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Presidential Fund for Innovation in International Studies awards second round of interdisciplinary international grants

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Catharine C. Kristian
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A proposal to assess the societal and security implications of the female deficit in China, a study of the impact of higher education's rapid expansion in large developing economies, and incentives for provision of health care services for one billion people in rural China were among the new projects funded by Stanford's Presidential Fund for Innovation in International Studies (PFIIS) in mid-February. Planning grants for an international health and society initiative in the Indian subcontinent and psychosocial treatment for children orphaned by the tsunami in Indonesia were also awarded.

"These projects show great potential to advance human knowledge, help devise sustainable solutions, and build a better, more secure future for millions around the world," said Stanford President John Hennessy. "In launching The Stanford Challenge, we committed to marshal university resources to address some of the 21st century's great challenges in human health, international peace and security, and the environment."

The $3 million, intellectual venture capital fund was established by the Office of the President and the Stanford International Initiative in 2005 to encourage new cross-campus, interdisciplinary research and teaching among all seven schools at Stanford on three overarching global challenges: pursuing peace and security, improving governance, and advancing human well-being. The first $1 million was awarded in February 2006 to eight interdisciplinary faculty teams examining such issues as the HIV/AIDS treatment revolution in sub-Saharan Africa, why Latin America has been left behind in recent gains by developing countries, and food security and the environment.

"It's impressive to see the committed, collaborative, and innovative ways Stanford faculty are joining together in new interdisciplinary research and teaching to generate new understanding of the linkages among complex problems and train a new generation of leaders to address them effectively," said Freeman Spogli Institute Director Coit D. Blacker, chair of the International Initiative Executive Committee.

New projects qualifying for funding and their principal investigators are:

  • Female Deficit and Social Stability in China: Implications for International Security. Melissa Brown, anthropological sciences; Marcus Feldman, biological sciences, and Matthew Sommer, history. As the number of surplus, marriage-age men in China approaches 47 million in 2050, this project will study factors that predict men's inability to marry before 30, the availability of social welfare to men and their families, their contribution to the floating population of rural-to- urban migrants, the labor-related migration of unmarried women, and the impact of this migration for domestic stability and international security.
  • Potential Economic and Social Impacts of Rapid Higher Education Expansion in the World's Largest Developing Economies. Martin Carnoy, education; Amos Nur, geophysics; and Krishna Saraswat, electrical engineering. The development of higher education systems in Brazil, Russia, India, and China (BRIC) will have a major impact on their ability to transition to large, developed, knowledge-based economies. Is the way nation states expand and reform higher education in response to global pressures an important indicator of societal capacity to achieve sustained economic growth? This project will examine differing approaches of BRIC governments to higher-education growth and reform, and ask whether these reflect differing levels of state capacity to expand the knowledge base for economic and social development and whether differing approaches result in significant changes in formation of analytical skills in university graduates, particularly scientists and engineers.
  • Health Care for One Billion: Experimenting with Incentives for the Supply of Health Care in Rural China. Scott Atlas, radiology; Scott Rozelle, the Walter H. Shorenstein Asia-Pacific Research Center, FSI. This project examines the effects of existing health policies and institutions in rural areas of China - including rural health insurance, privatization of rural clinics, and investment in township hospitals - and introduces a new experiment to study and realign incentives to address a serious flaw in China's health care system, the practice in which doctors both prescribe and derive significant profits from drugs.

Two planning grants were also awarded, as follows:

  • Stanford International Health and Society Initiative: Proposal to Plan for an Initial Program in the Indian Subcontinent. Vinod K. Bhutani, pediatrics; Nihar Nayak, obstetrics and gynecology. This project seeks to improve unacceptably high maternal and childhood morbidity and mortality rates in the Indian subcontinent by devising innovative strategies to bridge existing social and access barriers in the micro- and macro- health environment. Includes leadership training and cooperative work on practice and policy strategies with experts from Stanford and the subcontinent.
  • Psychosocial Treatment of Children Orphaned by the Asian Tsunami in Indonesia. Hugh Solvason, psychiatry; Donald Barr, sociology. This project's goal is to develop and implement changes to reduce the sense of dislocation, anxiety, and behavioral problems among tsunami orphans at the As-Syafi`iyah Orphanage in Jakarta. By arranging the children into more cohesive groups that can operate like "families" rather than their current state of random associations typically found in orphanages, the project will create a new and ordered social system. In addition, Solvason and Barr plan to develop a system of counseling interventions for the most severely symptomatic children (supervised by Stanford Psychiatry faculty). Translated measures of depression, anxiety, and PTSD will be used to assess the success of the intervention.

The projects will produce new field research, conferences, research papers, books, symposia, and courses for Stanford students.

A third round of project awards will be made in February 2008. A formal request for proposals will be issued in the fall of 2007, with proposals due by December 14, 2007. Priority is given to teams of faculty who do not typically work together, represent multiple disciplines, and address issues that fall broadly within the three primary research areas of the International Initiative. Projects are to be based on collaborative research and teaching involving faculty from two or more disciplines, and where possible, from two or more of Stanford's seven schools.

For additional information, contact Catharine Kristian, ckristian@stanford.edu.

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New Directions for Public Health Care Purchasers? Responses to Looming Challenges

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State public employee health plans (PEHPs) provide health benefits for millions of state and local workers, retirees, and their dependents nationwide. This paper explores major issues and challenges that PEHP leaders and state policymakers are addressing. These include the perennial challenge of funding benefits for a diverse and aging workforce; new accounting standards affecting public employers; and the changing relationship between states, retired public employees, and the Medicare program. Interviews with PEHP executives explored whether these are incremental challenges to which states can effectively adapt, or whether these challenges will catalyze broader and lasting change in the public employee and retiree health benefits arena.

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Early Infectious Disease Diagnosis Using Genomics

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A key pillar and unmet need in the defense against threats to health is the ability to recognize the etiological factor(s) and predict the course of disease, at early points in the timeline of the process. This ability would enable early intervention in the disease process when there is the greatest likelihood of benefit, as well as triaging of hosts, based on individual need. Genomic tools and approaches have enabled a more detailed description of host-microbe encounters, and shed light on fundamentally important processes, including the cellular responses associated with infection. Genome-wide transcript-abundance profiles, like other comprehensive molecular readouts of host physiological state, provide a detailed blueprint of the host-pathogen dialogue during microbial disease. Studies of cancer based on genome-wide transcript-abundance profiles have led to novel signatures that predict disease outcome and serve as useful clinical classifiers. The highly dynamic and compartmentalized aspects of the host response to pathogens complicate efforts to identify predictive signatures for infectious diseases. Yet, studies of systemic infectious diseases so far suggest the possibility of successfully discriminating between different types (classes) of infection and predicting clinical outcome. In addition, host gene expression analysis could lead to the identification of early signatures associated with a protective immune response, both to natural infection and to vaccination. Early explorations in some of these areas indicate the potential feasibility of this approach but also point to important unmet challenges.

David Relman is associate professor of medicine, and of microbiology and immunology at Stanford University. He is also chief, infectious diseases section, at the VA Palo Alto Health Care System in Palo Alto, California.

A native of Boston, Massachusetts, Relman holds an SB degree from the Massachusetts Institute of Technology and received his MD degree, magna cum laude, from Harvard Medical School in 1982. Following postdoctoral clinical training at Massachusetts General Hospital in internal medicine and in infectious diseases, Relman served as a postdoctoral research fellow in microbiology at Stanford University in the laboratory of Stanley Falkow from 1986 until 1992. He joined the Stanford University faculty in 1992 and was appointed associate professor (with tenure) in 2001. His research is directed towards the characterization of the human indigenous microbial communities of the mouth and gut, with emphasis on understanding variation in diversity, succession, the effects of disturbance, and the role of these communities in oral and intestinal disease.

Experimental approaches include molecular phylogenetics, ecological statistics, single cell genomics, and community-wide metagenomics. A second area of research concerns the classification structure of humans and non-human primates with systemic infectious diseases, based on patterns of genome-wide gene transcript abundance in blood and other tissues. The goals of this work are to recognize classes of pathogen and predict clinical outcome at early time points in the disease process, as well as gain further insights into virulence (e.g., of variola and monkeypox viruses). Past achievements include the description of a novel approach for identifying previously-unknown pathogens (selected as one of the 50 most important papers of the last century by the American Society for Microbiology), the identification of a number of new human microbial pathogens, including the agent of Whipple's disease, and the most extensive descriptions to date of the human indigenous microbial community. See http://relman.stanford.edu. Relman received the Squibb Award from the Infectious Diseases Society of America (2001), the Senior Scholar Award in Global Infectious Diseases from the Ellison Medical Foundation (2002), and is a recipient of an NIH Director's Pioneer Award (2006). He is a member of the American Society for Clinical Investigation and was named a Fellow of the American Academy of Microbiology in 2003.

Relman currently serves on the Board of Scientific Counselors of the National Institute of Dental and Craniofacial Research and was a member of the Board of Directors of the Infectious Diseases Society of America (2003-2006), and co-chair of the National Academy of Sciences' Committee on Advances in Technology and the Prevention of Their Application to Next Generation Biowarfare (2004-2006). He is a member of the National Science Advisory Board for Biosecurity, the Institute of Medicine's Forum on Microbial Threats, and advises several U.S. Government departments and agencies on matters related to microbial pathogen detection and future biological threats.

Reuben W. Hills Conference Room

David Relman Associate Professor of Medicine and of Microbiology and Immunology Speaker Stanford University
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CHP/PCOR Quarterly Update, fall 2006 issue

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This issue of CHP/PCOR's quarterly newsletter, which covers news from the summer 2006 quarter, includes articles about:

  • research by CHP/PCOR investigators that influenced the Centers for Disease Control and Prevention to recommend widespread voluntary HIV screening for all Americans ages 13 to 64 -- a significant change from the CDC's previous HIV screening guidelines;
  • a CHP/PCOR study on patient safety culture in U.S. hospitals -- the largest effort to date to measure hospitals' safety culture and seek to improve it through an intervention that gets hospital executives out of their offices and on to the hospital floors;
  • an early-stage project in which CHP/PCOR is collaborating with the Center on Democracy, Development and the Rule of Law to study the relationship between health interventions, governance and development;
  • an evidence report examining the challenges of diagnosing and treating anthrax in children, prepared by the Stanford-UCSF Evidence-based Practice Center; and
  • a study by CHP/PCOR fellow Kate Bundorf which found that depending on the definition of "affordability" that is used, health insurance is "affordable" to between one-quarter and three-quarters of the uninsured -- and many of those who can't afford insurance purchase it anyway.
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Benefits and Costs of Health Insurance Choice among Older Adults: The Case of Medicare Prescription Drug Plans

The perceptions of policy makers regarding the ability and desire of Medicare beneficiaries to make choices regarding their health insurance coverage has shaped the development of the Medicare program in fundamental, yet sometimes contradictory, ways. Yet relatively little is known about the factors that affect the decision making of older adults in this context.

Scientization: Making a World Safe for Organization

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All around the world, societies are experiencing an explosion of organizations and organizing: community clubs, religious groups, social movements, as well as schools, hospitals, businesses and government agencies, increasingly take the form of complex and formal organization. Why? Why is global society recast in this format and why so fiercely?

This book explores various dimensions of the trends of expansion, formalization, and standardization of organizing worldwide by exploring such organizational legacies as accounting, business management, corporate social responsibility, and performance benchmarks. Featuring contributions from prominent academics, the book argues that these processes can be attributed to globalization and to its specific tendencies of universalism, rationalization, and rise of the modern notion of the strongly bounded and purposive social actor.

An application of institutional arguments to global issues, the book will be of interest to academics and researchers of Organization Studies, Sociology, Political Science, and Geography.

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Oxford University Press in "Globalization and Organization"
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John Meyer

Do Mandates Requiring Insurers To Pay For Emergency Care Influence The Use of the Emergency Department?

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Many states have "prudent layperson" mandates that require health plans to reimburse hospitals for emergency department (ED) care delivered to patients who believe that they have symptoms warranting emergency treatment. Increased, and possibly unnecessary, ED use has often been attributed to these policies. We use data from thirty-five states to study relationships between passage of prudent layperson policies in the late 1990s and ED use among the privately insured. None of the analyses show evidence that the mandates are associated with increased use. We conclude that prudent layperson mandates are not associated with increases in ED visits among privately insured patients.

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Laurence C. Baker
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Group Visits to Improve Hypertension Management

Research objectives:

The primary goal of this project is to improve blood pressure control in patients with hypertension through a new model of care delivery, Group Medical Visits. Patients with hypertension receive regular medical care in a group setting that is designed to promote effective self-management of hypertension and to encourage patients to follow their primary care clinician's advice. Clinicians are given guideline-based information on antihypertensive drugs through the ATHENA Decision Support System.

Off-label Prescribing Among Office-Based Physicians

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Background:

Unlike medicines prescribed for Food and Drug Administration-approved indications, off-label uses may lack rigorous scientific scrutiny. Despite concerns about patient safety and costs to the health care system, little is known about the frequency of off-label drug use or the degree of scientific evidence supporting this practice.

Methods:

We used nationally representative data from the 2001 IMS Health National Disease and Therapeutic Index (NDTI) to define prescribing patterns by diagnosis for 160 commonly prescribed drugs. Each reported drug-diagnosis combination was identified as Food and Drug Administration-approved, off-label with strong scientific support, or off-label with limited or no scientific support. Outcome measures included (1) the proportion of uses that were off-label and (2) the proportion of off-label uses supported by strong scientific evidence. Multivariate analyses were used to identify drug-specific characteristics predictive of increased off-label use.

Results:

In 2001, there were an estimated 150 million (95% confidence interval, 127-173 million) off-label mentions (21% of overall use) among the sampled medications. Off-label use was most common among cardiac medications (46%, excluding antihyperlipidemic and antihypertensive agents) and anticonvulsants (46%), whereas gabapentin (83%) and amitriptyline hydrochloride (81%) had the greatest proportion of off-label use among specific medications. Most off-label drug mentions (73%; 95% confidence interval, 61%-84%) had little or no scientific support. Although several functional classes were associated with increased off-label use (P.05), few other drug characteristics predicted off-label prescription.

Conclusions:

Off-label medication use is common in outpatient care, and most occurs without scientific support. Efforts should be made to scrutinize underevaluated off-label prescribing that compromises patient safety or represents wasteful medication use.

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Archives of Internal Medicine
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