Rajlakshmi Krishnamurthy: Coordinated Care, Better Care

Transcript

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. Our guest today is Dr. Raj Krishnamurthy. And we are taping this a few days early because of a travel conflict. But I am glad that you and I get to sit down and do the intro and outro together, Harlan, because there’s so much to talk about. What do you have for us today?

Harlan Krumholz: Well, before I jump into some things, Howie, let’s just say that we’re taping this on Monday, and it’s a day of peace no matter where you fit on the political spectrum. Gosh. So, much suffering.

Howard Forman: Better today than yesterday. Yeah.

Harlan Krumholz: So, much going on. And just to see today that the ceasefire’s holding, that the hostages have been released, that the Palestinian prisoners are being released. Gosh. You just have to pause on that a minute, no matter what you think about anything else.

Howard Forman: I couldn’t agree more. I’m so glad to see the direction that we’re going in there, and I just hope that it can be a durable piece. That’s all I hope for.

Harlan Krumholz: Oh, my gosh. There’s so much further to go. There’s so much suffering that’s occurred. But it’s a day to be hopeful, so far. Hey, look, I wanted to try something new today. I was going to do some quick hits, but just because there’s so much going on in the health area and just get your feedback on it. So, let me start with number one, India’s toxic cough syrup deaths. I don’t know if you’ve seen about this.

Howard Forman: Only through you. I mean, I had not seen it. It’s pretty devastating. I mean, you want to explain what actually happened and why this is not something we in the United States should be worried about, but maybe?

Harlan Krumholz: Or why we want to think about the importance of regulation and inspection. So, 24 children in India have died after taking contaminated cough syrup. This was found to contain diethylene glycol. This is the stuff in brake fluid. The syrups came from this company, Shriram Pharma, where inspectors found hundreds of violations, dirty water storage, unqualified staff, missing safety records. And the WHO, World Health Organization, says the tragedy exposes deep gaps in India’s drug safety system and warns these toxic medicines can easily reach other countries.

And why it matters is because drug safety is only as strong as its weakest link. And when oversight fails anywhere, everywhere can be at risk because we’re really living in a global world with regard to how these things reach other countries. So, anyway, I just thought 24 kids, can you imagine giving your kid cough syrup?

Howard Forman: Horrible. And that’s what we know about at this point. It could even be higher than that. And just a reminder to people that there is a certain amount of reimportation of various drugs and even over-the-counter drugs from other countries and people should be very wary and actually have a great deal of pride in the fact that we do regulate our own drug manufacturing fairly well here.

Harlan Krumholz: Yeah. It gets back to the FDA. Why do we need a strong FDA? Why are all these things important? You just cannot make assumptions that things will always be great.

Howard Forman: 100%.

Harlan Krumholz: Okay. Here’s number two. You may have been reading about this. We’ve talked about it before on the program, the BIOSECURE Act. You know that this didn’t pass before, but it was much talked about. And now, the U.S. Senate has passed another version of the BIOSECURE Act tucked into the annual defense spending bill. This would bar U.S. pharma and biotech firms from working with certain Chinese contractors deemed national security risks, including companies that were once central to American drug manufacturing.

The supporters say it protects U.S. genetic data. Critics warn it could raise drug costs and slow innovation. This is interesting because before also one of the major companies that was the focus of it was WuXi. WuXi is this amazing company. There’s this guy, Li Ge, who started WuXi. He was a Columbia professor, Columbia University in New York. Goes back to China and starts this really remarkable company that stretches from molecular biology all the way to supply chain. And it turns out that a lot of U.S. pharmaceutical companies depend on this company.

Now, what’s interesting about this bill was, unlike the previous version, it doesn’t really mention WuXi among the group of companies. So, there’s a big question. What happened? What’s going on? Whether this is going to go. The bill matters because it mixes national security with drug pricing policy and gives Washington a new lever over the industry while reshaping global supply chains. And I don’t know if you saw this or if you have any thoughts about it.

Howard Forman: I’m not an expert at all on trade policy. It’s very hard for me to tease out how much of this is actually about national security, about patient privacy or about trade policy. I think the big issue about why companies aren’t mentioned now is that there’s a question as to the constitutionality of specifically mentioning companies as opposed to policy issues in the bill. And I think that was a nonstarter for some people.

So, I think it’s a bipartisan bill. It certainly is more about American chauvinism, nationalism, and America First Policy, but it may in fact be the right policy. I can’t judge it on my own.

Harlan Krumholz: Well, it’s hard to say because what exactly represents national security? As you know, we’re taping this early because I’m on my way to China this week.

Howard Forman: Yeah.

Harlan Krumholz: And I can tell you that some of the best science in the world in medicine is taking place now in China. China’s going to be a real engine of evidence-generation. Our research works best when there’s free flow of information. Somebody comes up with a cure, someone comes up with a new device, you want that to move across borders. What’s going on in medicine and molecular biology intersect with national security, intersect with global health initiatives? This is going to be really interesting to see how this plays out.

But as you know, for me, I’m trying to strengthen ties between the two countries. I’m trying to strengthen communication and openness around science that serves health and public health and we’ll see how all this goes.

Howard Forman: I know it’s considered negative now, but I still consider myself a globalist. I’m still somebody who’s in favor of free trade. This goes in the other direction, but it is the direction of overall national trade policy right now. And it’s not surprising to me.

Harlan Krumholz: Yeah. And there are legitimate reasons to be concerned about information that it does represent national security. So, it’s not unfounded. The question is, how do we find the right balance, and where does this go? Okay. Number three, I know this is going to be a favorite of yours. TrumpRx. TrumpRx, the Amazon of drugs. So, the Trump administration is preparing to launch this TrumpRx into, which was announced on Truth Social to much fanfare, government-backed website promising insurer-level prices on brand name drugs.

Like now you see GoodRx, Walgreens, other pharmacy groups are in talks to join. Signaling, it could grow into a national discount marketplace. Still, experts, a lot of experts, maybe you’re one of those, says savings may be hard to see amid what’s going on already with the confusing patchwork of coupons and copays. So, I just find this really interesting. It announces something, the details are a little hazy. People are coming in. Pfizer, as you know, jumped in on this soon after it was announced, or maybe it was part of the initial announcement.

It’s a question. This truly delivers transparent pricing. Could it really help patients bypass the middleman? What do you think about this?

Howard Forman: I think we’re going to have to wait a year or two to see whether this mattered at all. I think this is mostly populism that costs the government very little. It has the veneer of doing what’s right for consumers without necessarily doing much. And quite frankly, look, all presidents since literally the late 1990s have tried to jawbone the pharmaceutical industry to reduce one or another prices, whether it was insulin prices or helping to bring down the prices of specific chemotherapy drugs or other things. Everybody’s been trying to do it.

This is his effort. It’s one of the cheapest policies for him right now. But I’m not that optimistic that this will move the needle that much, but I also am not opposed to it in any material way. And the fact that GoodRx wants to get involved makes total sense because they’re basically being shut out otherwise.

Harlan Krumholz: And the question is the same thing that can make the president infuriating on some fronts, the same characteristics that make it so that he can just ignore the lobbyists, ignore all the external pressures, and really use sharp elbows to get progress in areas that’s hard to get progress in. It’s going to be very interesting to see how this plays out.

Howard Forman: I’d love to see lower prices for drugs because I think consumers would do well for it.

Harlan Krumholz: That’s right. We need that. Okay. Number four, Gates and the Pan-American Health Organization. They’re working here. The Gates Foundation and the Pan-American Health Organization are exploring ways to make the weight loss drugs like Wegovy and Mounjaro affordable in low-income countries. God, I love to hear this. Gates says he wants the foundation to make them super cheap so everybody can get them.

And for me, this is a recognition that these drugs really should be essential medications. The trials are showing better outcomes. It’s not just about how you look. This is about cardiometabolic health. It’s about reducing cardiovascular risk. Seventy percent of the world’s billion people with obesity live in poor countries and currently these drugs are out of reach for those individuals because even at hundreds of dollars a month, it’s just impossible. So, I thought this was an interesting initiative. If successful, it could transform obesity that can be treated in a rich nation only to a global health priority, just like vaccines were. I don’t know if you have thoughts about this one.

Howard Forman: I mean just look, semaglutide is coming off patent protection in certain countries very soon and then in other countries a little bit later than that. And over time, all of these drugs, because they’re all relatively small molecules, they’re peptides will come off patent and will be relatively cheap to produce. And I think what Gates is trying to do and others are trying to do is figure out how cheap this can be made and how fast can we actually get access to that. And I’m all in favor of that.

I do think, as you have alluded to in the past, we just got to keep doing the research and figuring out how to make these drugs safe, affordable, accessible. But remember also that I think only about a third of people who go on them stay on them. So, we still have to do more research to find better molecules that will be better tolerated.

Harlan Krumholz: Some of that may be about cost and access, and I think it’s about this transition to understand obesity as a disease, a condition, something like hypertension—rather than this is just lack of willpower or failure of character—and actually goes straight at it, because we don’t say that about hypertension. I think this is this part of transition.

Howard Forman: Yes.

Harlan Krumholz: Okay. My final one, this was like my five that I wanted to hit you on. So, there was an article on the Boston Globe that was talking about Boston’s biotech edge under pressure. So, for years, Boston and Cambridge have been, really, the center of the universe for global biotech powered by Harvard, MIT, Tufts, others, world-class hospitals, a flood of venture capital. And the concern is, this engine may be slowing, especially as federal research funding is under threat, new visa limits and particular issues around cost in Boston.

So, it may be that there’s time for another place to emerge. Hey, Howie, how about New Haven? How about New Haven for the next center of the universe? This occurred in ... I’ll just say one more thing. In the UK, Cambridge is that—Cambridge, UK—which is about the same size as New Haven. So, it doesn’t have to be a behemoth. It could be a community with one large anchor academic institution and more affordable prices and easy accessibility than you can find in some of the cities like London or Boston.

Howard Forman: Look, I think the Yale University has made an enormous investment in innovation. We’ve talked many times about Josh Geballe’s involvement and so many of the scientists in the med school and the other schools at Yale that have collaborated and helped build many startups that have gone on to be successful. I do think that the combination of a supportive university, a supportive city, a supportive state are the ingredients you need. And I think that we can absolutely be competitive with Boston in this space and hopefully ...

Harlan Krumholz: And anywhere else in the world. Anywhere else in the world.

Howard Forman: That’s right. And hopefully, we’re not even the end of it. I mean, let’s face it, places like Vanderbilt and in Chicago—there are other places that can do this too, and we should all benefit from that.

Harlan Krumholz: Yeah. Yeah. But I’m going to cheer for New Haven first.

Howard Forman: Good.

Harlan Krumholz: Go hometown! Hey, let’s get to the interview. I’m going to apologize that I’m not going to be part of this interview because I’m on my way to China, and you’d already scheduled this. I do want to say one thing about Raj. I was on this selection committee to pick the next population health officer for Yale and Yale New Haven. I can tell you that there were some spectacular candidates, and she was the best and she was really the choice of the committee, hands down that, despite ... Let me just give respect to everyone who applied, amazing people.

Raj stood above, and we were so lucky to be able to recruit her. I know you’re going to have a good interview, and I’m glad that we were able to schedule. I’m just so sorry I wasn’t able to be there for the interview.

Howard Forman: Dr. Raj Krishnamurthy is the associate dean of population health for Yale School of Medicine. She’s also the senior vice president and chief population health officer for Yale New Haven Health System. At Yale, Dr. Krishnamurthy is primarily responsible for improving value-based care and driving the strategic development of population health programs. Her research has previously focused and continues to focus on population health interventions and ambulatory care quality.

She received her bachelor’s degree and medical degree from Boston University in a combined program. And she previously served in leadership roles at Boston University School of Medicine and the University of Chicago Medicine before joining Yale Medicine just about a year and a half ago or a year and a few months ago. And what’s missing from that bio is that probably I think one of the more formative experiences you had and a very impactful experience for Yale, at least, was your time at Yale, which happened early in your career.

And I wanted to first hear a little bit about what that experience was like working at the VA, but doing medical education and residency education for Yale and how that informed what you’re doing now.

Rajlakshmi Krishnamurthy: Howie, thank you so much for inviting me. This is an incredible honor. In terms of my time at the West Haven VA, I think I was a clinician educator and a faculty member at the VA—Yale faculty member but based at the VA at a time when the VA was growing incredibly. It was a time when some of the insurance companies for older patients didn’t cover medications. It seems like a long time ago, but that was the case then.

So, veterans who had the opportunity to come to the VA, to get care and get their prescriptions covered at a covered rate, at a discounted rate, were flocking to the VA for care. It was also a time when the VA was really expanding and thinking about access and primary care and creating a real solid quality foundation. And it was just an incredible time to learn how to deliver care in a very holistic system where there’s integration of behavioral health into primary care. There was, in many ways, the support of something that we now call patient-centered medical home, where we really think about the clinician and the clinical primary care team as being that wraparound support for veterans.

And we were able to start measuring quality and outcomes. Things like, “How are we doing in blood pressure control? How are we doing in diabetes control for all of our veterans?” And even integrating social services for veterans and understanding that that was really important as a determinant of how their health and outcomes proceeded. So it was an amazing time and a really formative part of my development, I would say as a leader, as working with colleagues, working with trainees, working with data and systems. And also, another thing to remember, the VA had an electronic health record in the late—

Howard Forman: I was just going to ask you about that. Yep.

Rajlakshmi Krishnamurthy: ...and was very advanced in the mid to late ’90s. And that was also very important for developing measurement to figure out how we are doing and helping improve the care to the veterans that we were serving.

Howard Forman: You moved from Boston University School of Medicine to Newton-Wellesley Hospital for five years, and I think that was the first real heavy investment in administration and specific population health. And again, you did that at a time when Obamacare had already passed but was not fully implemented. I’d be curious to hear your thoughts because I’ve talked to many people in that timeframe when population health officers were just beginning to be talked about. A lot of this was motivated by law, by regulation and the attempt to get people to deliver more value-based care. Can you talk about what it was like to be on the ground at the beginning of this when people are just trying to figure this out?

Rajlakshmi Krishnamurthy: I will say it was very exciting, because it was new, helping clinicians, our care delivery teams, our physicians, our physician leaders, our administrative leaders in the hospital and clinics understand what is it you’re trying to do? How is this different? Explaining it, helping them understand and also helping to identify some quick wins in terms of that coordination, that collaboration. How could this really help their patients?

Sometimes they didn’t understand all the insurance, the value base, the construct where the motivation, but they saw that the programs we were starting to put in place were really helping our patients. Things like care management or transitions of care management or using teams to pull people back in who hadn’t connected to care or hadn’t gotten needed care done.

And so, I think for most of our clinicians and our primary care physicians, it was understanding that, “Hey, there’s different ways that a team of professionals, of nurses, community health workers, medical assistants could help their patients, get patients in and improve their chronic disease outcomes and their cancer screening and things like that.”

So, I think for the clinicians, it was understanding there’s different ways that a team could help them, a population health team could help them. But it was a lot of learning, a lot of trial and error. I still think we’re in many ways on the cutting edge of this work around understanding data, really complicated data from payers and internal to our electronic record and figuring out what are the right programs. Is this really impacting our patients, and can we see improvements from the work?

Howard Forman: So, when you move to Chicago, it’s your first executive officer role, and you’re in a population health leadership role. But these are still very different than playing those roles for either the VA, where it’s a fully integrated system, or Kaiser, where it’s a fully integrated system. Can you give us an idea of how difficult it is to make improvements and can you tell our audience specifically some examples of some wins that you had? How does it reach the patient? How does it make their lives better?

Rajlakshmi Krishnamurthy: Great, great question. So, in Chicago, compared to Boston and the Northeast, where value-based care was a little more ingrained, Chicago was just starting to tiptoe into this space. We had just signed up for a program with Medicare called a Medicare ACO or MSSP, Medicare Shared Savings Program. And we were just trying to figure out how does this work? How can we justify investment in care coordination, in community health workers to support our patients?

And I would say some examples because we didn’t have as—and it wasn’t so much like, again, we had primary care clinicians, trainees working really hard, doing their best, really coming from a place of earnest work. But we were seeing the number of ED visits.

Howard Forman: When we’re referring to ED, we’re saying emergency department?

Rajlakshmi Krishnamurthy: For our Medicare patients, very, very high, probably two times normal, or the average national mean. And some of it was the population we are taking care of. The University of Chicago is on the south side of Chicago, and there’s a high social need and social vulnerability in that population. So, it was working with our clinicians, working with our team, trying to start screening for some social needs that our patients have, working to justify with hospital leadership, investment in care coordination, helping patients understand what the needs were, what were the connections to social programs or to community service agencies that would really change the trajectory of their care.

And one specific example, we had a particular patient who was living in their car and getting dialysis through the emergency room and working with that patient and what things he qualified for. We helped set up housing. But these are not things primary care clinicians on their own can set up and have the time, energy to be able to do so. It’s really working upstream, justifying and supporting positions and working to create programming like care management, transitional management, phone calls, post-discharge to get patients what they need, pulling people in who haven’t been seen, those kinds of things, justifying that, supporting that, and showing that they could demonstrate outcomes.

And then I think for a big health system, it’s showing that, “Yes, you can make a difference, and it’s building up that confidence and that muscle that this is something we can do as a health system.”

Howard Forman: So, now, you’re here at Yale, and over the last several episodes, at least two times, we have talked about the challenges in the emergency room and how they reflect the greater challenges that our system faces where we have patients backing up into the waiting room. We have patients sitting in the hallways, we have patients staying in the emergency room for multiple days at a time.

And a large percent of the time occupied in the ER are driven by social drivers. There’s large homeless population, there’s a large number of substance use disorder patients in our population. And there aren’t great financial incentives to take care of these problems if you’re a health system or a medical school. But the reality is the costs are going to be borne one way or the other by the system. And these patients suffer no matter what. What strategies can we start to think about or even lobby for to improve the lot of this population, which ultimately I think improves the health and wellbeing of everybody?

Rajlakshmi Krishnamurthy: So, one, we can start with our patients who are connected to primary care services within our community or with existing federally qualified health centers. How do we coordinate, how do we message to patients? And one particular initiative, it has been improving how we triage. So, when our patients call us, how do we in a timely, organized, data-driven way, evidence-based way triage patients and bring them to the right side of care?

The other way that we can work in terms of partnerships is to think about community health workers to connect patients to primary care and more of a longitudinal system of care. Oftentimes, our patients come to the ER because they have no other options. And we do have options across the city, across our state. How do we make those connections and how do we support our patients in getting care at a more cost-effective and more comprehensive site of care potentially for them than using the ER?

And I’ve seen in other places like using a community health program that’s connected to community that can help reduce ED visits, and it should be something that we consider. How are we supporting our patients more broadly than we are now?

Howard Forman: And are you able to work with the community effectively right now? I know that the large community health centers like Fairhaven and Cornell Scott are deeply connected to Yale. But do you have partners in the community that you can reach out to try to build programs that keep patients out of the hospital and healthy?

Rajlakshmi Krishnamurthy: So, yes, we reach out to those partnerships. Also, we leverage our relationships with the Office of Health Strategy and with DSS, our Department of...

Howard Forman: Social Services, I think.

Rajlakshmi Krishnamurthy: Yes. Department of Social Services. Thank you. That helps us make connections and I think, think through what are the opportunities for... because it’s expensive for Medicaid, it’s expensive for state Medicaid, and it’s important. This work, in getting patients to connected and developing relationships with the best site of care that can help them comprehensively, is good for our patients on commercial insurance, with Medicare, with who are uninsured or have lots of social needs.

I think a lot of our work is making those upstream connections and being creative about what partnerships can we develop together, how are we acting as a convener to bring together the right parties who are interested and can help drive the change together we want to see.

Howard Forman: Is there a specific problem you are working on right now that you could speak to that you believe is going to bear fruit in this area that I think would give people a little more contours to what the issues are?

Rajlakshmi Krishnamurthy: Sure. So, right now, we’re looking at patients who have multiple visits to the hospital and to the ER. So, we’ve used as just a marker. If you’ve been seen in the hospital or in the ER, any of our hospitals, any of our ERs, four times in the last six months, we’re considering you someone who potentially could benefit from a program we’ve created, an MVP program where we meet that patient in the hospital, one of our community health workers, both in Bridgeport and New Haven, meets those specific patients in the hospital and asks, “What can we do to help you with your care?”

And then we dig, deeply. What are the social needs? What are the social drivers? Is it that you’re not able to get transportation? And we look. Just a particular example, sometimes it’s affordability or coverage of a specific drug. And we have worked with specific pharmaceutical companies on Indigenous programs that they sometimes have to help get drugs covered. And we’ve seen some outcome differences where they’ve not had to come back to the hospital. We’ve connected them to a federally qualified health center and connected them to that medication.

And just by doing some of the legwork that sometimes they’re not able to do for themselves, we can help avoid a hospitalization or an ED visit or multitudes of that and get them connected into the right care so that they’re feeling empowered to take care of themselves.

Howard Forman: And when was the first time that you thought, I want to be involved in hospital or healthcare administration at an early stage in your career? Most people don’t. I mean, I did. I had interests as well. I’m just saying most people don’t.

Rajlakshmi Krishnamurthy: So, early on, so my very first role as a clinician educator at the VA, I was asked to take on a diabetes care clinical pathway. And the team before me had been trying to do it and just wasn’t able to get it over the finish line. And I just loved doing that, working with different multidisciplinary teams and getting into understanding what everyone’s needs were and bringing that all together and then seeing our patients who had diabetes get a better care and experience and do better for themselves. So, it was just that bug, the quality improvement bug, that got me, and it’s gone from there.

Howard Forman: Yep. And we are very fortunate that it got you because we’re really happy to have you here, working with both our health system and our medical school in dual roles. And it’s great to have you on the podcast. It’s great to have you as a colleague and thanks for joining us.

Rajlakshmi Krishnamurthy: Likewise. Thank you so much. This has just been an absolute delight.

Harlan Krumholz: Hey, Howie. I’m joining you on the back end. I of course, I wasn’t there for the day that you did the interview, but I’m so looking forward to listening to it when I get back and let’s get to your part of the podcast now.

Howard Forman: Yeah. This will be quick, but I think it’s very timely. Study out of the Veterans Administration medical centers done by researchers in St. Louis, Washington University, gives us more information to inform our current COVID vaccination season. They used a novel observational study design comparing outcomes for two groups. One group, they chose to receive both vaccinations on the same dates. The other group chose to only receive the flu vaccine.

This approach attempts to isolate the effect of COVID-19 vaccine while reducing the risk of what’s called the healthy vaccinee bias, commonly encountered in observational studies, comparing vaccinated and unvaccinated persons. They excluded individuals who had recently been vaccinated or had flu or COVID recently. In the study, among those receiving a COVID vaccine, more than 99% received an mRNA vaccine, 164,000 were in the COVID vaccine group, 131,000 were in the flu-only group.

A minimum of six months follow-up was available for all. And this is a very recent study. They finished collection of data in June. They attempted to correct for as many differences as possible between the groups. So what did they find? Twenty-nine percent reduction in emergency room visits, 39% reduction in hospitalizations, and 64% reduction in deaths in those who received the COVID vaccine. They also showed that these protections waned between the first 60-day period and the last 60-day period. Though there was still substantial protection in that last period.

The study is not without limitations, but they did attempt to correct from multiple potential confounding variables and had a large population to work with, including a large number of individuals younger than the current recommended age of 65 or older. So, as we’re well into the season for vaccinations, I thought it worthwhile to highlight this for our listeners. I, for one, have already got my flu shot and intend to get my COVID shot in the next few weeks. For those local to New Haven, current wastewater levels are very low, but if history is any predictor, they should begin to rise soon.

Our colleague and recent guest, Katelyn Jetelina, has a great summary of her recommendations for vaccinations. We’ll put that in the show notes. And I believe she recommends getting COVID vaccinated as soon as feasible if you have not had a COVID infection in the last six months, so that you can anticipate the next wave.

Open to your thoughts, Harlan, about either the paper or your thoughts on the vaccination this year.

Harlan Krumholz: So, I think it’s a very interesting study. I’m not sure it can ever get away, in an observational study, from this healthy vaccination effect, the people who want to get more vaccines. I think what was interesting to me, Howie, was the absolute difference between them. So, it’s easy to talk about this percent effectiveness that ... So, for example, the estimate vaccine effectiveness was 29% against COVID-19 associated emergency department visits. And that sounds pretty good.

But the risk difference per 10,000 persons was 18, 18 per 10,000 persons. So, among 10,000 people, there are 18 people that end up with an emergency department visit who might not have otherwise if this is giving you the true effect of the vaccine. And only to say, I think it just puts it in the realm of personal choice. The real question for me has always been, “Is there a benefit to the community if I get vaccinated or is it a benefit to me? Does it affect transmissibility? Is it going to safeguard the immune-compromised person or is everyone going to get it?” I’m equally likely to infect other people, but it’s just not going to become rip-roaring.

Howard Forman: Yeah. I totally agree with that. I think at the present time, the vaccination is much less of a public health issue than it is about an individual health issue.

Harlan Krumholz: And then what about someone like me, who a month and a half ago had COVID?

Howard Forman: So, you shouldn’t be getting it for ... I mean, according to Katelyn Jetelina, six months, other people might say three or four months, but I think you have good protections.

Harlan Krumholz: It just makes it hard to know. And then the flu shot, similarly, I think we should be doing similar kinds of study to really understand, because these things drift in the questions of the importance. And this is different than measles.

Howard Forman: No questions.

Harlan Krumholz: There are differences here about whether we’re talking about whether there are ones for which we think that the benefit is so dominant and the benefit across, especially for vulnerable populations, so important that we think we should mandate them versus ones that are more discretionary. And by the way, are we going to be mandated to have influenza vaccine in the hospital this year like we have in the past?

Howard Forman: We are.

Harlan Krumholz: So, that’s very interesting to me, because I really wondered if the Trump administration will come in and say, “If you’re getting Medicare, you can’t mandate vaccines.”

Howard Forman: As you said, we haven’t really done this in a long time, a good study like this. I don’t know the basis for the mandatory vaccinations right now, because I don’t know how much it does reduce transmissibility. But I do know that during peak flu season, it is good for us to have fewer people sick and out of work. So, there is one argument to communicate.

Harlan Krumholz: But does it prevent you from getting influenza or does it make it that the influenza you get is less severe?

Howard Forman: I think it’s similar to COVID. I think it probably has a small impact on reducing transmissibility, but a much bigger impact on the morbidity associated with infection.

Harlan Krumholz: Yeah. So, anyway, there’s just still lots of questions. Let me just say as a cardiologist, of course, I’ve always been very pro about influenza vaccine. There are a series of papers, including ones I’ve been involved in, that have indicated that for high-risk individuals actually it can lower cardiovascular risk. But all of these, by and large, have not been on contemporary flu vaccines and so forth. But it’s enough for me as a clinician to suggest that I think the risk of the influenza vaccine is low and there’s enough evidence to suggest, particularly if you’re at high risk, this thing can trigger cardiovascular events or it can accelerate progression to cardiovascular events.

But I’m only just acknowledging, I think this is an area the government should be investing in to let us generate more evidence and we should be more rigorous about.

Howard Forman: But I do think the nice thing about this study is it was not set up in any way to favor one outcome or the other. And it does make a compelling case to reduce deaths, hospitalizations, and emergency room visits and deaths to a greater degree. From my point of view, it makes a more compelling case for elderly people, for people that have comorbid conditions to be able to get vaccinated. It does not compel me in any way to tell younger people to get vaccinated. I don’t think we have evidence to say that right now.

Harlan Krumholz: And I’ll just say one last thing. It’s not randomized. You say it doesn’t favor one or the other, but one group came in and said, “I’ll take both vaccines.” One group said, “I’ll take one vaccine.” There could be a case to be made that those who are more avid to be vaccinated follow more healthier behavior.

Howard Forman: No question. And they tried to correct for that. I mean, they do try to adjust for some of the bias in the groups. There are differences in the likelihood of people smoking, for instance. But I’m with you. I don’t think it’s perfect. To me it’s compelling enough to say that this is still working. Maybe not enough for one threshold. But I think for the groups that are strongly recommended, I feel pretty compelled about. I hope elderly people, in particular, people over 65 or with comorbid conditions do strongly consider it.

Harlan Krumholz: Yeah. And let me just say, a paper like this, I think depending on where you started, you’re likely to find something in this. You’re either going to think that it continues to be biased and is not strong enough, or you’re going to think that this is more evidence to support you. Anyways, more to come on the vaccine front.

You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

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Harlan Krumholz: Health & Veritas is fortunate to be sponsored by the Yale School of Management, the Yale School of Public Health. We are blessed with two superstar undergraduates, Gloria Beck, who’s with us here today, and Tobias Liu. We’ve got a marvelous producer, Miranda Shafer, who somehow makes us sound okay every week, better than we do actually in live. And I’ve got the most terrific co-host on the air, Howie Forman.

Howard Forman: Right back at you, Harlan. Glad to have you with us to tape this and looking forward to having you back fully next week.

Harlan Krumholz: Thanks, Howie. Talk to you soon.

Howard Forman: Thanks, Harlan. Talk to you soon.