Stanford Health Policy is a joint effort of the Freeman Spogli Institute for International Studies and the Stanford School of Medicine
FSI scholars produce research aimed at creating a safer world and examing the consequences of security policies on institutions and society. They look at longstanding issues including nuclear nonproliferation and the conflicts between countries like North and South Korea. But their research also examines new and emerging areas that transcend traditional borders – the drug war in Mexico and expanding terrorism networks. FSI researchers look at the changing methods of warfare with a focus on biosecurity and nuclear risk. They tackle cybersecurity with an eye toward privacy concerns and explore the implications of new actors like hackers.
Along with the changing face of conflict, terrorism and crime, FSI researchers study food security. They tackle the global problems of hunger, poverty and environmental degradation by generating knowledge and policy-relevant solutions.
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.
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.
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.
Few studies have examined the link between health system strength and important public health outcomes across nations. We examined the association between health system indicators and mortality rates.
We used mixed effects linear regression models to investigate the strength of association between outcome and explanatory variables, while accounting for geographic clustering of countries. We modelled infant mortality rate (IMR), child mortality rate (CMR), and maternal mortality rate (MMR) using 13 explanatory variables as outlined by the World Health Organization.
Significant protective health system determinants related to IMR included higher physician density (adjusted rate ratio [aRR] 0.81; 95% Confidence Interval [CI] 0.71-0.91), higher sustainable access to water and sanitation (aRR 0.85; 95% CI 0.78- 0.93), and having a less corrupt government (aRR 0.57; 95% CI 0.40- 0.80). Out-of-pocket expenditures on health (aRR 1.29; 95% CI 1.03- 1.62) were a risk factor. The same four variables were significantly related to CMR after controlling for other variables. Protective determinants of MMR included access to water and sanitation (aRR 0.88; 95% CI 0.82- 0.94), having a less corrupt government (aRR 0.49; 95%; CI 0.36- 0.66), and higher total expenditures on health per capita (aRR 0.84; 95% CI 0.7 0.92). Higher fertility rates (aRR 2.85; 95% CI: 2.02- 4.00) were found to be a significant risk factor for MMR.
Several key measures of a health system predict mortality in infants, children, and maternal mortality rates at the national level. Improving access to water and sanitation and reducing corruption within the health sector should become priorities.
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Objective: At times, caregivers make life-and-death decisions for loved ones. Yet very little is known about the factors that make caregivers more or less accurate as surrogate decision makers for their loved ones. Previous research suggests that in low stress situations, individuals with high attachment-related anxiety are attentive to their relationship partners' wishes and concerns, but get overwhelmed by stressful situations. Individuals with high attachment-related avoidance are likely to avoid intimacy and stressful situations altogether. We hypothesized that both of these insecure attachment patterns limit surrogates' ability to process distressing information and should therefore be associated with lower accuracy in the stressful task of predicting their loved ones' end-of-life health care wishes. Method: Older patients visiting a medical clinic stated their preferences toward end-of-life health care in different health contexts, and surrogate decision makers independently predicted those preferences. For comparison purposes, surrogates also predicted patients' perceptions of everyday living conditions so that surrogates' accuracy of their loved ones' perceptions in nonstressful situations could be assessed. Results: Surrogates high on either type of insecure attachment dimension were less accurate in predicting their loved ones' end-of-life health care wishes. It is interesting to note that even though surrogates' attachment-related anxiety was associated with lower accuracy of end-of-life health care wishes of their loved ones, it was associated with higher accuracy in the nonstressful task of predicting their loved ones' everyday living conditions. Conclusions: Attachment orientation plays an important role in accuracy about loved ones' end-of-life health care wishes. Interventions may target emotion regulation strategies associated with insecure attachment orientations. (PsycINFO Database Record (c) 2011 APA, all rights reserved).
Author information: IOM (Institute of Medicine) and NRC (National Research Council). (Committee: Goldstein BD, DeSimone JM, Ascher MS, Buehler JW, Cook KS, Crouch NA, Doyle FJ, Foldy S, Gursky EA, Hoffman S, Johnson CB, Keim P, Kellerman AL, Kleinman KP, Layton M, Lee EK, Mayor SD, Moshier TF, Murphy FA, Murray RW, Owens DK, Pollock SM, Resnick IG, Schaudies RP, Schultz JS)
Following the attacks of September 11, 2001 and the anthrax letters, the ability to detect biological threats as quickly as possible became a top priority. In 2003 the Department of Homeland Security (DHS) introduced the BioWatch program--a federal monitoring system intended to speed detection of specific biological agents that could be released in aerosolized form during a biological attack.
The present volume evaluates the costs and merits of both the current BioWatch program and the plans for a new generation of BioWatch devices. BioWatch and Public Health Surveillance also examines infectious disease surveillance through hospitals and public health agencies in the United States, and considers whether BioWatch and traditional infectious disease surveillance are redundant or complementary.
The Sourcebook is the result of ongoing Veterans Health Administration (VHA) efforts aimed at understanding the effects of military service on women’s lives. The first in a series, Sourcebook Vol. 1 describes women Veterans receiving VHA care in Fiscal Year 2009 overall and within key subgroups (by age and by service-connected disability status). It also presents gender comparisons between women and men in FY09. Finally, it presents longitudinal trends in utilization over the decade (FY00–FY09). Future volumes will include information on the use of fee basis care, rural status, race and ethnicity, and diagnoses.
Key findings of Sourcebook Vol. 1 include:
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David A. Relman, M.D., is the Thomas C. and Joan M. Merigan Professor in the Departments of Medicine, and of Microbiology and Immunology at Stanford University, and Chief of Infectious Diseases at the Veterans Affairs Palo Alto Health Care System in Palo Alto, California. He is also Senior Fellow at the Freeman Spogli Institute for International Studies (FSI) at Stanford, and served as science co-director at the Center for International Security and Cooperation at Stanford from 2013-2017. He is currently director of a new Biosecurity Initiative at FSI.
Relman was an early pioneer in the modern study of the human indigenous microbiota. Most recently, his work has focused on human microbial community assembly, and community stability and resilience in the face of disturbance. Ecological theory and predictions are tested in clinical studies with multiple approaches for characterizing the human microbiome. Previous work included the development of molecular methods for identifying novel microbial pathogens, and the subsequent identification of several historically important microbial disease agents. One of his papers was selected as “one of the 50 most important publications of the past century” by the American Society for Microbiology.
Dr. Relman received an S.B. (Biology) from MIT, M.D. from Harvard Medical School, and joined the faculty at Stanford in 1994. He served as vice-chair of the NAS Committee that reviewed the science performed as part of the FBI investigation of the 2001 Anthrax Letters, as a member of the National Science Advisory Board on Biosecurity, and as President of the Infectious Diseases Society of America. He is currently a member of the Intelligence Community Studies Board and the Committee on Science, Technology and the Law, both at the National Academies of Science. He has received an NIH Pioneer Award, an NIH Transformative Research Award, and was elected a member of the National Academy of Medicine in 2011.
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Dr. Babiarz’s research focuses on fertility and family planning programs, infant and maternal health, and the gender dynamics of global health. She has studied human trafficking in China and South East Asia, and currently works on quantitative approaches to issues of human trafficking and child labor in Brazil. Dr. Babiarz specializes in large-scale program evaluations and quasi-experimental study designs. She holds a PhD in Agricultural and Resource Economics from the University of California, Davis (2011).
Most smokers with mental illness do not receive tobacco cessation treatment.
To determine whether integrating smoking cessation treatment into mental health care for veterans with posttraumatic stress disorder (PTSD) improves long-term smoking abstinence rates.
A randomized controlled trial of 943 smokers with military-related PTSD who were recruited from outpatient PTSD clinics at 10 Veterans Affairs medical centers and followed up for 18 to 48 months between November 2004 and July 2009.
Smoking cessation treatment integrated within mental health care for PTSD delivered by mental health clinicians (integrated care [IC]) vs referral to Veterans Affairs smoking cessation clinics (SCC). Patients received smoking cessation treatment within 3 months of study enrollment.
Smoking outcomes included 12-month bioverified prolonged abstinence (primary outcome) and 7- and 30-day point prevalence abstinence assessed at 3-month intervals. Amount of smoking cessation medications and counseling sessions delivered were tested as mediators of outcome. Posttraumatic stress disorder and depression were repeatedly assessed using the PTSD Checklist and Patient Health Questionnaire 9, respectively, to determine if IC participation or quitting smoking worsened psychiatric status.
Integrated care was better than SCC on prolonged abstinence (8.9% vs 4.5%; adjusted odds ratio, 2.26; 95% confidence interval [CI], 1.30-3.91; P = .004). Differences between IC vs SCC were largest at 6 months for 7-day point prevalence abstinence (78/472 [16.5%] vs 34/471 [7.2%], P < .001) and remained significant at 18 months (86/472 [18.2%] vs 51/471 [10.8%], P < .001). Number of counseling sessions received and days of cessation medication used explained 39.1% of the treatment effect. Between baseline and 18 months, psychiatric status did not differ between treatment conditions. Posttraumatic stress disorder symptoms for quitters and nonquitters improved. Nonquitters worsened slightly on the Patient Health Questionnaire 9 relative to quitters (differences ranged between 0.4 and 2.1, P = .03), whose scores did not change over time.
Among smokers with military-related PTSD, integrating smoking cessation treatment into mental health care compared with referral to specialized cessation treatment resulted in greater prolonged abstinence.
clinicaltrials.gov Identifier: NCT00118534.
Background. The optimal community-level approach to control pandemic influenza is unknown. Methods. We estimated the health outcomes and costs of combinations of 4 social distancing strategies and 2 antiviral medication strategies to mitigate an influenza pandemic for a demographically typical US community. We used a social network, agent-based model to estimate strategy effectiveness and an economic model to estimate health resource use and costs. We used data from the literature to estimate clinical outcomes and health care utilization. Results. At 1% influenza mortality, moderate infectivity (R(o) of 2.1 or greater), and 60% population compliance, the preferred strategy is adult and child social distancing, school closure, and antiviral treatment and prophylaxis. This strategy reduces the prevalence of cases in the population from 35% to 10%, averts 2480 cases per 10,000 population, costs $2700 per case averted, and costs $31,300 per quality-adjusted life-year gained, compared with the same strategy without school closure. The addition of school closure to adult and child social distancing and antiviral treatment and prophylaxis, if available, is not cost-effective for viral strains with low infectivity (R(o) of 1.6 and below) and low case fatality rates (below 1%). High population compliance lowers costs to society substantially when the pandemic strain is severe (R(o) of 2.1 or greater). Conclusions. Multilayered mitigation strategies that include adult and child social distancing, use of antivirals, and school closure are cost-effective for a moderate to severe pandemic. Choice of strategy should be driven by the severity of the pandemic, as defined by the case fatality rate and infectivity.