Rural areas of China have made remarkable progress in reducing adult mortality within the past 15 years yet broadened health insurance was not a casual factor in that decline, according to a new study by an international research team that includes Asia Health Policy Program Director Karen Eggleston.

The New Cooperative Medical Scheme (NCMS), a government-subsidized insurance program that began in 2002-03, expanded to cover all of rural China within a decade. Examining NCMS and cause-specific mortality data for a sample of 72 counties between 2004 and 2012, the researchers found that there were no significant effects of health insurance expansion on increased life expectancy.

The study, published in the September issue of Health Affairs, showed results consistent with previous studies that also did not find a correlation between insurance and survival, although much research confirms NCMS increased access to healthcare, including preventive services, and shielded families from high health expenditures.

Commenting on the study, Eggleston said population health policies remain central to China’s efforts to increase life expectancy and to bridge the gap between rural and urban areas.

Eggleston also noted that multiple factors beyond the availability of health care determine how long people live, and anticipates the research team will continue to explore the impacts of NCMS by extending the study to look at infants and youth.

Read the study (may require subscription) and view a related article on the Stanford Scope blog.

Design learning and journey maps are all the rage here at Stanford University and in Silicon Valley. So why not apply it to health systems to reduce diagnostic errors?

That’s what Stanford Health Policy’s Kathryn M. McDonald is trying to do: Map the journey of worrisome scenarios that keep clinicians up at night, and then plant design seeds that might just help those clinicians get back to sleep.

One of those real-world scenarios involves a preventable diagnostic error made as a high-risk condition unfolds across multiple visits to the doctor. Missed cancer diagnoses, for example, are the leading cause for paid medical malpractice claims in the ambulatory setting, with one in 20 patients experiencing potentially preventable diagnostic errors each year.

“For example, a patient who has a positive fecal blood test, but no follow-up colonoscopy within a reasonable period may experience a missed opportunity to detect and successfully treat colon cancer,” McDonald said.

McDonald and her team worked with San Francisco public health clinics that cater to low-income patients to investigate this key problem — missed diagnosis and prevention activities during outpatient care — then came up with design seeds to plant possible solutions.

She and her co-authors published their research in the journal Implementation Science. The project was conducted at the Ambulatory Safety Center for Innovation (ASCENT), a patient safety learning laboratory led by Dr. Urmimala Sarkar at University of California San Francisco, and funded by the federal Agency for Healthcare Research and Quality.

The team used a research design approach called “journey mapping,” a tool that tells the story of a customer’s experience through his own viewpoint. They constructed maps for each pathway used by doctors to monitor patients with sinister findings, starting with the initial diagnostic assessment during an initial clinic visit and continuing through ongoing follow-up visits.

“Whenever participants in the study verbalized elements of the pathway that were particularly vulnerable to error or poor monitoring, we marked the activity with a bullseye target, also referred to by clinicians as a ‘pain point,’” the authors wrote. “To our knowledge, this technique has seldom been applied to the ambulatory setting, and has not been targeted to clinic workflow efficiency or patient safety intervention development.”

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“A design seed gives the specs for what a solution needs to do,” said McDonald, who is the executive director of Stanford Health Policy’s Center for Health Policy and Center for Primary Care and Outcomes Research. “Once you know the vulnerabilities through journey mapping, you create all the design seeds that are tied to the problem, then the implementation stage becomes much more straightforward and more likely to assure that all the key goals are met.”

To test out this theory, McDonald’s team spent the last two years working with doctors, residents, nurse practitioners and registered nurses with the San Francisco Health Network. The publicly funded integrated health network operates under the auspices of the San Francisco Department of Public Health and includes 14 primary care clinics, as well as urgent and specialty care at Zuckerberg San Francisco General hospital.

“The health system serves many of the most medically and socially vulnerable patients in San Francisco,” the authors wrote in their research paper. “Like many safety-net systems and ambulatory practices, the health system does not have a comprehensive electronic health record system and struggles with information transfer as well as fragmentation of health information across over 50 electronic platforms.”

The health system had more than half a million outpatient visits last year by people who could not afford care. Patients at the network’s main clinics and hospital are diverse: 35 percent are Latino, 21 percent are white, another 21 percent are Asians, and 17 percent are African-American.

Only 1 percent of the network population has commercial insurance; 10 percent were uninsured; 57 percent were on Medi-Cal — California’s Medicaid program — 21 percent were on Medicare and the remaining 11 percent were covered by other, mostly public sources.

This type of ambulatory health care is complex, requiring constant tracking and reconciliation of individual patient activities, patient data, and the unique evolution of each clinical case.

"Human factors and industrial design methodologies have tremendous potential to help unravel these complexities and provide fundamental insights that can drive the development of novel solutions," said co-author George Su of the University of California San Francisco School of Medicine.

McDonald said that journey mapping helped frontline clinic members see their workflow for a specific task, which in this case was monitoring this diverse population for follow-up visits after a potentially sinister finding. The system challenge is population management of an ill-defined problem.

“Lots of ambulatory care work is done one patient interaction at a time, but robust monitoring requires a view from a higher plane,” she said in an interview. “Journey mapping makes the aerial view more tangible and realistic for clinic team input.”

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McDonald’s team selected high-risk cancer situations: incidentally discovered pulmonary nodules; monitoring for breast, colorectal and prostate cancers; and ear, nose and throat cancers. These high-risk cancers require recurring and timely follow-up care to assure intervention whenever the disease takes hold.

The team interviewed clinicians from each of five specialty clinics responsible for these high-risk patients in pulmonary medicine, breast cancer, gastroenterology, urology, and otolaryngology. They asked the frontline clinicians: “What keeps you up and night? And what are your clinical hunches about who might fall through the cracks?”

While the providers talked about the types of patients who become lost to follow-up visits, the researchers found, none of the clinics had a standardized and efficient method of quantifying how many patients were lost to follow-up care and, perhaps more importantly, why.

“Many other health networks share similar struggles with incomplete documentation and measuring the real-time scope of patient safety problems,” wrote McDonald and co-authors Sarkar, Su and Sarah Lisker of the University of California San Francisco School of Medicine; and Emily S. Patterson of Ohio State University College of Medicine.

“When a patient has a warning signal for a serious condition that has yet to materialize but may in the future, the ability of a clinical team to watch the patient closely over time hinges on incredible vigilance on the part of individual clinicians — hardly an ideal solution,” McDonald said.

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This is the crux of the problem, she said, and where so-called “design seeds” are planted.

“The design seeds lay the groundwork in a very specific fashion. Journey mapping and process tracing figure out the problem, in our case, vulnerabilities, and then the design seeds are the first-stage of the solution,” McDonald said. “It’s very user-focused, learning directly from those who are on the frontlines of the work, and making sure that the problem is specified in a way that allows for the developments of solutions that can scale more flexibly during implementation.”

The team identified 45 vulnerabilities within San Francisco’s publicly funded health clinics.

“Repeatedly, we heard that clinicians worry about properly tracking these patients, and are troubled by the significant personnel time required in carrying out patient-level monitoring activities without tools and organization approaches for population-level monitoring,” they wrote.

But even then, the team did not jump straight to solutions. That’s the next step.

The team will launch a pilot project to test possible solutions that will grow from the design seeds, such as whether new digital technology, workflow arrangements, and structured data collection could help find those patients lost in the cracks of an overloaded system.

“Such focused and potentially scalable work is particularly needed for patients who may be lost to follow-up in systems that are stretched for dollars and time,” the authors concluded. “Providers will often create informal workarounds in response to the lack of comprehensive and coordinated record-keeping systems, which can result in errors as well as redundant efforts.”

The ASCENT team is already implementing a monitoring solution informed by the journey mapping activities, in subspecialty care clinics at Zuckerberg San Francisco General, by testing technical and workflow models.

“We determined the need for a registry for high-risk patients in the otolaryngology clinic to help us monitor the entire process,” said Sarkar, a primary care physician and head of the ASCENT lab at UCSF. “This means the final diagnosis, workup and treatment planning, the actual treatment itself and then surveillance and follow-up.”

After going in for a routine procedure, a man ends up with a punctured lung and a medical emergency. A woman's surgery goes well until her stomach is stitched up with a sponge inside. Most of us feel safe going to the doctor, but the road to high-quality care was not straightforward. In this FSI World Class Podcast, Stanford Health Policy's Kathryn McDonald tells us how the safe, high-quality care we expect got where it is today and what we can do to maintain it. Kathryn McDonald is the Executive Director of the Center for Health Policy/Primary Care and Outcomes Research at Stanford University.

And in this Q&A posted on Medium, McDonald responds to the age-old question: How can we improve the quality of health care?

"One of the lead agencies that’s responsible for generating evidence and moving it into practice is the Agency for Healthcare Research and Quality (AHRQ). They’re under Health and Human Services. They have a major program called AHRQ’s Evidence Now aimed at improving heart health in America. Lots of people are on aspirin to prevent heart attacks, but there are also lots of people who could benefit from it who aren’t on it. They’re working with the health-care delivery system to figure out how to get patients who need to be on aspirin to use it. These are driven by reforms to make the delivery system accountable for patients’ health. If you can change behavior — either of patients or of physicians — you can save more lives."

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Stanford Health Policy’s newest faculty member, Joshua Salomon, believes that one urgent need in global health research is to improve forecasts of the patterns and trends that are the major causes of death and disease.

Salomon, who is leaving leaving his position as professor of global health at the Harvard T.H. Chan School of Public Health to join Stanford on Aug. 1, works on modeling of infectious and chronic diseases and their associated intervention strategies, as well as methods for economic evaluation of public health programs and ways to measure the global burden of disease.

And he looks at the potential impact and cost effectiveness of new health technologies.

“Projections of future trends in health are crucial to formulating policy,” said Salomon, who has a PhD from Harvard. “To think strategically about the technologies and policies that would make the biggest impact on health over the next 20 to 50 years, we really need to start by understanding the range of likely trends in major health challenges over the coming decades.”

Stanford, he said, offers him a “rich collaborative environment” to better learn from advances in forecasting across a range of other disciplines, such as economics, political science, and environmental science.

“With a better picture of what the world is likely to look like over the next 50 years — and what are going to be the most pressing health problems — we can invest wisely and put ourselves in a position to respond more effectively.”

Salomon is also the director of the Prevention Policy Modeling Lab, which is funded by a five-year award from the Centers for Disease Control and Prevention. The consortium represents the collaborative research of experts from Massachusetts General Hospital, Boston Medical Center, Dana Farber Cancer Institute, Yale School of Public Health, Brown University School of Public Health, and the Massachusetts Department of Public Health and.

He will continue directing the lab from Stanford and intends to bring in new research threads from his colleagues here on the Farm. The lab works on a wide range of projects dealing with policy analysis for hepatitis, sexually transmitted infections and diseases such as HIV, and tuberculosis.

“It’s a rewarding grant for me to work on because, unlike a lot of modeling projects, the work that we do really starts from urgent public health questions that policymakers have,” he said. “All of the questions that we are working on are questions that originated directly from discussions with CDC and other public health partners.”

With Salomon’s move to Stanford, the university gains a dynamic duo.

Grace Lee joins Stanford as the Associate Chief Medical Officer at Lucile Packard Children's Hospital in the fall, 2017.

His wife, Grace Lee, MD, MPH, joins in the fall as the Associate Chief Medical Officer at Lucile Packard Children’s Hospital. As a professor of population medicine at Harvard Pilgrim Health Care Institute & Harvard Medical School, Lee has led research in vaccine safety in the FDA-funded Post-licensure Rapid Immunization Safety Monitoring (PRISM) program and the CDC-funded Vaccine Safety Datalink, which monitors the safety of vaccines and studies rare and adverse reactions from immunizations.

She has also examined the impact of financial penalties on rates of healthcare-associated infections, as the principal investigator of an AHRQ-funded study, as well as developed novel surveillance definitions for ventilator-related events in neonates and children.

While at Stanford, Lee said, she intends “to find opportunities to enhance the learning health system approach to improve patient outcomes and population health.”

Salomon has spent his entire career as a collaborator on the Global Burden of Disease project, the world’s most comprehensive epidemiological study commissioned by the World Bank in 1990, which tracks mortality and morbidity from major diseases, injuries and risks factors.

“The study has made a major contribution to global public health because before this study we just didn’t have a comprehensive, systematic understanding of the things that cause death and disability in low- and middle-income countries. But now we do,” he said. “It’s hugely ambitious and very sweeping in scope — and a lot of my work is around providing the evidence we need to inform policy.”

Much of Salomon’s work is global in nature. He’s most recently focused on older adults in one rural South African community, which has a high prevalence of HIV and one of the world’s highest levels of hypertension. His research there aims to inform urgent prevention initiatives tailored to older adults where HIV and cardiovascular risks are moderate or high, as in similar communities in sub-Saharan Africa.

“People don’t expect a high level of ongoing HIV transmission in older adults,” he said. “The double burden that we find, with a very high level of HIV, as well as the high prevalence of diabetes and heart disease, creates enormous strains on the health-care system.”

The Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center, in conjunction with The Next World Program, is soliciting papers for a workshop, “Inequality & Aging,” held at the University of Hohenheim from May 4-5, 2018. The workshop will result in a special issue of the Journal of the Economics of Ageing, and aims to address topics such as:

• Population dynamics and income distribution
• The evolution of inequality over time and with respect to age
• Health inequality in old age
• The effects of social security systems and pension schemes on inequality
• Policies to cope with demographic challenges and the challenges posed by inequality
• Family backgrounds and equality of opportunities
• Demographically induced poverty traps
• Effects of automation and the digital economy in ageing societies
• Flexible working time and careers, and their long-term implications
• The dynamics of inheritances, etc.

Researchers who seek to attend the workshop are invited to submit a full paper or at least a 1-page extended abstract directly to Klaus Prettner and Alfonso Sousa-Poza by Sept. 30, 2017.

Authors of accepted papers will be notified by the end of October and completed draft papers will be expected by Jan. 31, 2018. Economy airfare and accommodation will be provided to one author associated with each accepted paper. A selection of the presented papers will be published in the special issue; the best paper by an author below the age of 35 will receive an award and be made available online as a working paper.

Researchers who do not seek to attend the workshop are also invited to submit papers for the special issue. Those papers can be submitted directly online under “SI Inequality & Ageing” by May 31, 2018.

For complete details, please click on the link below to view the PDF.

Stanford Health Policy’s Michelle Mello is calling for reforms to the practice of overlapping surgery, a practice in which surgeons juggle multiple operations at the same time.

Primary surgeons who run multiple operating rooms delegate “non-critical” parts of the operations to trainees or physician assistants. Overlapping scheduling is considered an important means of giving surgical trainees hands-on experience before they enter the profession with a license to operate. But patients are often unaware about the prospect that their surgeon may be double-booked.

“As patients at a teaching hospital, we know that surgery is a team sport and trainees will be involved,” Mello said in an interview. “But learning that the surgeon we’ve entrusted ourselves to may be out of the room for extended periods while we’re under anesthesia comes as a surprise to many patients. Like other aspects of surgical care, policies and procedures need to be in place to make sure this can be done safely.”

Mello, who is a professor of health research and policy at Stanford Medicine and a professor of law at Stanford Law School, wrote in this JAMA editorial that the practice has dented patient trust in the surgical profession and that better research is needed to determine how patients are impacted by double booking. Mello wrote with co-author Edward H. Livingston, MD, of the Department of Surgery at the UT Southwestern School of Medicine in Dallas. Livingston is also deputy editor of JAMA.

For example, Mello and Livingston noted that The Seattle Times reported in February about the unusually high volume of neurosurgical operations “and reportedly poor outcomes” at the Swedish Neuroscience Institute. The top two neurosurgeons each billed more than $75 million in 2015, and clinical staffers who raised concerns were ignored. The news reports prompted federal and state investigations and the resignations of the hospital’s neurosurgery chief and chief executive officer.

Medicare regulations applicable to teaching hospitals allow surgeries to overlap, but primary surgeons can’t bill the government for an operation unless they personally perform the “critical or key portions.”

The Senate Committee on Finance, which oversees Medicare, issued a report last year that said patient safety and informed consent were key concerns raised by overlapping surgery. But they also found scant research on the consequences for patients.

Mello and Livingston write that six peer-reviewed studies have been published about the safety of overlaps, but note that they were all retrospective, single-institution studies.

“These studies suggest that overlapping surgery is not associated with increased risk of patient harm, but these observational studies have important limitations,” they said. 

For example, some studies lumped cases with just one second of overlap together with cases that overlapped significantly longer, making it hard to measure the relationship between the amount of overlap and surgical outcomes. They added that the generalizability of findings beyond the small number of institutions and surgeons studied is unknown.

In ongoing work with other Stanford Health Policy faculty, Mello plans to examine data from a large number of teaching hospitals. One issue requiring further investigation, she said, is whether the longer procedure times documented for overlapping cases mean more time under anesthesia, which elevates the risk of postoperative complications.

Citing a public opinion survey showing that 69 percent of Americans oppose the practice, the JAMA authors concluded, “Overall, the modest evidence base does not suggest that overlapping surgery is unsafe, but rather that the practice is not trusted.”

They believe patients and regulators may distrust it because of the possibility of harm to patients, lack of transparency about what is going on, and surgeons’ conflict of interest in determining on their own what aspects of operations they must personally perform.

Mello and Livingston believe restoring public trust in the surgical system requires stronger proof that overlapping scheduling is safe, including evidence from randomized studies, and better informed consent practices which ensure that patients are given full information about scheduling practices well ahead of surgery.

“The disclosure should include the likelihood that the operation will involve an overlap, a description of who will perform which parts of the operation and what their qualifications are, and the patient’s option if he or she objects to the scheduling,” they said.

Finally, hospitals have an obligation to ensure that their surgeons are performing the critical parts of an operation.

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Tens of thousands of Americans die from drug overdoses every year — around 50,000 in 2015 — and the number has been steadily climbing for at least the last decade and a half, according to the National Institute on Drug Abuse. Yet a team of Stanford neuroscientists and legal scholars argues that the nation’s drug policies are at times exactly the opposite from what science-based policies would look like.

Stanford Health Policy affiliate Keith Humphreys, a professor of psychiatry and behavioral science, and colleagues argue in the journal Science that basing public policy on neuroscience rather than on a desire to punish addicts would improve lives, including those of the victims of drug-related crimes.

“We have an opioid epidemic that looks like it’s going to be deadlier than AIDS, but the criminal justice system handles drug addiction in almost exactly opposite of what neuroscience and other behavioral sciences would suggest,” said Keith Humphreys, a professor of psychiatry and behavioral sciences and one of the leaders of the Stanford Neurosciences Institute’s Neurochoice Big Idea Initiative.

A central problem, the authors argue, is that drug use warps the brain’s decision-making mechanisms, so that what matters most to a person dealing with addiction is the here and now, not the possibility of a trip up the river a few months or years from today.

“We have relied heavily on the length of a prison term as our primary lever for trying to influence drug use and drug-related crime,” said Robert MacCoun, a professor of law and senior fellow at the Freeman Spogli Institute for International Studies. “But such sanction enhancements are psychologically remote and premised on an unrealistic model of rational planning with a long time horizon, which just isn’t consistent with how drug users behave.”

What might work better, Humphreys said, is smaller, more immediate incentives and punishments – perhaps a meal voucher in exchange for passing a drug test, along with daily monitoring.

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