An Indian businessman approached Stanford Medicine in 2005 with an outlandish proposition: Help us build an ambulance system across the sprawling South Asia nation, which is home to 10 percent of the world’s traffic deaths.

S.V. Mahadevan, MD, an associate professor of emergency medicine at Stanford Medicine, was skeptical the nonprofit GVK EMRI (Emergency Management and Research Institute) could truly pull it off.

They only had 14 ambulances in the world’s second most populous nation.

Today the system has expanded to a fleet of nearly 10,000 ambulances, manned by some 20,000 medical professionals who ply the roads in cities and rural villages to provide access to emergency care to 750 million people — three-quarters of India’s population — according to a story in Stanford Medicine magazine last year.

“It’s hard to fathom what this system has done in 10 years,” said Mahadevan, founder of Stanford Emergency Medicine International, which has provided medical expertise to GVK EMRI over the last decade, helping to train the EMTs who now belong to the largest ambulance service in the developing world.

“It could be regarded as one of the most important advances in global medicine in the world today," he said.

Yet up until now there has been no analytical research on the impact of the ambulance service. Though EMRI says its 911-like service has saved more than 1.4 million lives in its first decade, there has been no published research to back up that claim.

Now, research by Stanford Health Policy scholars published in the October edition of the health policy journal, Health Affairs, indicates EMRI’s system has had a significant impact on saving the lives of newborns and infants, one of the most challenging health dilemmas plaguing India today.

Focusing on the first two states served by GVK EMRI — with a combined population of 145 million — their results show that the organization’s services have reduced infant and neonatal mortality rates by at least 2 percent in high-mortality areas of the western state of Gujarat. There were similar effects statewide in the southeastern state of Andhra Pradesh.

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“With our modern medical knowledge, childbirth should not be so risky and newborns should not be dying at such high rates,” said Babiarz.

India has 28 maternal neonatal or infant deaths per 1,000 live births, according to the World Bank, making it one of the highest in the world. The global average is 19.2 deaths per 1,000 births; the rate drops to 4 in North America.

“These issues are particularly compelling to me as a mother,” Babiarz said. “It's wonderful to find a model that has found some success in connecting mothers and their infants with high-quality and timely emergency care when it is most needed.”

The authors used electronic service records from GVK EMRI, matched to population-representative surveys from the International Institute for Population Sciences, and their own survey that they conducted in Gujarat in 2010 through the Collaboration for Health System Improvement and Impact Evaluation in India. The combined surveys include information on over 16,000 live births.

The public-private nonprofit provides its services free of charge and most of its beneficiaries are the poorest of the poor. Each state contributes to the ambulance system, as does the federal government. It also depends on private philanthropy among some of India’s wealthiest industrialists.

The School of Medicine in 2007 signed a formal agreement to develop an educational curriculum and train the initial group of 180 skilled paramedics and instructors. Over the years, the Stanford instructors have learned to tailor the curriculum to local needs.

About one-third of the toll-free calls to 108 — an auspicious number in India — are from women in labor. Deliveries have traditionally been done at home, particularly in rural villages, where women often die of complications. So the Stanford team has since designed a special obstetrics curriculum and helped create the country’s first protocols for obstetric care.

Grant Miller, an associate professor of medicine, core faculty member at Stanford Health Policy and senior author of the study, has worked on many health policy projects in India over the years. The results aren’t always hopeful.

“I’ve conducted a number of evaluations of large-scale health programs in India, and there are disappointingly few programs and policies that we’ve found to be effective,” said Miller, who is also director of the Stanford Center for International Development and a senior fellow at the Stanford Institute for Economic Policy Research and the Freeman Spogli Institute for International Studies. “So it’s exciting to find one that may have worked quite well.”

Miller and his fellow authors note, however, that further research on emergency medical services in other Indian states and by other providers is still needed.

“We need to do a lot more work — but these results suggest that something important has happened,” he said. “With the release of more population-representative data from more states, we’re eager to expand our analysis to the rest of the country.”

Stanford Medicine’s Center for Innovation in Global Health also supported the authors’ research in India.

Ruthann Richter, director of media relations for the medical school's Office of Communication & Public Affairs, contributed to this story.

Imagine there’s a new pill on the market. It promises you a one in 200 chance of avoiding a heart attack, stroke, heart failure or death over the next year — if you take it religiously.

It also promises a one in 60 chance of landing you in the hospital for some serious complication: Maybe you passed out. Maybe the pill affected your kidney function. Maybe you developed a severe electrolyte imbalance.

Would you take it? How would you decide?

This question is confronting some patients with hypertension as well as their health-care providers who, like me, help manage their blood pressure. The “pill” is not a pill per se, but a treatment strategy.

In November of 2015, researchers published results of a large NIH-sponsored trial known as SPRINT, which compared two systolic blood pressure treatment targets for hypertensive adults: a higher, conventional target of 140 mm mercury compared to a more stringent target of 120.  Participants in the trial were older, did not have diabetes, and were generally at high risk of developing cardiovascular disease. They were prescribed commonly used blood pressure medications, which were carefully adjusted by investigators to achieve target blood pressures.

The trial demonstrated a large relative benefit: Those in the lower target group had about a 25 percent reduction in the rate of cardiovascular disease or death. The absolute benefit, though, was small, with only about one in 200 patients avoiding cardiovascular disease or death as a result of treatment. The trial also showed that complications in the lower target group were relatively common.

As a physician, I’d love to be able to tell the patient in my exam room whether she will be the lucky one out of 200 who will benefit. That dream is still a few years off. I can, though, answer a related question. If I treat a large group of patients, on the whole, will my patients benefit? Or will the harms of treatment outweigh the benefits? And if the treatment is overall beneficial, what investment will we need to achieve this gain in health?

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To answer this question, I teamed up with a group of researchers at Stanford. Our team included experts in cost-effectiveness analysis as well as students developing clinical and analytic expertise in this area. We used data from SPRINT along with other published sources to project the expected benefits, harms and costs from targeting a lower or higher blood pressure over the course of a lifetime.

Results of our study were published this week in JAMA Cardiology. We found that targeting a lower blood pressure results in a substantial net benefit, even after accounting for harms from common, serious adverse events. This net benefit, though, doesn’t come free: An investment of about $23,777 is required for every year of life gained from this strategy.

Is $23,777 “worth it?” It’s a hard question to answer and it depends, in part, on who is paying. But in the spectrum of medical interventions that we routinely use here in the United States, this would be considered a good deal, a bargain even.

So should we go all in? Should we push stringent blood pressure targets for everyone?

No. There are a number of other considerations. SPRINT answered a specific question about hypertension treatment in a specific group of patients. Whether other groups of patients, like those at lower risk of cardiovascular disease, would benefit is unclear. There were also methodological quirks that have left the trial open to criticism.

But if we believe that the findings from SPRINT are generally correct, a lower blood pressure target seems to provide significant health gains for a reasonable cost in patients who are at high risk of developing cardiovascular disease.

Ilana B. Richman, MD, is a VA Health Services Research and Development Fellow at Stanford Health Policy.

The Asia Health Policy Program at Stanford’s Shorenstein Asia-Pacific Research Center, in collaboration with scholars from Stanford Health Policy's Center on Demography and Economics of Health and Aging, the Stanford Institute for Economic Policy Research, and the Next World Program, is soliciting papers for the third annual workshop on the economics of ageing titled Financing Longevity: The Economics of Pensions, Health Insurance, Long-term Care and Disability Insurance held at Stanford from April 24-25, 2017, and for a related special issue of the Journal of the Economics of Ageing.

The triumph of longevity can pose a challenge to the fiscal integrity of public and private pension systems and other social support programs disproportionately used by older adults. High-income countries offer lessons – frequently cautionary tales – for low- and middle-income countries about how to design social protection programs to be sustainable in the face of population ageing. Technological change and income inequality interact with population ageing to threaten the sustainability and perceived fairness of conventional financing for many social programs. Promoting longer working lives and savings for retirement are obvious policy priorities; but in many cases the fiscal challenges are even more acute for other social programs, such as insurance systems for medical care, long-term care, and disability. Reform of entitlement programs is also often politically difficult, further highlighting how important it is for developing countries putting in place comprehensive social security systems to take account of the macroeconomic implications of population ageing.

The objective of the workshop is to explore the economics of ageing from the perspective of sustainable financing for longer lives. The workshop will bring together researchers to present recent empirical and theoretical research on the economics of ageing with special (yet not exclusive) foci on the following topics:

• Public and private roles in savings and retirement security
• Living and working in an Age of Longevity: Lessons for Finance
• Defined benefit, defined contribution, and innovations in design of pension programs
• Intergenerational and equity implications of different financing mechanisms for pensions and social insurance
• The impact of population aging on health insurance financing
• Economic incentives of long-term care insurance and disability insurance systems
• Precautionary savings and social protection system generosity
• Elderly cognitive function and financial planning
• Evaluation of policies aimed at increasing health and productivity of older adults
• Population ageing and financing economic growth
• Tax policies’ implications for capital deepening and investment in human capital
• The relationship between population age structure and capital market returns
• Evidence on policies designed to address disparities – gender, ethnic/racial, inter-regional, urban/rural – in old-age support
• The political economy of reforming pension systems as well as health, long-term care and disability insurance programs

Submission for the workshop

Interested authors are invited to submit a 1-page abstract by Sept. 30, 2016, to Karen Eggleston at karene@stanford.edu. The authors of accepted abstracts will be notified by Oct. 15, 2016, and completed draft papers will be expected by April 1, 2017.

Economy-class travel and accommodation costs for one author of each accepted paper will be covered by the organizers.

Invited authors are expected to submit their paper to the Journal of the Economics of Ageing. A selection of these papers will (assuming successful completion of the review process) be published in a special issue.

Submission to the special issue

Authors (also those interested who are not attending the workshop) are invited to submit papers for the special issue in the Journal of the Economics of Ageing by Aug. 1, 2017. Submissions should be made online. Please select article type “SI Financing Longevity.”

About the Next World Program

The Next World Program is a joint initiative of Harvard University’s Program on the Global Demography of Aging, the WDA Forum, Stanford’s Asia Health Policy Program, and Fudan University’s Working Group on Comparative Ageing Societies. These institutions organize an annual workshop and a special issue in the Journal of the Economics of Ageing on an important economic theme related to ageing societies.

More information can be found in the PDF below.

Studying the microorganisms that live in our gut is a relatively new field, one that has only really taken off in the last decade. In fact, it is estimated that half of the microbes that live in and around our GI track have yet to be discovered.

“This means there is a huge amount of this dark matter within us,” said Ami S. Bhatt, an assistant professor of medicine and genetics who runs the Bhatt Lab at the Stanford School of Medicine. The lab is devoted to exploiting disease vulnerabilities by cataloguing the human microbiome, the trillions of microbes living in and on our bodies.

“I think if we fast-forward to the impact of some these findings in 10 years, we’re going to learn that modifying the microbiota is a potent way to modulate health,” Bhatt said. “Humans are not only made up of human cells, but are a complex mixture of human cells and the microbes that live within us and among us — and these microorganisms are as critical to our well-being as we are to theirs.”

Bhatt, along with key collaborators at the University of Witwatersrand in Johannesburg, and the INDEPTH research consortium, now intends to take this research to Africa.

She is this year’s winner of the of the Rosenkranz Prize for Health Care Research in Developing Countries, awarded by Stanford Health Policy to promising young Stanford researchers who are investigating ways to improve health care in developing countries.

The $100,000 prize is targeted at Stanford’s emerging researchers who are dedicated to improving health care in poorer parts of the world, but may lack the financial resources.

Bhatt, MD, PhD, intends to take the prize money to execute the first multi-country microbiome research project focused on non-communicable disease risk in Africa. The project intends to explore the relationship between the gut microbiome composition and body mass index (BMI) in patients who are either severely malnourished or obese.

“As a rapidly developing continent with extremes of resource access, Africa is simultaneously faced with challenges relating to the extremes of metabolic status,” Bhatt wrote in her Rosenkranz project proposal. The Bay Area native, who is also the director of global oncology at Stanford, came to the School of Medicine in 2014 to focus on how changes in the microbiome are associated with cancer.

In this new project, Bhatt and members of her lab will team up with colleagues in Africa, first in South Africa, and then in Ghana, Burkina Faso, and Kenya. They will leverage the infrastructure already in place at the INDEPTH Network of researchers, using an existing cohort of 12,000 patients at within those four countries. The patients have already consented to be involved in DNA testing and have given blood and urine specimens.

Identifying alterations of the microbiome that are associated with severe malnutrition or obesity could pave the way for interventions that may mitigate the severity or prevalence of these disorders, Bhatt said.

“These organisms are critical to our health in that they are in a delicate balance with one another and their human hosts,” she said. “Alterations in the microbiome are associated with various diseases — but have mostly been studied in Western populations. Unfortunately, little is known about the generalizability of these findings to low- and middle-income countries – where most of the world’s population lives.”

Bhatt said that as Africa rapidly continues to develop, the continent is simultaneous faced with challenges relating to extreme weight gain and loss. While the wealthy are facing obesity and its associated disease such as stroke, heart failure and diabetes, many people are still faced with issues related to food insecurity, hunger and malnutrition.

The research, she hopes, could lead to aggressive behavioral, dietary and lifestyle modifications targeted at maintaining healthy BMI in at-risk individuals.

Video by Ankur Bhatt

Grant Miller, an associate professor of medicine and core faculty member at Stanford Health Policy who chaired the Rosenkranz Prize committee this year, believes Bhatt’s research could eventually break new ground.

“The entire Rosenkranz Prize selection committee was highly impressed with Ami and the innovation of her project,” Miller said. “Ami’s work on the human microbiome in the extremes of nutritional status in developing countries — including its potential link to obesity, an emerging challenge in low income countries — is potentially path-breaking.”

The award’s namesake, George Rosenkranz, first synthesized cortisone in 1951, and later progestin, the active ingredient in oral birth control pills. He went on to establish the Mexican National Institute for Genomic Medicine, and his family created the Rosenkranz Prize in 2009.

The award embodies Dr. Rosenkranz’s belief that young scientists hold the curiosity and drive necessary to find alternative solutions to longstanding health-care dilemmas.

Triage nurses typically assign patients to emergency room doctors who are on call or working a shift. But what if the doctors themselves determine whom among them is better suited to take on the next patient?

Classic economic theory predicts “moral hazard” in teams, which means one member behaves inefficiently because in the end someone else will pay the consequences. Yet many successful organizations promote teamwork.

So how does this puzzle relate to health care?

This is the question that Assistant Professor of Medicine David Chan, a core faculty member at Stanford Health Policy, tackles in his new study in the Journal of Political Economy.

Emergency departments (ED) nationwide cost a combined $136 billion to run each year, significantly impacting the growing health-care sector of the U.S. economy. Visits to the emergency rooms are increasing despite the implementation of the Affordable Care Act, causing them to be overcrowded and underfunded.

Chan studied two organizational models: one in which physicians are assigned patients in a nurse-managed system and one in which the doctors divide patients among themselves in a self-managed system.

“I find evidence that physicians in the same location have better information about each other and that, in the self-managed system, they use this information to assign patients,” Chan writes.

He said that by simply allowing physicians to choose patients, a self-managed system reduces emergency room lengths of stay by 11-15 percent, relative to the nurse-managed system.

“This effect occurs primarily by reducing a `foot-dragging’ moral hazard, in which physicians delay patient discharge to forestall new work,” Chan writes. A triage nurse is often in another room and has a difficult time observing true physician workload, whereas peer physicians who work together can.

“So, for example, if there are two physicians working at a time when there are a whole bunch of patients in the waiting room, then each physician knows that the minute he discharges a patient, he is more likely to get another one,” Chan said in an interview. This might lead the physician to dilly-dally on the release of that patient, knowing that he’ll immediately be signed another before he gets a break.

However, two physicians who can observe how busy the other one truly is will be less likely to stall, even if they want to avoid new patients.

Chan studied a large, academic emergency room that treated 380,699 patients over a six-year period. He looked at length of stay, measuring each physician’s individual contribution. He also observed patient demographics and used the Emergency Severity Index, an ED triage algorithm based on a patient’s pain level, mental status, vital signs and medical condition.

Besides measuring the effect of the self-managed system in this large hospital, Chan combined evidence to support the hypothesis that teamwork improves outcomes because of mutual management with better information.

He found that the only difference in outcomes between the two organizational systems was foot-dragging. Clinical outcomes or even the number of tests ordered were about the same under a self-managed or nurse-managed system.

Moreover, the foot-dragging behavior grows as physicians may anticipate future work by the number of patients in the waiting room, even if they end up seeing the same number of patients.

Finally, physicians refrain from this behavior when being watched by another physician in the same location, even in the nurse-managed system, when that other physician does not otherwise have any role in the physician’s patient care.

“I think the biggest takeaway is that such efficiency gains can be widespread in health care, particularly because there is so much at stake hidden behind information in patient care that is not transparent,” Chan said.

“Even if we don’t fully anticipate all of these gains, we could still achieve a lot by tinkering and using these changes as natural experiments to figure out what works and what doesn’t,” Chan said. “We can further use these results, particularly the evidence pointing at a mechanism, to think of what other innovations might work.”

The U.S. government has invested $1.4 billion in HIV prevention programs that promote sexual abstinence and marital fidelity, but there is no evidence that these programs have been effective at changing sexual behavior and reducing HIV risk, according to a new Stanford University School of Medicine study.

Previously: PEPFAR has saved lives – and not just from HIV/AIDS, Stanford study finds