NextBillion - An Initiative of the William Davidson Institute at the University of Michigan

Cardiovascular diseases (CVD) are becoming more prevalent due to lifestyle, genetic, environmental and dietary factors. More than half a billion people suffer from CVD, globally.

According to the World Health Organization (WHO), more than three-fourths of deaths due to CVD take place in low- and middle-income countries; more than $1 trillion in health care costs and lost wages can be directly attributed to CVD and coronary heart disease (CHD); and approximately 2 billion people suffer from hypertension and/or diabetes, which contribute to cardiovascular problems.

Based on various studies at Harvard Medical School in Boston and Loyola University in Chicago, the South Asian population has a much higher than average prevalence of cardiovascular disease due to genetic predisposition. In fact, Asia is expected to have more than 40 percent of CVD patients within this decade.

Other factors compounding the problem, especially in low-income countries, include a limited number of cardiologists and the high cost of diagnostics equipment. India has 60 million CVD patients but only 8,000 cardiologists. In countries such as India, the Philippines, Vietnam and Indonesia, many patients must travel long distances to reach a cardiac clinic to get an electrocardiogram (ECG) scan done and then go to a cardiologist for diagnosis and intervention. This access barrier results in many patients not seeking diagnosis during early stages of the disease and, when they actually do seek medical help, the only possible course of action for the doctor is to perform an invasive procedure – a significant cost relative to the patients’ income.

In many developing countries, the lack of formal health and disability insurance leaves the population at a huge financial risk, especially if a major health problem should occur in the family. And rural communities often lack cardiac clinics, meaning patients must travel to the nearest urban center for heart health diagnosis. The cost of travel and loss of wages often discourage many of the these patients from seeking expert advice or proper diagnosis.

In India, there are 840,000 general physicians and more than 99 percent of them perform patient diagnosis using a stethoscope and blood pressure monitor because of the high cost of diagnostic equipment such as an ECG monitor. Most clinics in rural and semi-urban areas have rudimentary equipment because of the time it takes to recover the capital equipment cost.

Cardiotrack

I’m the founder and CEO of uber Diagnostics. One of our products is Cardiotrack, a handheld ECG monitor that is easy to use, provides clinical grade output and performs predictive diagnosis to start intervention immediately, thus reducing the need for invasive intervention. It is a network-connected device; a patient’s ECG scan can be instantaneously transmitted to a cardiologist anywhere in the world. Its biggest advantage is that it saves cardiologists’ time by performing the diagnosis at the primary care level.

Since my previous NextBillion article about Cardiotrack, we have had lot more interaction with doctors, patients, caregivers, cardiologists, hospitals, clinics and pharmaceutical companies. Based on this interaction, the overall solution has been enhanced. Cardiotrack now offers one-lead, six-lead or 12-lead outputs and enhanced predictive diagnosis.

In fact, we’ve made several other improvements, including adding more sensors to make the diagnosis more complete and integrating Cardiotrack with hospital information systems and electronic medical records as well as popular information-sharing apps such as WhatsApp. We have also developed an app, zCardio, that facilitates collaboration and communication between patient, caregivers, doctor, cardiologist and cardiac clinics for complete cardiac care. We made these improvements without changing the subscription model or fee, which remains 50 cents (U.S.) per day.

Field trials

During the past 15 months, Cardiotrack has been used in at least 10 field trials in India. This includes adults in lower-income families and children at orphanages. These studies indicate that the prevalence of CVD is significantly higher than indicated by WHO research studies. Key findings include:

• Eight percent of the adults in semi-urban, low-income communities were found to have cardiovascular disease, based on ECG screenings of 250 adults. Although this is a statistically small sample, it’s interesting to note that CVD might not be just a lifestyle disease – it’s found among people in lower-income groups, as well.

• Children age 6-16 in two orphanages were tested using Cardiotrack and 13 percent were found to have abnormal ECG waveform. This highlights the need for ECG screening at an early age to detect congenital heart disease.

The most significant field trials were at St. John’s Research Institute, Ramakrishna Hospital, Maliyana Urban Health Post, Sri Jayadeva Institute of Cardiovascular Sciences & Research and SOCARE India. The testing was performed by our team with participation of doctors and cardiologists from the hospitals. At Jayadeva, side-by-side tests were performed using Cardiotrack and commercially available ECG machines to compare the results. At Maliyana, the Cardiotrack unit has been left with the doctor in charge for long-term testing. At SOCARE, a SOCARE nurse helped perform the ECG test.

Overall, more than 3,500 ECG scans have been taken using Cardiotrack. We have received validation reports from some of the hospitals and in other cases, the hospital has shared the results but not issued a formal test report. For IEC 60601 certification, the tests have been performed by Helix Corporation, an independent test and certification organization. We plan to publish these results in a suitable scientific/clinical forum soon. (Editor’s note: This paragraph was updated Dec. 1, 2015, to reflect the number of ECG scans to date and identify Helix as the certification organization.)

Revenue model

uber Diagnostics’ subscription model is being noticed by many in the health care industry as an innovative solution to introduce better diagnostics capabilities at the primary care level. Current revenue is small, compared to the investment to date; however, with the addition of several channel partners, the rate of deployment is expected to increase in coming months. Examples of such partners, in addition to hospital information systems and electronic medical records, include home health care. A small trial is being conducted in a tier-2 city in collaboration with a cardiologist and ambulatory care organization.

All of these are new approaches to support the entire health care ecosystem for cardiac care. In some cases, the subscription model may not be appropriate. However, we want to deploy Cardiotrack everywhere to build up a robust ecosystem for affordable cardiac care.

Based on the subscription model, we expect the manufacturing cost of a unit can be recovered in less than a year. The patient fees charged by primary care physicians more than offsets the subscription fee for Cardiotrack and allow doctors to generate additional revenue. The ability to share the information and send qualified referrals to cardiologists enhances the collaboration between the primary care physician and cardiologist.

Behavioral change

Affordable diagnosis using Cardiotrack can potentially change patients’ behavior; they may start treatment before their cardiovascular illness reaches the stage where the only possible intervention is an expensive invasive procedure. Each instance of early diagnosis of CVD helps prevent an invasive procedure and results in direct savings of U.S. $3,000. Based on WHO’s data about the number of patients suffering from cardiovascular illness, averting 1 percent of invasive procedures could provide direct savings of U.S. $200 million in India alone and potentially save 60,000 families from going into lifelong poverty. These savings could be derived from deploying 10,000 Cardiotracks at a total cost of U.S. $5 million. The return on investment is staggering.

Measuring social impact

uber Diagnostics is currently providing free ECG monitoring through heart health camps with the goal of having sufficient data to better understand the extent of the heart health challenge in India. So far, we’ve identified many new CVD patients and a small number have been diagnosed with a critical heart condition needing immediate intervention. Their lives were saved. More data should be collected; however, there’s clearly an immediate need for solutions such as Cardiotrack at the primary care level. For more about Cardiotrack, check out the video below:

Ashim Roy is the co-founder of uber Diagnostics.