The role of academic health science systems in the transformation of medicine

Abstract

The challenges facing the health of communities around the world are unprecedented, and the data are all too familiar. For 5 billion people living in developing countries, environmental factors and inadequacies in hygiene, economic development, and health-care access are the main causes of shortened life expectancies. Improvements in health status, including reductions in infant mortality and declining incidence of infectious diseases, are being met by the new epidemics of obesity, diabetes mellitus, and cardiovascular disease. Developed countries are beset by disparities in access to care and health outcomes, unreliable quality, and high costs. Increased demand for services, ageing populations, inadequate evidence to guide practice, and a misdirected emphasis on research and treatment in late-stage disease contribute to the high cost of health care. In many countries, these diffi culties are exacerbated by fragmented health-care delivery systems, resulting in inadequate continuity of care across community, primary-care, and tertiary-care settings. The creation of novel treatments remains protracted and expensive, new discoveries are not delivered swiftly to patients, and population-wide strategies using cheap, simple, and effi cient interventions are not eff ectively implemented. Many countries, including the USA, the UK, Singapore, the Netherlands, and Canada, have focused on the promise of academic health science centres (AHSCs) to improve health locally and globally while also supporting economic development. In this Viewpoint, we draw attention to the potential of these organisations in leading the transformation of medicine through the development of a discovery-care continuum—a network to disseminate knowledge and innovations globally—and describe a few activities that are underway with the aim to make the potential a reality. To resolve the diffi culties described above, AHSCs should create not only novel drugs, devices, and other technologies, but also new ways of deploying broad, inexpensive preventive and treatment strategies among populations. An amalgamation of broad public health and individualised care might seem contradictory, but a vision of transformation supported by a radical reorganisation of AHSCs can initiate a creative synthesis in which technological innovations, eff ective treatments, and delivery of care combine to formulate common solutions that can be applied to individuals and large populations. The discovery-care continuum (fi gure 1A) represents such a pathway, in which innovative ideas can be put into practice to improve patient care, irrespective of where on the continuum they arise. In order to achieve transformation, two distinct translational blocks or gaps in the discovery-care continuum must be overcome. The fi rst is the gap between a scientifi c discovery and its clinical translation (ie, from bench to bedside); the second is the gap between expert acceptance of the application and its broad adoption in practice by local and global communities (ie, from bedside to population). AHSCs traditionally give their discoveries to industry at the fi rst gap and to practising physicians at the second gap, thereby creating barriers and ineffi ciencies. We believe that AHSCs are ideally poised to become system integrators that are capable of bridging these translational gaps, thereby greatly reducing delays and ineffi ciencies between discovery and global adoption. These system integrators do not replace industry or non-academic providers, rather, they improve the capacity to develop and deliver new treatments by fi lling the spaces between academic discovery, science, industry, and the general health-care delivery system. In the USA, the Roadmap Initiative of the National Institutes of Health (Bethesda, MD), and resulting Clinical and Translational Science Awards have shown this perspective. Examples of US institutions that have begun to develop models of integrated translational research and care-delivery systems include the University of Pennsylvania (Philadelphia, PA), Johns Hopkins University (Baltimore, MD), and Harvard University-Partners Healthcare (Boston, MA). At Duke, we have developed an AHSC (Duke Medicine) that includes the Duke University Schools of Medicine and Nursing, the Duke University Health System, and related organisations. The UK is also creating AHSCs through the integration of academic (eg, education and research) and care-delivery systems, enabled by partnerships between universities and the National Health Service Trusts, such as Imperial College’s Academic Health Science Centre in London. To transform health care, we believe that AHSCs should evolve further into academic health science systems (AHSSs). The term AHSC connotes a specifi c location where patients receive care (eg, a medical campus), whereas AHSSs are thought of as integrated health-care delivery systems that not only include the traditional medical centre but also a network of community hospitals and practices. Ideally, each AHSS has missions, resources, and standards that are shared by the system to improve the way in which it helps patients and communities. To catalyse the needed transformation, we believe that AHSSs should focus on organisational structures, external partnerships, research translation, models of care delivery, new Lancet 2010; 375: 949–53