HEALTHCARE IN THE DIGITAL AGE

Author: Mike Ellis

Healthcare in developed countries is predominantly reactive. Health insurance systems reward doctors mostly for procedures and less for medical (i.e. non-operation) care. At the bottom of the policy priorities is prevention. This is based on the erroneous belief that if a patient presents with symptoms of heart disease that much can be offered. It is now becoming apparent that the best gains are made when there are no symptoms. Instead of waiting for onset of symptoms, we attend to have a risk stratification when we are young and seemingly in the prime of our lives.

The incidence of HT (hypertension, elevated blood pressure) is high. One in three USA adults has HT. Of the 61% who are under treatment, 35% have it under control and 65% do not have it under control.

WHO estimates, in 2003, 16.7 million people around the globe died of CVD each year. This is over 29% of all deaths globally. (www.who.int)

20 million people survive heart attacks and strokes every year; many require continuing costly clinical care. (WHO. CVD:Prevention and Control. 2006)

Coronary heart disease: in 2002 there were 7.2 million deaths from coronary heart disease globally. (Atlas of Heart Disease and stroke, WHO, Sept. 2004)

The AHA (American Heart Association, www.americanheart.org) recommended in 2002 that all adults have a risk stratification performed by their doctor at the age of 20years (Circulation. 2002;106:388-391.)

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Prevention has been shown to be the best route-from both clinical and economic perspectives. Prevention relies on targeted methods so that early assessment of risk is critically important AND it has to be possible to modify this measured risk with diet exercise and medication

The above does not occur in primary care for a number of reasons. Doctors are under-resourced and do not have machine technologies and IT support to assist in this process.

At a recent conference in Dubai, 3rd Partners International Cardiovascular conference 13-15 December 2006, it was stated that "The challenge of heart disease-one of the most serious health issues facing the ME was being assessed by a congress which attracted 300 leading specialists. The statistics which are well known were that a staggering 41% of all deaths in the UAE are the result of heart disease. Cardiovascular disease is claiming more and more lives at an even younger age each year and it is vital that public awareness is raised. The conference will help the development of the healthcare system in the region and help to promote the need for a healthier lifestyle"

Also recently, GE Healthcare announced plans to enhance the R&D profile of the ME region through the promise of investment of $1 billion annually in R&D with a focus on early health and identified that 70 to 80per cent of resources in healthcare are devoted to managing symptom-based advanced diseases. Shifting resources to early health and developing technologies that allow healthcare providers to diagnose disease at the earliest possible stage when there can be many treatment options is better medicine and makes economic sense. One welcomes this new refreshing corporate initiative from a huge global player in healthcare

The author has been a general practitioner in Melbourne Australia since 1975. I have used these new technologies in my general practice since 1999 (www.hsd.net.au). I have demonstrated the system at Arab Health Expo. These technologies have been developed in Australia and they assist clinicians in this quest for an early diagnosis of cardiovascular disease using inexpensive machines that can be used by practice assistants to collect data and then this data is transmitted using encrypted encoded web technology to a central server and a detailed report is sent to the testing clinic (which may be in the UAE) of the findings of the testing process. These results identify BP (blood pressure scores www.suntecmedical.com), ECG (www.norav.com) and two novel technologies. These are a measure of arterial stiffness using a SphygmoCor machine, www.atcormedical.com, and HRV (heart rate variability) using ECG data collection, (www.norav.com)
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Arterial stiffness using wave form analysis measures the degree of change in the arterial wall beyond normal ageing caused by pathology that gives rise to the development of atherosclerosis (the deposition of gunk in the wall of the artery known as the soft unstable plaque) which decades later causes the wall of the artery to rupture and give rise to serious symptoms and or death. These measurements have been found to better predict the response to drug treatments in trials such as the ASCOT trial.

Together with the blood test results for cholesterol, diabetes and a questionnaire about smoking, a Framingham absolute risk score is determined and this assists the clinician to choose the most appropriate, evidence based, therapy.

The addition of the HRV test permits a measure of the nerve control of the heart. Thus, if adrenaline stimulation is excessive, as it is in diabetes, this causes a serious complication of cardiac autonomic neuropathy where the heart appears to be in a permanent state of stimulation resulting in a faster resting heart and a greater risk of death. Conversely, the improvement in lifestyle including weight loss, exercise, nutrition and addition of the most appropriate medications causes a reduction in risk and an improvement in the scores. Thus, what has been a subjective estimate can now be given a number and this permits the optimization of the otherwise asymptomatic patient to a lower risk. The patient/client leaves the test with a comprehensive report of his health status and as a result of the testing is placed in a better position to participate in his treatment process.

The range from the worst score (both of arterial stiffness and HRV) and the best score is a risk increase of ten times. Certainly, it would be difficult to find anyone who would not feel better placed as a result of knowing the scores to commence and continue a process of change in the lifelong process of reducing risk in that patient who was born with a genetic predisposition to CV disease. Thus it is like a switch from analogue to digital car tune-ups! Also it is the switch from breakdown support with a towing truck for an auto analogy to routine maintenance to keep the auto going. Such a change produces a greater benefit for every dollar spent but all of us resist change and defend the status quo. But unless change is embraced, the need for invasive procedures (angioplasty or open heart surgery) grows and for the 50% who have survived the heart attack, the preventative procedures will be implemented after the patient qualified with the onset of the heart attack.

Thus primary prevention, the process of diagnosing and implementing the changes in lifestyle and addition of appropriate medication is assisted with new technologies that permit the tester to non-invasively "see" the condition of the circulation system and report the status. The partnership of patient/doctor is then better placed to choose and implement the best strategies to improve the wellness (and not only the health) of the patient. Commentators (The Wellness Revolution) are referring to healthcare as sickness care and not wellness care and the cost of healthcare in the USA accounts for 15% of GDP ($1.5 trillion dollars) and at 15% it cannot go much higher. The next question is how this money can be better spent to buy what can be described as better value services.

As the Middle East enters a phase of rapid expansion in medical service delivery it is uniquely placed to choose the best systems to buy to serve the population. With thousands of health product choices, as evidenced at major health expos, available it is the policy makers who have a responsibility to obtain the best the world can offer the region. It does not appear to be an easy decision process.

The testing using new technology is readily scaleable to be expanded to population testing and is run on inexpensive machines and the technician training can be achieved in a matter of days. To enable sufficient population reach, this low cost makes the implementation of the risk assessment and the subsequent intervention achievable I primary care systems with the advantage of limited training.

The reports are generated on a remote computer server and a quality control is put in place.

The appropriate business models will be put in place so that it would allow that such assessments and prevention strategies to be rolled out. The ME population, as a result of the high prevalence of metabolic syndrome, would benefit from such a roll-out. Alternatively, the continuation of usual care western models of testing and implementation of treatment strategies would not, in the opinion of the author, achieve similar scaleable solutions.