Emily Tuong-Vi Nguyen, a Stanford student studying human biology, writes about the Asia Health Policy Program’s international conference on diabetes

The Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center hosted the Net Value in Diabetes Management Workshop in March to discuss progress on an international research collaboration. Research teams from Hong Kong, Singapore, China, Taiwan, South Korea and the United States convened at the Stanford Center at Peking University (SCPKU) in Beijing to work on research that compares utilization and spending patterns on diabetes across different countries and to develop a method for measuring the net value of diabetes internationally, based on previous methods discussed in a Eggleston and Newhouse et al. 2009 study with Mayo Clinic Data for Type 2 diabetes.

The research teams from various Asian countries are attempting to calculate the net value of diabetes in those countries by observing the changes in diabetes value and spending. These calculations include monetizing the value of health benefits of new treatments and improvements in health, as well as avoided spending on treatments when prevention was effective, and associated mortality and probability of survival. Previous models used to measure diabetic values and risks, such as the United Kingdom Prospective Diabetes Study (UKPDS) risk engine that was created from U.K. data and populations, are not very relevant for Asian populations. The goal is to create separate risk models specifically suited for populations from Hong Kong, Singapore, China, Taiwan and South Korea.

During the workshop that spanned two days, the research teams had an opportunity to share updates on their individual projects and to discuss methods and ideas for future collaboration.

On the first day, each research team presented its work, describing data sets and explaining the risk models that were used or developed. Karen Eggleston, director of the Asia Health Policy Program, delivered introductory remarks and shared current progress by the Japan and Netherlands research teams on calculating value and risk for diabetes with data from the Netherlands and Japan. The data sets from those two countries were best estimated by the JJ Risk Engine for the Japan data and the UKPDS model for the Netherlands data.

Chao Quan of the University of Hong Kong presented the risk model used for Hong Kong populations. His work primarily looked at how the UKPDS risk engine predicted risk in Hong Kong populations as compared to a local Hong Kong risk engine and how to best calibrate the Hong Kong risk engine. His next step will be to monetize the value for improved survival in diabetes in Hong Kong. He offered to re-estimate the model using the risk factors available on others’ datasets so that the Hong Kong risk model could potentially be used by other teams as well.

Stefan Ma and Zheng Li Yau of the Ministry of Health of Singapore discussed the 5-year prediction model and statistical methods they used for all-cause mortality of Singaporean individuals with diabetes. Their work is based on Singapore’s extensive administrative and claims data as well as data provided by the national health surveys conducted every six years by the National Health Service of Singapore. The researchers plan to look into how their overall risk model compares with models for specific subpopulations, such as Chinese, Malay and Indian populations in Singapore.

Katherine Hastings from the Stanford University team, led by principal investigator Latha Palaniappan, presented preliminary ideas about measuring cardiovascular risk with the Atherosclerotic Cardiovascular Disease Risk Score in analyses of Stanford health system diabetic patients. The researchers are collaborating with a clinical bioinformatics team at Stanford to use machine learning to expedite the analysis.

Min Yu and Haibin Wu of the Zhejiang Center for Disease Control and Prevention shared results from their analysis of health data collected from community health centers for diabetes management, diabetes surveillance data, cause of death data and insurance claims data that showed relationships between different patient characteristics and insurance types. The researchers then estimated the annual cost of Type 2 diabetes and its complications in Tongxiang province, China.

Hai Fang and Huyang Zhang of Peking University worked with claims data of diabetic patients insured by the New Cooperative Medical Scheme in Beijing, and at the workshop, shared regression analyses on the relationship between outpatient visits and inpatient admissions.

Jianqun Dong of the People’s Republic of China Center for Disease Control and Prevention presented ongoing research about diabetes management in China, including preliminary results of a randomized control trial of diabetes self-management strategies.

Wankyo Chung of Seoul National University shared preliminary estimates of a risk model for mortality among diabetic patients in South Korea and discussed next steps for estimating net value of diabetes management using the detailed clinical and claims data available in South Korea.

On the second day, the workshop concluded with a videoconference between workshop participants in Beijing and collaborators at Stanford Graduate Business School, including Stanford professor Latha Palaniappan and Harvard visiting professor Joseph P. Newhouse, using the Highly Immersive Classroom.

The workshop was a good opportunity for the research teams to discuss preliminary models, to offer each other suggestions regarding research methods, and to discuss the future direction of the international collaboration on the net value of diabetes. All research teams are preparing comparative research papers that will be included in the working paper series of the Asia Health Policy Program. A follow-up event will be held at Stanford in November 2017 in recognition of World Diabetes Day.

End-stage renal disease makes up 7.2 percent of Medicare spending, even though those patients represent less than 1 percent of the Medicare population, according to a database that tracks chronic kidney disease.

Despite the gnashing of teeth about the runaway costs of Medicare spending, the national health-care system for the elderly, younger people with certain disabilities and chronic kidney disease appears to have found one way to lower costs.

Congress established the end-stage renal disease (ESRD) Prospective Payment System in 2008, as part of the Medicare Improvement for Patients and Providers Act. It mandated that ESRD Medicare patients treat themselves at home if able.

The new payment system introduced two incentives to increase home dialysis use: bundling injectable medications into a single payment for treatment and paying for training for patients to give themselves injections and treatment at home.

A new study by Stanford researchers shows home dialysis treatment among Medicare patients increased by 5.8 percent from January 2006 through August 2013. The researchers also found that non-Medicare patients covered by other forms of health insurance also turned to home dialysis by a jump of 4.1 percent.

“These spillover effects suggest that major payment changes in Medicare can affect all patients with end-stage renal disease,” the authors wrote in the study published in the latest edition of the Journal of the American Society of Nephrology. “One of the stated goals of the PPS payment reform was to incentivize an increase in-home dialysis use, and it appears that it has succeeded in this stated goal.”

Eugene Lin, a postdoctoral fellow in nephrology at the Stanford School of Medicine and lead author of the study, told me that most nephrologists believe the trend toward home dialysis is good for the taxpayers and for the patients.

People going through this phase of chronic kidney disease — when dialysis or a kidney transplant are the only chance of survival  — cost less to take care of at home and have similar outcomes to in-center hemodialysis patients.

“It’s hard to say if one therapy is definitively better than the other,” Lin said, “though home dialysis generally offers patients more independence and potentially better quality of life.”

Lin explained the difference between in-center hemodialysis and home treatment: At a center, blood is filtered through a machine, whereas home dialysis entails either having a hemodialysis machine at home (and having a caregiver help with the treatments) or performing peritoneal dialysis.

The latter is the most commonly used at-home treatment and involves using the abdominal compartment as a filter. The toxins in the blood get filtered through the abdominal membranes into clean fluid, which is then removed and discarded.

Similar drugs are used both in centers and at home, but they’re easier to give in the hemodialysis setting, so had a higher likelihood of overuse prior to payment reform.

“Once they bundled the drug reimbursement with the treatment, we saw dramatic decreases in the use of these drugs and a concurrent increase in home dialysis use,” Lin said.

The researchers, including senior author Jay Bhattacharya of Stanford Health Policy, noted that home dialysis remained stagnant at around 11 percent from 1983 to 1992 and steadily declined until 2008.

“While the cause of this decline is unknown, several policies made home dialysis less favorable than in-center hemodialysis economically,” they wrote.

First, the federal Centers for Medicare & Medicaid Services in 1991 revised its reimbursement policy for the erythropoietin-stimulating agent needed for functioning kidneys, making it the most profitable component of in-centers hemodialysis. Then, CMS introduced a tiered fee-for-service physician payment in 2004, providing the potential for enhanced revenues with in-center dialysis.

But the PPS bundling shifted erythropoietin from the profit side to the cost side, so it was no longer advantageous to use high doses common with in-center hemodialysis, Lin said. This paved the way for an increase in home dialysis use, which is less costly to administer.

Stanford Health Policy’s Douglas K. Owens has been appointed vice chair of the U.S. Preventive Services Task Force, an independent, volunteer panel of national experts in prevention and evidence-based medicine.

Owens, the Henry J. Kaiser, Jr. Professor at Stanford University is a general internist at the VA Palo Alto Health Care System, and a professor of medicine, health research and policy, and management science and engineering at Stanford.

He is the director of the Center for Health Policy in the Freeman Spogli Institute for International Studies, where he is also a senior fellow, and the Center for Primary Care and Outcomes Research in the Department of Medicine and School of Medicine, and Associate Director of the Center for Innovation to Implementation at the VA Palo Alto Health Care System.

“Through his stellar work, Dr. Owens enables Stanford Medicine to advance its mission to precisely predict and prevent disease,” said Lloyd Minor, MD, dean of the Stanford School of Medicine. “As our country faces an increasingly diverse, aging patient population and rising health care costs, I am thrilled that Dr. Owens will contribute his perspective and expertise to this national task force.”

Owens served a previous four-year term on the independent, volunteer panel of national experts in prevention and evidence-based medicine. He will serve for two years as vice chair and then a year as chair. Members come from health-related fields ranging from internal medicine, family medicine, pediatrics, behavioral health, obstetrics/gynecology, and nursing.

The task force issues preventive care guidelines based on detailed assessment of the evidence about preventive interventions and is supported by the Agency for Healthcare Research and Quality within the U.S. Department of Health and Human Services.

“It’s humbling because the task force guidelines impact virtually every primary care patient in the United States,” said Owens, who is also past president of the Society for Medical Decision Making. “Having an unbiased, independent assessment of the benefits and harms of preventive services is very important for primary care clinicians and patients.”

The task force works to improve American’s health by making evidence-based recommendations about clinical preventive services such as screenings, counseling services and preventive medications. Its members have tackled everything from whether to screen for certain cancers, which medications should be taken to prevent diseases and reduce blood pressure and high cholesterol, and screening for infectious diseases, including HIV, HCV, TB, syphilis and other sexually transmitted diseases.

“We are honored to welcome Dr. Owens back to the task force in a leadership role,” said task force chair David C. Grossman, MD, MPH, a senior investigator and medical director for population health strategy at the Group Health Research Institute.

“His experience in guideline development, both with the task force and partner organizations, and his work in evidence-based medicine and clinical decision-making are valuable additions to our leadership team,” Grossman said.

The task force, for example, just released its draft guideline on prostate cancer screening. And some of the medical topics under development are screening for cervical and BRCA-related cancer, as well as pre-exposure prophylaxis for HIV infection.

Owens said that it was critical that the task force remains unbiased and independent. The 16 volunteer members who are nationally recognized experts in prevention, evidence-based medicine and primary care, carefully evaluate the science behind preventive interventions.

“The task force has very rigorous methods for assessing evidence, and we are fortunate to have state-of-the-art evidence reviews provided by AHRQ funded Evidence-Based Practice Centers,” he said.

Each year, the task force makes a report to Congress that identifies critical evidence gaps in research related to clinical prevention services and recommends priority areas that deserve further explanation. All their reports and recommendations are made public on the task force website and leave room for public comment.

After the 2012 mass shooting of children and teachers at Sandy Hook Elementary School in Connecticut, a leader of the National Rifle Association proclaimed: “The only thing that stops a bad guy with a gun is a good guy with a gun.”

It would seem that many Californians agreed, according to new research by Stanford Health Policy’s David Studdert and other researchers at academic institutions.

In the six weeks after the Newtown shootings — when a young man fatally gunned down 20 children and six adults — handgun acquisitions in California rose by 53 percent among first-time gun owners over expected levels.

When a couple armed with semi-automatic weapons targeted a San Bernardino County public health event in December 2015, killing 14 people in 2015, handgun purchase rates were 85 percent higher than expected among residents of the city of San Bernardino and adjacent neighborhoods, compared with 35 percent higher elsewhere in California.

In a new study in the Annals of Internal Medicine, lead author Studdert, a professor of medicine at Stanford Medicine and professor of law at Stanford Law School, writes that their findings have implications for public health as firearm ownership is a risk factor for firearm-related suicide and homicide.

“There is strong evidence linking gun ownership to risks of gunshot injuries, so any sudden boost in firearm ownership could have public health implications,” Studdert said. On their own, these two mass shootings are unlikely to have caused enough of a change in ownership patterns to have significant public health effects.

“But over time, purchasing responses to a succession of unnerving events like this — from mass shootings to terrorist attacks, to elections — could change levels of gun ownership enough to increase overall rates of gun injury and death.”

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The authors write that for some, mass shootings may induce repulsion at the idea of owning a weapon. But for others, they note, it may motivate acquisition.

“Mass shootings are likely to boost sales if they heighten concerns over personal security because self-protection is the most commonly cited reason for owning a firearm,” they said.

More than 32,000 people die of gunshot wounds in the United States each year, according to the Centers for Disease Control and Prevention. While mass shootings account for less than 1 percent of those deaths, they are the most visible form of firearm violence because of the extensive broadcast and social media coverage that surround them.

Using detailed individual-level information on firearm transactions in California between 2007 and 2016, the researchers analyzed acquisition patterns after two of the highest-profile mass shootings in U.S. history. They found large and significant spikes occurred among whites and Hispanics, and among individuals who had no record of having previously acquired a handgun.

Although these spikes in handgun purchases after both mass shootings were large, they were also short-lived and accounted for less than 10 percent of annual handgun purchases statewide.

“Concerns about firearm violence and the public health risks of firearm ownership should stay focused on the much larger volume of weapons that routinely changes hands, and the immense stock that already sits in households,” write Studdert and his colleagues, Stanford Health Policy researcher Yifan Zhang, PhD; Jonathan Rodden, PhD, a professor of political science at Stanford; Rob J. Hyndman, PhD, a professor of statistics at Monash University in Australia; and Garen J. Wintemute, MD, MPH, an expert on gun violence at the University of California, Davis.

“On the other hand, the cumulative effect of such ‘shocks’ as Newtown and San Bernardino shootings on firearm prevalence may be substantial,” they write. “Moreover, firearm acquisitions seem to be sensitive to a range of other events that are also common, such as federal elections, new firearm safety laws, and terrorist attacks.”

Taken as a whole, they said, these events may drive significant increases in overall firearm prevalence, which may, in turn, increase the risk for firearm-related morbidity and mortality in the long run. The authors urge further research should explore the cumulative effects and temporary shifts in acquisition patterns, their causes, and their implications for public health, crime and social cohesion.

Jonathan Chen has a doctorate in computer science and could have his pick of lucrative jobs here in Silicon Valley today.

Instead, he pursued his medical degree and is working on ways to help physicians quickly mine clinical data to reach better diagnoses for their patients.

“I walked away from higher paying jobs because I was looking for a greater purpose in my work and a rewarding career,” said Chen, a physician-scientist at Stanford who was a VA Medical Informatics Fellow at Stanford Health Policy.

Future works like his — supported by a five-year grant from the National Institutes of Health — may be on the chopping block.

The Trump administration’s proposed budget intends to cut NIH funding by $7 billion over the next 18 months, which could severely compromise research grants that lead to major biomedical breakthroughs.

Chen is currently building OrderRex, a digital platform that data-mines electronic medical records that show clinical practice patterns and outcomes to inform medical decisions. He hopes it will one day be the Amazon of electronic medical records.

After more than 20 years of hard work — a college freshman when he was only 13  — Chen is finally poised to become a junior faculty member. But now he has to wonder whether he made the right choice.

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“Seeing the proposed research budget cuts gives me pause,” Chen said. “And I’m considering whether it is foolish for me to even be joining the academic ranks now, chasing down grants that will be increasingly difficult to come by, amidst a political climate that does not seem to care for science.”

The administration has said it respects and would support the work of the NIH, which Secretary of Health and Human Services Tom Price recently called “very important.” But, he added, the American taxpayers should be getting “a bigger bang for the buck.”

About 80 percent of the federal NIH funding goes to grants for clinical and translational researchers at small businesses and academic institutions.

Here at Stanford Health Policy, the grants have funded research into everything from the epidemic of diagnostic errors to the economic harm of the tsetse fly on African economies; the impact of urbanization on obesity and chronic disease in India, to a global data analysis about whether foreign aid is directly linked to an increase in life expectancy in developing countries.

The National Institutes of Health — which has supported the research of some 148 Nobel Prize winners — has touched the work of nearly every SHP researcher.

“Cutting scientific research budgets could turn a generation of young minds away from the larger purposes of academic medical research and instead send them off into finance, tech, pharma — leaving behind the country’s talent pool in the decades to come,” said Chen.

Eran Bendavid, an assistant professor of medicine and core faculty at Stanford Health Policy, uses political science, economics, and epidemiology to study the prevention and treatment of infectious diseases in developing countries.

The infectious disease physician also depends, in part, on NIH funding.

“There is no substitute for NIH support for basic and applied research,” Bendavid said. “It has been a central actor in the progress of the biomedical fields and made the U.S. the global leader in innovation. It is also good diplomacy, promoting cooperation and partnerships across the globe.”

Bendavid and SHP colleague Grant Miller led the research that showed that declining use of safe contraception led to an increase in abortion rates in sub-Saharan Africa, a region in which family planning services are heavily financed by U.S. foreign aid. Their work was widely cited in news reports as a counterpoint to the Trump administration’s pledge to cut funding to international family planning organizations that also offer abortion.

“Even if many of the budgetary provisions are scaled back, this is an unfortunate place to anchor the negotiations,” Bendavid said of the proposed NIH cuts, which are so severe they are already facing opposition from some members of Congress. “This could signal real changes in what we do as individuals, as a division, and as an institution.”

House Speaker Paul Ryan was asked specifically about President Trump's proposed cuts to the National Institutes of Health. The speaker avoided criticizing the administration for that proposal — but indicated it was unlikely Congress would go along.

“I don’t try to get into making my opinion on this, on specific provisions,” Ryan said. “All I would say is perhaps the most popular domestic funding we have among Republicans is NIH.”

Michele Barry, director of the Center for Innovation in Global Health and senior associate dean for Global Health at Stanford University — as well as one of SHP’s key faculty members — wrote in this editorial on March 28 that such drastic cuts to biomedical research would make us more susceptible to global epidemics.

“We live in a time when pandemics cross borders faster than ever,” Barry wrote. “Yet to the horror of many of us working in global health, President Trump’s budget would completely eliminate the NIH’s Fogarty International Center — one of the most effective tools we have to fight global diseases.”

The GOP’s proposed American Health Care Act may have gone down in flames, but health policy experts say there are plenty of other health-care reforms the Trump administration may attempt.

Michelle Mello and David Studdert, both professors at Stanford University School of Medicine and Stanford Law School and core faculty members at Stanford Health Policy, say medical malpractice reform, for one, is back on the federal policy agenda.

The two write in this New England Journal of Medicine commentary that Secretary of Health and Human Services Tom Price, an orthopedic surgeon and Republican congressman from Georgia before he was appointed to the Trump administration, sponsored several bills aimed at limiting medical liability.

House Speaker Paul Ryan and Price have both said medical malpractice is in crisis, with frivolous lawsuits driving up malpractice insurance premiums and forcing physicians out of business. Hospitals and doctors are so afraid of being sued they overprescribe costly tests and treatments, driving up the cost of health care.

But according to a study published last year, medical errors are the third leading cause of death in the United States. And those who follow medical malpractice insurance say the industry has stabilized in the last decade.

Mello and Studdert write that medical malpractice reform is worth pursuing. The liability system has a host of well-documented problems and its reform was omitted from the Affordable Care Act.  But, they argue, Republican proposals tilt too far towards protecting physicians, with harmful consequences for patients.

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“Two of the key reforms measures on the Republican agenda — ‘safe harbors’ for physicians who comply with clinical practice guidelines and the adjudication of medical injury disputes by expert panels — are promising ideas that have received a good deal of attention in the academic literature over the last 20 years,” Studdert said.

“However, design details matter,” he said. “The versions currently being considered in Congress are quite unconventional; they look more like physician-protection initiatives than reforms designed to improve safety or protect the interests of patients in other ways.” 

The “safe harbors” from liability for providers who adhere to clinical practice guidelines would involve the establishment of tribunals of medical experts who would decide malpractice claims. Price has also proposed “administrative health-care tribunals” that would be presided over by special judges with health care expertise and would issue binding rulings aided by testimony from independent experts.

One worrisome aspect of the Republican proposals is that they would replace ordinary standards of evidence with a requirement that patients prove “gross negligence.” 

“That means that if your physician was merely careless or unskilled, you’re out of luck as a plaintiff,” Mello explained. “You have to show something akin to willful and wanton misconduct — like the case in Boston where the surgeon left in the middle of an operation to deposit money in his bank.”

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Price has claimed that defensive medicine is responsible for a quarter of U.S. health-care spending, about $650 billion, but the authors’ best estimates are closer to $50 billion.

Yet, in their commentary, the authors say this could be an ideal time to pursue reform, which ordinarily rises on the policy agenda only when a “malpractice crisis” occurs and liability insurance costs spike.  “When acutely stressed providers are clamoring for 
immediate relief, cool-headed policy deliberation rarely ensues,” they wrote. 


But, they add, reforms must be fair to patients as well as providers. They note that Price articulated a vision of health system reform that puts patients’ needs front and center.

“Medical liability reform needs the same vision,” they said.

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