Freeman Spogli Institute for International Studies Annual Report 2007, CHP/PCOR contribution

By Amber Hsiao | November 2007

From devastating infectious diseases to chronic illness, and hospital care to preventive care, CHP/PCOR researchers are expanding the evidence base to guide policy formation and clinical practice.

Chronic Illness in Children In a recent Health Affairs issue, core faculty member Paul Wise co-authored a piece that examined the evolving standard of preventive pediatric care in the United States, as it relates to the Early and Periodic Screening, Diagnosis, and Treatment benefit within Medicaid. As the primary insurance for low-income children in the United States, Medicaid shapes the pediatric health-care infrastructure for millions of children. As disease patterns for children have shifted toward a higher prevalence of chronic illness, an understanding of early determinants of chronic illness is becoming more crucial to develop prevention strategies and associated delivery systems. The U.S. system allows for demonstration projects and differing approaches that through trial and error provide models to best serve the needs of children.

Wise’s knowledge of U.S. pediatric health systems carries over to his work in Guatemala, where chronic illness in children is problematic and difficult to address. A large percentage of mortality in children is still due to preventable conditions such as malnutrition and parasitic diseases. Care for children remains episodic — children often do not see a doctor until they are very sick. And, the relatively low level of health expenditures as a percentage of gross domestic product (5.2 percent compared with 15.2 percent in the United States) prevents effective responses to new pediatric challenges.

As a pediatrician, Wise’s focus has been on trying to provide data that will help shift policies to respond more effectively to such pediatric challenges. He regularly travels to Guatemala — accompanied by medical school students — to teach and collaborate with health promoters to develop health programs in reducing health disparities.

Global Health in the 21st Century In spite of the increased funding for many international HIV/AIDS programs, countries such as Zimbabwe have been largely neglected due to their social and political turmoil. To fill this gap, core faculty member Grant Miller has collaborated with CDDRL and CISAC faculty member Jeremy Weinstein, along with a number of other professors within and outside of Stanford, to address the issue of HIV/AIDS care in Zimbabwe.

The team has designed a combination antiretroviral treatment campaign in Chitungwiza, Zimbabwe, located south of the capital city, Harare. Unlike others, this campaign delivers enhanced antiretroviral treatment literacy materials in conjunction with home-based HIV testing, to test whether increased education, greater access to testing and treatment, and collaboration with local health systems will improve outcomes for HIV/AIDS patients.

On the Russian front, HIV/AIDS has become an increasingly prominent issue for its health system and population, as an estimated 940,000 people are living with HIV and the numbers continue to rise. The spread of HIV in Russia is especially high among intravenous drug users, who face stigma from the legal system and lack access to clean needles.

“The death of any child is always a tragedy but the death of any child from preventable causes is always unjust...”
— Paul H. Wise, Core Faculty Member, CHP/PCOR

CHP/PCOR researchers including core faculty member Douglas Owens and faculty fellow Margaret Brandeau, professor of management science and engineering, have conducted influential decision-modeling research on care for HIV/AIDS patients both in the United States and abroad. In September 2006, Owens led a team of investigators in an analysis of strategies for cost-effective HIV screening, published in the New England Journal of Medicine, that led to the implementation of new screening guidelines for all Americans ages 13 to 64 — a significant change from previous guidelines that recommended testing only for high-risk individuals, such as intravenous drug users or individuals with multiple sex partners.

On the financing end, Brandeau and a colleague from the University of Western Ontario published a study in Medical Decision Making evaluating funding allocation approaches at the regional level (e.g., international aid organization) and the local level (e.g., city-based needle-exchange program). These multi-level allocations are often made in proportion to HIV prevalence or population size. The researchers examined alternative allocation strategies and found that allocating HIV funds to populations based on efficiency at both levels results in more infections averted compared with the proportional approach.

CHP/PCOR researchers have extended their policy-level decision analyses work to the Russian context. Research has been conducted on the cost-effectiveness of HIV monitoring in resource-constrained settings, HIV screening in Russia, and the effect of reduced antiretroviral prices in Russia to expand HIV treatment. The findings from such research can help optimize solutions to the growing HIV/AIDS crisis in Russia where there is currently no screening, mandatory testing, or recommended testing.

To promote interactions among researchers, the local community, and international policymakers, CHP/PCOR and FSI recently hosted two prominent international leaders. David Heymann, assistant director-general for communicable diseases of the World Health Organization, and Peter Piot, executive director of UNAIDS, both spoke urgently about the global challenge of addressing HIV/AIDS and other infectious diseases with effective, multidisciplinary strategies.

Health Costs and Outcomes in the United States and Germany As a senior lecturer in the department of health-care management at Berlin University of Technology in Germany, Jonas Schreyögg examines issues of pharmaceutical regulation, health financing and management, and economic evaluation. Mentored by CHP/PCOR Director and core faculty member Alan Garber and supported by the Commonwealth Fund’s Harkness Fellowship program in health-care policy, Schreyögg served as the 2006–07 visiting scholar and conducted cross-country comparisons of costs between hospital systems in the U.S. Veterans Health Administration (VHA) and Germany.

Keying in on three episodes of care — appendectomies, hip replacements, and acute myocardial infarctions — Schreyögg collected data and analyzed productivity to explain variations in costs as a measure of efficiency in the countries’ systems. The aim was to explain why U.S. health care is more expensive than health care in Europe, taking Germany as an example.

Schreyögg used micro-level data to provide an analytic framework for exploring variations in costs and hospital mortality at the hospital and patient level, using data from 130 VHA hospitals and 18 German hospitals. After controlling for differences in individual patients, his analysis showed that German hospitals are more cost-efficient and hospital mortality is lower compared with VHA hospitals. Even after adjusting for purchasing power parity, co-morbid conditions, and other factors, VHA hospitals bore costs 1.4 times greater than those of German hospitals, and VHA mortality rates were 1.8 times higher than those of German hospitals.

A large part of the cost difference can be attributed to higher nursing costs and higher overhead costs in VHA hospitals. About 40 percent of the difference in nursing costs can be attributed to wage differences, while 60 percent of the difference is due to the higher nursing ratio of VHA hospitals. However, the marginal costs of technology and average length of stay are lower for VHA than for German hospitals.

Schreyögg’s study has many implications for policy, delivery, and the practice of medicine in the United States and Germany. Standardization and broader availability of micro-level data would facilitate comparative hospital performance measurements across health-care systems. The study shows that increased use of technology would not necessarily lower mortality or costs. Other factors, such as central purchasing practices by hospital networks and social health insurance funds, could help lower prices for technology and drugs in the German health-care system.

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Originally appeared in the Stanford University Freeman Spogli Institute for International Studies Annual Report. See the full Annual Report. CHP/PCOR section appears on pages 16–19.