India’s Vast Potential for Clinical Outcomes Research—a Global Leader in Waiting!

India is a vast country with a population of 1.25 billion (2015). With a population growth rate of 1.22 %, the population of India is due to surpass that of China in the near future [1]. This rising population will significantly increase the health care needs of the expanding nation. In addition, with a gross domestic product (purchasing power parity adjusted for 2015) of $ 8.027 trillion and a gross domestic product growth rate of 7.3 % (2015), India is categorized as an emerging economy. Improving economic standards injects Btransitions^ into various aspects of the country’s fabric. Similar to the phenomenon of Beconomic transition^ (initiated in the 1990s), India is currently meandering its way through Btransitions^ involving health care delivery, education, etc. The improving living standards, combined with an increasingly medically literate population, demands the delivery of high-quality, value-appropriate, timely, compassionate, and evidence-based care. While several factors influence the delivery of high-quality health care, one of the most important steps starts with assessment of the current status. A rigorous assessment of the current health care delivery based on stringent quality metrics serves as the stimulant to address areas for improvement. Several systems consisting of variable metrics have been implanted into practice in the USA such as the Surgical Care Improvement Project (SCIP) [2] and Patient Safety Indicators [3]. In addition to these government-mandated metrics, the surgical community in the USA has been pioneering the way in assessing its own outcomes and setting the standards of care far ahead of most other disciplines. The ACS National Surgical Quality Improvement Program (ACS NSQIP®) is a prime example, which is a clinical database that is maintained and monitored by surgeons [4]. The ACS NSQIP® provides the platform that has been used extensively to conduct research into clinical outcomes which can contribute to improved patient care. It is this real-time research in clinical outcomes that can be the driver to improve patient care in real time. Research can extend across several realms from basic science and translational to clinical research. The ability to conduct research in any of these avenues depends on the presence of particular academic capital and financial resources specific to each avenue. Full-scale basic and translational science research conducted by clinical surgeons may be in its infancy in India due to a multitude of barriers and reasons. But the barriers to conducting clinical outcome research should theoretically be fewer in India. A very simplified schema of clinical outcomes research pipeline is presented in Fig. 1. A review of this schema can highlight the strengths but more importantly focus on the weak links that are preventing India from becoming a powerhouse for clinical outcome research. To begin with, a good clinical outcome study needs the presence of a large pool of patients. The larger the Bn,^ the more weighty are the conclusions. With its rising population and increase in the number of diseases, India has the potential to contribute to large clinical outcome studies. A review of the abstracts submitted to the annual meeting of the Indian Association of Surgical Oncology (IASO) reveals the strength in numbers. A study that highlighted a novel and less-invasive technique for port placement was able to document the outcomes for 1200 patients in a short period of 5 years. A study to determine the feasibility of laparoscopic radical hysterectomy for early-stage cervical cancer over a period of less than 5 years included 224 patients. Similarly, a study on the emerging field of cytoreductive surgery in India was able to accrue 87 * Chandrakanth Are care@unmc.edu