Health Care

Aging Asia: Economic and Social Implications of Rapid Demographic Change in China, Japan, and Korea

Wednesday, February 25, 2009 | 9:00 AM -Wednesday, February 25, 2009 | 5:30 PM

This conference, sponsored by the Asia Health Policy Program at the Walter H. Shorenstein Asia-Pacific Research Center and the Global Aging Program of Stanford Center on Longevity, explored the impact of rapid aging on economic growth, labor markets, social insurance financing, long term care, and health care in China, Japan, and Korea.

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Marcus W. Feldman

428 Herrin Labs
Department of Biological Sciences
Stanford University
Stanford, CA 94305-5020

(650) 725-7727 (650) 725-7745

marc@charles.stanford.edu

Burnet C. and Mildred Finley Wohlford Professor of Biological Sciences

Director of the Morrison Institute for Population and Resource Studies

marcus-feldman_profilephoto.jpeg MS, PhD

Marcus Feldman is the Burnet C. and Mildred Finley Wohlford Professor of Biological Sciences and director of the Morrison Institute for Population and Resource Studies at Stanford University. He uses applied mathematics and computer modeling to simulate and analyze the process of evolution. His specific areas of research include the evolution of complex genetic systems that can undergo both natural selection and recombination, and the evolution of learning as one interface between modern methods in artificial intelligence and models of biological processes, including communication. He also studies the evolution of modern humans using models for the dynamics of molecular polymorphisms, especially DNA variants. He helped develop the quantitative theory of cultural evolution, which he applies to issues in human behavior, and also the theory of niche construction, which has wide applications in ecology and evolutionary analysis. He also has a large research program on demographic issues related to the gender ratio in China.

Feldman is a trustee and member of the science steering committee of the Santa Fe Institute. He is managing editor of Theoretical Population Biology and associate editor of the journals Genetics; Human Genomics; Complexity; the Annals of Human Genetics; and the Annals of Human Biology. He is a former editor of The American Naturalist. He is a fellow of the American Academy of Arts and Sciences and of the California Academy of Science. His work received the "Paper of the Year 2003" award in all of biomedical science from The Lancet. He has written more than 335 scientific papers and four books on evolution, ecology, and mathematical biology. He received a BSc in mathematics and statistics from the University of Western Australia, an MSc in mathematics from Monash University (Australia), and a PhD in mathematical biology from Stanford. He has been a member of the Stanford faculty since 1971.

Stanford Health Policy Associate

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Marcus_Feldman-CV.pdf

Striving for Good Feelings or Averting Bad Ones? The Role of Affective Goals in Health Care Decisions across the Life Span

Read more about Striving for Good Feelings or Averting Bad Ones? The Role of Affective Goals in Health Care Decisions across the Life Span

Previous research suggests that the emotions people value ("ideal affect") can help explain cultural differences in health care preferences. For example, those valuing excitement tend to prefer physicians who promote excitement and medications that induce feelings of excitement. However, the emotions people want to avoid ("avoided affect") may be just as influential, particularly among older adults and East Asian Americans who tend to be motivated more by avoiding (versus approaching) certain outcomes.

Incidental Pulmonary Nodules on Cardiac Computed Tomography: Prognosis and Use

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BACKGROUND: Small asymptomatic lung nodules are found frequently in the course of cardiac computed tomography (CT) scanning. However, the utility of assessing and reporting incidental findings in healthy, asymptomatic subjects is unknown.

METHODS: The sample comprised 1023 60- to 69-year-old subjects free of clinical cardiovascular disease and cancer who participated in the Atherosclerotic Disease, VAscular functioN and genetiC Epidemiology Study. All subjects underwent cardiac CT for determination of coronary calcium between 2001 and 2004, and the first 459 subjects were assessed for incidental pulmonary findings. We used health plan clinical databases to ascertain 24-month health care use and clinical outcomes.

RESULTS: Noncalcified pulmonary nodules were reported in 81 of 459 subjects (18%). Chest CT was performed on 78% of participants in the 24 months after notification, compared with 2.5% in the previous 24 months. Chest x-ray use increased from 28% to 49%. The mean number of chest CT scans per subject was 1.3 (range, 0-5). Although no malignant lesions were diagnosed in the group who had pulmonary findings read, 1 lung cancer case was diagnosed in the group who did not have lung findings read. Among the 63 participants followed up by CT, the original lesion was not identified in 22 participants (35%), the lesion had decreased or remained stable in 39 participants (62%), and there was interval growth in 2 participants (3%).

CONCLUSION: Reporting noncalcified pulmonary nodules resulted in substantial rescanning that overwhelmingly revealed resolution or stability of pulmonary nodules, arguing for benign processes.

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Publication Type

Journal Articles

Publication Date

November 1, 2008

Journal Publisher

American Journal of Medicine

Authors

Mark A. Hlatky

Patient Safety Climate in US hospitals: Variation by Management Level

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BACKGROUND: Strengthening hospital safety culture offers promise for reducing adverse events, but efforts to improve culture may not succeed if hospital managers perceive safety differently from frontline workers.

OBJECTIVES: To determine whether frontline workers and supervisors perceive a more negative patient safety climate (ie, surface features, reflective of the underlying safety culture) than senior managers in their institutions. To ascertain patterns of variation within management levels by professional discipline.

RESEARCH DESIGN: A safety climate survey was administered from March 2004 to May 2005 in 92 US hospitals. Individual-level cross sectional comparisons related safety climate to management level. Hierarchical and hospital-fixed effects modeling tested differences in perceptions.

SUBJECTS: Random sample of hospital personnel (18,361 respondents).

MEASURES: Frequency of responses indicating absence of safety climate (percent problematic response) overall and for 8 survey dimensions.

RESULTS: Frontline workers' safety climate perceptions were 4.8 percentage points (1.4 times) more problematic than were senior managers', and supervisors' perceptions were 3.1 percentage points (1.25 times) more problematic than were senior managers'. Differences were consistent among 7 safety climate dimensions. Differences by management level depended on discipline: senior manager versus frontline worker discrepancies were less pronounced for physicians and more pronounced for nurses, than they were for other disciplines.

CONCLUSIONS: Senior managers perceived patient safety climate more positively than nonsenior managers overall and across 7 discrete safety climate domains. Patterns of variation by management level differed by professional discipline. Continuing efforts to improve patient safety should address perceptual differences, both among and within groups by management level.

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Publication Type

Journal Articles

Publication Date

November 1, 2008

Journal Publisher

Medical Care

Authors

Sara J. Singer

Laurence C. Baker

External URL

http://www.lww-medicalcare.com/pt/re/medcare/pdfhandler.00005650-200811000-0000…

Transforming Preconceptional, Prenatal, and Interconceptional Care into a Comprehensive Commitment to Women's Health

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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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Publication Type

Journal Articles

Publication Date

November 1, 2008

Journal Publisher

Women's Health Issues

Authors

Paul H. Wise

External URL

http://download.journals.elsevierhealth.com/pdfs/journals/1049-3867/PIIS1049386…

Private Providers and Public-Private Partnerships in Health: Asia in Comparative Perspective

Tuesday, January 27, 2009 | 12:00 PM -Tuesday, January 27, 2009 | 1:15 PM

Dr. Forsberg will present findings from studies in China and Vietnam and put those findings into a broader comparative perspective regarding the future role of the private sector in improving health service delivery and population health.

Birger Carl Forsberg is a public health specialist and lecturer in International Health at the Karolinska Institute in Stockholm, Sweden from where he holds an MD and a PhD. He is also trained in economics and has health economics as one of his areas of work. Dr Forsberg has more than 20 years experience from international health from around 25 low- and middle-income countries as an adviser to bilateral donors and international organisations. Since 2002 he has been a consultant to the World Bank on public private sector collaboration in health. He is also coordinator since 2002 of a joint Harvard-Karolinska research programme called Private Sector Programme in Health (PSP). The programme has coordinated studies of the private health sector in five countries in Asia and Africa. In his talk Dr Forsberg will present findings from PSP studies in China and Vietnam and put those findings into a broader perspective on the future role of the private sector in health service delivery for increased access to health services and improved health.

Philippines Conference Room

Birger Carl Forsberg, MD Private Sector Program in Health Coordinator Speaker Karolinska Institutet, Sweden

Seminars

Is American Health Care Uniquely Inefficient?

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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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Publication Type

Journal Articles

Publication Date

October 1, 2008

Journal Publisher

Journal of Economic Perspectives

Authors

External URL

http://www.aeaweb.org/articles.php?doi=10.1257/jep.22.4.27

Front-line Staff Perspectives on Opportunities for Improving the Safety and Efficiency of Hospital Work Systems

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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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Publication Type

Journal Articles

Publication Date

October 1, 2008

Journal Publisher

Health Services Research

Authors

Sara J. Singer

Cost-Effectiveness of HIV Monitoring Strategies in Resource-Limited Settings

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Background: Although the number of infected people receiving highly active anti-retroviral therapy (HAART) in low- and middle- income countries increased dramatically, optimal disease management is not well defined.

Methods: We developed a model to compare the costs and benefits of three types of Human Immunodeficiency Virus monitoring strategies: symptom-based strategies, CD4-based strategies, and CD4 plus viral load strategies for starting, switching, and stopping HAART. We used clinical and cost data from southern Africa and performed a cost-effectiveness analysis. All assumptions were tested in sensitivity analyses.

Results: Compared to the symptom-based approaches, monitoring CD4 every 6 months and starting treatment at a threshold of 200 cells/μl was associated with a life expectancy gain of 6.5 months (61.9 vs. 68.4) and a discounted lifetime cost savings of $464 per person (4,069 vs. 3,605 discounted 2007 USD). CD4-based strategies where treatment was started at the higher threshold of 350 cells/μl provided an additional life expectancy gain of 5.3 months at a cost effectiveness of $107 per life-year gained compared to a threshold of 200 cells/μl. Monitoring viral load with CD4 was more expensive than monitoring CD4 alone, added 2.0 months of life, and had an incremental cost-effectiveness ratio of $5,414/life-year gained relative to monitoring CD4 counts. In sensitivity analyses, the cost-savings from CD4 monitoring compared to symptom-based approaches was sensitive to cost of inpatient care, and the cost-effectiveness of viral load monitoring was influenced by the per-test costs and rates of virologic failure.

Conclusions: Use of CD4 monitoring and early HAART initiation in southern Africa provides large health benefits relative to symptom-based approaches for HAART management. In southern African countries with relatively high costs of hospitalization, CD4 monitoring would likely reduce total health care expenditures. The cost-effectiveness of viral load monitoring depends on test prices and rates of virologic failure.

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Publication Type

Journal Articles

Publication Date

September 22, 2008

Journal Publisher

Archives of Internal Medicine

Authors

Eran Bendavid