Health Policy

In an unusual collaboration, officials from the health-care and nuclear industries met last July to discuss each field’s similarities and differences between four topic areas, including diagnostic and prognostic technologies and human factors that affect risk and reliability. The Association for the Advancement of Medical Instrumentation recently released a 120-page monograph detailing the lessons learned during the tw0-day workshop.

Today’s issue of Inside Stanford Medicine includes a Q&A with David Gaba, MD, professor of anesthesia and the associate dean for immersive and simulation-based learning at the School of Medicine, discussing his participation in last year’s meeting and what health-care providers can learn from the nuclear industry. He says:

One big one is the need for standard operating procedures, where possible, which also retain flexibility as needed. A major spinoff of this principle, used extensively in nuclear power, is to provide graphically enhanced written protocols for emergency situations. It is long recognized that nuclear power operators cannot remember everything they need to know in managing an adverse event in a nuclear plant — memory is too fallible. Thus, the use of written procedures is a mainstay in this setting. Health care has long depended largely on the individual skill and memory of physicians and nurses. Protocols and checklists or emergency manuals were decried as cheat sheets or cribs. We now know that the best people use these kinds of supports — not because they are stupid but because that is the best way to get the best results in tough situations. My lab and other colleagues at Stanford have been working for some time on written cognitive aids and emergency manuals for anesthesia professionals. These have now been disseminated to all the anesthetizing locations in Stanford’s hospitals and those of its close affiliates. This lesson has clearly come from the nuclear industry and from others such as aviation.

Another lesson from the nuclear industry is the importance of the safety culture in an organization. When the organization favors throughput so heavily that people cut corners on safety, or when personnel are afraid to speak up when they see something unsafe, the risk climbs.

Something near and dear to my heart is the utility of simulation for training of skilled professionals. My lab’s development of simulators and simulation-based curricula in health care was triggered by knowing a little bit about how they are used in aviation and other industries like nuclear power. But I actually had no idea, until this workshop, just how much simulation is required for nuclear power operators. They spend six weeks doing their usual shifts in the control room, and the seventh week is spent in training simulations. All year round, no matter how much prior experience they have. Health care is just scratching the surface in simulation compared to that, but at least we have started our way down a similar road.

Previously: Sully Sullenberger talks about patient safety

When we think of the AIDS epidemic, many of us turn to the developing world, overlooking the fact that HIV is very much a problem here in the United States. Every year some 50,000 people in this country are newly diagnosed with HIV, and many of these individuals previously had no idea they were infected with the virus.

To help prevent further spread of the disease, which affects an estimated 1.2 million Americans, the U.S. Preventive Services Task Force has issued (.pdf) a final recommendation that every adult between 15 and 65 be screened for the virus. Younger adolescents and older adults considered at risk also should be screened, as well as all pregnant women in labor whose HIV status is not known, the task force suggests.

“Treatment for HIV has advanced remarkably, helping people live longer and healthier lives, and reducing HIV transmission,” Stanford professor Douglas K. Owens, MD, one of the members of the task force, told me last week. “Treatment is most effective when offered early in the course of HIV disease, typically well before people have symptoms, and screening enables people to learn they have HIV in time to get the full benefit from treatment.”

“Screening is especially important because up to quarter of people who have HIV do not know they have it,” Owens added.

Studies have shown that people who are infected with the virus are significantly less likely to pass it along if they are receiving ARV treatment, which reduces the amount of virus circulating in the blood. Moreover, people who are infected are more likely to do better - suffering fewer opportunistic infections - if they receive treatment early on, rather than wait until symptoms occur and the disease becomes more advanced. For these reasons, identifying infected individuals through universal screening makes good public health sense.

The task force’s latest recommendation, published in the new issue of the Annals of Internal Medicine, is in keeping with the guidelines of the American College of Physicians, the American Academy of Pediatrics and the federal Centers for Disease Control and Prevention. Owens talked more about this issue with me last fall, after the task force’s draft recommendations were released.

Previously: Stanford expert discusses recommendation for universal HIV screening, Task force issues draft recommendation for universal HIV screening and National HIV screening and testing could be very cost-effective

This month, a new California law went into effect requiring doctors statewide to notify women if their breast tissue is dense. Dense breast tissue has been linked to an increased risk of breast cancer because it can make tumors more difficult to spot. As Stanford breast cancer surgeon Fredrick Dirbas, MD, and colleagues explained in a recent Stanford Hospital & Clinics video, this notification isn’t meant to alarm women, but rather to educate them about their bodies and empower them in making better health-care decisions.

To expand on the conversation on the breast density notification law and clear up confusion over recommendations regarding mammograms, we’ve asked Dirbas to respond to your questions about breast cancer screening and advances in diagnostics and therapies. As head of the Breast Disease Management Group at the Stanford Women’s Cancer Center, Dirbas works with an interdisciplinary team of radiologists, oncologists, pathologists, researchers and support programs to provide patients with a comprehensive treatment approach. His research focuses on improving breast cancer therapy by refining existing diagnostic and treatment options and introducing new methods that reduce side effects and improve patients’ quality of life.

A 2011 Stanford Hospital Health Notes article describes how Dirbas and colleagues are at the forefront of exploring new ideas for delivering radiation in a more targeted and accelerated fashion, including methods such as intraoperative radiotherapy and another approach using external radiation therapy after surgery.

Questions can be submitted to Dirbas by either sending a tweet that includes the hashtag #AskSUMed or posting your question in the comments section below. We’ll collect questions until Wednesday (May 1) at 5 PM Pacific Time.

When submitting questions, please abide by the following ground rules:

• Stay on topic
• Be respectful to the person answering your questions
• Be respectful to one another in submitting questions
• Do not monopolize the conversation or post the same question repeatedly
• Kindly ignore disrespectful or off topic comments
• Know that Twitter handles and/or names may be used in the responses

Dirbas will respond to a selection of the questions submitted, but not all of them, in a future entry on Scope.

Finally – and you may have already guessed this – an answer to any question submitted as part of this feature is meant to offer medical information, not medical advice. These answers are not a basis for any action or inaction, and they’re also not meant to replace the evaluation and determination of your doctor, who will address your specific medical needs and can make a diagnosis and give you the appropriate care.

Previously: California’s new law on dense breast notification: What it means for women and Five days instead of five weeks: A less-invasive breast cancer therapy
Photo by Army Medicine

Medicaid, the federal health-insurance program for low-income individuals, is set to undergo a big expansion in 2014 as part of the implementation of the Affordable Care Act. That expansion is good news for the children of low-income adults who will be newly eligible for health insurance, according to an opinion piece published online yesterday in JAMA Pediatrics.

Under the current system, Medicaid and SCHIP health insurance cover a much larger proportion of low-income children than adults, with the result that many insured children have uninsured parents. While insuring kids is important, it isn’t always enough, say the authors of the new piece, who are from Indiana University and Boston University.

“Children with uninsured parents are significantly less likely to receive recommended health services, even if they themselves are covered,” they write.

However, because of the U.S. Supreme Court’s 2012 decision on the Affordable Care Act, states get to choose whether or not to expand Medicaid. (The Supreme Court ruled that the ACA’s Medicaid-expansion mandate was coercive.) This is where the story gets really interesting. The piece describes states’ financial concerns about Medicaid expansion - essentially, that it will be expensive to add people to the Medicaid rolls - but then elaborates on some of the financial factors that states turning down Medicaid expansion may not be considering:

…[O]verall, the cost of the Medicaid expansion to states would be less than 1% of their local gross state product. Others have illustrated that, because uncompensated care reimbursements will decrease under the ACA and because some individuals will shift from Medicaid coverage to coverage through the private exchanges, many states might actuallywind up saving money by accepting the expansion. Medicaid can also have a stimulative effect on the economy, leading to increased employment and revenues, and, once again, can increase the potential for overall savings for many states.

Refusing the expansion will also come at a cost to clinicians, offices, and hospitals. Disproportionate hospital share payments will be trimmed by the ACA, reducing a source of income to hospitals. If many citizens are denied Medicaid, then it is likely that they will remain uninsured. Providers that continue to care for them will do so at a significant loss. Although many complain that Medicaid reimbursements are too low, they are still better than nothing. Such a complaint also ignores the fact that reimbursements for primary care services (even those provided by subspecialists) will go up significantly under the ACA, starting this year.

The authors hope that some or all of the states that have announced they will not expand Medicaid will eventually decide the expansion would be beneficial for their low-income citizens, including parents and children, and for their overall financial picture.

Previously: Stanford economist Victor Fuchs: Affordable Care Act “just a start”, Roundtable of doctors discuss Affordable Care Act and Analysis: The Supreme Court upholds the health reform act (really)

The latest Stanford Health Policy Forum featuring science and health reporter Pam Belluck is now available online. A staff writer for the New York Times for more than 15 years, Belluck has written about a wide range of health-related topics, including stories for the newspaper’s Vanishing Mind series about Alzheimer’s disease and dementia across various cultures and countries. She also authored the recently released book, “Island Practice”, which chronicles the life of the only surgeon residing on the island of Nantucket.

During the forum, Paul Costello, chief communications officer at the medical school, talked with Belluck about what sparked her interest in writing the book and her distinguished journalism career covering health and science.

Previously: New York Times’ Pam Belluck to discuss work as health, science reporter

Effective today, radiologists across California will be required by law to notify women when their mammography screening shows they have dense breast tissue. Approximately 50 percent of women have dense breast tissue - more fibrograndular tissue than fatty tissue as seen on a mammogram - so falling into this category is quite normal.

If you’re a woman with dense breast tissue, you’ll receive a letter in the mail that includes an explanation that this is a risk factor for developing breast cancer and that having such tissue may make it more difficult to detect a tumor. (However, having dense breast tissue is only a small risk factor for developing breast cancer and mammography is still considered the gold standard in breast-cancer screening.)

While this notification is meant to educate women about their own bodies and empower them to make better health-care decisions, it could also result in needlessly alarming or confusing patients. It’s important that women understand why they’re receiving this information and what they can do about it, which is why Stanford Hospital prepared the video above.

As a New York Times’ science and health reporter, Pam Belluck has written about many different health-related subjects - fetal surgery, hospital delirium, Alzheimer’s disease and the donation of HIV-infected organs. Next week, as part of the Stanford Health Policy Forum series, she’ll discuss her work in a conversation with Paul Costello, chief communications officer at the medical school.

“Health Care in Practice: A Journalist’s Perspective,” will take place on March 20. A flyer (.pdf) for the free event offers more details.

Belluck joined the Times in 1995 as a general assignment reporter on the metropolitan desk, and she began covering health and science in 2009. She is also author of Island Practice, a book about an eccentric doctor and the adventures and challenges of his community on the island of Nantucket.

As I wrote about yesterday, new research in PLOS ONE suggests that sugar may play a stronger role in the origins of diabetes than anyone realized. Countries with more sugar in their food supplies have higher rates of diabetes, independent of sugar’s ties to obesity, other parts of the diet, and several economic and demographic factors, the researchers found.

Although the study focused on diabetes rates among adults aged 20 to 79, it got me thinking about children’s health. Type 2 diabetes, which accounts for 90 percent of adult cases and is tied to obesity, used to be unheard-of in kids. But over the last few decades, it has been showing up in many more children and teens at younger and younger ages. Meanwhile, reducing kids’ sugar intake is already the focus of several preventive-health efforts, such as campaigns to remove sugary drinks from schools and children’s hospitals.

To get some perspective on how the new findings apply to children, I turned to Thomas Robinson, MD, a Stanford pediatric obesity researcher who directs the Center for Healthy Weight at Lucile Packard Children’s Hospital. Though Robinson, also a professor of pediatrics at the School of Medicine, cautioned that the epidemiological, “10,000-foot view” given by this study doesn’t prove a cause-and-effect link between sugar and diabetes in individuals - “it does not prove that the amount of sugar an individual eats is related to his or her diabetes risk,” he said - he had lots to say about the new results.

What do you think the findings mean for children’s health?

Children’s behaviors and environmental exposures have an impact on adult health and disease. This study used sugar data for entire countries, not individuals. That means that both the children and the adults were living in countries where higher levels of sugars in the food supply were associated with higher rates of diabetes. The potential implications are even stronger for children than adults. Children are being exposed to that environment for a much longer time. This is particularly a problem in developing countries where their food supplies, diets and weights are changing so rapidly.

A number of us here at Stanford focus on what we can do in early life, and throughout the lifespan, to prevent diseases that have origins in childhood but only first become apparent in adulthood. One can consider our work on obesity, physical activity, sedentary behavior and nutrition in children as really the prevention of diabetes, heart disease, many cancers and other chronic diseases in adults.

What factors has prior research identified as the biggest contributors to the increase in diagnoses of type 2 diabetes in pediatric patients?

The biggest contributor identified has been increased weight, but the increasing rate of type 2 diabetes at younger and younger ages probably reflects obesity plus lots of different changes, including changes in our diets, such as more sugars and processed foods, and less physical activity. The CDC now projects that 1 in 3 U.S. children will have diabetes in their lifetimes, and it will be 1 in 2 among African-American and Latina girls. That is a pretty scary thought. That is why we focus so strongly on helping families improve their diets, increase activity levels, and reduce sedentary time. We want to prevent and control excessive weight gain and all the problems that go with it, of which diabetes is just one.

In light of the new findings, do you think that parents whose children are not obese should be concerned about how sugar consumption could raise their children’s diabetes risk?

This study doesn’t really address the question of what happens at the level of an individual child. However, it is still consistent with the advice we would give now, for both normal weight and overweight children. I definitely recommend that parents try to reduce sugars in their children’s diets. Most parents are not even aware how much sugar their children are eating. Sure, sodas and sweets are the obvious sources but sugars are also added to seemingly all processed foods, including even bread, pizza and French fries. The added sugars are just empty calories — providing extra calories and no additional nutritional benefit. So I recommend that all parents try at least to reduce the obvious sources of sugary drinks, sweets and desserts.

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Across-the-board cuts to discretionary spending required under the Budget Control Act of 2011 (.pdf) are set to take effect a week from today. Yesterday, National Institutes of Health Director Francis Collins, MD, PhD, and others warned that the budget sequester would “slow scientific progress, delay clinical trials, and put a generation of young researchers at risk if NIH’s $31 billion budget for this year is trimmed by $1.5 billion.”

A group of researchers from universities around the country have created a series of videos highlighting the far-reaching impact that the funding cuts imposed by the sequester will have on the nation’s ability to discover, innovate, educate and maintain its scientific and technological leadership.

In this video, Melinda Crommie, PhD, a postdoctoral research fellow at Stanford, discusses her research on the tissue engineering of muscle at the Palo Alto VA Hospital and speaks out in defense of funding for scientific and medical research. As she explains, her work has helped veterans home from deployment with battlefield injuries and led to the creation of a company.

Previously: Why basic research is the venture capital of the biomedical world, Future of medical research is at risk, says Stanford medical school dean and The economic benefits of publicly funded medical research

Last week, I wrote about efforts to boost IUD use in developing countries. This form of birth control, despite its benefits, isn’t widely embraced here in the United States, either - with surveys showing that less than 10 percent of women of reproductive age use it. But, as reported earlier this week by Kaiser Health News, the recently enacted Affordable Care Act might change that:

IUDs and the hormonal implant — a matchstick-sized rod that is inserted under the skin of the arm that releases pregnancy-preventing hormones for up to three years — generally cost between $400 and $1,000. The steep upfront cost has deterred many women from trying them, women’s health advocates say, even though they are cost-effective in the long run compared with other methods, because they last far longer.

Under the Affordable Care Act, new plans or those that lose their grandfathered status are required to provide a range of preventive benefits, including birth control, without patient cost-sharing. Yet even when insurance is covering the cost of the device and insertion, some plans may require women to pick up related expenses, such as lab charges.

Long-acting reversible contraceptives (LARCs) require no effort once they’re put into place, so they can be an appealing birth-control option for teens and young women, whose rates of unintended pregnancy are highest, experts say.

Via Our Bodies, Our Blog
Previously: Promoting the use of IUDs in the developing world, For many women, no more co-pay for birth control and A look at the federal mandate to cover contraceptives