Federal health advisors say women can now consider three options when it's time for their cervical cancer screening tests. The influential group, the U.S. Preventive Services Task Force (USPSTF), has expanded its recommendations for this potentially life-saving exam.
The new recommendations were published in the latest issue of JAMA.
Pap smears have saved many lives since they became available decades ago. Inspecting samples of cervical tissue for pre-cancerous changes is effective at catching possible cancer, and is still the go-to test for women aged 21 to 29, according to the USPSTF guidelines. But there's another option.
"Most cervical cancer is caused by what's called the human papilloma virus, or HPV," says Stanford Health Policy's Dr. Douglas Owens, a professor of medicine at Stanford Medicine and vice-chair of the USPSTF. "And we now have tests for HPV and that's an important step forward."
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Ben Priestley provides leadership and oversight for financial operations, strategic planning, human resources, grant and contract administration, academic affairs, and facilities/space planning. Ben has expertise in interventional clinical research operations and management, specifically in cancer trials. His interest and career in public health began in the field of Parkinson’s Disease research. He received his MPH from Johns Hopkins Bloomberg School of Public Health and his BS in Cognitive Science from University of California San Diego.
In this study published in the American Journal of Managed Care, the authors found that premiums for ACA Marketplace plans were higher in rating areas in which physician, hospital, and insurance markets were less competitive. An increase from the 10th to the 90th percentile of physician concentration and hospital concentration was associated with increases of $393 and $189, respectively, in annual premiums for the Silver plan with the second lowest cost. A similar increase in the number of insurers was associated with a $421 decrease in premiums. Physician–hospital integration was not significantly associated with premiums.
Does Diversity Matter for Health? Experimental Evidence from Oakland
Abstract:
We study the effect of diversity in the physician workforce on the demand for preventive care among African-American men. Black men have the lowest life expectancy of any major demographic group in the U.S., and much of the disadvantage is due to chronic diseases which are amenable to primary and secondary prevention. In a field experiment in Oakland, California, we randomize black men to black or non-black male medical doctors and to incentives for one of the five offered preventives - the flu vaccine. We use a two-stage design, measuring decisions about cardiovascular screening and the flu vaccine before (ex ante) and after (ex post) meeting their assigned doctor. Black men select a similar number of preventives in the ex-ante stage but are much more likely to select every preventive service, particularly invasive services, once meeting with a doctor who is of the same race. The effects are most pronounced for men who mistrust the medical system and for those who experienced greater hassle costs associated with their visit. Subjects are more likely to talk with a black doctor about their health problems and black doctors are more likely to write additional notes about the subjects. The results are more consistent with better patient-doctor communication during the encounter rather than the differential quality of doctors or discrimination. our finding suggests black doctors could help reduce cardiovascular mortality by 16 deaths per 100,000 per year - leading to a 19% reduction in the black-white male gap in cardiovascular mortality.
Marcella Alsan, MD, MPH, PhD
Associate Professor of Medicine and Core Faculty Member at the Center for Health Policy and Primary Care and Outcomes Research, Stanford University
Marcella Alsan, MD, MPH, PhD, is an Associate Professor of Medicine at the Stanford School of Medicine and a Core Faculty Member at the Center for Health Policy / Primary Care and Outcomes Research. Alsan received a BA from Harvard University, a master’s in international public health from Harvard School of Public Health, a MD from Loyola University, and a PhD in Economics from Harvard University. Alsan trained at Brigham and Women’s Hospital - in the Hiatt Global Health Equity Residency Fellowship - then combined the PhD with an Infectious Disease Fellowship at Massachusetts General Hospital. Alsan attends in infectious disease at the Veterans Affairs Hospital.
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Conversational software programs might provide patients a less risky environment for discussing mental health, but they come with some risks to privacy or accuracy. Stanford scholars discuss the pros and cons of this trend.
Interacting with a machine may seem like a strange and impersonal way to seek mental health care, but advances in technology and artificial intelligence are making that type of engagement more and more a reality. Online sites such as 7 Cups of Tea and Crisis Text Line are providing counseling services via web and text, but this style of treatment has not been widely utilized by hospitals and mental health facilities.
Stanford scholars Adam Miner, Arnold Milstein and Jeff Hancockexamined the benefits and risks associated with this trend in a Sept. 21 article in the Journal of the American Medical Association. They discuss how technological advances now offer the capability for patients to have personal health discussions with devices like smartphones and digital assistants.
Stanford News Service interviewed Miner, Milstein and Hancock about this trend.
Conversational software programs are making it possible for people to seek mental health care online and via text, but the risks and benefits need further study, Stanford experts say. (Image credit: roshinio / Getty Images)
Humanitarians in Crisis: Lessons from the Battle for Mosul, Iraq
The Battle of Mosul was one of the largest urban sieges since World War II. From October 2016 and July 2017, Iraqi and Kurdish forces fought to retake Iraq’s second largest city, which had fallen to ISIL in 2014. They were backed by U.S.-led coalition forces. More than 940,000 civilians fled during the siege, and thousands were injured as they sought safety.
Paul H. Wise, MD, MPH
Professor of Pediatrics, Director, Center for Policy, Outcomes, and Prevention, and Richard E. Behrman Professor of Child Health and Society, Stanford University
Paul H Wise, Richard E. Behrman Professor of Child Health and Society, Professor of Pediatrics, and Senior Fellow at the Freeman Spogli Institute for International Studies, was part of a small team tasked to evaluate the health response to the fighting in Mosul. Their report has raised serious questions regarding the continued utility of traditional humanitarian health responses to violent conflict. This presentation will convey the findings of the report and the profound challenges the lessons of Mosul have generated for physicians, humanitarians, and war-fighters around the world.
When a close relative dies, the stress can be overwhelming. But for many adults and children, mourning and grief often give way to healing.
A pair of Stanford scholars now focuses on the impact that loss has on often-overlooked family members: babies. A new publication by Petra Persson and Maya Rossin-Slater indicates that losing a loved one during pregnancy may actually impact the mental health of the child as he or she grows into adulthood.
“We find that prenatal exposure to the death of a maternal relative increases take-up of ADHD medications during childhood and anti-anxiety and depression medications in adulthood,” the researchers wrote in the April edition of the American Economic Review.
Petra Persson
Both are faculty fellows at the Stanford Institute for Economic Policy and Research (SIEPR); Rossin-Slater is an assistant professor of health research and policy with Stanford Medicine and Persson is an assistant professor of economics in the Department of Economics.
“Of course, you cannot prevent family members from dying, and we certainly do not want our findings to constitute yet another source of stress for expecting mothers, who already face rather intense pressure to eat the right foods, avoid activities deemed harmful, and experience an avalanche of health advice,” Persson said. “But our findings potentially point to the importance of generally reducing stress during pregnancy, for example through prenatal paid maternity leave and programs that provide resources and social support to poor, pregnant women.”
Their research focused specifically on singleton children in Sweden born between 1973 and 2011 whose mother lost a close relative during her pregnancy. They used population registers to construct family trees that span four generations, from the children to their maternal great-grandparents. Their sample included all children whose mother lost a close relative — a sibling, parent, maternal grandparent, the child’s father or her own older child — in the nine months after the child’s date of conception or the year after the child’s birth. The study did not account for the quality of those relationships.
Their analysis compared the outcomes of children whose mothers experienced a relative’s death while they were pregnant with those of children whose maternal relatives died in the year after birth. They were thus able to isolate the impacts of fetal exposure to maternal stress from bereavement from all other consequences associated with a family member’s passing, such as changes to family resources or household composition, which affect all children in their sample.
Additionally, by considering the deaths of different relatives, their approach presents a new measure of intensity of stress exposure: the closeness between the mother and the relative who passed in the family tree.
The researchers merged the Swedish data with information about the children’s health throughout childhood and into adulthood, using birth and medical records. They were aided by Sweden’s novel prescription drug registry, which contains all prescription drug purchases and the exact substances and doses prescribed in the country.
“Our research suggests that policies that can reduce stress during pregnancy can have substantial benefits for the next generation,” Rossin-Slater said in an interview. “Moreover, since poor families are more likely to experience stress than more advantaged ones, our results imply that stress-reducing policies that target low-income pregnant women could play a role in mitigating the persistence of socio-economic inequality across generations.”
Persson and Rossin-Slater said they were initially inspired by two recent economic studies using data from Uganda and Iraq, which found that fetal exposure to malnutrition has adverse consequences for adult mental illness.
“Our study offers complementary evidence linking early-life circumstance to adult mental health, but breaks new ground by focusing on stress,” the authors wrote, “which may be more pertinent than malnutrition in modern developed countries such as the United States and Sweden, and by tracing health outcomes throughout the time period between the fetal shock and adulthood.”
Mental illness results in great financial and social costs. In 2008, the market for prescription drugs treating depression totaled $9.6 billion in the United States alone, a sales volume exceeded only by cholesterol and pain medications.
In 2013, one in seven school-age boys were treated with prescription drugs for Attention Deficit Hyperactivity Disorder, fueling a $9 billion market, five times larger than the $1.7 billion market just a decade earlier. The authors note that estimates also suggest that mental illness accounts for more than one-half of the rise in disability costs among men in the last two decades.
Moreover, in Sweden — the setting for their paper – mental illness accounts for a larger share of health expenditures on prescription drugs than any other therapeutic class.
The scholars said that their study contributes to the research in this area by documenting a causal link between fetal stress exposure and mental health later in life. Moreover, by following the same children from birth to adulthood, they were able to observe the onset of adverse effects of exposure to maternal bereavement in utero.
“In sum, our results show that the death of a relative up to three generations apart during pregnancy has far-reaching consequences for mental health during childhood and adulthood,” Persson and Rossin-Slater said.
Their findings suggest large welfare gains of preventing fetal exposure to severe stress: For example, based on the 2008 figure for the U.S. market, the 8 percent decrease in the consumption of prescription drugs treating depression alone can be valued at around $800 million annually.
They conducted a back-of-the-envelope calculation to understand how exposure to economically induced stress during pregnancy might affect the mental well-being of the next generation by relying on past research estimating cortisol responses to grief and to economic shocks like unemployment and poverty.
“Our calculation suggests that in-utero exposure to stress from unemployment may lead to a 17.3 percent increase in the likelihood of ever purchasing a drug to treat ADHD in middle childhood,” they concluded, “and a 9 percent and 5.5 percent increases in the likelihoods of ever purchasing drugs to treat anxiety and depression in adulthood, respectively.”
The newly published findings can inform one way by which policymakers and the medical community can tackle the prevalence and rising costs of mental health issues: by considering ways to make pregnancy — an inherently stressful time — a little easier to manage.
Changes in Clinical Practice Among Physicians with Legal Problems
David Studdert, LLB, ScD, MPH with Co-Authors Michelle Mello, PhD, JD & Matthew Spittal, PhD
Recent evidence indicates that a small group of physicians accounts for a surprisingly large share of all malpractice claims and patient complaints. Next to nothing is known about the career trajectories of these claim-prone physicians. Do they continue to practice, and if so, do they alter their clinical load? Do they cut ties—voluntarily or involuntarily—with hospitals and large practice groups? Do they seek to put their checkered history behind them by relocating—interstate or to areas where clinicians are in short supply? We explore these questions in a large cohort of US physicians.
As millions marched against gun violence across the country on Saturday, research by Stanford Health Policy experts about the impact of gun ownership on public health was also in the spotlight.
The Washington Post published an in-depth story about how the work of gun researchers is finally getting attention — an unfortunate consequence of the recent mass shootings in the United States.
“The explosion of national interest in the problem of gun violence since the Parkland shooting has been remarkable,” said Studdert, who is also a core faculty member at Stanford Health Policy. “And it is inspiring to hear students’ voices — that is definitely a new twist in the politics around this issue. I think there is momentum for change, but I remain pessimistic that we will see the enactment of any substantial reforms at the federal level.”
The Post wrote:
Studdert’s group is using a data set unique to California because of the state’s strict gun laws. Every time a gun is sold in California, a background check logs the purchase and purchaser with California authorities, who also have been unique in their willingness to share such politically fraught data with academic researchers.
Using a sample of 25 million people (taken from California’s voter registration records), Studdert’s team plans to identify handgun owners with the firearm sales records, then compare that against state death records.
The resulting data in theory will help them determine the relationship — whether good or bad — between gun ownership and death.
They call the project LongSHOT, a nod to the project’s scale and ambition.
Academic researchers who were studying the impact of gun violence on public health were dealt a huge financial and political blow in 1996, when the so-called Dickey Amendment was passed by Congress under pressure from gun lobbyists. The law forbids the Centers for Disease Control and Prevention to fund research that might be seen as advocating for gun control. This choked off federal grant money and essential data-gathering on gun violence.
But tucked into the government spending bill in Congress last week was language that indicates the CDC now has the authority to conduct research on the causes and effects of gun violence. Though gun researchers are skeptical that the change in tone will lead to any significant support or funding, some believe that it’s a start. The $1.3 trillion government funding measure also includes efforts to improve state compliance with the national background check system, as well as funding for school counseling and safety programs.
Again, from The Post story:
Yifan Zhang was finishing her PhD in biostatistics at Harvard five years ago when news broke of the Sandy Hook Elementary School shooting.
As a graduate student from China, specializing in highly technical design of clinical drug trials, she had little connection to America’s long-running debate over gun violence. But even now, she said, the anguished faces of those parents she saw on television remain seared in her memory.
So when she heard about a gun-violence research project at Stanford University that could use the statistical skills she had honed on pharmaceuticals, she jumped at the chance.
“I have a son who just turned 1,” said Zhang, 31. “When I think about what I will need to teach him about protecting himself, I think about that school shooting.”
Zhang hopes the Stanford team can one day have an impact.
“I think there are going to be some big decisions that the whole country has to make together, and I’m hoping that our research can help provide evidence and information for the decision making,” she said.
At age 94, with an extensive collection of health policy research and publications under his belt, Victor Fuchs has a lot to say about the health care system.
The high cost. The uninsured. The fragmentation.
During a speech at the Stanford Institute for Economic Policy Research (SIEPR), the pioneering health economist narrowed his gaze to whether a single-payer system is the fix to those problems.
The answer is complicated, and it depends on the questions behind the question, said Fuchs, a SIEPR Senior Fellow and the Henry J. Kaiser, Jr., Professor of Economics and Health Research and Policy, emeritus. He is also a senior fellow at the Freeman Spogli Institute for International Studies and a core faculty member at Stanford Health Policy.
Recent challenges to the Affordable Care Act have rekindled a debate over the merits of a single-payer health care system — where one entity, namely the federal government, would foot the bill for essential services for all — and Fuchs spoke at SIEPR to succinctly explain what a single-payer system could achieve, what would probably never happen, and why.
The problem, Fuchs pointed out, is that the United States spends the most of any high-income country on health care, yet Americans are not achieving better health outcomes. Part of the solution would have to address the nation’s higher administrative costs, higher prices for prescription drugs, and the expensive increasing mix of services and specialists.
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Fuchs contended a single-payer system would lower costs. For one, it would create the bargaining power needed to offset the monopolistic powers of those providing the drugs, medical services and equipment.
To control costs, “we must move to something like a single-payer plan, but that alone will not be sufficient,” Fuchs said. “It will depend on what kind of single-payer plan it is.”
Even as it provides for universal health care insurance coverage, a single-payer system could take on various forms, including a blend of private and public controls.
And to have any chance at success, Fuchs said, the single-payer system would have to be simple, require minimum bureaucracy, and provide choice.
Then comes the rub, of course: The political will has historically tread against single-payer.
Americans are not willing to provide subsidies for those too poor to afford health insurance; neither do they have a compulsion for everyone to acquire coverage and contribute to those subsidies.
“The country as a whole has not been willing to fully embrace these two principles,” he said. “And I feel you need to have a strong majority of both if you’re going to have universal coverage.”
And unfortunately, Fuchs added, he does not believe universal health coverage would necessarily improve health outcomes. Many other socio-economic and environmental factors also play a role there.
In leading a brief discussion with Fuchs, Mark Cullen, a SIEPR Senior Fellow and professor of medicine, asked what makes him think the federal government would work to control costs under a single-payer system — when it has thus far chosen to exert little buying power under the current structure.
“I have not discussed the political feasibility of this, deliberately,” Fuchs quipped.
Victor Fuchs talks about the viability of a single-payer health insurance system at a Feb. 5, 2018, talk at the Stanford Institute for Economics Policy Research.
Petra Persson
