Health and Medicine

FSI’s researchers assess health and medicine through the lenses of economics, nutrition and politics. They’re studying and influencing public health policies of local and national governments and the roles that corporations and nongovernmental organizations play in providing health care around the world. Scholars look at how governance affects citizens’ health, how children’s health care access affects the aging process and how to improve children’s health in Guatemala and rural China. They want to know what it will take for people to cook more safely and breathe more easily in developing countries.

FSI professors investigate how lifestyles affect health. What good does gardening do for older Americans? What are the benefits of eating organic food or growing genetically modified rice in China? They study cost-effectiveness by examining programs like those aimed at preventing the spread of tuberculosis in Russian prisons. Policies that impact obesity and undernutrition are examined; as are the public health implications of limiting salt in processed foods and the role of smoking among men who work in Chinese factories. FSI health research looks at sweeping domestic policies like the Affordable Care Act and the role of foreign aid in affecting the price of HIV drugs in Africa.

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When Former New York City Mayor Michael Bloomberg took a stand on sugary drinks, banning large sizes to encourage moderation, his efforts were met with some applause—but also with jeers of derision, one New York Post headline dubbing him the “Soda Jerk.”

But with one third of the nation’s adult population considered obese, and alarming evidence about the health dangers and economic toll of obesity, research on ways to slim America’s collective waistband is sorely needed.  

Stepping back from the frenzy, faculty and students at Stanford Law School are digging into the issue to try to tease out the data and offer an unbiased empirical view. 

Last spring, Jordan Flanders, JD ’15, worked with Michelle Mello (BA ’93) and David Studdert, two members of Stanford Law’s health law faculty, on a research paper that analyzed legal, economic, and political issues raised by sugary drink laws in different countries, explaining five major categories of regulations (taxes, government procurement regulations, school-based regulations, advertising restrictions, and labeling rules) and parsing out the biggest challenges to implementing each. The result, “Searching for Public Health Law’s Sweet Spot: The Regulation of Sugar-Sweetened Beverages,” was published in July in PLoS Medicine, a highly regarded international medical journal, and went a long way to inform the debate. 

Stanford has taken the need for lawyers working in the critical area of health law seriously. Mello and Studdert, both professors of law with joint appointments with the medical school, were hired in the last two years. They joined Hank Greely, Deane F. and Kate Edelman Johnson Professor of Law, and Daniel Kessler, professor of law—increasing to four the number of faculty who are fully focused on health law. They are joined by half a dozen law faculty whose scholarship often touches on diverse subjects such as psychology, drug regulation, and environmental issues at this intersection of law.

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"Preventing Cardiovascular Disease: Pathways through Diagnostic Testing, Clinical Guidelines, and Patient Decision Making"

 

Please note: All research in progress seminars are off-the-record. Any information about methodology and/or results is embargoed until publication.

 

Abstract

Cardiovascular disease is the leading cause of death in the United States and consumes 17% of our national healthcare expenditures. Diagnostic testing in clinical settings—particularly for coronary heart disease—and incorporation of economic evidence into professional society guidelines represent underdeveloped opportunities to catalyze adoption of preventive health measures. Financial incentives that influence patient decision-making may also be an effective tool to increase adoption of preventive health measures, and we are currently testing their effectiveness and return on investment in high-risk, hospitalized smokers.

Joseph Ladapo New York University
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Abstract

 

PURPOSE:

To evaluate the academic advancement and productivity of Department of Veterans Affairs Health Services Research and Development (HSR&D) Career Development Award (CDA) program recipients, National Institutes of Health (NIH) K awardees in health services research (HSR), and Agency for Healthcare Research and Quality (AHRQ) K awardees.

METHOD:

In all, 219 HSR&D CDA recipients from fiscal year (FY) 1991 through FY2010; 154 NIH K01, K08, and K23 awardees FY1991-FY2010; and 69 AHRQ K01 and K08 awardees FY2000-FY2010 were included. Most data were obtained from curricula vitae. Academic advancement, publications, grants, recognition, and mentoring were compared after adjusting for years since award, and personal characteristics, training, and productivity prior to the award.

RESULTS:

No significant differences emerged in covariate-adjusted tenure-track academic rank, number of grants as primary investigator (PI), major journal articles as first/sole author, Hirsch h-index scores, likelihood of a journal editorship position or membership in a major granting review panel, or mentoring postgraduate researchers between the HSR&D CDA and NIH K awardees from FY1991-FY2010, or among the three groups of awardees from FY2000 or later. Among those who reported grant funding levels, HSR&D CDAs from FY1991-2010 had been PI on more grants of $100,000 than NIH K awardees. HSR&D CDAs had a higher mean number of major journal articles than NIH K awardees from FY1991-2010.

CONCLUSIONS:

Findings show that all three HSR career development programs are successfully selecting and mentoring awardees, ensuring additional HSR capacity to improve the quality and delivery of high-value care.

 

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Academic Medicine
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Douglas K. Owens
Ruth C. Cronkite
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“Improving Symptoms and Quality of Life in Chronic Heart Failure”

 

Please note: All research in progress seminars are off-the-record. Any information about methodology and/or results is embargoed until publication.

 

*Please note the irregular time for this seminar*

 

Abstract

David Bekelman, MD, MPH is a visiting lecturer at Stanford University and the VA Palo Alto Health Care System.  He is an Associate Professor of Medicine and Nursing at the University of Colorado Anschutz Medical Campus.  Dr. Bekelman is a board-certified internist, psychiatrist, and palliative care specialist. In this talk, he will present his research related to measuring and improving quality of life, testing novel health care delivery interventions, and behavioral clinical trials.  He will describe his ongoing research that is examining ways to integrate palliative and psychosocial care into the primary care setting.  These interventions expand the “reach” of palliative care by combining training of nurses and social workers in basic palliative care with case review by palliative care specialists.  He will also discuss how his team has managed challenges in recruiting ill patients and their family caregivers into research, coordinating care, and integrating specialist care in the patient-centered medical home.

David Bekelman
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Charlotte J. Haug
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In August 2015, the publisher Springer retracted 64 articles from 10 different subscription journals “after editorial checks spotted fake email addresses, and subsequent internal investigations uncovered fabricated peer review reports,” according to a statement on their website. The retractions came only months after BioMed Central, an open-access publisher also owned by Springer, retracted 43 articles for the same reason.

Charlotte J. Haug, MD, PhD, a visiting scholar at Stanford Health Policy, writes in this New England Journal of Medicine perspective that the pressure to publish is huge for scientists, what with rewards such as promotions and financial incentives. This is leading to a growing number of cases of plagiarism and errors.

"The pressure to publish is huge for scientists everywhere, and the competition for space in the best journals harder than ever," she tells Stanford Health Policy. "One reason for this is the rapidly increasing amount of research and number of researchers coming from emerging economies like Brazil, India, Turkey and China — to mention a few. When the rewards for publishing is also very high (promotion, money), one might be more willing to take some short-cuts to get published." Haug, who was the editor-in-chief of The Journal of the Norwegian Medical Association and is a international correspondent for the New England Journal, said that as long as authors are rewarded for publishing many articles, and editors are rewarded for publishing them rapidly, new ways of gaming the traditional publication models will be invented more quickly than new control measures can be put in place. "Science is a collaborative endeavor," she said. "Not only in the sense that most scientific papers have a number of authors, but also in the sense that all science builds on previous science. One — or more — bad apple can have tremendously negative effects by leading other researchers in the wrong direction, wasting their time or directly harming for example patients that get the wrong treatment." You can read her full commentary here
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Medical School Office Building
1265 Welch Road
Stanford, CA 94305

(650) 725-7747
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Assistant Professor of Medicine
r01palhsm07.r01.med_.va_.govhomedirvhapalzulmadmy_documentsmy_picturesdonna_zulman037_12-13-11.jpg MD, MS

Donna Zulman, MD, MS, is an assistant professor in the Division of General Medical Disciplines at Stanford University, and an investigator at the Center for Innovation to Implementation (Ci2i) in the VA Palo Alto Health Care System. Dr. Zulman received her MD from the University of California, Los Angeles. After completing a residency in Internal Medicine at the University of Michigan, she received a Masters in Health and Health Care Research through the Robert Wood Johnson Clinical Scholars Program at the University of Michigan and the Ann Arbor VA.

Dr. Zulman's research focuses on improving health care delivery for patients with multiple chronic conditions and complex medical and social needs, and optimizing health-related technology to personalize care and improve outcomes for high-risk patients. Dr. Zulman is currently supported by a VA Health Services Research & Development Career Development Award.

Physician Investigator at the VA Palo Alto Health Care System
(650) 725-3894
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Professor, Health Policy
Professor, Law
mello-scott_macdonald-profile.jpg JD, PhD

Michelle Mello is Professor of Law at Stanford Law School and Professor of Health Policy in the Department of Health Policy at Stanford University School of Medicine.  She conducts empirical research into issues at the intersection of law, ethics, and health policy.  She is the author of more than 230 articles on medical liability, public health law, the public health response to COVID-19, pharmaceuticals and vaccines, biomedical research ethics and governance, health information privacy, and other topics.
 
The recipient of a number of awards for her research, Dr. Mello was elected to the National Academy of Medicine at the age of 40.  From 2000 to 2014, she was a professor at the Harvard School of Public Health, where she directed the School’s Program in Law and Public Health.
 
Dr. Mello teaches courses in torts, public health law, and health policy.  She holds a J.D. from the Yale Law School, a Ph.D. in Health Policy and Administration from the University of North Carolina at Chapel Hill, an M.Phil. from Oxford University, where she was a Marshall Scholar, and a B.A. from Stanford University. 

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Background

Since its founding in 2002, the Global Fund to Fight AIDS, Tuberculosis, and Malaria (Global Fund) has become the dominant multilateral health financier in low- and middle-income countries. The health impact of the Global Fund remains unknown because existing evaluations measure intermediate outcomes or do not account for preexisting and counterfactual trends.

Methods

We conducted an econometric analysis of data from all countries eligible to receive Global Fund grants from 1995 to 2010, prior to and during the Global Fund’s activities. We analyzed three outcomes: all-cause adult (15–59 years), all-cause under-five, and malaria-specific under-five mortality. Our main exposure was a continuous longitudinal measure of Global Fund disbursements per capita. We used panel fixed effect regressions, and analyzed mortality trends controlling for health spending, health worker density (a measure of health system capacity), gross domestic product, urbanization, and country fixed-effects.

Results and discussion

We find that following Global Fund disbursements, adult mortality rate declined by 1.4 % per year faster with every $10 per capita increase in disbursements (p = 0.005). Similarly, malaria-specific under-five mortality declined by 6.9 % per year faster (p = 0.033) with every $10 high per capita Global Fund disbursements. However, we find no association between Global Fund support and all-cause under-five mortality. These findings were consistent after subanalyses by baseline HIV prevalence, adjusting for effects of concurrent health aid from other donors, and varying time lags between funding and mortality changes.

Conclusions

Grants from the Global Fund are closely related to accelerated reductions in all-cause adult mortality and malaria-specific under-five mortality. However, up to 2010 the Global Fund has not measurably contributed to reducing all-cause under-five mortality.

 

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BMC Public Health
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Eran Bendavid
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Background

Demographic and socioeconomic changes such as increasing urbanization, migration, and female education shape population health in many low- and middle-income countries. These changes are rarely reflected in computational epidemiological models, which are commonly used to understand population health trends and evaluate policy interventions. Our goal was to create a “backbone” simulation modeling approach to allow computational epidemiologists to explicitly reflect changing demographic and socioeconomic conditions in population health models.

Methods

We developed, evaluated, and “open-sourced” a generalized approach to incorporate longitudinal, commonly available demographic and socioeconomic data into epidemiological simulations, illustrating the feasibility and utility of our approach with data from India. We constructed a series of nested microsimulations of increasing complexity, calibrating each model to longitudinal sociodemographic and vital registration data. We then selected the model that was most consistent with the data (i.e., greater accuracy) while containing the fewest parameters (i.e., greater parsimony). We validated the selected model against additional data sources not used for calibration.

Results

We found that standard computational epidemiology models that do not incorporate demographic and socioeconomic trends quickly diverged from past mortality and population size estimates, while our approach remained consistent with observed data over decadal time courses. Our approach additionally enabled the examination of complex relations between demographic, socioeconomic and health parameters, such as the relationship between changes in educational attainment or urbanization and changes in fertility, mortality, and migration rates.

Conclusions

Incorporating demographic and socioeconomic trends in computational epidemiology is feasible through the “open source” approach, and could critically alter population health projections and model-based evaluations of health policy interventions in unintuitive ways.

 

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Population Health Metrics
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Jeremy Goldhaber-Fiebert
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Most Americans will get at least one faulty diagnosis in their lifetime, sometimes with devastating consequences. “Urgent change is warranted to address this challenge,” according to a recent landmark report from the Institute of Medicine.

The September report, by a committee of medical experts, found that despite dramatic improvements in patient safety over the last 15 years, diagnostic errors have been the critical blind spot of health-care providers.

Kathryn McDonald, executive director of Stanford’s Center for Health Policy/Center for Primary Care and Outcomes Research, is a member of the committee that wrote the report, “Improving Diagnosis in Health Care.”

We ask McDonald Five Questions about the report’s findings and also got her suggestions for limiting one of the most overlooked health-care dilemmas today. You can read her responses here on the Stanford Medicine news center website.

Read more here about the report when it came out last month.

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