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This issue of CHP/PCOR's Quarterly Update covers news from the Summer 2007 quarter and includes articles about:

  • two reports on care coordination -- one on care coordination strategies in general, and a second on care coordination specifically for children with special health care needs;

  • an international health section that features work done by undergraduates this summer (with mentorship and guidance from CHP/PCOR staff) on the GOBI initiative, as well as a summary of a the new Children's Project established by core faculty member Paul H. Wise;
  • two Research in Brief selections -- one highlights the impact of pay for performance reimbursement structures on end-stage renal disease care, and the second examines the link between obesity and wages in Europe;
  • a Medicare restructuring and refinancing piece that highlights the work of director and core faculty member Alan M. Garber, core faculty member Victor R. Fuchs, and colleagues;
  • a piece on the effect of chronic illnesses such as obesity on disability trends in the near-elderly population;
  • a Staff Spotlight feature on two CHP/PCOR research assistants.
The newsletter also contains various other news items that may be of interest to our readers.

Note to the reader:

The newsletter is fully-navigational. Any text that is surrounded by a dashed box is clickable and will allow the reader to navigate the newsletter more efficiently. The end of each article contains a special symbol (§) that, when clicked, will take the reader back to the table of contents. Please feel free to contact Amber Hsiao with any questions.

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Dr. Lee currently holds the Edward G. and Nancy S. Jordan Endowed Chair in Economics and is a professor in the Department of Demography at University of California - Berkeley (Berkeley). He has taught courses in economic demography, population theory, population and economic development, demographic forecasting, population aging, indirect estimation, and research design, as well as a number of pro-seminars.

Professor Lee is also the director of the Center on the Economics and Demography of Aging at Berkeley, funded by the National Institute of Aging. His current research includes including modeling and forecasting demographic time series, the evolutionary theory of life histories, population aging, Social Security, and intergenerational transfers.

He has received several honors, including Presidency of the Population Association of America, the Mindel C. Sheps Award for research in mathematical demography, the PAA Irene B. Taeuber Award for outstanding contributions in the field of demography. He is an elected member of the National Academy of Sciences, the American Association for the Advancement of Science, the American Academy of Arts and Sciences, and a Corresponding member of the British Academy. He has chaired the population and social science study section for NIH and the National Academy of Sciences Committee on Population, and served on the National Advisory Committee on Aging (NIA Council).

Professor Lee holds an MA in demography from the University of California, Berkeley, and a PhD in economics from Harvard University.

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Ronald Lee Director of the Center on the Economics and Demography of Aging Speaker University of California - Berkeley
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"Ethnicity in Today's Europe" November 7, 2007- November 9, 2007 Stanford University Sponsored by the Stanford Humanities Center and the Forum on Contemporary Europe

RELATED PRESIDENTIAL LECTURE

Partha Chatterjee - Director and Professor of Political Science, Centre for Studies in Social Sciences, Calcutta; Professor of Anthropology, Columbia University, New York

PANELISTS

Leslie Adelson - German Studies, Cornell University

Rogers Brubaker - Sociology, UCLA

Salvador Cardús Ros - Sociology, Universitat Autònoma de Barcelona

Carole Fink - History, Ohio State University

Alec Hargreaves - French, Florida State University

Kader Konuk - Germanic Languages and Literatures, University of Michigan

Saskia Sassen - Sociology, Columbia University

Bassam Tibi - International Relations, University of Göttingen, Germany

Zelimir Zilnik - Filmmaker

CONFERENCE STATEMENT

Headlines today blaze with stories about the fate of Europe. There is a sense, both in Europe and around the world, that a sort of "tipping point" has been reached. A recurrent theme is the question of demographics. For instance, how are European social welfare systems going to cope with an aging population? What role will immigrants from outside Europe's borders, both recent and less recent, play in European society? What will be the impact of immigration between the member states of the European Union? What place will Europe's growing population of Muslims have in twenty-first century Europe?

As the ongoing process of unification redraws Europe's borders, as the populations of major European cities become more and more diverse, the question of ethnicity is at the forefront of many of the most important debates on the continent. On the one hand the long history of European national and ethnic identities is at play, as is the legacy of colonialism. On the other, a significant recent upswing in the movement of peoples around the globe has changed the face of Europe, often literally. Movement, of course, from outside Europe's borders into European states. But also, and crucially, movement within the space between Portugal and the Urals. Such movement certainly responds to a number of economic and social needs. At the same time, European conceptions of citizenship, equity, and nationhood often exist in tension with the realities of changing ethnic populations.

The conference "Ethnicity in the New Europe" at Stanford will address this topic in an interdisciplinary manner. Participants will focus on the question: "What's new about the situation in Europe today?" Bringing together scholars from different disciplines, the conference will provide a historical perspective together with contributions addressing economic, social, cultural, and political issues. Some themes that may be discussed include: how the current situation mirrors or departs from the past; the role of the media in portraying the interaction between different groups; the different perspectives of specific populations within Europe; whether Europe's diversity is best described under the rubric of ethnicity, nationality, race, or some other term; similarities and differences between European nation-states with regard to diversity within their borders. Above all, participants will use their own disciplinary perspective to assess what is at stake in the interaction between peoples in Europe as the twenty-first century gets underway.

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Shorenstein APARC
Stanford University
Encina Hall, Room E301
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For the past 14 years, Jongkyu Park has worked on various macroeconomic policy issues of Korean economy including economic forecasts, monetary policy, inflation, budget deficit, exchange rate, savings rate, population aging, realestate bubble, Japan's economic slowdown and revival, etc. He received B.A. in Economics from Seoul National University in Korea, M.S. in Statistics from University of North Carolina at Chapel Hill and Ph. D. in Economics from Princeton University.

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Objective: Findings from the Women's Health Initiative (WHI) failed to confirm previous expectations about the net benefits of menopausal hormone therapy and have resulted in reduced use of these medications. The aim of this study was to evaluate women's awareness and knowledge concerning the risks and benefits of hormone therapy.

Design: A nationally representative survey was completed for a sample of 781 women (ages 40-60 y, mean 49 y) drawn from the Knowledge Networks Internet panel 24 months after publication of the first WHI findings, in June 2004. Responses were weighted to reflect the demographics of the US population. The main outcome measures were awareness of WHI and knowledge of its findings. An aggregate score was constructed to assess women's knowledge of the impact of hormone therapy on seven key disease outcomes. Logistic regression determined the independent predictors of (1) WHI awareness and (2) a positive aggregate knowledge score, reflecting appropriate responses about risks and benefits.

Results: Only 29% of women were aware of the WHI results. Only 40% of women had a positive aggregate knowledge score. Aside from awareness of WHI and independent of other factors, knowledge scores were lower for African American women (odds ratio, 0.4; 95% CI: 0.2-0.6) and among women with less education (odds ratio, 0.5; 95% CI: 0.3-0.9). Knowledge was greatest for breast cancer and osteoporosis outcomes and most limited for colorectal cancer and memory loss.

Conclusion: Surveyed women had limited awareness and knowledge of the WHI results, suggesting limited diffusion. Targeting younger, less educated, and African American women is warranted.

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Daniel C. Sneider
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Japan's ruling party suffered a historic defeat Sunday. For the first time since the conservative Liberal Democratic Party (LDP) was formed in 1955, an opposition party has become the largest party in the upper house.

The powerful message delivered by Japanese voters has significant implications not only for Japan but also for the rest of the world, not least for its close ally, the United States.

The election result revives momentum in Japan toward creation of a viable two-party system, potentially ending the conservative postwar monopoly on power. Japanese voters expressed deep anxiety about the impact of economic change upon their treasured social order. They embraced the campaign of the Democratic Party (the main opposition) against growing income inequality and the failure of the state to take care of an aging population.

Equally important, the vote was a humiliating defeat for Prime Minister Shinzo Abe's agenda of giving priority to revising Japan's antiwar Constitution and allowing its military to take on a global role in support of the US. Democratic Party leader Ichiro Ozawa effectively portrayed Mr. Abe as a man out of touch with the concerns of ordinary Japanese. But he also articulated an alternative vision of Japan's international role, calling for closer ties to its Asian neighbors and sending troops overseas only under the auspices of United Nations peacekeeping missions.

Since 9/11, Japan has been among the most loyal, if not unquestioning, of US allies. It sent troops to Iraq, provided logistical support to the war in Afghanistan, and outdid the US in putting pressure on North Korea. Most recently, Abe echoed the rhetoric of the Bush administration, calling for formation of a "values-based" alliance of democracies along with India and Australia, implicitly aimed at containing a rising China. The election results will certainly slow, if not reverse, this tight synchronization.

For the business community, the vote will raise concerns that needed economic policy actions such as fiscal reforms will get stalled in a gridlocked parliament. The vote reminds politicians that the economic recovery has left an awful lot of Japanese behind, with real wages falling, youth unemployment high, and the elderly drawing down their savings to survive. Abe's feel-good rhetoric and focus on security just angered those Japanese.

There remains strong support for gradual change. Most Japanese want the country to take on a more "normal" security role, but one that will stop far short of overdrawn fears of a remilitarized Japan. And many Japanese, particularly in the younger generation, back economic reform, though not at the expense of social stability.

The most intriguing question is the future of Japan's democracy. Abe is resisting calls for his resignation, attributing the vote to a series of scandals in his Cabinet and most of all to the revelation that the government's national pension system had lost the records of some 50 million people. The election result was bad luck, Abe claimed, not a repudiation of his administration's overall policies -- a view shared by Washington policymakers.

Exit polls do confirm that voters were strongly motivated by these issues. But they also express little faith in the personal leadership of Abe, who tried to cover up the pension debacle. He suffered from an unfavorable comparison to his predecessor, Junichiro Koizumi, one of Japan's most popular postwar leaders.

But the election suggests that Mr. Koizumi's personal charisma only temporarily reversed a longer trend of drift away from the ruling conservatives, particularly by unaffiliated swing voters in Japan's cities and suburbs. Mr. Ozawa, one of Japan's most brilliant politicians, managed to both regain those voters and steal away traditional conservative backers in rural areas among farmers and pensioners worried about their future.

Ozawa, whom I have known for more than two decades, is a man of uncommon political vision. He is a former LDP stalwart who has relentlessly pursued the goal of creating a clearly defined two-party system that can create real competition. He was the architect of a split in the LDP that briefly brought the opposition to power in the early 1990s.

Over dinner last fall, Ozawa laid out to me what seemed then like an incredibly audacious plan to regain power. First to win a series of local elections, leading up to a defeat of the LDP in the upper house election, forcing in turn the dissolution of the lower house and new elections. He clearly hopes to split the LDP again and pry away its coalition partner, the New Komeito Party, as part of his strategy of realignment.

The Democratic Party has yet to demonstrate its own ability to rule, but it would be unwise to underestimate Ozawa. And it would be foolish to dismiss the desire for change delivered by Japanese voters on Sunday.

Reprinted with permission by the Christian Science Monitor.

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In recent decades, elderly Americans have enjoyed enormous gains in longevity and reductions in disability. The causes of this progress remain unclear, however. This paper investigates the role of fetal programming, exploring how economic progress early in the 20th century might be related to declining disability today. Specifically, we match sudden unexpected economic changes experienced in utero in America's Dust Bowl during the Great Depression to unusually detailed individual-level information about old-age disability and chronic disease. We are unable to detect any meaningful relationship between early life factors and outcomes in later life. We conclude that, if such a relationship exists in the United States, it is most likely not a quantitatively important explanation for declining disability today.

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Proceedings of the National Academy of Sciences of the United States of America
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Grant Miller

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Stanford University
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Senior Fellow at the Freeman Spogli Institute for International Studies
Center Fellow at the Center for Health Policy and the Center for Primary Care and Outcomes Research
Faculty Research Fellow of the National Bureau of Economic Research
Faculty Affiliate at the Stanford Center on China's Economy and Institutions
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Karen Eggleston is a Senior Fellow at the Freeman Spogli Institute for International Studies (FSI) at Stanford University and Director of the Stanford Asia Health Policy Program at the Shorenstein Asia-Pacific Research Center at FSI. She is also a Fellow with the Center for Innovation in Global Health at Stanford University School of Medicine, and a Faculty Research Fellow of the National Bureau of Economic Research (NBER). Her research focuses on government and market roles in the health sector and Asia health policy, especially in China, India, Japan, and Korea; healthcare productivity; and the economics of the demographic transition.

Eggleston earned her PhD in public policy from Harvard University and has MA degrees in economics and Asian studies from the University of Hawaii and a BA in Asian studies summa cum laude (valedictorian) from Dartmouth College. Eggleston studied in China for two years and was a Fulbright scholar in Korea. She served on the Strategic Technical Advisory Committee for the Asia Pacific Observatory on Health Systems and Policies and has been a consultant to the World Bank, the Asian Development Bank, and the WHO regarding health system reforms in the PRC.

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Director of the Asia Health Policy Program, Shorenstein Asia-Pacific Research Center
Stanford Health Policy Associate
Faculty Fellow at the Stanford Center at Peking University, June and August of 2016
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Background: Electronic health records (EHRs) have been proposed as a sustainable solution for improving the quality of medical care. We assessed the association between EHR use, as implemented, and the quality of ambulatory care in a nationally representative survey.

Methods: We performed a retrospective, cross-sectional analysis of visits in the 2003 and 2004 National Ambulatory Medical Care Survey. We examined EHR use throughout the United States and the association of EHR use with 17 ambulatory quality indicators. Performance on quality indicators was defined as the percentage of applicable visits in which patients received recommended care.

Results: Electronic health records were used in 18% (95% confidence interval [CI], 15%-22%) of the estimated 1.8 billion ambulatory visits (95% CI, 1.7-2.0 billion) in the United States in 2003 and 2004. For 14 of the 17 quality indicators, there was no significant difference in performance between visits with vs without EHR use. Categories of these indicators included medical management of common diseases, recommended antibiotic prescribing, preventive counseling, screening tests, and avoiding potentially inappropriate medication prescribing in elderly patients. For 2 quality indicators, visits to medical practices using EHRs had significantly better performance: avoiding benzodiazepine use for patients with depression (91% vs 84%; P = .01) and avoiding routine urinalysis during general medical examinations (94% vs 91%; P = .003). For 1 quality indicator, visits to practices using EHRs had significantly worse quality: statin prescribing to patients with hypercholesterolemia (33% vs 47%; P = .01).

Conclusion: As implemented, EHRs were not associated with better quality ambulatory care.

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Although the global declines in structure have been documented in the aging human brain, little is known about the functional integrity of the striatum and prefrontal cortex in older adults during incentive processing. We used event-related functional magnetic resonance imaging to determine whether younger and older adults differed in both self-reported and neural responsiveness to anticipated monetary gains and losses. The present study provides evidence for intact striatal and insular activation during gain anticipation with age, but shows a relative reduction in activation during loss anticipation. These findings suggest that there is an asymmetry in the procession of gains and losses in older adults that may have implications for decision-making.

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