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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The availability of computed tomography (CT) and magnetic resonance imaging (MRI) scanning has grown rapidly, but the value of increased availability is not clear. We document the relationship between CT and MRI availability and use, and we consider potentially important sources of benefits. We discuss key questions that need to be addressed if value is to be well understood. In an example we study, expanded imaging may be valuable because it provides quicker access to more precise diagnostic information, although evidence for improved health outcomes is limited. This may be a common situation; thus, a particularly important question is how non-health-outcome benefits of imaging can be quantified.

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Journal Articles
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Health Affairs (Project Hope)
Authors
Laurence C. Baker
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Preconception and interconception care respond to the growing body of evidence that many of the most important determinants of birth outcomes may exist before pregnancy occurs. In this sense, the strategy of extending prenatal care into the preconception and interconception periods marks a useful step in reforming the public health approach to improving birth outcomes. However, although helpful in underscoring the continuity of risk that can ultimately find expression in adverse birth outcomes, the concern is that without greater critical attention these relatively new care constructs have the potential to undermine rather than strengthen a comprehensive system of women's health care.

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Journal Articles
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Women's Health Issues
Authors
Paul H. Wise
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BACKGROUND: Diabetes mellitus is common, costly, and increasingly prevalent. Despite innovations in therapy, little is known about patterns and costs of drug treatment.

METHODS: We used the National Disease and Therapeutic Index to analyze medications prescribed between 1994 and 2007 for all US office visits among patients 35 years and older with type 2 diabetes. We used the National Prescription Audit to assess medication costs between 2001 and 2007.

RESULTS: The estimated number of patient visits for treated diabetes increased from 25 million (95% confidence interval [CI], 23 million to 27 million) in 1994 to 36 million (95% CI, 34 million to 38 million) by 2007. The mean number of diabetes medications per treated patient increased from 1.14 (95% CI, 1.06-1.22) in 1994 to 1.63 (1.54-1.72) in 2007. Monotherapy declined from 82% (95% CI, 75%-89%) of visits during which a treatment was used in 1994 to 47% (43%-51%) in 2007. Insulin use decreased from 38% of treatment visits in 1994 to a nadir of 25% in 2000 and then increased to 28% in 2007. Sulfonylurea use decreased from 67% of treatment visits in 1994 to 34% in 2007. By 2007, biguanides (54% of treatment visits) and glitazones (thiazolidinediones) (28%) were leading therapeutic classes. Increasing use of glitazones, newer insulins, sitagliptin phosphate, and exenatide largely accounted for recent increases in the mean cost per prescription ($56 in 2001 to $76 in 2007) and aggregate drug expenditures ($6.7 billion in 2001 to $12.5 billion in 2007).

CONCLUSIONS: Increasingly complex and costly diabetes treatments are being applied to an increasing population. The magnitude of these rapid changes raises concerns about whether these more costly therapies will result in proportionately improved outcomes.

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Journal Articles
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Journal Publisher
Archives of Internal Medicine
Authors
Randall S. Stafford

Department of Health Research and Policy
HRP Redwood Building, Room T223
Stanford University School of Medicine
Stanford, CA 94305-5405

(650) 723-6854 (650) 725-6951
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Associate Professor of Health Research and Policy (Epidemiology)
lorene-nelson-20.jpg PhD, MS
Associate Director of the Center for Population Health Sciences
Stanford Health Policy Associate

Office of Public Health Surveillance & Research
VA Palo Alto Health Care System
3801 Miranda Ave. (132)
Palo Alto, California 94304-5107

holodniy@stanford.edu

(650) 852-3408 (650) 858-3978
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Professor of Medicine, Stanford University School of Medicine
holodniy_mark_9-19-16.jpg MD, FACP, FIDSA

Dr. Holodniy is Professor of Medicine (Infectious Diseases & Geographic Medicine) at Stanford University and has been a full time employee of the Department of Veterans Affairs (VA) for over 25 years. He has been national director of Public Health Surveillance and Research (PHSR) in VA since 1999, which is a national program office based at the VA Palo Alto Health Care System (VAPAHCS). His current VA responsibilities include public health surveillance, conducting outbreak and large-scale lookback investigations within VA, and directing the VA Public Health Reference Laboratory (PHRL). PHRL is a national VA laboratory, aligned with CDC and the Laboratory Response Network (LRN), which supports clinical care and public health investigations utilizing state-of-the-art diagnostic microbiology methods and equipment. He also serves as the hospital epidemiologist and staff infectious disease physician for the VAPAHCS. Previously, he directed pharmacy services at the VAPAHCS from 1996-1999, the HIV clinical program at VAPAHCS from 1991-2011, and was the acting director of the VA Cooperative Studies Program Coordinating Center at VAPAHCS from 2007-2009, where he oversaw a portfolio of several multicenter VA studies and the VA DNA Bank Genomics Program.

His research program focuses on viral evolution, microbial development of drug resistance, clinical trial evaluation of novel diagnostics and antimicrobial compounds, and evaluation of clinical outcomes associated with infectious diseases. In that capacity, Dr. Holodniy has overseen the conduct of over 80 clinical and diagnostic assay trials at VAPAHCS since 1991. He has also mentored many infectious disease fellows, graduate students, and Epidemic Intelligence Service (EIS) officers, in collaboration with CDC.

 

Stanford Health Policy Associate

700 Welch Road Suite #225
Palo Alto, California 94304

(650) 736-0629 (650) 497-8465
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Professor of Pediatrics, Stanford University School of Medicine
Medical Director at the Center for Quality and Clinical Effectiveness at Lucile Packard Children’s Hospital Stanford
Chief Clinical Patient Safety Officer at Lucile Packard Children’s Hospital Stanford
Sharek_Paul10-08-08.jpg MD, MPH

Paul graduated from Columbia University Medical School in New York, completed residency and chief residency in pediatrics at the University of California, San Francisco, received a Masters of Public Health from University of California, Berkeley and completed a fellowship in health services research at Stanford University.

Paul is presently a Professor of Pediatrics at Stanford University, a pediatric hospitalist, and is the creator and Medical Director of the LPCH Center for Quality and Clinical Effectiveness and Chief Clinical Patient Safety Officer at Lucile Packard Children’s Hospital. Paul is presently the Director of Quality Improvement for the California Perinatal Quality of Care Collaborative (CPQCC), is a founding and current member of the Solutions for Patient Safety Clinical Steering Committee, and is on the Strategic Planning Committee for Quality and Patient Safety for CHA (Children’s Hospital Association). In 2013, Paul was awarded the inaugural Paul V. Miles Fellow in Quality Improvement from the American Board of Pediatrics, an Award bestowed on individuals who have “dedicated themselves to quality improvement and demonstrated accomplishments leading to better healthcare for children”. Paul is presently an investigator or co-investigator on numerous grants focused on pediatric patient safety. Most recently, Paul has dedicated his research and administrative efforts to translating the tenets of high reliability organization theory into healthcare, and is partnering with human factors engineers to translate “design thinking” into the healthcare industry to accelerate patient safety and quality improvement. Paul has given a substantial number of presentations at national and international academic meetings related to quality of care and patient safety and is a faculty member of the Institute for Healthcare Improvement (IHI). Paul has been a visiting professor on quality/patient safety at numerous children’s hospitals across the world including Great Ormond Street Hospital for Children in London, The Hospital for Sick Kids in Toronto, The Children’s Hospital of Eastern Ontario in Ottawa, and several national children’s hospitals including, Children’s National Hospital in Washington DC, Morgan Stanley Children’s Hospital of Columbia University, Children’s Hospital of Los Angeles, Children’s Hospital of Colorado, St Louis Children’s Hospital, Nationwide Children’s Hospital, and St Jude Children’s Research Hospital. Paul has published extensively on the topics of pediatric quality of care and patient safety, including a Nov 2007 study correlating a Rapid Response Team intervention with decreased mortality in JAMA, and a Nov 2010 study on adverse events over time in the New England Journal of Medicine, and is recognized internationally as a thought leader in the area of pediatric quality and patient safety.

Stanford Health Policy Associate
CV
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The U.S. health system has been described as the most competitive, heterogeneous, inefficient, fragmented, and advanced system of care in the world. In this paper, we consider two questions: First, is the U.S. healthcare system productively efficient relative to other wealthy countries, in the sense of producing better health for a given bundle of hospital beds, physicians, nurses, and other factor inputs? Second, is the United States allocatively efficient relative to other countries, in the sense of providing highly valued care to consumers? For both questions, the answer is most likely no. Although no country can claim to have eliminated inefficiency, the United States has high administrative costs, fragmented care, and stands out with regard to heterogeneity in treatment because of race, income, and geography. The U.S. healthcare system is also more likely to pay for diagnostic tests, treatments, and other forms of care before effectiveness is established and with little consideration of the value they provide. A number of proposed reforms that are designed to ameliorate shortcomings of the U.S. healthcare system, such as quality improvement initiatives and coverage expansions, are unlikely by themselves to reduce expenditures. Addressing allocative inefficiency is a far more difficult task but central to controlling costs.

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Journal Articles
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Journal of Economic Perspectives
Authors
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OBJECTIVE: To contrast the safety-related concerns raised by front-line staff about hospital work systems (operational failures) with national patient safety initiatives.

DATA SOURCES: Primary data included 1,732 staff-identified operational failures at 20 U.S. hospitals from 2004 to 2006.

STUDY DESIGN: Senior managers observed front-line staff and facilitated open discussion meetings with employees about their patient safety concerns.

DATA COLLECTION: Hospitals submitted data on the operational failures identified through managers' interactions with front-line workers. Data were analyzed for type of failure and frequency of occurrence. Recommendations from staff were compared with recommendations from national initiatives.

PRINCIPAL FINDINGS: The two most frequent categories of operational failures, equipment/supplies and facility issues, posed safety risks and diminished staff efficiency, but have not been priorities in national initiatives.

CONCLUSIONS: Our study suggests an underutilized strategy for improving patient safety and staff efficiency: leveraging front-line staff experiences with work systems to identify and address operational failures. In contrast to the perceived tradeoff between safety and efficiency, fixing operational failures can yield benefits for both. Thus, prioritizing improvement of work systems in general, rather than focusing more narrowly on specific clinical conditions, can increase safety and efficiency of hospitals.

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Journal Articles
Publication Date
Journal Publisher
Health Services Research
Authors
Sara J. Singer

Landau Economics Bldg, Room 230
Stanford, CA 94305-6015

(650) 725-1870
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Assistant Professor of Economics
CHP/PCOR Affiliate
CDDRL Affiliated Faculty

Seema Jayachandran is an assistant professor in the Department of Economics at Stanford University. She is also a Faculty Research Fellow at the National Bureau of Economic Research (NBER) and a Research Affiliate of the Bureau for Research and Economic Analysis of Development (BREAD), Centre for Economic Policy Research (CEPR), and Stanford Center for International Development (SCID).

Her research focuses on microeconomic issues in developing countries, including health, education, labor markets, and political economy. Her work has been published in the American Economic Review ("Odious Debt," on sovereign debt incurred by dictators), Journal of Political Economy ("Selling Labor Low," on labor market risk in India), and the Quarterly Journal of Economics ("Life Expectancy and Human Capital Investments," on increased education caused by declines in maternal mortality in Sri Lanka), and other journals. Her current projects are based in India, Nepal, and Zimbabwe.

She also works on social issues in the United States. Previously she was a Robert Wood Johnson Scholar in Health Policy Research at the University of California, Berkeley. She also worked as a management consultant with McKinsey & Company in San Francisco. She earned a PhD and master's degree from Harvard University, a master's degree from the University of Oxford where she was a Marshall Scholar, and a bachelor's degree from MIT.

CV
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