Stanford Health Policy’s Kathy McDonald — one of the nation’s leading experts in patient safety and health-care quality — has been named a distinguished professor at Johns Hopkins University, and will soon be leaving the Stanford Cardinal for the Hopkins Blue Jays.

McDonald, PhD, is the founding executive director of the Center for Primary Care and Outcomes Research at the Stanford School of Medicine and the Center for Health Policy in the Freeman Spogli Institute for International Studies (CHP/PCOR). She has spent 25 years at Stanford and says it’s tough to leave the Stanford Health Policy community, whose members are like family.

“CHP/PCOR has given me a community of close colleagues who care about each other and what we do together,” McDonald said. “And we’ve done a lot together over the years, much more than the usual academic products of grants, publications and courses. We have built a reputation for being ahead of the curve of health-system concerns. We also keep doing a fabulous job pushing the science envelope, and coming up with insights for everything from big policy to every day practice decisions, in the U.S. and abroad.”

McDonald soon heads East as the Bloomberg Distinguished Professor of Health Systems, Quality, and Safety. She will hold primary appointments in the Johns Hopkins schools of Nursing and Medicine and joint appointments in the Carey Business School and the Bloomberg School of Public Health, and affiliated with the Malone Center for Engineering in Healthcare. She will continue to explore what makes safe, affordable and high-quality health-care delivery systems, as well as the obstacles that prevent health organizations from achieving those goals.

McDonald told the Johns Hopkins University blog, the Hub, in a recent story that she intends to collaborate with faculty colleagues across the university and continue borrowing from other disciplines to optimize health-care delivery, just as she has done in her role at Stanford.

“All of us at CHP/PCOR owe Kathy an incredible debt,” said CHP/PCOR Director Doug Owens, who has worked alongside McDonald for more than a decade. “She helped found the centers, and we’ve benefited from her vision and extraordinary leadership for over 20 years. She is one of the top scholars in the nation in her areas of work, and her position at Johns Hopkins recognizes her exceptional accomplishments. We will miss Kathy greatly, but are thrilled with the opportunity she has to broaden her national leadership.”  

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For her PhD in health policy from the University of California, Berkeley, McDonald wrote her dissertation on diagnostic errors — an area McDonald believes is a critical blind spot of health-care providers. She was a member of the committee that issued a landmark report by the National Academy of Medicine, the medical arm of the National Academies of Sciences, which found that most Americans will get at least one faulty diagnosis in their lifetime. Despite dramatic improvements in patient safety in the last 20 years, the committee found, medical experts estimate that more than 12 million adults are misdiagnosed every year.

As Johns Hopkins pointed out in its release about her becoming the 46th Bloomberg Distinguished Professor, in addition to publishing more than 100 scholarly peer-reviewed studies and white papers, McDonald has published more than 40 government reports and developed tools for measuring patient safety and quality that have been used by private and public care providers alike. She was tapped by the federal Agency for Healthcare Research and Quality to create a series of reviews and seminal reports outlining practices for improving patient safety and health care quality, and also authored the Care Coordination Measures Atlas. 

Her research team also worked on a set of standardized health-care quality measurements called Quality Indicators for the agency, which can be used to analyze administrative data from hospitals to identify potential quality concerns and track changes over time.

Those Quality Indicators from the AHRQ were implemented at the Johns Hopkins Hospital in 2012. According to a case study published in May, McDonald and her team's Quality Indicators helped Johns Hopkins Hospital improve its postoperative ventilator procedures and reduce the incidence of perioperative pulmonary embolism, hemorrhage, and hematoma.

“Kathryn McDonald’s ideas have improved the lives of the patients, including here at Johns Hopkins,” said Paul B. Rothman, CEO of Johns Hopkins Medicine. “We’re thrilled to welcome her to Johns Hopkins, where she can help us continue to develop and innovate health care delivery, here and across the country.” 

McDonald is also the principal investigator of a project at the Society to Improve Diagnosis in Medicine that is addressing ways that a patient’s age, race and gender — particularly women, young adults and African-Americans — may contribute to errors in medical diagnoses and disparities in patient outcomes. And she’ll continue to examine how the growing time constraints on clinicians — conducting patient consults faster, logging results in EMRs sooner, keeping up with regulatory changes — are impacting patient safety as the shortage of health professionals sgrows larger each year in the United States.

In a study published last year in the American Public Health Association journal, Medicare Care, McDonald and her colleagues wrote that despite concerns about the impact of growing time pressures on clinicians and the delivery of health care, “scant evidence exists about types of time stress, the organizational factors that shape such stressors in routine care settings, and consequences for patients and practitioners alike.” 

Focusing on Quality of Care for Patients, Best Practices for Clinicians

“Kathryn McDonald is a pioneer in bringing systematic and evidence-based approaches to the study of health care delivery,” Patricia Davidson, dean of the Johns Hopkin’s School of Nursing, told the Hub. “She has a track record of collaboration and innovation across disciplines and will bring with her new insights into the best practices for measuring health care outcomes to ensure patient safety for all people.”

McDonald told the Hub she believes it’s important to look at health care from a patient-centered point of view, where it’s often the easiest place to spot trends.

“There's a shift happening right now,” she said. “More people are accessing different entry points for health care, and we need to think about their journey to staying healthy or dealing with a health crisis.”

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California vaccine laws are among the toughest in the nation, particularly since the state did away with the personal belief and religious exemption in 2015 following a measles outbreak that began in Disneyland. 

Governor Gavin Newsom signed a new law in September that gives the state stronger powers to reject suspicious medical exemptions for vaccines.

But both laws are complicated, and antivaccination parents and advocates continue to resist. Some mothers — most of them white, well-educated and affluent — refuse to vaccinate their children as they believe they should be the ones who make the medical decisions for their children; some parents don’t believe vaccines are safe.

Stanford Health Policy’s Michelle Mello, a professor of law and professor of medicine, writes in this Annals of Internal Medicine editorial that California’s experience is a cautionary tale about what happens when vaccination exemption laws have holes.

“The key lesson from California and beyond, therefore, is not that laws tightening vaccination exemptions are unhelpful, but that suboptimal policy design and political compromises may keep them from achieving all they can,” Mello writes in the editorial, which accompanies a wide-ranging assessment of exemptions from vaccination in California by Paul Delamater at the Carolina Population Center.

Delamater, an assistant professor of geography at the University of North Carolina at Chapel Hill, and a team at Yale University found that although the 2015 California law eliminating personal belief exemptions improved overall rates of vaccination in the state, its projected impact would be less than anticipated due to substitution of medical exemptions and other loopholes.

“Lawmakers should anticipate that antivaccination groups will mobilize to assist parents in identifying ways to get around new requirements,” Mello writes. In California’s case, the legislature had to go back to the drawing board to patch the holes, again confronting bitter resistance. Antivaxxers were so incensed by the new law that they threw blood on California senators during the final night of the legislative debate on Sept. 13.

“Avoiding repeated skirmishes requires getting it right the first time,” Mello writes. She recommends that laws narrowing vaccination exemptions include five key provisions:

1.     They should require that medical exemptions come from a pediatrician or family physician whom the child sees for regular care. 

“The physician evaluating whether a child has a medical condition that precludes vaccination should be someone who has been treating the child and is trained in a relevant specialty—not the anesthesiologist who lives next door or the physician hundreds of miles away who offers exemptions on the internet,” Mello said.

2.     They should limit the justifications for medical exemptions to valid, recognized contraindications to immunization.

3.     They should provide for review of medical exemptions by the department of health, as well as action against physicians who do not provide a specific and valid clinical rationale.

4.     The laws should clearly task the department of health — not schools — with reviewing exemptions.

5.     They should avoid grandfather clauses that allow children with existing conditions to forgo their vaccines. 

“Other states can also learn from what California did right,” Mello writes, such as jettisoning personal belief exemptions of all kinds and applying the rules to private schools and daycare centers as well as public ones.

California also makes public an expansive list of required immunizations and makes annual data on school-level exemption rates public.

“In the wake of the recent measles outbreak, state legislatures have been active in considering how to ensure that their laws are up to the challenge of preventing future outbreaks,” Mello writes in the editorial. “To be dispirited about the prospects for legal reform to help improve immunization rates is an empirical mistake. 

“The devil, as Delameter and colleagues show, is in the details.”

Global warming and more days of extreme heat are exacerbating the health risks of pregnancy, particularly among African-American women, according to new Stanford-led research.

The maternal mortality rate among all women in the United States is already the worst of any industrialized nation. And black women are three to four times more likely to die from pregnancy-related problems than white women.

“It is truly a crisis that in America, one of the wealthiest countries in the world, more women are dying from pregnancy or childbirth complications than in any other developed country,” said Maya Rossin-Slater, a core faculty member at Stanford Health Policy and a faculty fellow at the Stanford Institute for Economic Policy Research.

In a new working paper published by the National Bureau of Economic Research, Rossin-Slater and two other health economists underscore how little research is out there about the impact of rising temperatures on the health of mothers and their newborns.

Pregnant women, for example, are not able to regulate body temperature as efficiently as non-pregnant individuals due to the physiological changes they undergo during gestation. Heat exposure can alter blood flow in the placenta, which can weaken the placenta and lead to complications. And high heat can lead to other pregnancy complications, such as hypertension, preeclampsia and prolonged premature rupture of membranes.

“All of these issues can translate into women needing to be hospitalized during pregnancy and experiencing complications during childbirth,” wrote Rossin-Slater, an assistant professor of health research and policy at Stanford Medicine. Her co-authors are Jiyoon Kim, assistant professor of economics at Elon University, and Ajin Lee, an assistant professor of economics at Michigan State University.

The researchers said most of the discussion about maternal health focuses on the health-care system, but that other determinants of poor maternal health and racial disparities are much less understood, particularly when it comes to how the environment is impacting pregnancy.

So they launched what they believe is the first study to identify the causal effects of prenatal exposures to extreme temperatures on the health of the mothers themselves.

As the Earth Warms, So Does Exposure to Extreme Heat

Their paper focuses on an environmental factor that is becoming increasingly relevant due to the growing consensus that climate change is contributing to a gradual warming of the earth: exposure to extreme heat.

The researchers studied the effects of exposure to extreme temperatures during pregnancy on maternal and child hospitalizations, using inpatient discharge records from three U.S. states with different climates: Arizona, New York and Washington. Their data comes from the State Inpatient Databases from the Healthcare Cost and Utilization Project, including 2.7 million inpatient records of 2.7 million infants and 2.2 million mothers in those three states.

And to measure temperature exposure, the researchers obtained data from the National Oceanic and Atmospheric Administration (NOAA).

For every county in their data, the researchers calculated the average temperature for every month. Then for every given day in a specific month in that county, they looked at the historic average for how high or low that day’s temperature was relative to the overall temperature in that month in that county.

For example, a 90-degree day in Arizona in September would not be classified as extreme heat since it’s relatively common. But a 90-degree day in New York would be, since temperatures that high are much less common. They classified “extreme heat” as a given day when the temperature is more than three standard deviations (3SD) above that historic county mean.

Then, they compared the outcomes of women who are of the same race giving birth in the same county and calendar month, but in different years. These women are likely similar in terms of their demographics and socioeconomic status, but may be exposed to different temperatures during pregnancy. For example, consider a black woman giving birth in November 2011 in Queens County, New York, and a black woman giving birth in November 2012 in the same county. If there were a heat wave in Queens in the August 2012, then the latter woman is exposed to more extreme heat during pregnancy than the former. 

The economists found that each additional day with heat that is at least 3SDs — or substantially higher than the historic county-month average — during the second trimester of pregnancy increases the likelihood that a newborn is diagnosed with dehydration by .008 percentage points.

“Our results provide new estimates of the health costs of climate change and identify environmental drivers of the black-white maternal health gap,” they wrote. “Understanding the health consequences of this increase in extreme heat is critical information for discussions about the costs of climate change and the possible benefits of mitigating policies.”

The researchers found that each additional day of extreme heat exposure during pregnancy increases black women’s likelihood of hospitalization during pregnancy. Since black women on average are exposed to more extreme heat than white women — due to different residence patterns and access to mitigating technologies like air conditioning — extreme heat may contribute to exacerbating the already large gap in maternal health between black and white women.

Detrimental Consequences of Rising Temperatures

Scientists predict global average temperatures will continue to rise over the next 50 to 100 years as greenhouse gases continue to trap more heat in the Earth’s atmosphere. The U.N. Intergovernmental Panel on Climate Change last year warned that nations worldwide must quickly reduce fossil fuel use to keep the rise in global temperatures below 1.5°C by 2050. 

The panel also said the number of days with mean temperatures above 32°C in the average American county is forecasted to increase from about 1 to 43 days per year by 2070-2099.

That could have detrimental consequences for babies and mothers alike.

“Overall, our findings on infant health suggest that exposure to extreme heat during the second trimester increases the likelihood of the baby being dehydrated at the time of birth,” the researchers wrote. “This, in turn, appears to increase the likelihood of subsequent readmission to the hospital many months later for causes linked to dehydration.”

And these impacts are typically missed when researchers only measure infant health using more standard variables, such as birth weight.

The authors note dehydration is one of the leading causes of morbidity and mortality in children. Studies show that children under 5 years old who have an average of two episodes of gastroenteritis associated with dehydration per year leads to 2 to 3 million pediatric office visits and accounts for 10% of all pediatric hospital admissions in the United States. 

Experts believe black women are three- to four-times more likely to die from pregnancy-related causes due to lack of access to and the poor quality of health care, as well as clinicians not monitoring black women as closely — or actually dismissing their symptoms altogether.

“The fact that the adverse impacts on health during pregnancy are larger for black than for white mothers suggests that climate change may exacerbate the already large racial gap in maternal health,” the researchers said.

Stanford Medicine has announced a merger of its Division of Health Services Research from the Department of Health Research and Policy with the Center for Health Policy and the Center for Primary Care and Outcomes Research — joining together the School of Medicine’s leading researchers in the field of health policy.

The three centers have all been under the Stanford Health Policy umbrella for several years — CHP is a part of the Freeman Spogli Institute for International Studies and PCOR is a division in the Department of Medicine. The faculty will now all sit under one roof at Stanford Health Policy’s newly renovated offices in Encina Commons.

“On behalf of CHP/PCOR, I want to say how delighted we are to be coming together as one health policy unit,” said Douglas K. Owens, the director of both centers. “We very much look forward to further strengthening our ongoing collaborations in research and training, and the merger will provide great opportunities for synergy.”

Loren Baker, who worked with Kate Bundorf to lead the efforts at the Division of Health Services Research, called the melding of the faculty “a real opportunity to build on the strengths Stanford has in health policy,” and said it would position Stanford Health Policy faculty for further success in their research and education programs.

“We’ve had a long history of working together and we hope that this will lead to more and better opportunities to do that going forward,” Baker said.

Owens said he wanted to thank Loren and Kate “for their terrific leadership as we have worked out how to bring our groups together,” as well as the Dean’s Office, the Department of Medicine, and FSI for their support and guidance.