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.”

Stanford Health Policy’s Michelle Mello is calling for reforms to the practice of overlapping surgery, a practice in which surgeons juggle multiple operations at the same time.

Primary surgeons who run multiple operating rooms delegate “non-critical” parts of the operations to trainees or physician assistants. Overlapping scheduling is considered an important means of giving surgical trainees hands-on experience before they enter the profession with a license to operate. But patients are often unaware about the prospect that their surgeon may be double-booked.

“As patients at a teaching hospital, we know that surgery is a team sport and trainees will be involved,” Mello said in an interview. “But learning that the surgeon we’ve entrusted ourselves to may be out of the room for extended periods while we’re under anesthesia comes as a surprise to many patients. Like other aspects of surgical care, policies and procedures need to be in place to make sure this can be done safely.”

Mello, who is a professor of health research and policy at Stanford Medicine and a professor of law at Stanford Law School, wrote in this JAMA editorial that the practice has dented patient trust in the surgical profession and that better research is needed to determine how patients are impacted by double booking. Mello wrote with co-author Edward H. Livingston, MD, of the Department of Surgery at the UT Southwestern School of Medicine in Dallas. Livingston is also deputy editor of JAMA.

For example, Mello and Livingston noted that The Seattle Times reported in February about the unusually high volume of neurosurgical operations “and reportedly poor outcomes” at the Swedish Neuroscience Institute. The top two neurosurgeons each billed more than $75 million in 2015, and clinical staffers who raised concerns were ignored. The news reports prompted federal and state investigations and the resignations of the hospital’s neurosurgery chief and chief executive officer.

Medicare regulations applicable to teaching hospitals allow surgeries to overlap, but primary surgeons can’t bill the government for an operation unless they personally perform the “critical or key portions.”

The Senate Committee on Finance, which oversees Medicare, issued a report last year that said patient safety and informed consent were key concerns raised by overlapping surgery. But they also found scant research on the consequences for patients.

Mello and Livingston write that six peer-reviewed studies have been published about the safety of overlaps, but note that they were all retrospective, single-institution studies.

“These studies suggest that overlapping surgery is not associated with increased risk of patient harm, but these observational studies have important limitations,” they said. 

For example, some studies lumped cases with just one second of overlap together with cases that overlapped significantly longer, making it hard to measure the relationship between the amount of overlap and surgical outcomes. They added that the generalizability of findings beyond the small number of institutions and surgeons studied is unknown.

In ongoing work with other Stanford Health Policy faculty, Mello plans to examine data from a large number of teaching hospitals. One issue requiring further investigation, she said, is whether the longer procedure times documented for overlapping cases mean more time under anesthesia, which elevates the risk of postoperative complications.

Citing a public opinion survey showing that 69 percent of Americans oppose the practice, the JAMA authors concluded, “Overall, the modest evidence base does not suggest that overlapping surgery is unsafe, but rather that the practice is not trusted.”

They believe patients and regulators may distrust it because of the possibility of harm to patients, lack of transparency about what is going on, and surgeons’ conflict of interest in determining on their own what aspects of operations they must personally perform.

Mello and Livingston believe restoring public trust in the surgical system requires stronger proof that overlapping scheduling is safe, including evidence from randomized studies, and better informed consent practices which ensure that patients are given full information about scheduling practices well ahead of surgery.

“The disclosure should include the likelihood that the operation will involve an overlap, a description of who will perform which parts of the operation and what their qualifications are, and the patient’s option if he or she objects to the scheduling,” they said.

Finally, hospitals have an obligation to ensure that their surgeons are performing the critical parts of an operation.

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Tens of thousands of Americans die from drug overdoses every year — around 50,000 in 2015 — and the number has been steadily climbing for at least the last decade and a half, according to the National Institute on Drug Abuse. Yet a team of Stanford neuroscientists and legal scholars argues that the nation’s drug policies are at times exactly the opposite from what science-based policies would look like.

Stanford Health Policy affiliate Keith Humphreys, a professor of psychiatry and behavioral science, and colleagues argue in the journal Science that basing public policy on neuroscience rather than on a desire to punish addicts would improve lives, including those of the victims of drug-related crimes.

“We have an opioid epidemic that looks like it’s going to be deadlier than AIDS, but the criminal justice system handles drug addiction in almost exactly opposite of what neuroscience and other behavioral sciences would suggest,” said Keith Humphreys, a professor of psychiatry and behavioral sciences and one of the leaders of the Stanford Neurosciences Institute’s Neurochoice Big Idea Initiative.

A central problem, the authors argue, is that drug use warps the brain’s decision-making mechanisms, so that what matters most to a person dealing with addiction is the here and now, not the possibility of a trip up the river a few months or years from today.

“We have relied heavily on the length of a prison term as our primary lever for trying to influence drug use and drug-related crime,” said Robert MacCoun, a professor of law and senior fellow at the Freeman Spogli Institute for International Studies. “But such sanction enhancements are psychologically remote and premised on an unrealistic model of rational planning with a long time horizon, which just isn’t consistent with how drug users behave.”

What might work better, Humphreys said, is smaller, more immediate incentives and punishments – perhaps a meal voucher in exchange for passing a drug test, along with daily monitoring.

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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.

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.

When one thinks of the casualties of war, it is easy to imagine severed limbs, bullet holes, shrapnel, perhaps even sarin gas or Agent Orange. But in a recent Daedalus essay, Paul Wise argues that the most damaging health impacts of war are often indirect. Losing access to food supplies, medication and electricity can kill more people than battle itself. In this video by the American Academy of Arts and Sciences, Wise, a professor of pediatrics and Stanford Health Policy core faculty member, explains how fatal the indirect costs of war can be.

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A panel of experts has released a draft recommendation that men aged 55 to 69 with no sign of prostate cancer should still talk to their physicians about whether they should be screened for the second leading cause of cancer deaths in American men.

The U.S. Preventive Services Task Force issued a contentious recommendation in 2012 leaning against screening among men of average risk because of the substantial potential harms associated with screening and treatment.

Prostate cancer screenings are done using a blood test that measures the amount of a prostate-specific antigen, a type of protein, in a man’s blood. When a man has elevated PSA, it may be caused by prostate cancer, but it could also be caused by other conditions such as inflammation of the prostate.

One of the challenges of prostate cancer is that a substantial proportion of prostate cancer grows so slowly that it would not harm the patient.  The task force found that detecting prostate cancer early might not reduce the chance of dying from the disease and that treatment often caused impotence and urinary incontinence.

But now the task force members, using new data from a European trial and evidence about current treatment practices, believe there is more evidence to suggest the benefits of the screening might outweigh the harms for certain men — and that the choice should be one made with their physicians.

“The benefits and harms of prostate cancer screening are closely balanced and our new draft guideline suggests that men discuss screening with their physicians,” said Stanford Health Policy’s Douglas K. Owens, who was a member of the task force during the development of the guideline.

“We now have a long-term follow-up from clinical trials that show modest benefits and more men are being treated with active surveillance which may mitigate some of the harms of overtreatment,” said Owens.

Some 181,000 men in the United States are diagnosed with prostate cancer each year. Of those, an estimated 26,000 men die from the disease.

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The task force changed its draft recommendation for screening from a D to a C for men aged 55 to 69, but continues to recommend against men 70 and older being screened. The draft recommendation is open for public comment through May 8 on its new prostate cancer screening website.

“Prostate cancer is one of the most common cancers to affect men, and the decision about screening using PSA-based testing is complex,” said Task Force Member Alex H. Krist, MD, MPH. “In the end, men who are considering screening deserve to be aware of what the science says, so they can make the best choice for themselves, together with their doctor.”

The Task Force is an independent, volunteer panel of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive serves such as screenings, counseling services, and preventive medications.

Task Force Chair Kirsten Bibbins-Domingo, PhD, MD, said members reviewed evidence on the benefits and harms of screening for men at higher risk for prostate cancer, such as African-American men and those with a family history.

“Clinicians should speak with their African-American patients about their increased risk of developing and dying from prostate cancer, as well as the potential benefits and harms of screening,” said Bibbins-Domingo.

She noted that there remains a “striking absence” of evidence to guide high-risk men as they make their decisions about screening: “Additional research on prostate cancer in African-American men should be a national priority.”

Many national medical associations are aligned with the task force’s new recommendations, including the American Urological Association, the American Cancer Society and the American College of Physicians.

Some critics continue to have concerns about screening.

“In my mind, the greatest misconception about the test is that we say it ‘saves lives,’ when that is uncertain,” writes Vinay Prasad, an oncologist, in the popular medical blog, STAT News. “PSA testing reduces the risk of dying of prostate cancer, but there is no evidence it reduces the risk of dying,”

Jonathan Chen has a doctorate in computer science and could have his pick of lucrative jobs here in Silicon Valley today.

Instead, he pursued his medical degree and is working on ways to help physicians quickly mine clinical data to reach better diagnoses for their patients.

“I walked away from higher paying jobs because I was looking for a greater purpose in my work and a rewarding career,” said Chen, a physician-scientist at Stanford who was a VA Medical Informatics Fellow at Stanford Health Policy.

Future works like his — supported by a five-year grant from the National Institutes of Health — may be on the chopping block.

The Trump administration’s proposed budget intends to cut NIH funding by $7 billion over the next 18 months, which could severely compromise research grants that lead to major biomedical breakthroughs.

Chen is currently building OrderRex, a digital platform that data-mines electronic medical records that show clinical practice patterns and outcomes to inform medical decisions. He hopes it will one day be the Amazon of electronic medical records.

After more than 20 years of hard work — a college freshman when he was only 13  — Chen is finally poised to become a junior faculty member. But now he has to wonder whether he made the right choice.

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“Seeing the proposed research budget cuts gives me pause,” Chen said. “And I’m considering whether it is foolish for me to even be joining the academic ranks now, chasing down grants that will be increasingly difficult to come by, amidst a political climate that does not seem to care for science.”

The administration has said it respects and would support the work of the NIH, which Secretary of Health and Human Services Tom Price recently called “very important.” But, he added, the American taxpayers should be getting “a bigger bang for the buck.”

About 80 percent of the federal NIH funding goes to grants for clinical and translational researchers at small businesses and academic institutions.

Here at Stanford Health Policy, the grants have funded research into everything from the epidemic of diagnostic errors to the economic harm of the tsetse fly on African economies; the impact of urbanization on obesity and chronic disease in India, to a global data analysis about whether foreign aid is directly linked to an increase in life expectancy in developing countries.

The National Institutes of Health — which has supported the research of some 148 Nobel Prize winners — has touched the work of nearly every SHP researcher.

“Cutting scientific research budgets could turn a generation of young minds away from the larger purposes of academic medical research and instead send them off into finance, tech, pharma — leaving behind the country’s talent pool in the decades to come,” said Chen.

Eran Bendavid, an assistant professor of medicine and core faculty at Stanford Health Policy, uses political science, economics, and epidemiology to study the prevention and treatment of infectious diseases in developing countries.

The infectious disease physician also depends, in part, on NIH funding.

“There is no substitute for NIH support for basic and applied research,” Bendavid said. “It has been a central actor in the progress of the biomedical fields and made the U.S. the global leader in innovation. It is also good diplomacy, promoting cooperation and partnerships across the globe.”

Bendavid and SHP colleague Grant Miller led the research that showed that declining use of safe contraception led to an increase in abortion rates in sub-Saharan Africa, a region in which family planning services are heavily financed by U.S. foreign aid. Their work was widely cited in news reports as a counterpoint to the Trump administration’s pledge to cut funding to international family planning organizations that also offer abortion.

“Even if many of the budgetary provisions are scaled back, this is an unfortunate place to anchor the negotiations,” Bendavid said of the proposed NIH cuts, which are so severe they are already facing opposition from some members of Congress. “This could signal real changes in what we do as individuals, as a division, and as an institution.”

House Speaker Paul Ryan was asked specifically about President Trump's proposed cuts to the National Institutes of Health. The speaker avoided criticizing the administration for that proposal — but indicated it was unlikely Congress would go along.

“I don’t try to get into making my opinion on this, on specific provisions,” Ryan said. “All I would say is perhaps the most popular domestic funding we have among Republicans is NIH.”

Michele Barry, director of the Center for Innovation in Global Health and senior associate dean for Global Health at Stanford University — as well as one of SHP’s key faculty members — wrote in this editorial on March 28 that such drastic cuts to biomedical research would make us more susceptible to global epidemics.

“We live in a time when pandemics cross borders faster than ever,” Barry wrote. “Yet to the horror of many of us working in global health, President Trump’s budget would completely eliminate the NIH’s Fogarty International Center — one of the most effective tools we have to fight global diseases.”