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This issue of CHP/PCOR's quarterly newsletter, which covers news from the summer 2005 quarter, includes articles about:

  • our new core faculty member Grant Miller, a Harvard-trained health economist with an interest in improving health in developing countries;
  • a discussion with center director Alan Garber on key issues and challenges facing the Medicare program;
  • the fourth meeting of the Patient Safety Consortium, a group of more than 100 U.S. hospitals taking part in CHP/PCOR research on patient safety culture;
  • core faculty member Jay Bhattacharya's research on HIV patients' perceptions of their lifespan as examined through viatical settlement transactions; and
  • a research project on technology coverage decisions in the U.S. vs. the U.K., undertaken by Stirling Bryan, a U.K.-based Harkness Fellow in Health Care Policy who is spending the next academic year at CHP/PCOR.
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A new united nations report recommending the most sweeping reform in the institution's history offers a global vision of collective security for the 21st century that is as committed to development in poor nations as it is to prevention of nuclear terrorism in rich ones.

A new united nations report recommending the most sweeping reform in the institution's history offers a global vision of collective security for the 21st century that is as committed to development in poor nations as it is to prevention of nuclear terrorism in rich ones.

The point is, according to the report's research director, Stephen Stedman, a threat to one is a threat to all in today's world. "Globalization means that a major terrorist attack anywhere in the industrial world would have devastating consequences for the well-being of millions around the developing world," the document states. The report's value lies in putting forward a comparative framework of collective security that addresses all the compelling threats of the day, Stedman explained. "The recommendations really are the most important possible makeover of the institution in 60 years," he said. "I think something is going to come out of it." Stedman, a senior fellow at the Center for International Security and Cooperation (CISAC) at the Stanford Institute for International Studies (SIIS), was recruited a year ago by U.N. Secretary General Kofi Annan to direct research for the High-Level Panel on Threats, Challenges, and Change. Stedman is an expert on civil wars, mediation, conflict prevention, and peacekeeping.

Annan created the 16-member blue-ribbon panel, made up mostly of former government leaders and ministers, in the wake of widespread heated criticism of the United Nations following the U.S.-led war in Iraq. In Annan's annual report to the General Assembly in 2003, he said, "Rarely have such dire forecasts been made about the U.N. ... We have reached a fork in the road ... a moment no less decisive than 1945 itself, when the U.N. was founded." The panel was charged with analyzing global security threats and proposing far-reaching reforms to the international system.

On December 2 the panel, chaired by former Thai prime minister Anand Panyarachun, issued its 95-page report: "A More Secure World: Our Shared Responsibility." The document identifies six major threats to global security:

-War between states;

-Violence within states, including civil wars, large-scale human rights abuses, and genocide;

-Poverty, infectious disease, and environmental degradation;

-Nuclear, radiological, chemical, and biological weapons;

-Terrorism; and

-Transnational organized crime.

Although states do not face these threats equally, a collective security system must take all member states' threats seriously and deal with them equitably, the report noted. It specifically mentioned the world's appallingly slow response to AIDS.

The report makes 101 recommendations for collective prevention and response to the threats, including ways to reform the United Nations. Annan described these in a December 3 editorial in the International Herald Tribune as "the most comprehensive and coherent set of proposals for forging a common response to common threats that I have seen."

The document also reaffirms the right of states to defend themselves-even preemptively-when an attack is imminent, and it offers guidelines to help the Security Council decide when to authorize the use of force. Stedman said other significant proposals involve improving biosecurity, strengthening nuclear nonproliferation, and defining terrorism. Panel members agreed that any politically motivated violence against civilians should be regarded as terrorism and condemned.

The panel was very critical of the Human Rights Commission, a body that has often harmed the United Nations' reputation by permitting the membership of some of the worst human-rights violators, including Cuba, Libya, and Sudan. The report also discussed the need for new institutions, such as a peace-building commission, that would support countries emerging from conflict.

Scott Sagan, co-director of CISAC, described the report as hard-hitting, although he said he would have tried to extend the withdrawal clause of the nonproliferation treaty from three months to a year. "I think it's the beginning of some major changes that will be helpful," he said. "We need to get states to work together to reform the U.N. rather than sniping at it."

CISAC was closely involved in the panel's work and was named in a cover letter accompanying the report from Panyarachun to Annan. Co-director Chris Chyba served on the panel's 30-member resource group, providing expertise on nuclear nonproliferation and bioterrorism. Bruce Jones, a former CISAC Hamburg Fellow, acted as Stedman's deputy, and Tarun Chhabra, a graduate of CISAC's undergraduate honors program and recent Marshall Scholarship recipient, worked as a research officer. Political science Professors David Laitin and James Fearon, and SIIS Senior Fellow David Victor, provided, respectively, expertise on terrorism, civil wars, and the environment, Stedman said. "There is an immense amount of Stanford influence in the report," he added.

CISAC also hosted a nuclear nonproliferation workshop for the panel on campus last March and helped organize a meeting during the summer in Bangkok. SIIS co-hosted a conference on governance and sovereignty on campus in April and a meeting at Oxford University in June. CISAC provided workspace to give the research team a quiet place to focus on writing the report's first draft in August.

The report has attracted intense international media interest in part because it calls for expanding the U.N. Security Council, its top decision-making group, from 15 to 24 members. The panel was unable to agree on one proposal and offers two options that would make the council more representative and democratic. "I believe either formula would strengthen the legitimacy in the eyes of the world, by bringing its membership closer to the realities of the 21st century-as opposed to those of 1945, when the U.N. Charter was drafted," Annan wrote in the International Herald Tribune.

According to Stedman, the media has highlighted the Security Council's proposed expansion because so many nations have a stake in it. "But in the absence of a new consensus on international peace and security, expansion of the council will not be effective," he explained.

In March, Annan will use the report to inform a series of proposals he will present to the 191 U.N. member states. These, in turn, will be submitted to a summit of world leaders before the General Assembly convenes next September in New York. Stedman said he has been asked to stay on for another year as a special advisor to the secretary general to keep the United Nations "on message" during negotiations.

Engagement by the United States, which has openly questioned the institution's relevance, will be critical to implementing the report's recommendations, said Stedman, who added that the superpower can benefit from a revamped United Nations. "Putting threats to the United States into a global framework makes it more secure," he said.

Stedman noted that one of the most disturbing aspects of the panel's consultations was listening to government representatives from civil-society organizations dismiss the seriousness of bio- and nuclear terror threats against the United States. "They were essentially denying this as a real threat to American security," he said. "I said it's as real a threat to the U.S. as other threats are to you."

When Stedman accepted the job, he thought he would spend 80 percent of his time on research and writing and 20 percent on consultations and negotiating. In fact, he said, it was the other way around. "It's unlike anything I've ever done," he said. "It's been a blast." In contrast to academia, where a researcher presents his or her best findings and defends them, Stedman was faced with 16 people who would push back, reject, or accept his work. "I had to work to change language to include their concerns," he said. "My biggest concern at the beginning was that the report would be based on the lowest common denominator. It's not."

Stedman said the panel members remained open-minded throughout the year. "They showed flexibility, listened to arguments, and changed their minds," he said. "Our job was to be as persuasive, rigorous, and comprehensive in our analysis as we were able to achieve."

In the end, Stedman said, the report belongs to the panel. "Parts of what the exercise shows is that access to those making policy is really important," he said. "If you do really good work and you have access, you have a chance of being heard. Kofi Annan gave me that opportunity."

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This paper presents empirical evidence on a specific mechanism through which demographic transition affects economic growth. The evidence provides support for the models of demographic transition emphasizing the demand for children. Using a panel of African countries during 1985-2000, I show that the AIDS epidemic effects the total fertility rates positively and the school enrollment rates negatively. These patterns are consistent with the theoretical models that argue the existence of a precautionary demand for children in the face of uncertainty about child survival. Parents, who are faced with a high mortality environment for young adults, choose to have more children and provide each of them with less education, leading a reversal in the fertility transition and a reduction in the aggregate amount of human capital investment. The empirical estimates show that a country that has witnessed the average increase in AIDS incidence for Africa, have 0.8 more births and 30 percentage points less primary school enrollment since 1985. The results imply lower economic growth and welfare for the current and future African generations.

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The Walter H. Shorenstein Asia-Pacific Research Center (Shorenstein APARC) at the Freeman Spogli Institute for International Studies at Stanford University invites applications to receive funding grants for activities or programs focusing on health care policy in Asia. Shorenstein APARC welcomes research proposals on a wide range of topics from diverse disciplines, but has particular interest in international studies of demography; the effects of an aging population on social, economic, and political systems; and the causes and prevention of epidemics such as AIDS and Avian Influenza in Asian countries.

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This issue of CHP/PCOR's quarterly newsletter covers developments from the spring 2005 quarter. It includes articles about:

  • research on HIV/AIDS in Russia -- presented in May at an international conference -- which shows that in order to contain the country's rapidly expanding HIV/AIDS epidemic, Russia must aggressively treat HIV-positive injection drug users;
  • a CHP/PCOR-hosted discussion session with Edward Sondik, director of the National Center for Health Statistics;
  • an ongoing CHP/PCOR study that examines older adults' preferences about health states in which they would need help with basic tasks like bathing or eating;
  • a panel discussion on "International Responses to Infectious Diseases," led by CHP/PCOR at the Stanford Institute for International Studies' first annual conference, featuring the World Health Organization's chief of infectious diseases;
  • a widely publicized study by CHP/PCOR researchers which found that obese workers are paid less than non-obese workers in similar jobs, but only when they have employer-sponsored health insurance -- a finding suggesting that the wage gap is due to obese workers' higher medical costs, rather than outright prejudice; and
  • an update on the Center on Advancing Decision Making for Aging, including two new seed projects and a lecture given by economics and psychology professor George Loewenstein.
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Purpose:

To examine U.S. adolescents' (age 13-18) utilization of ambulatory care and the likelihood of receiving preventive counseling from 1993 through 2000.

Methods:

The National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey provided visit-based data on counseling services that occurred in private physician offices and hospital outpatient departments. Main outcome measures included adolescents' use of outpatient care and their likelihood of being counseled on 3 health promotion topics (i.e., diet, exercise, and growth/development) and 5 risk reduction topics (i.e., tobacco use/exposure, skin cancer prevention, injury prevention, family planning/contraception, and HIV/STD transmission).

Results:

Adolescents had the lowest rates of outpatient visits among all age groups, with particularly low rates among boys and ethnic minorities. Most frequently, adolescent visits were for upper respiratory tract conditions, acne, routine medical or physical examinations, and, for girls, prenatal care. In 1997-2000, counseling services were documented for 39% (99% CI: 32-46%) of all adolescent general medical/physical examination (GME) visits. Diet [26% of GME visits (20-32%)] and exercise [22% (17-28%)] were the most frequent counseling topics. The counseling rates of the other six topics ranged from as low as 3 to 20%, with skin cancer prevention, HIV/STD transmission, and family planning/contraception ranking the lowest. These rates represented minimal improvements from 1993-1996 both in absolute term and in relation to the gaps between practices and recommendations.

Conclusions:

Adolescents underutilize primary care, and even those who do receive care are underserved for their health counseling needs. The noted lack of change over time suggests that satisfactory improvement is unlikely unless substantial interventions are undertaken.

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This issue of CHP/PCOR's quarterly newsletter covers news and developments from the winter 2004 quarter. It features articles about:

  • a widely publicized study by CHP/PCOR researchers which found that routine HIV screening is cost-effective and would extend the lives of HIV-positive patients;
  • publication of the first three volumes of "Closing the Quality Gap," a report prepared by researchers at CHP/PCOR and UCSF that evaluates quality improvement strategies for specific medical conditions;
  • a health vouchers plan co-authored by Victor Fuchs, which would provide comprehensive health coverage for all Americans, while maintaining individual choice and free-market competition;
  • a research collaboration led by CHP/PCOR that has been awarded a grant to develop a comprehensive Medicare reform plan; and
  • the work of former CHP/PCOR trainee Jessica Haberer, who is doing HIV/AIDS research in China for the William J. Clinton foundation, and recently met the former president in this capacity.
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Background: Although the Centers for Disease Control and Prevention (CDC) recommend routine HIV counseling, testing, and referral (HIVCTR) in settings with at least a 1 percent prevalence of HIV, roughly 280,000 Americans are unaware of their human immunodeficiency virus (HIV) infection. The effect of expanded screening for HIV is unknown in the era of effective antiretroviral therapy.

Methods: We developed a computer simulation model of HIV screening and treatment to compare routine, voluntary HIVCTR with current practice in three target populations: "high-risk" (3.0 percent prevalence of undiagnosed HIV infection; 1.2 percent annual incidence); "CDC threshold" (1.0 percent and 0.12 percent, respectively); and "U.S. general" (0.1 percent and 0.01 percent). Input data were derived from clinical trials and observational cohorts. Outcomes included quality-adjusted survival, cost, and cost-effectiveness.

Results: In the high-risk population, the addition of one-time screening for HIV antibodies with an enzyme-linked immunosorbent assay (ELISA) to current practice was associated with earlier diagnosis of HIV (mean CD4 cell count at diagnosis, 210 vs. 154 per cubic millimeter). One-time screening also improved average survival time among HIV-infected patients (quality-adjusted survival, 220.7 months vs. 219.8 months). The incremental cost-effectiveness was $36,000 per quality-adjusted life-year gained. Testing every five years cost $50,000 per quality-adjusted life-year gained, and testing every three years cost $63,000 per quality-adjusted life-year gained. In the CDC threshold population, the cost-effectiveness ratio for one-time screening with ELISA was $38,000 per quality-adjusted life-year gained, whereas testing every five years cost $71,000 per quality-adjusted life-year gained, and testing every three years cost $85,000 per quality-adjusted life-year gained. In the U.S. general population, one-time screening cost $113,000 per quality-adjusted life-year gained.

Conclusions: In all but the lowest-risk populations, routine, voluntary screening for HIV once every three to five years is justified on both clinical and cost-effectiveness grounds. One-time screening in the general population may also be cost-effective.

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New England Journal of Medicine
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Background:

The costs, benefits, and cost-effectiveness of screening for human immunodeficiency virus (HIV) in health care settings during the era of highly active antiretroviral therapy (HAART) have not been determined.

Methods:

We developed a Markov model of costs, quality of life, and survival associated with an HIV-screening program as compared with current practice. In both strategies, symptomatic patients were identified through symptom-based case finding. Identified patients started treatment when their CD4 count dropped to 350 cells per cubic millimeter. Disease progression was defined on the basis of CD4 levels and viral load. The likelihood of sexual transmission was based on viral load, knowledge of HIV status, and efficacy of counseling.

Results:

Given a 1 percent prevalence of unidentified HIV infection, screening increased life expectancy by 5.48 days, or 4.70 quality-adjusted days, at an estimated cost of $194 per screened patient, for a cost-effectiveness ratio of $15,078 per quality-adjusted life-year. Screening cost less than $50,000 per quality-adjusted life-year if the prevalence of unidentified HIV infection exceeded 0.05 percent. Excluding HIV transmission, the cost-effectiveness of screening was $41,736 per quality-adjusted life-year. Screening every five years, as compared with a one-time screening program, cost $57,138 per quality-adjusted life-year, but was more attractive in settings with a high incidence of infection. Our results were sensitive to the efficacy of behavior modification, the benefit of early identification and therapy, and the prevalence and incidence of HIV infection.

Conclusions:

The cost-effectiveness of routine HIV screening in health care settings, even in relatively low-prevalence populations, is similar to that of commonly accepted interventions, and such programs should be expanded.

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New England Journal of Medicine
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Douglas K. Owens
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