Jointly with partners throughout Asia, the Asia Health Policy Program (AHPP) at Shorenstein APARC has developed comparative research on health care use, medical spending, and clinical outcomes for patients with diabetes in the region and other parts of the world as a lens for understanding the economics of chronic disease management. Karen Eggleston, AHPP director and APARC deputy director, recently traveled to South Korea, where she led three project-related events.

On November 29, a workshop on Net Value Diabetes Management was held at Seoul National University (SNU) School of Medicine. This was the third such workshop convened through the project, following two previous ones held in Beijing at the Stanford Center at Peking University. Another workshop, on diabetes modeling, hosted by the Mt. Hood Diabetes Challenge Network, was held at Chung Ang University on December 1. Finally, on December 5, Eggleston held an information session, titled Comparative Economics Research on Diabetes, during the 2019 International Diabetes Federation (IDF) at BEXCO in Busan. These events were also made available through video conferencing to enable remote participation by collaborators who were unable to travel to Korea.

[Learn more about AHPP’s Net Value in Diabetes Management research project]

Diabetes Net Value Workshop

The workshop brought together team members from multiple health systems — including South Korea, Japan, Taiwan, Hong Kong, Thailand, India, the Netherlands, and the United States — to discuss comparative research on the economics of diabetes control. Eggleston shared the results of a study outlined in a working paper on the net value of diabetes management in Japan, the Netherlands, Taiwan, and Hong Kong. This research is part of a broader series of studies aimed to help address the policy challenge of finding the best strategies to improve health through cost effective prevention and healthcare productivity in chronic disease management.

The key to this research was to measure changes in quality or health outcomes over time by predicting mortality risk using blood pressure, blood sugar, and other factors amenable to patient and provider control and improvement (controlling for age and duration of diabetes diagnosis). The research seeks to understand how we can control cost and eliminate waste without cutting out the things that are valuable and improving people’s quality of life. Further studies probe determinants of relative net value of a pay-for-performance program in Taiwan, adherence to medications and vertical integration in Japan, and net value based on a randomized controlled trial in India.

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Young Kyung Do of SNU reported that according to his evaluation project for diabetes care, the quality of care and treatment in South Korea has improved and is similar to Hong Kong and Singapore. The goal of the program is to provide more comprehensive care to diabetes patients.

Talitha Feestra of the Netherlands net value team presented her proposal for joint research to develop new prediction models for specific populations as a core component of health economics decision models in Diabetes. Feestra will take the lead to develop the plan and time frame for the continuation of this research in 2020.

Several additional comparative studies were proposed and discussed. Participants who attended the workshop and contributed to discussion included Junfeng Wang from the Netherlands net value team; Jianchao Quan and Carmen Ng from Hong Kong University; Daejung Kim from the Korea Institute for Health and Social Affairs (KIHASA); Taehoon Lee, Eun Sil Yoon, and Hongsoo Kim from SNU; Piya Hanvoravongchai from Chulalongkorn University; and Gregory Ang from National University of Singapore. Remote participants included Vismanathan Baskar from Madras Diabetes Research Foundation; Wasin Laohavinij from Chulalongkorn University (visiting Stanford University autumn quarter); and Rachel Lu from Chang Gung University.

Mt. Hood Diabetes Challenge Workshop on Diabetes Modeling

Philip Clarke from the Health Economics Research Center, University of Oxford, presented the history of insulin as a cure for diabetes and discussed in detail methods for economic modeling of diabetes, including quality of life and diabetes cost, drawing from his rich experience developing the UK Prospective Diabetes Study outcomes model. The second presenter was Andrew Palmer of University of Tasmania, Australia. His presentation included many additional economic modeling pointers, especially regarding drawing in the literature for building models.

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We are grateful to Professors Clarke and Palmer for graciously allowing the AHPP network researchers to join the workshop both in person and remotely, adding to their chronic disease modeling skills, and for inviting Karen Eggleston to present a keynote at the Mt Hood conference that took place before the modeling workshop.

Information Session: Comparative Economics Research on Diabetes

The third and final component of the diabetes research events was held on December 5 as part of the International Diabetes Federation congress in Busan, Korea, and presented the network to clinicians and public health researchers. Participants from China, India, and Australia attended. They shared updates on their individual projects and discussed methods and ideas for future collaboration.

As of December 2019, at least 245 primary and secondary schools in the United States have experienced a shooting, killing 146 people and injuring 310, since the first major school shooting at Columbine in April 1999.

Now, new Stanford-led research sounds an alarm to what was once a silent reckoning: the mental health impact to tens of thousands of surviving students who were attending schools where gunshots rang out.

A study has found that local exposure to fatal school shootings increased antidepressant use among youths.

Specifically, the average rate of antidepressant use among youths under age 20 rose by 21%in the local communities where fatal school shootings occurred, according to the study. And the rate increase – based on comparisons two years before the incident and two years after – persisted even in the third year out.

“There are articles that suggest school shootings are the new norm – they’re happening so frequently that we’re getting desensitized to them – and that maybe for the people who survive, they just go back to normal life because this is just life in America. But what our study shows is that does not appear to be the case,” said Maya Rossin-Slater, a core faculty member at Stanford Health Policy and faculty fellow at the Stanford Institute for Economic Policy Research(SIEPR). “There are real consequences on an important marker of mental health.”

The study is detailed in a working paper published Monday by the National Bureau of Economic Research. It was co-authored by Rossin-Slater, an assistant professor of health policy in the Stanford School of Medicine; Molly Schnell, a former postdoctoral fellow at SIEPR now an assistant professor at Northwestern University; Hannes Schwandt, an assistant professor at Northwestern and former visiting fellow at SIEPR; Sam Trejo, a Stanford doctoral candidate in economics and education; and Lindsey Uniat, a former predoctoral research fellow at SIEPR now a PhD student at Yale University.

Their collaborative research – accelerated by their simultaneous stints at SIEPR – is the largest study to date on the effects of school shootings on youth mental health.

The study comes as the issue of gun safety continues to stoke political wrangling and public debate. And the researchers say their findings suggest policymakers should take a wide lens to their decision-making process.

“When we think about the cost of school shootings, they’re often quantified in terms of the cost to the individuals who die or are injured, and their families,” Rossin-Slater noted. “Those costs are unfathomable and undeniable. But the reality is that there are many more students exposed to school shootings who survive. And the broad implication is to think about the cost not just to the direct victims but to those who are indirectly affected.”

A Driver for Antidepressant Use

More than 240,000 students have been exposed to school shootings in America since the mass shooting in Columbine in April 1999, according to data used in the study. And the number of school shootings per year has been trending up since 2015.

Yet despite this “uniquely American phenomenon” – since 2009, over 50 times more school shootings have occurred in the U.S. than in Canada, Japan, Germany, Italy, France and the United Kingdom combined – little is known about the effects of such gun violence on the mental health of the nation’s youth, the study stated.

“We know that poor mental health in childhood can have negative consequences throughout life,” Schwandt said. “At the same time, children are known to show significant levels of resilience, so it really wasn’t clear what we would find as we started this project.”

The researchers examined 44 shootings at schools across the country between January 2008 and April 2013. They used a database that covered the near universe of prescriptions filled at U.S. retail pharmacies along with information on the address of the medical provider who prescribed each drug. They compared the antidepressant prescription rates of providers practicing in areas within a 5-mile radius of a school shooting to those practicing in areas 10-to-15 miles away, looking at two years prior and two to three years after the incident.

Of those 44 school shootings, 15 of them involved at least one death. The 44 shootings occurred in 10 states: Alabama, California, Connecticut, Florida, Nebraska, North Carolina, Ohio, South Carolina, Tennessee and Texas.

Researchers found a marked increase in the rate of antidepressant prescriptions for youths nearby, but only for the shootings that were fatal. They did not see a significant effect on prescriptions for youths exposed to non-fatal school shootings.

“The immediate impact on antidepressant use that we find, and its remarkable persistence over two, and even three years, certainly constitutes a stronger effect pattern than what we would have expected,” Schwandt said.

Meanwhile, adult antidepressant use did not appear to be significantly impacted by local exposure to school shootings.

Layers of Costs, More Unknowns

The researchers also analyzed whether the concentration of child mental health providers in areas affected by fatal school shootings made a difference in the antidepressant rates, and they drilled a further comparison between the prevalence of those who can prescribe drugs, such as psychiatrists and other medical doctors, and those who cannot prescribe drugs, such as psychologists and licensed social workers.

Increases in antidepressant rates were the same across areas with both high and low concentrations of prescribing doctors, the researchers found. But in areas with higher concentrations of non-prescribing mental health providers, the increases in antidepressant use were significantly smaller – indicating perhaps a greater reliance on non-pharmacological treatments or therapy for shooting-related trauma.

The researchers also found no evidence that the rise in antidepressant usage stemmed from mental health conditions that were previously undiagnosed prior to the shootings.

In totality, the researchers say the results in the study clearly pointed to an adverse impact from a fatal shooting on the mental health of youths in the local community. Furthermore, the results capture only a portion of the mental health consequences: Non-drug related treatments could have been undertaken as well.

“Increased incidence of poor mental health is at least part of the story,” Schnell said.

Though their analysis included only 44 schools and 15 fatal school shootings, Rossin-Slater noted how the trend of school shootings is growing. She believes the mental health impact found on the local communities they studied “can be generalizable to other communities’ experiences.”

That’s all the more reason why policymakers should consider the overall negative effects of school shootings, and how further research will be needed to gauge other societal consequences, the researchers said.

“Think of it as layers of costs,” Rossin-Slater said. And when it comes to evaluating gun violence at schools, “we think our numbers say, ‘Hey, these are costly things, and it’s costlier than we previously thought.’”

Understanding the value of chronic disease care is critical to confronting the challenges of aging societies. In a new ebook published by the Centre for Economic Policy Research, APARC Deputy Director and Asia Health Policy Program Director Karen Eggleston provides a framework for assessing the social value of health spending.

The world population is aging faster than ever before and governments must confront the increasing burden of healthcare spending on their economies. At a time when the economics of aging is inseparable from the economics of healthcare, successful adaptations to older population age structures necessitate better understanding of the value of medical care. Policymakers, in particular, must incorporate value into considerations of healthcare cost growth, so they can determine the extent to which average health improvements offset added cost, reduce cases in which health spending rises without sufficient corresponding health outcomes, and reward those in which “we are getting what we pay for.”

A new book chapter, authored by APARC Deputy Director and Asia Health Policy Program Director Karen Eggleston, provides a framework for assessing the social value of health spending. Titled “Understanding ‘value for money’ in healthy aging,” the chapter is part of an ebook, Live Long and Prosper? The Economics of Ageing, published by the Centre for Economic Policy Research (CEPR).

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Quality-Adjusted Cost of Care

How do health economists incorporate value into measurements of health spending and how do they measure the social value of medical care? First they assume each additional year of life brings a given monetary value. Then they measure the growth in value to patients as monetized gains in “quality-adjusted life-years,” a metric that includes increases in life expectancy and quality of life. The difference between the change in health spending and the change in monetized gains on improved survival is the net change in quality-adjusted health spending or the net value of medical care.

Understanding the value of chronic disease care is especially critical in aging societies, as governments must transform their health systems to support patients who will live with chronic diseases for decades. Health benefits of medical care, however, are difficult to aggregate across disparate services and diseases, and hence focusing on management of a single important chronic disease allows researchers to develop metrics of quality improvement and value that are linked to rigorous clinical studies. Eggleston describes a recent international research collaboration, which she was part of, that did just that. The researchers studied quality adjustment for one disease of growing global prevalence, type 2 diabetes, in four different health systems: one in Europe (the Netherlands) and three in East Asia (Japan, Hong Kong, and Taiwan).

Results of the study suggest that, in each health system, the value of improved survival outweighs the increase in health spending. For example, in the case of Japan, Eggleston and her colleagues found a positive value net of $2,595 for $100,000 value of a life-year. They also compared net value across the four health systems and different patient samples, finding mean net value that ranged between $600 and $10,000 for a $100,000 value of a life-year. Moreover, net value was positive for all age groups and remains positive and significant for individuals well beyond traditional retirement ages. These results, says Eggleston, indicate “the importance of continuing investments in medical treatments and services that deliver health outcomes of commensurate or higher value.”

Policy Implications

Confronting the challenges of aging societies requires careful thinking about the value of investments in new technologies for managing chronic conditions. To promote healthy aging governments must be “resiliently persistent in measuring the value of innovations for healthy aging and rewarding those that deliver high net value,” argues Eggleston. The goal should be improving the “value for money” of medical care rather than applying largescale cost controls that might stifle important breakthroughs.

The four-system study by Eggleston and her colleagues provides a framework for developing methods for assessing quality improvement and the net value of chronic disease spending and, more broadly, for measuring the value of healthy aging.

Download Eggleston’s chapter as part of the entire ebook >>

Learn more about Dr. Karen Eggleston’s research agenda seeking to assess net value in diabetes management and to identify and analyze innovation for healthy aging.

In a new article published by the Milken Institute Review, APARC Deputy Director and Asia Health Policy Program Director Karen Eggleston offers an overview of the successes of China’s health reforms and the challenges ahead if the country is to increase the efficiency of health care delivery as it expands quality and usage.

Creating a high-quality universal health care system is an immense challenge anywhere, let alone in a country as large and diverse as China. But equal access to care will become ever more important as China converges on higher incomes, slower economic growth, population aging, and dependence on a skilled workforce to approach OECD living standards. With its health reforms over the past two decades, its growing technological prowess, and its application of innovative business models, China has made significant progress towards supporting higher-quality and more convenient health care for its 1.4 billion people. However, it is yet to deal with a host of challenges.

In a new article, Healing One-Fifth of Humanity, published in fall quarter 2019 of the Milken Institute Review, APARC Deputy Director and Asia Health Policy Program Director Karen Eggleston offers a progress report on China’s efforts to provide decent health care to all of its citizens, detailing how the reforms are working and what is left to do.

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A Tale of Two Chinas

One complex challenge China faces is addressing the gap in living standards between its rising middle class and its poorest citizens. Eggleston’s research shows stark gaps between urban and rural China in multiple measures, including life expectancy (almost 10 years differences as of 2013), infant mortality, and under-age-5 mortality. Health outcomes differ along other dimensions, too — between urban regions with higher and lower per capita income and among individuals with more or fewer years of schooling.

There are also striking inequalities in the burden of chronic disease and in health care and risk protection. For example, diabetes is associated with greater excess mortality in rural China, although prevalence is higher in urban areas. Moreover, although China has attained universal health coverage and put in place policies to enhance access while decreasing households’ out-of-pocket spending burden, the coverage of rural insurance is less generous than coverage for urbanites. Therefore, the prospect of catastrophic medical spending on delayed care remains substantially higher for rural than urban residents.

Additional challenges abound in multiple other areas, from addressing patient-provider tensions and trust, to changing provider incentives to promote value rather than volume, to deciding which new medical therapies qualify as basic. In broad terms, argues Eggleston, “China must build an infrastructure that increases the efficiency of health care delivery as it expands quality and usage.”

An important issue is the extent to which leveling public policy will ameliorate disparities, even as an array of social and economic forces push to widen disparities in health, health care use and burden of medical spending over a lifetime. The good news, says Eggleston, is that the process of catching up on one critical component of social justice, that is, universal health care, has begun, and there is evidence suggesting “that health investments can narrow the gaps in outcomes by compensating for health disadvantages.” There is also good reason to believe that policies that go beyond direct medical intervention – notably, investments in the quantity and quality of schooling – can have even greater influence on health and survival than access to medical care.

“The challenge now,” concludes Eggleston, “is to persist in an endeavor that requires flexibility, sensitivity to competing interests — and lots and lots of money.”

When it comes to rooting out wasteful spending in federal entitlement programs, attention has long focused on preventing beneficiaries from gaming the system.

A new Stanford study identifies a fresh cause for concern: the for-profit companies that the U.S. government increasingly tasks with providing benefits to Americans who are often poor, elderly or both.

In a new working paper, Maria Polyakova, an assistant professor of medicine, finds that outsourcing public assistance services to third parties can lead to unanticipated effects on prices as well as on which beneficiaries gain the most from public dollars.

That’s because companies are in the business of making money. And when they know which of their consumers are likely to get certain levels of public support, they will try to use this information to maximize their profits, according to the research published this week by the National Bureau of Economic Research.

Polyakova shows that when companies act in their self-interest, unforeseen inequities and inefficiencies can arise that may hurt some consumers while helping others. At a time when governments in the United States and around the world are increasingly turning to the private sector to provide public benefits — namely in health care and in education — Polyakova says policymakers need to better understand how these intermediaries are affecting welfare programs.

“Policymakers have to be more careful about introducing intermediaries into public services,” says Polyakova, who is a faculty fellow at the Stanford Institute for Economic Policy Research (SIEPR), and teaches at the Stanford School of Medicine. She is also a core faculty member of Stanford Health Policy. “They may want to revisit how they think about outsourcing when research is showing that there are unintended consequences that may be positive or negative.”

Health Insurance Pricing under the Microscope

Intermediaries are central to a number of public services where the U.S. government provides subsidies to consumers, often based on income, age or employment status. Prominent examples include privately-managed Medicare Advantage Plans, drug benefits under Medicare Plan D, and charter schools in secondary education.

According to Polyakova, most research into wasteful spending within government subsidies has focused on consumers and how they try to trick the system by, for example, hiding income to qualify for a tax credit or cash assistance. Governments, though imperfect, have long been seen as benign players.

The increasing involvement of for-profit companies, she says, shows there’s a need to closely examine what’s happening on the supply side of public welfare.

To do that, Polyakova found an ideal setting: the federal health insurance marketplace created by the Affordable Care Act of 2010. Most consumers who shop for coverage through www.healthcare.gov receive a subsidy in the form of a tax credit that covers all or part of their insurance premium. The amount of their tax credit is tied to their household income.

The dollars at stake are significant. The Congressional Budget Office estimates that in 2019 the federal government will pay $560 billion in subsidies for privately-provided health insurance, including the spending on the Affordable Care Act marketplaces as well as other similarly designed programs. That figure is expected to hit $1.2 trillion over the next decade.

The Neighborhood Effect

Polyakova and her co-author — Stephen Ryan of Washington University’s Olin Business School — analyzed data from 2017 covering more than 9 million enrollees across some 2,570 counties around the country. They find that the presence of an intermediary significantly impacts insurance prices and key measures economists use to calculate the effects of a policy beyond a given benefit’s face value.

Specifically, they show that health insurance companies will have an incentive to raise premiums in markets where more consumers receive the higher tax credit because their incomes are low and the government is required to subsidize them.

On the flip side, insurers will charge lower prices in places where such subsidized consumers are less willing to buy coverage if they think it costs too much.

To illustrate the unintended consequences of the insurers’ actions, the researchers point out that, in the first instance where prices increase, consumers with incomes that are slightly higher than other community members will end up paying more for the same coverage. Under the second scenario, consumers who don’t qualify for the tax credit because their incomes are too high benefit from the lower premiums aimed at nearby residents.

“The price you pay for insurance will depend on who your neighbors are,” says Polyakova. “If you live near people who are poorer than you, you will be affected differently than if you live near people who are richer than you.”

Change the subsidy, change the calculation

Like with financial aid, tax credits for insurance coverage are calculated based on consumer income. But there is another type of subsidy that policymakers could use — flat vouchers, in which all members of a market receive the same benefit regardless of income, age or some other characteristic. For their research, Polyakova and Ryan also analyze how flat vouchers that only vary by age, but not by income, would hypothetically alter private health insurance prices in the federal Affordable Care Act marketplace.

Here, too, the scholars find different impacts on different types of consumers whether the subsidy is based on income or delivered as a flat voucher.

The analyses, says Polyakova, drive home the point that policymakers need to understand that there are trade-offs to relying on for-profit companies to provide government services and that the type of subsidy offered can alter how they calculate prices in disparate ways.

“There’s nothing wrong with companies trying to maximize their profits,” says Polyakova. “But sophisticated policymakers need to understand what happens when private markets get involved.”

I always find it hard to believe so many people are living in poverty: some 39.7 million Americans, or 12.3% of the population. It’s such a wealthy country, yet so many are poor.

In a twist that could be interpreted as good news — it doesn’t seem fair to say there is anything positive about living in poverty — I recently learned that older, low-income Americans tend to be healthier if they live in more affluent areas of the country.

Not only are they healthier, but their physical well-being is better across the board with a lower prevalence of dozens of chronic conditions, particularly if they live in rural communities. This, despite their income having less purchasing power in those better-resourced neighborhoods.

This was the key finding in new research published by Stanford Health Policy’s Maria Polyakova in the Annals of Internal Medicine.

While recent studies have reported that low-income adults living in more affluent areas of the United States have longer life expectancies, less has been known about the relationship between the affluence of a geographic area and morbidity of the low-income population.

“I was interested in figuring out whether the same relationship holds for morbidity: Are poorer people less sick in richer areas?” Polyakova told me. “And if so, are there any specific conditions that drive these differences that could be the target for policy-making?”

So Polyakova, a faculty fellow at the Stanford Institute for Economic Policy Research, and her co-author, Lynn M. Hua at the University of Pennsylvania, set out to evaluate the association between chronic conditions among low-income, older adults and the economic affluence of a local area. 

They focused on nearly 6.4 million Medicare beneficiaries in 2015 aged 66 to 100 years old who received low-income support under Medicare Part D, a prescription drug program for Medicare enrollees. They investigated the prevalence of 48 chronic conditions among these patients, including common chronic conditions such as hypertension, depression, diabetes and Alzheimer’s disease. They found the presence of all conditions is highly correlated: places, where the poor tend to have a high prevalence of one disease, are likely to have a high prevalence of all 48 conditions.

“While we cannot ascertain a causal relationship, our results clearly point towards the importance of further understanding why the socioeconomic environment of low-income, older adults is so tightly linked to such a broad measure of health,” the researchers wrote. 

The results, they said, were broadly consistent with the extensive literature on the social determinants of health. But their work takes that literature even further.

“Our study extends this research by providing measures of the prevalence of chronic conditions among low-income, older adults for a large national sample of the U.S. population,” Polyakova said. 

The researchers used clinical, rather than self-reported measures of diagnoses and reported this group’s variation in morbidity across local areas of the country, rather than nationally. 

“Our results raise the bar for researchers who are trying to find out what factors drive health disparities in the U.S.; these factors would have to be able to explain the differences in nearly 50 condition,” Polyakova said.

The study supported by the National Institute on Aging came to three key conclusions:

1. The health of low-income, older adults in the United States varies substantially across local geographic regions, and this variation cannot be attributed to one specific disease or a narrow set of conditions. 
2. Consistent with their original hypothesis, they found that more affluent local areas of the country have a lower prevalence of chronic conditions in the low-income, older adult population.
3. The researchers found that low-income, older adults have better health in rural areas of the country.

I wondered why these poor, older adults do particularly well in rural communities, as those regions often lack easy access to high-quality health care and state-of-the-art hospitals.

“We don’t know the exact answer, but there is a general sense that differences in the social fabric and lifestyle in rural areas — could contribute to this pattern,” Polyakova told me. “It appears that better health in these areas persists, despite challenges of accessing formal care.”

A task force of national health experts has released a draft recommendation to screen all adults 18 to 79 years for the hepatitis C virus (HCV), noting the opioid epidemic has fueled what has become the most common chronic bloodborne pathogen in the United States.

Cases of acute HCV have increased 3.5-fold over the last decade, particularly among young, white, injection drug users who live in rural areas. Women aged 15 to 44 have also been hit hard by the virus that is spread through contaminated blood.

The U.S. Preventive Services Task Force, which makes recommendations followed by primary care clinicians nationwide, has until now recommended that people who are at high risk be tested for hepatitis C, as well as “baby boomers” born between 1945 and 1965.

“Unfortunately, HCV now affects a broader age range than previously with three times as many new infections per year,” said Stanford Health Policy’s Douglas K. Owens, chair of the independent, voluntary panel of national experts in prevention and evidence-based medicine.

The Task Force now recommends that clinicians encourage all their adult patients, even those with no symptoms or known liver disease, get a blood test for the virus. Pregnant women should also be screened; from 2009 to 2014, the prevalence of HCV infection among women giving birth has nearly doubled.

“The explosive growth in HCV has been fueled by the opioid epidemic, with the spread of HCV into younger populations,” said Owens, director of the Center for Health Policy and the Center for Primary Care and Outcomes Research. “HCV now kills more Americans than all other reportable infectious diseases combined, including HIV.”

An estimated 4.1 million people in the United States are carrying HCV antibodies; about 2.4 million are living with the virus, according to the Task Force. The HCV infection becomes chronic in 75% to 85% of cases and some of those people develop symptoms such as chronic fatigue and depression, and liver diseases that can range from cirrhosis to liver cancer.

Approximately one-third of people ages 18 to 30 who inject drugs are infected with the virus; 70% to 90% of older injection-drug users are infected.

There currently is no vaccine for hepatitis C although research in the development of a vaccine is underway. But there are effective oral direct-acting antiviral (DAA) medications that can clear the virus from the body, particularly if caught early.

“The good news is that treatment for HCV is far better, and far better tolerated than in the past, offering a cure to most people,” Owens said. “Early identification of HCV is important to prevent long-term complications of HCV including liver failure, liver cancer, and death.”

The Task Force said in a release that there are several key research gaps that could inform the benefit of screening for HCV infection:

1. ·     Research is needed on the yield of repeat vs. one-time screening for HCV.
2. ·     Research is needed to identify labor management practices and treatment of HCV infection prior to pregnancy to reduce the risk of mother-to-child transmission.
3. ·     Trials and cohort studies that measure effects on quality of life, function, and extrahepatic effects of HCV infection (such as renal function, cardiovascular effects or diabetes) would be helpful for evaluating the impact of DAA regimens on short-term health outcomes.
4. ·     Additional studies are needed to examine the epidemiology of HCV infection and the effectiveness of DAA regimens in adolescents.

Physician training has long been notorious for marathon shifts, sleepless nights on call, and holidays worked. But that began to change in 2003, when the medical profession placed restrictions on work hours during residency. However, experts wondered, can we train residents in fewer hours and still make good doctors?

A new study in the BMJ says yes. The researchers, led by Dr. Anupam Jena, a professor of health care policy and medicine at Harvard Medical School, and Stanford Health Policy's Jay Bhattacharya, looked at the performance of internal medicine doctors in their first year of unsupervised medical practice after completing their training. 

They compared the outcomes for patients of two groups of physicians: those trained before 2003, when the typical work week was 100 hours; and those trained later under the new rules, which capped weekly hours at a mere 80, with no individual shift exceeding 30 hours. For the three quality measures examined — mortality within 30 days of being hospitalized, readmissions, and hospital services used (a measure of efficiency) — they found no differences between the groups.

Read More from this article published in STAT News.

A U.S. foreign policy that cuts money to nongovernmental organizations performing or promoting abortions abroad has actually led to an increase in abortions, according to Stanford researchers who have conducted the most comprehensive academic study of the policy’s impact.

Eran Bendavid and Grant Miller — both associate professors at Stanford University School of Medicine and core faculty members at Stanford Health Policy — and doctoral candidate Nina Brooks find that abortions increased among women living in African countries where NGOs, such as the International Planned Parenthood Federation, were most vulnerable to the policy’s requirements.

The policy, widely known as the Mexico City Policy, explicitly prohibits U.S. foreign aid from flowing to any NGO that will not abide by the policy’s main condition: no performing or discussing abortion as a method of family planning, even if just in the form of education or counseling.

The policy has been a political hot potato since its inception. Enacted under Ronald Reagan in 1984, it’s been enforced by subsequent Republican administrations while Democrats in the White House revoked the policy within days of taking office.

The study by Brooks, Bendavid and Miller, published June 27 in The Lancet Global Health, looked at the policy’s effects in more than two dozen African countries over a span of 20 years under three presidents: Bill Clinton, George W. Bush and Barack Obama. It finds that, when the policy was in place during the Bush years, abortions were 40 percent higher relative to the Clinton and Obama administrations.

When the policy was suspended during Obama’s two terms, the research shows that the upward trend in abortion rates reversed.

“Our research suggests that a policy that is supported by taxpayers ostensibly wishing to drive down abortion rates worldwide does the opposite,” said Bendavid, a faculty affiliate of the Stanford King Center on Global Development, which is part of the Stanford Institute for Economic Policy Research (SIEPR).

A key reason for the uptick in abortions is that many NGOs affected by the policy also provide contraceptives – and funding cuts mean birth control is harder to get, said Brooks.

“By undercutting the ability to supply modern contraceptives, the unintended consequence is that abortion rates increase,” she said.

And the policy’s scope has expanded under the Trump administration. While it originally restricted aid directed only toward providing family planning and reproductive health services, President Trump has extended the policy to cover any group engaged in global health, including organizations providing services for HIV or child health – not just family planning.

Groundbreaking Research

The stakes are high. America is the world’s largest provider of development assistance and spent about $7 billion on international health aid in 2017. Many women in sub-Saharan Africa depend on this aid for contraceptives.

In sub-Saharan Africa, NGOs are often primary providers of family planning services. Two of the world’s largest family planning organizations – International Planned Parenthood Federation and Marie Stopes International – have forfeited large sums of U.S. cash for refusing to comply with the policy, according to news reports.

The research findings were based on records of nearly 750,000 women in 26 sub-Saharan African countries from 1995 to 2014. When the policy was in effect under George W. Bush, contraceptive use fell by 14 percent, pregnancies rose by 12 percent and abortions rose by 40 percent relative to the Clinton and subsequent Obama years – an impact sharply timed with the policy and in proportion to the importance of foreign assistance across sub-Saharan Africa.

The paper is the second study of the rule’s impact by Bendavid and Miller, who are both faculty members of Stanford Health Policy. The research is also one of the very few evidence-based analyses of the policy.

Their earlier research, the first quantitative, large-scale effort to examine the policy’s impacts, looked at a smaller set of African countries during the Clinton and Bush administrations and also found an increase in abortion rates when the policy was enacted in 2001.

“Our latest study strengthened our earlier findings because we were able to look at what happens when the rule was turned off, then on, and then off again,” said Bendavid, referring to the policy’s whipsawing under Clinton, Bush and then Obama.

Miller, who is the director of the King Center and a SIEPR senior fellow, says the team’s research reveals a deeply flawed policy.

“We set out to provide the best and most rigorous evidence on the consequences of this policy,” he said. “What we found is a clear-cut case of government action that everyone on all sides of the abortion debate should agree is not desirable.”

Signs of a Global Pushback

Brooks also notes that their findings may underestimate the rule’s full impact.

“The excess abortions performed due to the policy are more likely to be performed unsafely, potentially harming women beyond pregnancy terminations,” she said.

Under Trump, the international response to U.S. funding cuts has shifted. Norway, Canada and several other countries have pledged to increase funding of international NGOs affected by the policy – though not by enough to cover the expected shortfall, says Miller.

“This shows us,” he said, “that despite the intense partisanship in the U.S. over the rule and its implementation, there are ways that policymakers around the world can offset its effects – by ensuring higher levels of family planning funding, for example.”