Krishna Udayakumar

Perspective: global medicine: opportunities and challenges for academic health science systems.

Globalization is having a growing impact on health and health care, presenting challenges as well as opportunities for the U.S. health care industry in general and for academic health science systems (AHSSs) in particular. The authors believe that AHSSs must develop long-term strategies that address their future role in global medicine. AHSSs should meet global challenges through planning, engagement, and innovation that combine traditional academic activities with entrepreneurial approaches to health care delivery, research, and education, including international public-private partnerships. The opportunities for U.S.-based AHSSs to be global health care leaders and establish partnerships that improve health locally and globally more than offset the potential financial, organizational, politico-legal, and reputational risks that exist in the global health care arena. By examining recent international activities of leading AHSSs, the authors review the risks and the critical factors for success and discuss external policy shifts in workforce development and accreditation that would further support the growth of global medicine.

Lessons From India In Organizational Innovation: A Tale Of Two Heart Hospitals

Recent discussions in health reform circles have pinned great hopes on the prospect of innovation as the solution to the high-cost, inadequate-quality U.S. health system. But U.S. health care institutions-insurers, providers, and specialists-have ceded leadership in innovation to Indian hospitals such as Care Hospital in Hyderabad and the Fortis Hospitals around New Delhi, which have U.S.-trained doctors and can perform open heart surgery for

Translation of acute coronary syndrome therapies: From evidence to routine clinical practice

6,000 (compared to

The need for transformative innovation in hypertension management

100,000 in the United States). The Indian success is a window into Americas stalemate with inflating costs and stagnant innovation.

Innovations In Diabetes Care Around the World: Case Studies Of Care Transformation Through Accountable Care Reforms

BACKGROUND The use of evidence-based therapies has improved the outcome of patients with acute coronary syndrome (ACS), but there is a time lag between the generation of clinical evidence and its application in routine clinical practice. We sought to quantify temporal lags in the lifecycle of American College of Cardiology (ACC)/American Heart Association (AHA) class IA ACS therapies. METHODS Using current and historical ACC/AHA guideline publications, we retrieved publication dates of pivotal clinical trials (PCTs) and class IA guideline-recommended therapies for patients with ST-elevation myocardial infarction (STEMI) and unstable angina (UA)/non-STEMI (NSTEMI). Clinical practice uptake data for each therapy were retrieved from the National Registry for Myocardial Infarction, Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines, and Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines, which are registries containing publicly available peer-reviewed data. Descriptive data were calculated and compared for each phase of the evidence lifecycle for both STEMI and UA/NSTEMI drug classifications. RESULTS We identified 11 class IA- and 4 class IB/IC-recommended therapies for acute, inhospital, and discharge use for patients with STEMI or UA/NSTEMI. The median time lags were 2 years (interquartile range [IQR], 1-4 years) from PCT to practice guideline recommendation, 14 years (IQR, 11-15 years) from guideline recommendation to 90% practice uptake, and overall, a 16-year median (IQR, 13-19 years) from PCT to 90% practice uptake. CONCLUSIONS The time of PCT publication to meaningful uptake of class IA ACS therapies into clinical practice took a median of 16 years. This significant time lag indicates systemic barriers to the translation of therapeutics into routine clinical practice.

Improving Care And Lowering Costs: Evidence And Lessons From A Global Analysis Of Accountable Care Reforms

Despite multiple available effective therapies for hypertension, many patients with high blood pressure in the United States are not adequately controlled. This inability to effectively manage hypertension can be attributed to patient, provider, and system failures. To create an effective model for hypertension management, current care delivery systems must be reorganized around the following principles: improved patient engagement and patient-provider communication, increased use of nonphysician providers, better performance monitoring and feedback systems, and better aligned reimbursement models. Transformation of care around these principles would lead to marked improvements in cost, quality, and access to care.

Global Lessons In Frugal Innovation To Improve Health Care Delivery In The United States

The rising prevalence, health burden, and cost of chronic diseases such as diabetes have accelerated global interest in innovative care models that use approaches such as community-based care and information technology to improve or transform disease prevention, diagnosis, and treatment. Although evidence on the effectiveness of innovative care models is emerging, scaling up or extending these models beyond their original setting has been difficult. We developed a framework to highlight policy barriers-institutional, regulatory, and financial-to the diffusion of transformative innovations in diabetes care. The framework builds on accountable care principles that support higher-value care, or better patient-level outcomes at lower cost. We applied this framework to three case studies from the United States, Mexico, and India to describe how innovators and policy leaders have addressed barriers, with a focus on important financing barriers to provider and consumer payment. The lessons have implications for policy reform to promote innovation through new funding approaches, institutional reforms, and performance measures with the goal of addressing the growing burdens of diabetes and other chronic diseases.

Caught on Capsule: Iron-deficiency Anemia Due to Hookworm Infection.

Policy makers and providers are under increasing pressure to find innovative approaches to achieving better health outcomes as efficiently as possible. Accountable care, which holds providers accountable for results rather than specific services, is emerging in many countries to support such care innovations. However, these reforms are challenging and complex to implement, requiring significant policy and delivery changes. Despite global interest, the evidence on how to implement accountable care successfully remains limited. To improve the evidence base and increase the likelihood of success, we applied a comprehensive framework for assessing accountable care implementation to three promising reforms outside the United States. The framework relates accountable care policy reforms to the competencies of health care organizations and their health policy environments to facilitate qualitative comparisons of innovations and factors that influence success. We present emerging lessons to guide future implementation and evaluation of accountable care reforms to improve access to and the quality and affordability of care.

Chapter 6 – Future Directions

In a 2015 global study of low-cost or frugal innovations, we identified five leading innovations that scaled successfully in their original contexts and that may provide insights for scaling such innovations in the United States. We describe common themes among these diverse innovations, critical factors for their translation to the United States to improve the efficiency and quality of health care, and lessons for the implementation and scaling of other innovations. We highlight promising trends in the United States that support adapting these innovations, including growing interest in moving care out of health care facilities and into community and home settings; the growth of alternative payment models and incentives to experiment with new approaches to population health and care delivery; and the increasing use of diverse health professionals, such as community health workers and advanced practice providers. Our findings should inspire policy makers and health care professionals and inform them about the potential for globally sourced frugal innovations to benefit US health care.

Training the next generation of physician-executives: an innovative residency pathway in management and leadership.

PRESENTATION A tiny ingestible camera identified an otherwise elusive source of anemia in a 63-year-old man. The patient presented to an outside hospital with a 2-week history of generalized weakness, malaise, nausea, and loss of appetite. He denied rectal bleeding. His past medical history was significant for a Billroth II gastric bypass and prior gastric angioectasias. Initial laboratory studies showed that his hemoglobin level, at 7.3 g/dL, was lower than it had been 1 week earlier, when it was 9.9 g/dL, and that, in turn, was reduced from a baseline measurement of 13-15 g/dL, which had been obtained several months prior. Results were also remarkable for leukocytosis at 21.4 10 cells/mm. A rectal examination revealed brown stool that proved positive for blood with a Hemoccult test. Push enteroscopy, with intubation of afferent and efferent limbs of the patient’s Billroth reconstruction, showed mild erythema in the gastric remnant but no angioectasias, ulcers, or evidence of bleeding. Colonoscopy subsequently disclosed internal grade I hemorrhoids and melena throughout the colon and distal small bowel. No source of bleeding was evident. Five units of packed red blood cells did not produce an appreciable increase in his hemoglobin. He was then transferred to our hospital for further workup for a presumed source of bleeding in the small bowel. Upon the patient’s presentation, his wife reported that he had been having dark-colored stools for the past 3-4 years. He had undergone upper endoscopy 1 year earlier and been diagnosed with an angioectasia. This was treated with argon plasma coagulation.