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As promised during his campaign, and under pressure from many quarters, President-elect Barack Obama may seek badly needed changes in the way the United States finances and delivers health care. Responding to public interest and perceived need, several previous presidents have attempted to enact some kind of national health insurance: Harry Truman in the 1940s, Richard Nixon in the 1970s, and most recently Bill Clinton in the 1990s. These attempts went nowhere. In pursuing comprehensive health care reform, President-elect Obama should be aware of four major reasons why, in the past, we heard so much talk and saw so little action.

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New England Journal of Medicine
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This issue of CHP/PCOR's Quarterly Update covers news from the Fall 2007 quarter and includes articles about:

  • the 2007 Eisenberg Legacy Lecture event, featuring CHP/PCOR core faculty member Victor R. Fuchs;
  • annual meeting and conference coverage, including the Society for Medical Decision Meeting's Annual Meeting, and the Freeman Spogli Institute for International Studies conference;
  • two Research in Brief selections -- one highlights differences in gender use care in the VA system, and the second examines health risk assessment tools;
  • how the Geriatrics Research team at the VA is using informatics to improve quality of health care;
  • international health features from the field and from a research perspective;
  • a Q & A with senior scholar Dena M. Bravata, who led a popular pedometer that received lots of media attention in past months.

The newsletter also contains various other news items that may be of interest to our readers.

Note to the reader:

The newsletter is fully-navigational. Any text that is surrounded by a dashed box is clickable and will allow the reader to navigate the newsletter more efficiently. The end of each article contains a special symbol (§) that, when clicked, will take the reader back to the table of contents. Please feel free to contact Amber Hsiao with any questions.

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Quarterly Update
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Abstract

The authors examined how the association between quality improvement (QI) implementation in hospitals and hospital clinical quality is moderated by hospital organizational and environmental context. The authors used Ordinary Least Squares regression analysis of 1,784 community hospitals to model seven quality indicators as a function of four measures of QI implementation and a variety of control variables. They found that forces that are external and internal to the hospital condition the impact of particular QI activities on quality indicators: specifically data use, statistical tool use, and organizational emphasis on Continuous Quality Improvement (CQI). Results supported the proposition that QI implementation is unlikely to improve quality of care in hospital settings without a commensurate fit with the financial, strategic, and market imperatives faced by the hospital.

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Hospital Topics
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Laurence C. Baker
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Background
In populations with chronic illness, outcomes improve with the use of care models that integrate clinical information, evidence-based treatments, and proactive management of care. Health information technology is believed to be critical for efficient implementation of these chronic care models. Health care organizations have implemented information technologies, such as electronic medical records, to varying degrees. However, considerable uncertainty remains regarding the relative impact of specific informatics technologies on chronic illness care.
Objective
To summarize knowledge and increase expert consensus regarding informatics components that support improvement in chronic illness care. Design: A systematic review of the literature was performed. “Use case” models were then developed, based on the literature review, and guidance from clinicians and national quality improvement projects. A national expert panel process was conducted to increase consensus regarding information system components that can be used to improve chronic illness care.
Results
The expert panel agreed that informatics should be patient-centered, focused on improving outcomes, and provide support for illness self-management. They concurred that outcomes should be routinely assessed, provided to clinicians during the clinical encounter, and used for population-based care management. It was recommended that interactive, sequential, disorder-specific treatment pathways be implemented to quickly provide clinicians with patient clinical status, treatment history, and decision support.
Conclusions
Specific informatics strategies have the potential to improve care for chronic illness. Software to implement these strategies should be developed, and rigorously evaluated within the context of organizational efforts to improve care.
Electronic supplementary material
Supplementary material is available for this article at doi: 10.1007/s11606-007-0303-4.
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Journal of General Internal Medicine
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Mary K. Goldstein
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Black patients receiving dialysis for end-stage renal disease in the United States have lower mortality rates than white patients. Whether racial differences exist in mortality after acute renal failure is not known. We studied acute renal failure in patients hospitalized between 2000 and 2003 using the Nationwide Inpatient Sample and found that black patients had an 18% (95% confidence interval [CI] 16 to 21%) lower odds of death than white patients after adjusting for age, sex, comorbidity, and the need for mechanical ventilation. Similarly, among those with acute renal failure requiring dialysis, black patients had a 16% (95% CI 10 to 22%) lower odds of death than white patients. In stratified analyses of patients with acute renal failure, black patients had significantly lower adjusted odds of death than white patients in settings of coronary artery bypass grafting, cardiac catheterization, acute myocardial infarction, congestive heart failure, pneumonia, sepsis, and gastrointestinal hemorrhage. Black patients were more likely than white patients to be treated in hospitals that care for a larger number of patients with acute renal failure, and black patients had lower in-hospital mortality than white patients in all four quartiles of hospital volume. In conclusion, in-hospital mortality is lower for black patients with acute renal failure than white patients. Future studies should assess the reasons for this difference.

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J Am Soc Nephrol
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OBJECTIVES: We sought to determine the prevalence of HIV in both inpatient and outpatient settings in 6 Department of Veterans Affairs (VA) health care sites. METHODS: We collected demographic data and data on comorbid conditions and then conducted blinded, anonymous HIV testing. We conducted a multivariate analysis to determine predictors of HIV infection. RESULTS: We tested 4500 outpatient blood specimens and 4205 inpatient blood specimens; 326 (3.7%) patients tested positive for HIV. Inpatient HIV prevalence ranged from 1.2% to 6.9%; outpatient HIV prevalence ranged from 0.9% to 8.9%. Having a history of hepatitis B or C infection, a sexually transmitted disease, or pneumonia also predicted HIV infection. The prevalence of previously undocumented HIV infection varied from 0.1% to 2.8% among outpatients and from 0.0% to 1.7% among inpatients. CONCLUSIONS: The prevalence of undocumented HIV infection was sufficiently high for routine voluntary screening to be cost effective in each of the 6 sites we evaluated. Many VA health care systems should consider expanded routine voluntary HIV screening.

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Am J Public Health
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Douglas K. Owens
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We report the results of a review of the Chinese- and English-language literatures on service delivery in China, asking how well China's health-care providers perform and what determines their performance. Although data and methodological limitations suggest caution in drawing conclusions, a critical reading of the available evidence suggests that current health service delivery in China leaves room for improvement, in terms of quality, responsiveness to patients, efficiency, cost escalation, and equity. The literature suggests that these problems will not be solved by simply shifting ownership to the private sector or by simply encouraging providers - public and private - to compete with one another for individual patients. By contrast, substantial improvements could be (and in some places have already been) made by changing the way providers are paid - shifting away from fee-for-service and the distorted price schedule. Other elements of active purchasing by insurers could further improve outcomes. Rigorous evaluations, based on richer micro-level data, could considerably strengthen the evidence base for service delivery policy in China.

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Health Economics
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Karen Eggleston
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Two common means of controlling infectious diseases are screening and contact tracing. Which should be used, and when? We consider the problem of determining the cheapest mix of screening and contact tracing necessary to achieve a desired endemic prevalence of a disease or to identify a specified number of cases. We perform a partial equilibrium analysis of small-scale interventions, assuming that prevalence is unaffected by the intervention; we develop a full equilibrium analysis where we compare the long-term cost of various combinations of screening and contact tracing needed to achieve a given equilibrium prevalence; and we solve the problem of minimizing the total costs of identifying and treating disease cases plus the cost of untreated disease cases. Our analysis provides several insights.

First, contact tracing is only cost effective when prevalence is below a threshold value. This threshold depends on the relative cost per case found by screening versus contact tracing. Second, for a given contact tracing policy, the screening rate needed to achieve a given prevalence or identify a specified number of cases is a decreasing function of disease prevalence. As prevalence increases above the threshold (and contact tracing is discontinued), the screening rate jumps discontinuously to a higher level. Third, these qualitative results hold when we consider unchanged or changed prevalence, and short-term or long-term costs.

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Health Care Management Science
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Background: Women with acute myocardial infarction have a higher hospital mortality rate than men. This difference has been ascribed to their older age, more frequent comorbidities, and less frequent use of revascularization. The aim of this study is to assess these factors in relation to excess mortality in women.

Methods and Results All hospital admissions in France with a discharge diagnosis of acute myocardial infarction were extracted from the national payment database. Logistic regression on mortality was performed for age, comorbidities, and coronary interventions. Nonparametric microsimulation models estimated the percutaneous coronary intervention and mortality rates that women would experience if they were "treated like men." Data were analyzed from 74 389 patients hospitalized with acute myocardial infarction, 30.0% of whom were women. Women were older (75 versus 63 years of age; P0.001) and had a higher rate of hospital mortality (14.8% versus 6.1%; P0.0001) than men. Percutaneous coronary interventions were more frequent in men (7.4% versus 4.8%; 24.4% versus 14.2% with stent; P0.001). Mortality adjusted for age and comorbidities was higher in women (P0.001), with an excess adjusted absolute mortality of 1.95%. Simulation models related 0.46% of this excess to reduced use of procedures. Survival benefit related to percutaneous coronary intervention was lower among women.

Conclusions The difference in mortality rate between men and women with acute myocardial infarction is due largely to the different age structure of these populations. However, age-adjusted hospital mortality was higher for women and was associated with a lower rate of percutaneous coronary intervention. Simulations suggest that women would derive benefit from more frequent use of percutaneous coronary intervention, although these procedures appear less protective in women than in men.

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Circulation
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China's Harmonious Society colloquium series is co-sponsored by the Stanford China Program and the Center for East Asian Studies

Since 2006, the official doctrine of China's Communist Party calls for the creation of a "harmonious society" (HeXieSheHui). This policy, identified with the Hu Jintao leadership, acknowledges the new problems that have emerged as China continues its amazing economic growth. The economy is booming but so are tensions from rising inequality, environmental damage, health problems, diverse ethnicities, and attempts to break the "iron rice bowl." In this series of colloquia, leading authorities will discuss the causes of these tensions, their seriousness, and China's ability to solve these challenges.

Depending on where one stands, China's state-owned enterprises have reformed too slowly or too fast. Some lament the incompleteness of China's efforts to break the "iron rice bowl," to free firms from inefficient industrial practices, to rid firms of non-production expenses. Yet, as incomplete and slow as the reforms seem to some, New Left critics charge that China's reforms have gone too far, that SOEs have been subject to asset stripping, that firms have been "given away," and that the privileged few, particularly factory managers, have become rich capitalists overnight, through corruption and collusion with local officials. The losers in this view are the workers, who have been left unemployed, subject to layoffs, without health care, and sometimes without even their promised pensions-the very problems that prompted Hu Jintao's call for fixes to create a new "harmonious society." These two views of SOE reform, while seeming to convey different realities, reflect the political cross currents that have shaped China's corporate restructuring. Based on recent research in China, Jean Oi will discuss how those charged with reforming SOEs have tried to walk the tightrope between too slow and too fast reform, and the consequences.

Philippines Conference Room

Department of Political Science
Stanford University
616 Serra Street
Stanford, CA 94305-26044

(650) 723-2843 (650) 725-9401
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Senior Fellow at the Freeman Spogli Institute for International Studies
William Haas Professor in Chinese Politics
jean_oi_headshot.jpg PhD

Jean C. Oi is the William Haas Professor of Chinese Politics in the department of political science and a Senior Fellow of the Freeman Spogli Institute for International Studies at Stanford University. She is the founding director of the Stanford China Program at the Walter H. Shorenstein Asia-Pacific Research Center. Professor Oi is also the founding Lee Shau Kee Director of the Stanford Center at Peking University.

A PhD in political science from the University of Michigan, Oi first taught at Lehigh University and later in the Department of Government at Harvard University before joining the Stanford faculty in 1997.

Her work focuses on comparative politics, with special expertise on political economy and the process of reform in transitional systems. Oi has written extensively on China's rural politics and political economy. Her State and Peasant in Contemporary China (University of California Press, 1989) examined the core of rural politics in the Mao period—the struggle over the distribution of the grain harvest—and the clientelistic politics that ensued. Her Rural China Takes Off (University of California Press, 1999 and Choice Outstanding Academic Title, 1999) examines the property rights necessary for growth and coined the term “local state corporatism" to describe local-state-led growth that has been the cornerstone of China’s development model. 

She has edited a number of conference volumes on key issues in China’s reforms. The first was Growing Pains: Tensions and Opportunity in China's Transformation (Brookings Institution Press, 2010), co-edited with Scott Rozelle and Xueguang Zhou, which examined the earlier phases of reform. Most recently, she co-edited with Thomas Fingar, Fateful Decisions: Choices That Will Shape China’s Future (Stanford University Press, 2020). The volume examines the difficult choices and tradeoffs that China leaders face after forty years of reform, when the economy has slowed and the population is aging, and with increasing demand for and costs of education, healthcare, elder care, and other social benefits.

Oi also works on the politics of corporate restructuring, with a focus on the incentives and institutional constraints of state actors. She has published three edited volumes related to this topic: one on China, Going Private in China: The Politics of Corporate Restructuring and System Reform (Shorenstein APARC, 2011); one on Korea, co-edited with Byung-Kook Kim and Eun Mee Kim, Adapt, Fragment, Transform: Corporate Restructuring and System Reform in Korea (Shorenstein APARC, 2012); and a third on Japan, Syncretism: The Politics of Economic Restructuring and System Reform in Japan, co-edited with Kenji E. Kushida and Kay Shimizu (Brookings Institution, 2013). Other more recent articles include “Creating Corporate Groups to Strengthen China’s State-Owned Enterprises,” with Zhang Xiaowen, in Kjeld Erik Brodsgard, ed., Globalization and Public Sector Reform in China (Routledge, 2014) and "Unpacking the Patterns of Corporate Restructuring during China's SOE Reform," co-authored with Xiaojun Li, Economic and Political Studies, Vol. 6, No. 2, 2018.

Oi continues her research on rural finance and local governance in China. She has done collaborative work with scholars in China, including conducting fieldwork on the organization of rural communities, the provision of public goods, and the fiscal pressures of rapid urbanization. This research is brought together in a co-edited volume, Challenges in the Process of China’s Urbanization (Brookings Institution Shorenstein APARC Series, 2017), with Karen Eggleston and Wang Yiming. Included in this volume is her “Institutional Challenges in Providing Affordable Housing in the People’s Republic of China,” with Niny Khor. 

As a member of the research team who began studying in the late 1980s one county in China, Oi with Steven Goldstein provides a window on China’s dramatic change over the decades in Zouping Revisited: Adaptive Governance in a Chinese County (Stanford University Press, 2018). This volume assesses the later phases of reform and asks how this rural county has been able to manage governance with seemingly unchanged political institutions when the economy and society have transformed beyond recognition. The findings reveal a process of adaptive governance and institutional agility in the way that institutions actually operate, even as their outward appearances remain seemingly unchanged.

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Director of the China Program
Lee Shau Kee Director of the Stanford Center at Peking University
Faculty Affiliate at the Stanford Center on China's Economy and Institutions
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Jean C. Oi William Haas Professor in Chinese Politics, Professor of Political Science, Senior Fellow at FSI, and Director, Stanford China Program Speaker Stanford University
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