialysis, Lin said. This paved the way for an increase in home dialysis use, which is less costly to administer.

Stanford Health Policy’s Douglas K. Owens has been appointed vice chair of the U.S. Preventive Services Task Force, an independent, volunteer panel of national experts in prevention and evidence-based medicine.

Owens, the Henry J. Kaiser, Jr. Professor at Stanford University is a general internist at the VA Palo Alto Health Care System, and a professor of medicine, health research and policy, and management science and engineering at Stanford.

He is the director of the Center for Health Policy in the Freeman Spogli Institute for International Studies, where he is also a senior fellow, and the Center for Primary Care and Outcomes Research in the Department of Medicine and School of Medicine, and Associate Director of the Center for Innovation to Implementation at the VA Palo Alto Health Care System.

“Through his stellar work, Dr. Owens enables Stanford Medicine to advance its mission to precisely predict and prevent disease,” said Lloyd Minor, MD, dean of the Stanford School of Medicine. “As our country faces an increasingly diverse, aging patient population and rising health care costs, I am thrilled that Dr. Owens will contribute his perspective and expertise to this national task force.”

Owens served a previous four-year term on the independent, volunteer panel of national experts in prevention and evidence-based medicine. He will serve for two years as vice chair and then a year as chair. Members come from health-related fields ranging from internal medicine, family medicine, pediatrics, behavioral health, obstetrics/gynecology, and nursing.

The task force issues preventive care guidelines based on detailed assessment of the evidence about preventive interventions and is supported by the Agency for Healthcare Research and Quality within the U.S. Department of Health and Human Services.

“It’s humbling because the task force guidelines impact virtually every primary care patient in the United States,” said Owens, who is also past president of the Society for Medical Decision Making. “Having an unbiased, independent assessment of the benefits and harms of preventive services is very important for primary care clinicians and patients.”

The task force works to improve American’s health by making evidence-based recommendations about clinical preventive services such as screenings, counseling services and preventive medications. Its members have tackled everything from whether to screen for certain cancers, which medications should be taken to prevent diseases and reduce blood pressure and high cholesterol, and screening for infectious diseases, including HIV, HCV, TB, syphilis and other sexually transmitted diseases.

“We are honored to welcome Dr. Owens back to the task force in a leadership role,” said task force chair David C. Grossman, MD, MPH, a senior investigator and medical director for population health strategy at the Group Health Research Institute.

“His experience in guideline development, both with the task force and partner organizations, and his work in evidence-based medicine and clinical decision-making are valuable additions to our leadership team,” Grossman said.

The task force, for example, just released its draft guideline on prostate cancer screening. And some of the medical topics under development are screening for cervical and BRCA-related cancer, as well as pre-exposure prophylaxis for HIV infection.

Owens said that it was critical that the task force remains unbiased and independent. The 16 volunteer members who are nationally recognized experts in prevention, evidence-based medicine and primary care, carefully evaluate the science behind preventive interventions.

“The task force has very rigorous methods for assessing evidence, and we are fortunate to have state-of-the-art evidence reviews provided by AHRQ funded Evidence-Based Practice Centers,” he said.

Each year, the task force makes a report to Congress that identifies critical evidence gaps in research related to clinical prevention services and recommends priority areas that deserve further explanation. All their reports and recommendations are made public on the task force website and leave room for public comment.

The Journal of General Internal Medicine (JGIM) has appointed Stanford Health Policy’s Steve Asch as an editor-in-chief.

JGIM is the highest rated journal for primary care research in the world. It publishes research on health services, implementation science, medical education and the humanities in addition to primary care.

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“Steve is widely known as an outstanding writer and editor, and as having very broad methodological expertise,” said Douglas Owens, director of the Center for Health Policy/Primary Care and Outcomes Research. “He's a terrific choice to lead JGIM.”

Asch’s work focuses on quality improvement, and he has lead several national projects to develop tools that measure quality of care for veterans, Medicare users and the public. An avid mentor, Asch has trained dozens of physician fellows in health services research at Stanford and the VA system.

“We’re going to try to get research out there where it can make a difference in the world,” said Asch.

The editor team plans to focus more on best practices and implementation science. By combining the efforts of many researchers, they hope to ensure that doctors get the best answers to the big questions in health care.

“I think it’s going to be fun,” said Asch.

He looks forward to mentoring researchers to submit articles to journals like JGIM.

“Primary care is important,” said Asch. “As the health-care system transforms, it will play an increasingly important role, and the journal is very much in the lead in trying to publish new ways of organizing primary care.”

After the 2012 mass shooting of children and teachers at Sandy Hook Elementary School in Connecticut, a leader of the National Rifle Association proclaimed: “The only thing that stops a bad guy with a gun is a good guy with a gun.”

It would seem that many Californians agreed, according to new research by Stanford Health Policy’s David Studdert and other researchers at academic institutions.

In the six weeks after the Newtown shootings — when a young man fatally gunned down 20 children and six adults — handgun acquisitions in California rose by 53 percent among first-time gun owners over expected levels.

When a couple armed with semi-automatic weapons targeted a San Bernardino County public health event in December 2015, killing 14 people in 2015, handgun purchase rates were 85 percent higher than expected among residents of the city of San Bernardino and adjacent neighborhoods, compared with 35 percent higher elsewhere in California.

In a new study in the Annals of Internal Medicine, lead author Studdert, a professor of medicine at Stanford Medicine and professor of law at Stanford Law School, writes that their findings have implications for public health as firearm ownership is a risk factor for firearm-related suicide and homicide.

“There is strong evidence linking gun ownership to risks of gunshot injuries, so any sudden boost in firearm ownership could have public health implications,” Studdert said. On their own, these two mass shootings are unlikely to have caused enough of a change in ownership patterns to have significant public health effects.

“But over time, purchasing responses to a succession of unnerving events like this — from mass shootings to terrorist attacks, to elections — could change levels of gun ownership enough to increase overall rates of gun injury and death.”

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The authors write that for some, mass shootings may induce repulsion at the idea of owning a weapon. But for others, they note, it may motivate acquisition.

“Mass shootings are likely to boost sales if they heighten concerns over personal security because self-protection is the most commonly cited reason for owning a firearm,” they said.

More than 32,000 people die of gunshot wounds in the United States each year, according to the Centers for Disease Control and Prevention. While mass shootings account for less than 1 percent of those deaths, they are the most visible form of firearm violence because of the extensive broadcast and social media coverage that surround them.

Using detailed individual-level information on firearm transactions in California between 2007 and 2016, the researchers analyzed acquisition patterns after two of the highest-profile mass shootings in U.S. history. They found large and significant spikes occurred among whites and Hispanics, and among individuals who had no record of having previously acquired a handgun.

Although these spikes in handgun purchases after both mass shootings were large, they were also short-lived and accounted for less than 10 percent of annual handgun purchases statewide.

“Concerns about firearm violence and the public health risks of firearm ownership should stay focused on the much larger volume of weapons that routinely changes hands, and the immense stock that already sits in households,” write Studdert and his colleagues, Stanford Health Policy researcher Yifan Zhang, PhD; Jonathan Rodden, PhD, a professor of political science at Stanford; Rob J. Hyndman, PhD, a professor of statistics at Monash University in Australia; and Garen J. Wintemute, MD, MPH, an expert on gun violence at the University of California, Davis.

“On the other hand, the cumulative effect of such ‘shocks’ as Newtown and San Bernardino shootings on firearm prevalence may be substantial,” they write. “Moreover, firearm acquisitions seem to be sensitive to a range of other events that are also common, such as federal elections, new firearm safety laws, and terrorist attacks.”

Taken as a whole, they said, these events may drive significant increases in overall firearm prevalence, which may, in turn, increase the risk for firearm-related morbidity and mortality in the long run. The authors urge further research should explore the cumulative effects and temporary shifts in acquisition patterns, their causes, and their implications for public health, crime and social cohesion.