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.
As India's middle class has expanded, the nation's public health concerns have shifted. Obesity rates have risen, coinciding with a surge in diabetes. The number of Indians with type 2 diabetes is expected to double by 2030 to nearly 80 million. Meanwhile, 43 percent of children in India are underweight.
Study objective: We describe the availability of preventive health services in US emergency departments (EDs), as well as ED directors' preferred service and perceptions of barriers to offering preventive services.
Methods: Using the 2007 National Emergency Department Inventory (NEDI)-USA, we randomly sampled 350 (7%) of 4,874 EDs. We surveyed directors of these EDs to determine the availability of
ED directors were asked to select the service they would most like to implement and to rate 5 potential barriers to offering preventive services.
Results: Two hundred seventy-seven EDs (80%) responded across 46 states. Availability of services ranged from 66% for intimate partner violence screening to 19% for HIV screening. ED directors wanted to implement primary care linkage most (17%) and HIV screening least (2%). ED directors "agreed/strongly agreed" that the following are barriers to ED preventive care: cost (74%), increased patient length of stay (64%), lack of follow-up (60%), resource shifting leading to worse patient outcomes (53%), and philosophical opposition (27%).
Conclusion: Most US EDs offer preventive services, but availability and ED director preference for type of service vary greatly. The maj ority of EDs do not routinely offer Centers for Disease Control and Prevention- recommended HIV screening. Most ED directors are not philosophically opposed to offering preventive services but are concerned with added costs, effects on ED operations, and potential lack of follow- up.
With the awareness of maternal depression as a prevalent public health issue and its important link to child physical and mental health, attention has turned to how healthcare providers can respond effectively. Intimate partner violence (IPV) and the use of alcohol, tobacco, and other drugs are strongly related to depression, particularly for low-income women. The American College of Obstetricians and Gynecologists (ACOG) recommends psychosocial screening of pregnant women at least once per trimester, yet screening is uncommonly done. Research suggests that a collaborative care approach improves identification, outcomes, and cost-effectiveness of care. This article presents The Perinatal Mental Health Model, a community-based model that developed screening and referral partnerships for use in community obstetric settings in order to specifically address the psychosocial needs of culturally diverse, low-income mothers.
Objectives: Emergency departments (EDs) are increasingly proposed as high-yield venues for providing preventive health education to a population at risk for unhealthy behaviors and unmet primary care needs. This study sought to determine the preferred health education topics and teaching modality among ED patients and visitors.
Methods: For two 24-hour periods, patients aged 18 years and older presenting to four Boston EDs were consecutively enrolled, and waiting room visitors were surveyed every 3 hours. The survey assessed interest in 28 health conditions and topics, which were further classified into nine composite health education categories. Also assessed was the participants' preferred teaching modality.
Results: Among 1,321 eligible subjects, 1,010 (76%) completed the survey, of whom 56% were patients and 44% were visitors. Among the health conditions, respondents were most interested in learning about stress and depression (32%). Among the health topics, respondents were most interested in exercise and nutrition (43%). With regard to learning modality, 34% of subjects chose brochures/book, 25% video, 24% speaking with an expert, 14% using a computer, and 3% another mode of learning (e.g., a class). Speaking with an expert was the overall preferred modality for those with less than high school education and Hispanics, as well as those interested in HIV screening, youth violence, and stroke. Video was the preferred modality for those interested in learning more about depression, alcohol, drugs, firearm safety, and smoke detectors.
Conclusions: Emergency department patients and visitors were most interested in health education on stress, depression, exercise, and nutrition, compared to topics more commonly targeted to the ED population such as substance abuse, sexual health (including HIV testing), and injury prevention. Despite many recent innovations in health education, most ED patients and visitors in our study preferred the traditional form of books and brochures. Future ED health education efforts may be optimized by taking into account the learning preferences of the target ED population.
We examined military-related sexual trauma among deployed Operation Enduring Freedom and Operation Iraqi Freedom veterans. Of 125 729 veterans who received Veterans Health Administration primary care or mental health services, 15.1% of the women and 0.7% of the men reported military sexual trauma when screened. Military sexual trauma was associated with increased odds of a mental disorder diagnosis, including posttraumatic stress disorder, other anxiety disorders, depression, and substance use disorders. Sexual trauma is an important postdeployment mental health issue in this population.
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.
The world of genomics is transforming medicine, and is likely to influence the future development of new drugs, diagnostics, and vaccines. To date, the greater focus of genomics and medicine has been on conditions affecting resourcewealthy settings, primarily involving scientists and companies in those settings. However, we believe that it is possible to expand genomics into a more global technology that can also focus on diseases of resource-limited settings. This goal can be achieved if genomics is made a global priority. We feel one way to move in this direction is through a comprehensive approach to infectious diseases-i.e., an Infectious Disease Genomics Project-that would mirror the Human Genome Project. Without an active, unified effort specifically focused on allowing actors at any level to participate in the genomics revolution, infectious diseases that primarily affect the poor will likely not achieve the same level of scientifici advancement as diseases affecting the wealthy.
Background: Decisions on the timing and extent of vaccination against pandemic (H1N1) 2009 virus are complex.
Objective: To estimate the effectiveness and cost-effectiveness of pandemic influenza (H1N1) vaccination under different scenarios in October or November 2009.
Design: Compartmental epidemic model in conjunction with a Markov model of disease progression.
Data Sources: Literature and expert opinion.
Target Population: Residents of a major U.S. metropolitan city with a population of 8.3 million.
Time Horizon: Lifetime.
Perspective: Societal.
Interventions: Vaccination in mid-October or mid-November 2009.
Outcome Measures: Infections and deaths averted, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness.
Results of Base-Case Analysis: Assuming each primary infection causes 1.5 secondary infections, vaccinating 40% of the population in October or November would be cost-saving. Vaccination in October would avert 2051 deaths, gain 69 679 QALYs, and save $469 million compared with no vaccination; vaccination in November would avert 1468 deaths, gain 49 422 QALYs, and save $302 million.
Results of Sensitivity Analysis: Vaccination is even more cost-saving if longer incubation periods, lower rates of infectiousness, or increased implementation of nonpharmaceutical interventions delay time to the peak of the pandemic. Vaccination saves fewer lives and is less cost-effective if the epidemic peaks earlier than mid-October.
Limitations: The model assumed homogenous mixing of case-patients and contacts; heterogeneous mixing would result in faster initial spread, followed by slower spread. Additional costs and savings not included in the model would make vaccination more cost-saving.
Conclusion: Earlier vaccination against pandemic (H1N1) 2009 prevents more deaths and is more cost-saving. Complete population coverage is not necessary to reduce the viral reproductive rate sufficiently to help shorten the pandemic.
Primary Funding Source: Agency for Healthcare Research and Quality and National Institute on Drug Abuse.
Background: The pandemic potential of influenza A (H5N1) virus is a prominent public health concern of the 21st century.
Objective: To estimate the effectiveness and cost-effectiveness of alternative pandemic (H5N1) mitigation and response strategies.
Design: Compartmental epidemic model in conjunction with a Markov model of disease progression.
Data Sources: Literature and expert opinion.
Target Population: Residents of a U.S. metropolitan city with a population of 8.3 million.
Time Horizon: Lifetime.
Perspective: Societal.
Interventions: 3 scenarios: 1) vaccination and antiviral pharmacotherapy in quantities similar to those currently available in the U.S. stockpile (stockpiled strategy), 2) stockpiled strategy but with expanded distribution of antiviral agents (expanded prophylaxis strategy), and 3) stockpiled strategy but with adjuvanted vaccine (expanded vaccination strategy). All scenarios assumed standard nonpharmaceutical interventions.
Outcome Measures: Infections and deaths averted, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness.
Results of Base-Case Analysis: Expanded vaccination was the most effective and cost-effective of the 3 strategies, averting 68% of infections and deaths and gaining 404 030 QALYs at $10 844 per QALY gained relative to the stockpiled strategy.
Results of Sensitivity Analysis: Expanded vaccination remained incrementally cost-effective over a wide range of assumptions.
Limitations: The model assumed homogenous mixing of cases and contacts; heterogeneous mixing would result in faster initial spread, followed by slower spread. We did not model interventions for children or older adults; the model is not designed to target interventions to specific groups.
Conclusion: Expanded adjuvanted vaccination is an effective and cost-effective mitigation strategy for an influenza A (H5N1) pandemic. Expanded antiviral prophylaxis can help delay the pandemic while additional strategies are implemented.
Primary Funding Source: National Institutes of Health and Agency for Healthcare Research and Quality.
Context: The aging of the baby boom generation, the extension of life, and progressive increases in disability-free life expectancy have generated a dramatic demographic transition in the United States. Official government forecasts may, however, have inadvertently underestimated life expectancy, which would have major policy implications, since small differences in forecasts of life expectancy produce very large differences in the number of people surviving to an older age. This article presents a new set of population and life expectancy forecasts for the United States, focusing on transitions that will take place by midcentury.
Methods: Forecasts were made with a cohort-components methodology, based on the premise that the risk of death will be influenced in the coming decades by accelerated advances in biomedical technology that either delay the onset and age progression of major fatal diseases or that slow the aging process itself.
Findings: Results indicate that the current forecasts of the U.S. Social Security Administration and U.S. Census Bureau may underestimate the rise in life expectancy at birth for men and women combined, by 2050, from 3.1 to 7.9 years.
Conclusions: The cumulative outlays for Medicare and Social Security could be higher by $3.2 to $8.3 trillion relative to current government forecasts. This article discusses the implications of these results regarding the benefits and costs of an aging society and the prospect that health disparities could attenuate some of these changes.