Peter will discuss work at SRI and the University of Cambridge under two projects currently funded by DARPA, relating to clean-slate architectures for hardware, software, networking, and clouds, aimed at higher-assurance security, resilience, evolvability, and other critical requirements.
Two papers provide some early views of the ongoing work:
http://www.csl.sri.com/neumann/law10.pdf
http://www.csl.sri.com/neumann/2012resolve-cheri.pdf
Peter G. Neumann (Neumann@CSL.sri.com) has doctorates from Harvard and Darmstadt. After 10 years at Bell Labs in Murray Hill, New Jersey, in the 1960s, during which he was heavily involved in the Multics development jointly with MIT and Honeywell, he has been in SRI's Computer Science Lab since September 1971. He is concerned with computer systems and networks, trustworthiness/dependability, high assurance, security, reliability, survivability, safety, and many risks-related issues such as election-system integrity, crypto applications and policies, health care, social implications, and human needs -- especially those including privacy. He is currently PI on two DARPA projects: clean-slate trustworthy hosts for the CRASH program with new hardware and new software, and clean-slate networking for the Mission-oriented Resilient Clouds program. He moderates the ACM Risks Forum, has been responsible for CACM's Inside Risks columns monthly from 1990 to 2007, tri-annually since then, chairs the ACM Committee on Computers and Public Policy, and chairs the National Committee for Voting Integrity (http://www.votingintegrity.org). He created ACM SIGSOFT's Software Engineering Notes in 1976, was its editor for 19 years, and still contributes the RISKS section. He is on the editorial board of IEEE Security and Privacy. He has participated in four studies for the National Academies of Science: Multilevel Data Management Security (1982), Computers at Risk (1991), Cryptography's Role in Securing the Information Society (1996), and Improving Cybersecurity for the 21st Century: Rationalizing the Agenda (2007). His 1995 book, Computer-Related Risks, is still timely. He is a Fellow of the ACM, IEEE, and AAAS, and is also an SRI Fellow. He received the National Computer System Security Award in 2002 and the ACM SIGSAC Outstanding Contributions Award in 2005. He is a member of the U.S. Government Accountability Office Executive Council on Information Management and Technology, and the California Office of Privacy Protection advisory council. In 2012, he was elected to the newly created National Cybersecurity Hall of Fame as one of the first set of inductees. He co-founded People For Internet Responsibility. He has taught courses at Darmstadt, Stanford, U.C. Berkeley, and the University of Maryland. See his website (http://www.csl.sri.com/neumann) for testimonies for the U.S. Senate and House and California state Senate and Legislature, papers, bibliography, further background, etc.
CISAC Conference Room
Controversy surrounds the role of the private sector in health service delivery, including primary care and population health services. China’s recent health reforms call for non-discrimination against private providers and emphasize strengthening primary care, but formal contracting-out initiatives remain few, and the associated empirical evidence is very limited. This paper presents a case study of contracting with private providers for urban primary and preventive health services in Shandong Province, China. The case study draws on three primary sources of data: administrative records; a household survey of over 1600 community residents in Weifang and City Y; and a provider survey of over 1000 staff at community health stations (CHS) in both Weifang and City Y. We supplement the quantitative data with one-on-one, in-depth interviews with key informants, including local officials in charge of public health and government finance.
We find significant differences in patient mix: Residents in the communities served by private community health stations are of lower socioeconomic status (more likely to be uninsured and to report poor health), compared to residents in communities served by a government-owned CHS. Analysis of a household survey of 1013 residents shows that they are more willing to do a routine health exam at their neighborhood CHS if they are of low socioeconomic status (as measured either by education or income). Government and private community health stations in Weifang did not statistically differ in their performance on contracted dimensions, after controlling for size and other CHS characteristics. In contrast, the comparison City Y had lower performance and a large gap between public and private providers. We discuss why these patterns arose and what policymakers and residents considered to be the main issues and concerns regarding primary care services.
Private providers; Contracting; Ownership; Primary care; Prevention; China
Objective To examine the relationship between hospital volume and in-hospital adverse events. Data Sources Patient safety indicator (PSI) was used to identify hospital-acquired adverse events in the Nationwide Inpatient Sample database in abdominal aortic aneurysm, coronary artery bypass graft, and Roux-en-Y gastric bypass from 2005 to 2008. Study Design In this observational study, volume thresholds were defined by mean year-specific terciles. PSI risk-adjusted rates were analyzed by volume tercile for each procedure. Principal Findings Overall, hospital volume was inversely related to preventable adverse events. High-volume hospitals had significantly lower risk-adjusted PSI rates compared to lower volume hospitals (p <.05). Conclusion These data support the relationship between hospital volume and quality health care delivery in select surgical cases. This study highlights differences between hospital volume and risk-adjusted PSI rates for three common surgical procedures and highlights areas of focus for future studies to identify pathways to reduce hospital-acquired events. © Health Research and Educational Trust.
Patient safety is a national priority. Patient Safety Indicators (PSIs) monitor potential adverse events during hospital stays. Surgical specialty PSI benchmarks do not exist, and are needed to account for differences in the range of procedures performed, reasons for the procedure, and differences in patient characteristics. A comprehensive profile of adverse events in vascular surgery was created.
The Nationwide Inpatient Sample was queried for 8 vascular procedures using ICD-9-CM codes from 2005 to 2009. Factors associated with PSI development were evaluated in univariate and multivariate analyses.
A total of 1,412,703 patients underwent a vascular procedure and a PSI developed in 5.2%. PSIs were more frequent in female, nonwhite patients with public payers (p < 0.01). Patients at mid and low-volume hospitals had greater odds of developing a PSI (odds ratio [OR] = 1.17; 95% CI, 1.10-1.23 and OR = 1.69; 95% CI, 1.53-1.87). Amputations had highest PSI risk-adjusted rate and carotid endarterectomy and endovascular abdominal aortic aneurysm repair had lower risk-adjusted rate (p < 0.0001). PSI risk-adjusted rate increased linearly by severity of patient indication: claudicants (OR = 0.40; 95% CI, 0.35-0.46), rest pain patients (OR = 0.78; 95% CI, 0.69-0.90), ulcer (OR = 1.20; 95% CI, 1.07-1.34), and gangrene patients (OR = 1.85; 95% CI, 1.66-2.06).
Patient safety events in vascular surgery were high and varied by procedure, with amputations and open abdominal aortic aneurysm repair having considerably more potential adverse events. PSIs were associated with black race, public payer, and procedure indication. It is important to note the overall higher rates of PSIs occurring in vascular patients and to adjust benchmarks for this surgical specialty appropriately.
Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
On October 30, the Program on Human Rights (PHR) at Stanford's Center on Democracy, Development and the Rule of Law (CDDRL) held a day-long conference to examine health and human rights. The conference was held to discuss how a rights-based approach to health services can impact the delivery of effective health interventions and advance other socio-economic and cultural rights in developing regions. The conference titled, “Why We Should Care: Health and Human Rights” was divided into five panels with presenters from diverse backgrounds and professions including lawyers, doctors, public health experts, students and activists.
The Program:
The conference started with a welcoming address by Helen Stacy, director of the Program on Human Rights. CDDRL Director Larry Diamond introduced the keynote speaker Paul H. Wise, professor of child health and society and pediatrics at Stanford University’s School of Medicine, and director of the Center for Policy, Outcomes and Prevention. Wise's opening remarks began on a somber note, “The language of rights means very little to a child stillborn, an infant dying in pain from pneumonia or a child desiccated by famine.” In his address, Wise emphasized the need for an aligned and integrated rights-based approach that does not undermine effective and efficient medical interventions. “We need to fill the gap between the worlds of child health and child rights so that our programs and policies are both effective and just,” he stressed.
Following the keynote address, the conference presenters shared their work according to a geographic or thematic focus. The first panel brought together three generations of speakers from Stanford - a faculty member, a pre-doctoral fellow and a recent graduate - in a unique opportunity to share ideas and discuss possibilities of health work in Africa. Rebecca Walker, clinical instructor in emergency medicine at Stanford School of Medicine, presented her impressions and reactions on Mindy Roseman’s study of forced sterilization in Namibia. Roseman, academic director of the Human Rights Program and lecturer on law at Harvard Law School, was unable to attend due to flight complications after hurricane Sandy hit the East Coast.
Eric Kramon, 2011-2012 pre-doctoral fellow at CDDRL, spoke about the political sources of ethnic inequality in health outcomes in Africa. Kramon’s work in Kenya illustrated how politics plays a determinant role in ethnic inequalities and consequently in access to health and health outcomes. Jeffrey Tran, a 2011 Stanford graduate in human biology, described the vision behind the launch of the Project of Emergency First Aid Responder in Western Cape Province, South Africa that he helped implement. Tran explained, “Individuals and communities are an integral part of the solution and we work with the communities to develop first aid training programs that are taught and eventually run by community members.”
Panel two was dedicated to the health impact of drones in Pakistan and in Gaza. Based on research by the Stanford International Clinic on Human Rights and Conflict Negotiation in Pakistan, Professor James Cavallaro and Stanford law school student Omar Shakir, explained that drones are not only responsible for deaths of civilians but also constitute a constant disturbance to social life and mental health of ordinary people, including their relations with children and the elderly. Drones impact other rights as well - such as the right to education - as children are prevented from attending schools for fear of drone strikes. Rajaie S. Batniji, resident physician in internal medicine at Stanford and a CDDRL affiliate, explained the clinical diagnosis of traumatic disorders that result from constant surveillance and insecurity. He cited the work of Jonathan Mann in defining dignity and the devastating effects on physical, mental, and social well-being when these senses are violated. Batniji explained that populations in Gaza are prevented from living life with dignity and respect because they live under constant threat to their security and intrusion into their homes and communications.
Vivek Srinivasan, manager of the Program on Liberation Technology at CDDRL, presented his experience on the Right to Food Campaign in India. He believes that this campaign has led to the mobilization for rights and the provision of services. “Not all demands are confrontational. Communities begin demanding something that is perceived as small in scope but have ramifications that extend to other rights such as the right to education, the right to housing and the right to work.” According to Srinivasan, the Right to Food Campaign in India has had a tremendous impact in putting hunger on the policy agenda. Suchi Pande, an activist-researcher who worked on the Right to Information Campaign in India for over seven years and was the secretary for the National Campaign for People’s Right to Information from 2006 to 2008, supported Srinivasan’s argument of strong correlation in achievements and right-based mobilization. However, Pande pointed out that despite successes in the Right to Food Campaign, other economic and social rights including the right to health in India continues to be a non-issue for politicians and the government. She is optimistic and believes that rural public hearings, the role of the right to information and its supporting mechanisms will facilitate access to public health in rural India.
In panel four, Sarah MacCarthy showed results that suggest that counseling and testing services for HIV-positive pregnant women remain limited, insufficient or lacking in quality in Salvador, Brazil. “While Brazil’s HIV/AIDS program has been internationally acclaimed, national practice still fails to meet national and global guidelines,” she explained. Calling attention to the regional discrepancies in the HIV/AIDS policy and program implementation in Brazil, Nadejda Marques, manager of the Program on Human Rights at CDDRL,, expressed concerns about the implementation of an HIV/AIDS program in a context of limited resources. “In Angola, counseling and voluntary testing units for HIV/AIDS don’t have drinking water or sanitary conditions to receive patients. They lack basic equipment for testing and data collection, there is a generalized shortage of doctors, and health care providers have no specific training on HIV/AIDS.” Despite this alarming situation, Marques explained that advocating for the rights of persons living with HIV/AIDS in Angola has put in evidence the failure of a heath system unable to provide even the most basic services to its population and has enabled mobilization in a context where human rights are routinely violated.
Ami Laws, adjunct associate professor of medicine at Stanford, described how a physician can provide services in collaboration with the judicial system to advance human rights. Laws is an expert witness on cases of torture survivors that require asylum status in the U.S. and has worked mainly with victims of torture in the Punjab region in India. Everaldo Lamprea, a JSD candidate at Stanford Law School and an assistant professor at Los Andes Law School in Bogotá, Colombia, spoke about his recent comparative study on health litigation in low and middle-income countries. The escalation of right-to-health litigation in these countries can have unexpected and harmful consequences to healthcare reforms and the enforceability of the right to health. In part, this is because significant financial resources are allocated to the litigation processes and not to the health system. In addition, while litigation can highlight gaps that exist in the health system that need regulation, countries have been very slow to adapt and adjust to these signals.
Next Steps:
A number of key ideas, questions and insights emerged from the conference including:
. How to identify an effective intervention that will also mobilize communities to advocate for its implementation?
. How to provide services to the more vulnerable populations without alienating a contingent that has access to basic health care services?
. What instruments can be used to share best practices among national healthcare systems?
. How do global priorities adapt to contexts of limited financial resources and human capital?
. How can punctual achievements in rights that guarantee access to health be expanded for the achievement of other social, economic and cultural rights?
The Program on Human Rights at CDDRL will continue to pursue a research agenda examining health and human rights following the conference and announced that it will be the thematic focus of the Sanela Diana Jenkins Speakers Series in 2014. The PHR is also actively seeking support for research projects that include a right to health component at the core of its academic investigation for the 2012-2013 academic year.
BACKGROUND: Emergency department (ED) ward admissions subsequently transferred to the intensive care unit (ICU) within 24 hours have higher mortality than direct ICU admissions.
DESIGN, SETTING, PATIENTS: Describe risk factors for unplanned ICU transfer within 24 hours of ward arrival from the ED.
METHODS: Evaluation of 178,315 ED non-ICU admissions to 13 US community hospitals. We tabulated the outcome of unplanned ICU transfer by patient characteristics and hospital volume. We present factors associated with unplanned ICU transfer after adjusting for patient and hospital differences in a hierarchical logistic regression.
RESULTS: There were 4252 (2.4%) non-ICU admissions transferred to the ICU within 24 hours. Admitting diagnoses most associated with unplanned transfer, listed by descending prevalence were: pneumonia (odds ratio [OR] 1.5; 95% confidence interval [CI] 1.2–1.9), myocardial infarction (MI) (OR 1.5; 95% CI 1.2–2.0), chronic obstructive pulmonary disease (COPD) (OR 1.4; 95% CI 1.1–1.9), sepsis (OR 2.5; 95% CI 1.9–3.3), and catastrophic conditions (OR 2.3; 95% CI 1.7–3.0). Other significant predictors included: male sex, Comorbidity Points Score >145, Laboratory Acute Physiology Score
Inflammatory bowel diseases are costly chronic gastrointestinal diseases. We aimed to determine whether immediate colectomy with ileal pouch-anal anastamosis (IPAA) after diagnosis of severe ulcerative colitis (UC) was cost-effective compared to the standard medical therapy.
We created a Markov model simulating 2 cohorts of 21-year-old patients with severe UC, following them until 100 years of age or death, comparing early colectomy with IPAA strategy to the standard medical therapy strategy. Deterministic and probabilistic analyses were performed.
Standard medical care accrued a discounted lifetime cost of $236,370 per patient. In contrast, early colectomy with IPAA accrued a discounted lifetime cost of $147,763 per patient. Lifetime quality-adjusted life-years gained (QALY-gained) for standard medical therapy was 20.78, while QALY-gained for early colectomy with IPAA was 20.72. The resulting incremental cost-effectiveness ratio (Δcosts/ΔQALY) was approximately $1.5 million per QALY-gained. Results were robust to one-way sensitivity analyses for all variables in the model. Quality-of-life after colectomy with IPAA was the most sensitive variable impacting cost-effectiveness. A low utility value of less than 0.7 after colectomy with IPAA was necessary for the colectomy with IPAA strategy to be cost-ineffective.
Under the appropriate clinical settings, early colectomy with IPAA after diagnosis of severe UC reduces health care expenditures and provides comparable quality of life compared to exhaustive standard medical therapy.