Featured Publications

In this JAMA Health Forum commentary, SHP's Michelle Mello and colleagues argue that the $1.7 trillion omnibus bill that Congress passed in December 2022 responds to several urgent public health needs, yet only narrowly addresses some of the critical determinants of pandemic preparedness.

Objective: To evaluate the cost effectiveness of California's statewide perinatal quality collaborative for reducing severe maternal morbidity (SMM) from hemorrhage.

Results: The collaborative was cost effective, exhibiting strong dominance when compared with the baseline or standard of care. In a theoretical cohort of 480,000 births, collaborative implementation added 182 QALYs (0.000379/birth) by averting 913 cases of SMM, 28 emergency hysterectomies, and one maternal mortality. Additionally, it saved $9 million ($17.78/birth) due to averted SMM costs. Although sensitivity analyses across parameter uncertainty ranges provided cases where the intervention was not cost saving, it remained cost effective throughout all analyses. Additionally, scenario-based sensitivity analysis found the intervention cost effective regardless of birth volume and implementation costs.

Abstract

Low rates of vaccination, emergence of novel variants of SARS-CoV-2, and increasing transmission relating to seasonal changes and relaxation of mitigation measures leave many US communities at risk for surges of COVID-19 that might strain hospital capacity, as in previous waves. The trajectories of COVID-19 hospitalizations differ across communities depending on their age distributions, vaccination coverage, cumulative incidence, and adoption of risk mitigating behaviors. Yet, existing predictive models of COVID-19 hospitalizations are almost exclusively focused on national- and state-level predictions. This leaves local policymakers in urgent need of tools that can provide early warnings about the possibility that COVID-19 hospitalizations may rise to levels that exceed local capacity. In this work, we develop a framework to generate simple classification rules to predict whether COVID-19 hospitalization will exceed the local hospitalization capacity within a 4- or 8-week period if no additional mitigating strategies are implemented during this time. This framework uses a simulation model of SARS-CoV-2 transmission and COVID-19 hospitalizations in the US to train classification decision trees that are robust to changes in the data-generating process and future uncertainties. These generated classification rules use real-time data related to hospital occupancy and new hospitalizations associated with COVID-19, and when available, genomic surveillance of SARS-CoV-2. We show that these classification rules present reasonable accuracy, sensitivity, and specificity (all ≥ 80%) in predicting local surges in hospitalizations under numerous simulated scenarios, which capture substantial uncertainties over the future trajectories of COVID-19. Our proposed classification rules are simple, visual, and straightforward to use in practice by local decision makers without the need to perform numerical computations.

The COVID-19 pandemic spurred a rapid expansion of wastewater-based infectious disease surveillance systems to monitor and anticipate disease trends in communities.The Centers for Disease Control and Prevention (CDC) launched the National Wastewater Surveillance System in September 2020 to help coordinate and build upon those efforts. Produced at the request of CDC, this report reviews the usefulness of community-level wastewater surveillance during the pandemic and assesses its potential value for control and prevention of infectious diseases beyond COVID-19.

Objective: To develop a measure for fair inclusion in pivotal trials by assessing transparency and representation of enrolled women, older adults (aged 65 years and older), and racially and ethnically minoritized patients.

Federal courts in Texas are fast becoming known as the graveyards of U.S. health policies.1 Decisions concerning a range of statutes, from the Affordable Care Act (ACA) to the Emergency Medical Treatment and Labor Act, have chipped away at federal powers to protect the public’s health. The latest case in this series, Braidwood Management Inc. v. Becerra,2 targets the ACA’s use of U.S. Preventive Services Task Force (USPSTF) recommendations as a basis for mandating insurance coverage for preventive care. The Braidwood decision not only destabilizes efforts to ensure access to essential insurance benefits but also illustrates an emerging strategy among litigants with antiregulatory agendas: wielding heretofore sleepy doctrines of administrative and constitutional law to undercut health initiatives.

In this cross-sectional study of nearly 800,000 U.S. participants aged 5 to 17 years with family income under 200% of the federal poverty threshold, researchers found that higher family income was significantly associated with a lower prevalence of diagnosed infections, mental health disorders, injury, asthma, anemia, and substance use disorders and lower 10-year mortality. Read the full original investigation in JAMA.

During the first year of the pandemic, East Asian countries have reported fewer infections, hospitalizations, and deaths from COVID-19 disease than most countries in Europe and the Americas. Our goal in this paper is to generate and evaluate hypothesis that may explain this striking fact. We consider five possible explanations: (1) population age structure (younger people tend to have less severe COVID-19 disease upon infection than older people); (2) the early adoption of lockdown strategies to control disease spread; (3) genetic differences between East Asian population and European and American populations that confer protection against COVID-19 disease; (4) seasonal and climactic contributors to COVID-19 spread; and (5) immunological differences between East Asian countries and the rest of the world. The evidence suggests that the first four hypotheses are unlikely to be important in explaining East Asian COVID-19 exceptionalism. Lockdowns, in particular, fail as an explanation because East Asian countries experienced similarly good infection outcomes despite vast differences in lockdown policies adopted by different countries to control the COVID-19 epidemic. The evidence to date is consistent with our fifth hypothesis – pre-existing immunity unique to East Asia – but there are still essential parts of this story left for scientists to check.

Abstract

This paper analyzes the impact of paid family leave (PFL) policies in California, New Jersey, and New York on the labor market and mental health outcomes of individuals whose spouses or children experience health shocks. We use data from the 1996-2019 restricted-use version of the Medical Expenditure Panel Survey (MEPS), which provides state of residence and the precise timing of hospitalizations and surgeries, our health shock measures. We use difference-in-difference and event-study models to compare the differences in post-health-shock labor market and mental health outcomes between spouses and parents before and after PFL implementation relative to analogous differences in states with no change in PFL access. We find that PFL access leads to a 7.0 percentage point decline in the likelihood that the (healthy) wives of individuals with medical conditions or limitations who experience a hospitalization or surgery report “leaving a job to care for home or family” in the post-health-shock rounds. Impacts of PFL access on women's mental health outcomes and on men whose spouses have health shocks are more mixed, and we find no effects on parents of children with health shocks. Lastly, we show that improvements in job continuity are concentrated among caregivers with 12 or fewer years of education, suggesting that government-provided PFL might reduce disparities in leave access.

Importance  Statin-associated muscle symptoms (SAMS) are common and may lead to discontinuation of indicated statin therapy. Observational studies suggest that vitamin D therapy is associated with reduced statin intolerance, but no randomized studies have been reported.

Objective  To test whether vitamin D supplementation was associated with prevention of SAMS and a reduction of statin discontinuation.

We evaluated the protection conferred by mRNA vaccines and previous infection against infection with the omicron variant in two high-risk populations: residents and staff in the California state prison system. We used a retrospective cohort design to analyze the risk of infection during the omicron wave using data collected from December 24, 2021, through April 14, 2022. Weighted Cox models were used to compare the effectiveness (measured as 1 minus the hazard ratio) of vaccination and previous infection across combinations of vaccination history (stratified according to the number of mRNA doses received) and infection history (none or infection before or during the period of B.1.617.2 [delta]–variant predominance). A secondary analysis used a rolling matched-cohort design to evaluate the effectiveness of three vaccine doses as compared with two doses.

We use linked administrative data that combines the universe of California birth records, hospitalizations, and death records with parental income from Internal Revenue Service tax records and the Longitudinal Employer-Household Dynamics file to provide novel evidence on economic inequality in infant and maternal health. We find that birth outcomes vary nonmonotonically with parental income, and that children of parents in the top ventile of the income distribution have higher rates of low birth weight and preterm birth than those in the bottom ventile. However, unlike birth outcomes, infant mortality varies monotonically with income, and infants of parents in the top ventile of the income distribution---who have the worst birth outcomes---have a death rate that is half that of infants of parents in the bottom ventile. When studying maternal health, we find a similar pattern of non-monotonicity between income and severe maternal morbidity, and a monotonic and decreasing relationship between income and maternal mortality. At the same time, these disparities by parental income are small when compared to racial disparities, and we observe virtually no convergence in health outcomes across racial and ethnic groups as income rises. Indeed, infant and maternal health in Black families at the top of the income distribution is markedly worse than that of white families at the bottom of the income distribution.Lastly, we benchmark the health gradients in California to those in Sweden, finding that infant and maternal health is worse in California than in Sweden for most outcomes throughout the entire income distribution.

Men living alone may have particular difficulty in managing chronic medical conditions. Anticoagulation control, a sensitive indicator of self-management, was significantly worse among men living alone.

We use linked survey and administrative data to document and decompose the striking differences across demographic groups in both economic and health impacts of the first year of the COVID-19 pandemic in the United States. The impacts of the pandemic on all-cause mortality and on employment were concentrated in the same racial, ethnic, and education groups, with non-White individuals and those without a college degree experiencing higher excess all-cause mortality as well as a greater employment loss. Observable differences in living arrangements and the nature of work – which likely affected exposure to the virus and to economic contractions – can explain 15 percent of the Hispanic-White difference in excess mortality, almost one-quarter of the non- Hispanic Black-White difference, and almost half of the difference between those with and without a Bachelor’s degree; they can also explain 35 to 40 percent of the differences in economic damages between these groups. These findings underscore the importance of non-medical factors in contributing to the disparate impacts of public health shocks.

Abstract

Professions play a key role in determining the division of labor and the returns to skilled work. This paper studies the productivity difference between physicians and nurse practitioners (NPs), two health care professions performing overlapping tasks but with stark differences in background, training, and pay. Using data from the Veterans Health Administration and quasi-experimental variation in the patient probability of being treated by physicians versus NPs in the emergency department, we find that, compared to physicians, NPs significantly increase resource utilization but achieve worse patient outcomes. We find evidence suggesting mechanisms relating to lower human capital among NPs relative to physicians and worker-task assignment responding to the lower skill of NPs. Counterfactual analysis suggests a net increase in medical costs with NPs, even when accounting for NPs’ wages that are half as much as physicians’. Despite large productivity differences between professions, we find even larger productivity differences within professions and substantial productivity overlap between professions. Yet there is little overlap in wages between NPs and physicians and, within professions, no significant correlation between productivity and wages.

Background

A population health approach to depression screening using patient portals may be a promising strategy to proactively engage and identify patients with depression.

In this JAMA Forum article by Stanford Health Policy's Michelle Mello, the professor of health policy and law writes that reports are mounting of pregnant patients being denied potentially lifesaving care in emergency departments.

ABSTRACT

Child servitude is a form of economic exploitation of children around the world. We examine this phenomenon with local specificity, in Liberia, where it represents a perennial failure of the government to protect children, who are among its most vulnerable citizens. Despite its persistence and high prevalence, child servitude has not been the focus of academic research on Liberia. This paper explores the interplay of transmuted American chattel slavery and indigenous specific Liberian cultural practices of human subjugation against a backdrop of socio-economic inequalities, and their linkages to contemporary child servitude in postwar Liberia. We discuss the impacts of child servitude on victims and recommend policy measures to protect the rights of Liberian children. If postwar Liberia is to achieve its pro-poor developmental agenda, policies must be formulated that address child servitude and other forms of exploitation against Liberian children.

The U.S. Centers for Disease Control and Prevention (CDC) is responsible for preventing the introduction, transmission, and spread of communicable diseases into the United States. It does this primarily through the Division of Global Migration and Quarantine (DGMQ), which oversees the federal quarantine station network. Over the past two decades, the frequency and volume of microbial threats worldwide have continued to intensify. The COVID-19 pandemic, in particular, has prompted a reevaluation of many of our current disease control mechanisms, including the use and role of quarantine as a public health tool.

The emergence of COVID-19 prompted CDC to request that the National Academies of Sciences, Engineering, and Medicine convene a committee to assess the role of DGMQ and the federal quarantine station network in mitigating the risk of onward communicable disease transmission in light of changes in the global environment, including large increases in international travel, threats posed by emerging infections, and the movement of animals and cargo. The committee was also tasked with identifying how lessons learned during COVID-19 and other public health emergencies can be leveraged to strengthen pandemic response. The report's findings and recommendations span five domains: organizational capacity, disease control and response efforts, new technologies and data systems, coordination and collaboration, and legal and regulatory authority.

Abstract

Decision models can combine information from different sources to simulate the long-term consequences of alternative strategies in the presence of uncertainty. A cohort state-transition model (cSTM) is a decision model commonly used in medical decision making to simulate the transitions of a hypothetical cohort among various health states over time. This tutorial focuses on time-independent cSTM, in which transition probabilities among health states remain constant over time. We implement time-independent cSTM in R, an open-source mathematical and statistical programming language. We illustrate time-independent cSTMs using a previously published decision model, calculate costs and effectiveness outcomes, and conduct a cost-effectiveness analysis of multiple strategies, including a probabilistic sensitivity analysis. We provide open-source code in R to facilitate wider adoption. In a second, more advanced tutorial, we illustrate time-dependent cSTMs.

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Millions of Americans may have asked themselves these questions, or versions of them—especially in the wake of horrific mass shootings like those in Buffalo and Uvalde. Record-breaking spikes in gun sales over the last two years, alongside surveys indicating that self-protection continues to be the dominant reason for buying guns, underscore a widely-held belief that a gun in the home has security benefits.

A new study from my research team, recently published in the Annals of Internal Medicine, shows no such benefits. We found the opposite: people living in homes with guns face substantially higher risks of being fatally assaulted.

 Is operating overnight associated with worse outcomes for surgical procedures performed by the attending surgeon the subsequent day? In this cross-sectional study of 498,234 daytime operations performed by 1,131 surgeons at 20 US institutions, there was no significant association between operating the previous night and the incidence of in-hospital death or major complications (sepsis, pneumonia, myocardial infarction, thromboembolic event, or stroke) for daytime operations performed the subsequent day. After adjusting for confounders, the incidence of death or major complications was 5.89% among daytime operations when the attending surgeon operated the night before compared with 5.87% among daytime operations when the attending surgeon did not. These findings suggest that operating overnight does not appear to be associated with worse outcomes when the attending surgeon continues to operate the next day.

Does the risk of suicide change for women when someone they live with in a previously handgun-free household lawfully acquires a handgun? In this retrospective cohort study of 9.5 million women living in handgun-free homes, the suicide rate increased substantially after a cohabitant acquired a handgun compared with the rate among women whose cohabitants never acquired handguns. The increased rate of suicide was entirely from excess of firearm suicides.The findings suggest that the rate of suicide for women living in handgun-free homes increased significantly after an adult they lived with became a handgun owner.