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8 years, 2 months ago

Diabetes and cardiovascular disease

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Directory:
Diabetes
Tags:
blood pressure control
commentary
CVD
diabetes complications
diabetes management
glycaemic control
insulin therapy
type 1 diabetes
type 2 diabetes
  • Diabetes is closely associated with cardiovascular disease (CVD)
  • Heart attack and stroke cause premature death in people with diabetes
  • People living with type-2 diabetes can prevent or slow the onset of CVD
  • Lower CVD risk by exercising, eating healthily, controlling your weight, and giving up smoking
 
Diabetes and cardiovascular disease

Diabetes is treatable, but people with diabetes have a greater risk of developing cardiovascular disease (CVD) than people who do not have diabetes. Indeed, adults with diabetes are two to four times more likely to develop heart disease or a stroke than adults without diabetes. The reason for this is because people with diabetes, particularly type-2 diabetes (T2DM), may have specific conditions that contribute to their risk of developing CVD. These include high blood pressure, abnormal cholesterol and high triglycerides, obesity, physical inactivity, high and poorly controlled blood sugars, and smoking.

Keeping your diabetes under control by managing the risk factors will help protect your heart health. Most people with T2DM are prone to accelerated atherosclerosis, and could ultimately die of cardiovascular disease (CVD). Many will die prematurely. Overall, the incidence of CVD is declining, but for people with diabetes it is increasing.

Much of diabetes care is the prevention of CVD by modifying blood pressure, blood glucose, and lipids, and this involves both medical therapies, and lifestyle changes, as Dr Roni Sharvanu Saha, Consultant in Acute Medicine, Diabetes and Endocrinology at St George's Hospital, London, explains:
 
 
Blood pressure and glycaemic control

Blood pressure and glycaemic control often require multiple drug therapies, which are less likely to produce side effects than a signal agent. Glycaemic control is important for controlling both macro and micro vascular disease. The former includes myocardial infarction and stroke; the prime causes of excess mortality in diabetes. Preventing microvascular complications is important to reduce the risk of retinopathy, and nephropathy. 
 
Insulin therapy

Increasing numbers of people with T2DM are using insulin therapy to achieve tight glycaemic control. The challenge is to reconcile reduced HbA1c with the risk of hypoglycaemia. There is an important debate between tight and adequate glycaemic control.  A 2014 Australian study reported in the New England Journal of Medicine suggests that there is no evidence that tight glucose control leads to long-term benefits with respect to mortality or macrovascular events. 
 
Antihypertensive medication
 
The majority of people with T2DM whose blood pressure is not within the 140/80-range will require antihypertensive medication, which is usually an angiotensin converting enzyme (ACE) inhibitor. If the target blood pressure is not achieved, a calcium channel blocker or diuretic can be taken in combination. ACE inhibitors are inappropriate for pregnant women, and may be a less effective alternative for those of Afro Caribbean descent where a calcium channel blocker may be more effective.
 
Lipid lowering
 
Lipids are fat-like substances in the blood, and cholesterol is one type of lipid. In order for lipids to travel in the blood they must be coated with protein: lipoprotein. Excess cholesterol is detected by measuring lipoprotein. High cholesterol is a major controllable risk factor for CVD. As blood cholesterol rises, so does the risk of CVD. Recommended targets for cholesterol lowering in diabetes are total cholesterol bad cholesterol,

People with high cholesterol may be prescribed a statin, which is a group of medications that can lower bad cholesterol, and thereby reduce the risk of CVD, as Professor Olaf Wendler,Consultant Cardiothoracic Surgeon at King’s College Hospital and  Professor of Cardiac Surgery at King’s College London explains :
 

However, high cholesterol is just one risk, and statins are usually offered to people who have been diagnosed with a form of CVD, or whose personal and family medical histories suggest they are likely to develop CVD at some point over the next 10 years.
 
Side effects

Statins are tablets to be taken at the same time once a day, and in most cases, will need to continue for life, as stopping the medication will cause high cholesterol levels to return within a few weeks.
 
There are significant risks associated with mixing statins and grapefruit, which include muscle breakdown, liver damage and kidney failure. Statins also carry other risks, such as digestive problems, increased blood sugar and neurological side effects, including confusion and memory loss.
 
Lifestyle

In addition to drugs, people with T2DM experiencing hypertension, and high cholesterol are encouraged to eat a healthy diet low in saturated fats, exercise regularly, stop smoking, and reduce salt and alcohol. Smoking is particularly harmful for people with diabetes since it increases the risk of macrovascular disease and microvascular complications.
 
Takeaways

Diabetes is closely associated with CVD. Heart attack and stroke are the major causes of premature death in people with diabetes. With the rising prevalence of diabetes, especially in developed countries, the double jeopardy of diabetes and CVD is set to result in an explosion unless preventive action is taken.
 
Managing T2DM involves a combination of drugs and lifestyle. Self-management is enhanced by increased knowledge of the condition. People living with T2DM can either prevent or slow the onset of CVD by increasing their physical exercise, eating a healthy balanced diet, controlling their weight, and giving up smoking.
 
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8 years, 3 months ago

Diabetes and kidney disease

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Directory:
Diabetes
Tags:
chronic kidney disease
CKD
commentary
diabetes complications
diabetic kidney disease
kidney damage
renal function
type 1 diabetes
type 2 diabetes
 

  • Diabetic kidney disease is an epidemic
  • People with severe kidney disease often do not realize it as its symptoms are non specific
  • People living with the condition need to become more active in its management
  • GPs often do not recognise diabetic kidney disease and fail to refer patients to specialists
  • Kidney failure is one of the most severe and life-threatening complications of diabetes
  • Kidney damage from diabetes accounts for 35% of people with end stage renal disease
  • Chronic kidney disease  (CKD) is diagnosed through specific blood and urine tests
  • CKD can be treated with medicines and lifestyle changes
  • Management of CKD includes glycaemic control, blood pressure control and smoking cessation

Diabetes and kidney disease

Diabetic kidney disease has become an epidemic; people living with diabetes need to become more active in its management in order to either slow the onset of kidney disease or to stabilize it.
 
It is not easy.
 
People with severe kidney disease often do not realize it. Primary care doctors often do not recognise it, and fail to refer patients to specialists. According to the US Renal Data System, 42% of patients with end-stage renal disease (ESRD) had not seen a kidney specialist or nephrologist prior to beginning therapy.  

Kidney failure is one of the most severe and life-threatening complications of diabetes. About 30% of people with type-1 diabetes, and between 10% and 40% of those with type-2 diabetes eventually will suffer from kidney failure. Over the next decade, it is projected that twice as many people will suffer from diabetes related kidney failure.
 
Silent killer

"There is an explosion of kidney disease, but a lot of doctors are not aware of the strong association with diabetes, cardiovascular disease and hypertension," says Dr Robert Stanton, chief of the kidney and hypertension section at Harvard’s Joslin Diabetes Center. "You can slow down kidney disease, and maybe stabilize it. But if you wait too long, very little can be done," says Stanton.
 
Kidney damage from diabetes (diabetic nephropathy) accounts for 35% of people with ESRD. In 2015 some 35,000 people in the UK required kidney dialysis. In the US, more than 100,000 people are diagnosed with kidney failure each year, and an estimated 31 million people have chronic kidney disease (CKD). In India there are some eight million people suffering from chronic kidney failure. Lloyd Vincent, Senior Consultant Nephrologist at Narayana Hrudayalaya, Bangalore, India, here explains how diabetes control is related to kidney function:
 

 
The only way to find out for sure whether you have CKD is through specific blood and urine tests. Once detected, CKD can be treated with medicines and lifestyle changes. These treatments usually decrease the rate at which CKD worsens, and can prevent additional health problems.
 
Your kidneys and diabetes

Your kidneys perform vital functions such as filtering your blood and stimulating your red blood cell production. Diabetes damages small blood vessels in your body, including those in your kidneys. This means your kidneys cannot clean your blood properly, and wastes cannot be removed from your blood, which means kidney failure. Diabetes may also result in nerve damage, which can cause difficulty in emptying your bladder. The pressure resulting from a full bladder can back-up and injure your kidneys. Also, if urine remains in your bladder for a long time, you can develop an infection from the rapid growth of bacteria in urine, and this can affect your kidneys.
 
Early signs

An early sign of diabetic kidney disease (DKD) is an increased excretion of albumin in the urine. Albumin is present long before usual tests show evidence of kidney disease. Weight gain, high blood pressure, ankle swelling, and the need to use the bathroom more at night are also signs. A person with diabetes should have their blood, urine and blood pressure checked at least once a year. Maintaining control of diabetes can lower the risk of developing severe kidney disease.
 
Late signs

As kidneys fail, blood urea nitrogen (BUN) levels rise, as do levels of creatinine in your blood. Signs of late stage kidney disease include nausea, vomiting, appetite loss, weakness, fatigue, itching, muscle cramps (especially in the legs), and anaemia. Also, a person with diabetes might find they need less insulin, which is because diseased kidneys cause less breakdown of insulin.
 
Takeaways
 
Diabetic kidney disease is essentially a microvascular complication, which triggers a vicious circle by promoting macrovascular processes as well. Early intervention is crucial and prevention encouraged. The most effective strategies include: glycaemic control, blood pressure control, and smoking cessation.
 
 
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8 years, 4 months ago

Slowing the steep rise of antimicrobial resistance

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Directory:
Medical Technology
Tags:
AMR
antibiotics overuse
antimicrobial resistance
biosensors
biosensor technology
commentary
diagnostic biomarkers
diagnostic device
sensing technology
wide spectrum antibiotics

  • Currently 700,000 people die each year from Antimicrobial Resistance (AMR) and this could rise to 10 milion by 2050
  • AMR could make routine surgeries and childbirth as dangerous and lethal as in the pre-antibiotic era killing millions and costing trillions worldwide
  • Doctors inappropriately prescribing antibiotics for minor aliments shorten the useful life of antibiotics threatening modern medicine as there is an antibiotic pipeline deficiency
  • 90% of GPs feel pressured by patients to prescribe antibiotics
  • 70% of GPs are unsure whether sore throat and respiratory infections are viral or bacterial resulting in 50% of sore throats receiving antibiotics
  • Clinical diagnosis leads to 50% of patients with a sore throat being prescribed antibiotics without having Group A Streptococcal infection
  • 30% of patients with pharyngitis will not be treated but will be infected with Group A Streptococci
  • 24% of doctors say they lack easy-to-use diagnostic tools
  • 10m prescriptions for antibiotics are handed out in England each year to patients who do not need them
  • A Nobel Laureate has developed a new technology to provide rapid, accurate, cost-effective diagnosis of bacterial sore throat resulting in informed prescribing and reducing unnecessary antibiotic usage
 
Slowing the steep rise of antimicrobial resistance
 
Should we listen when a professor of medicine and a Nobel Laureate says that the technology already exists to develop a cheap hand held device, which can rapidly and accurately diagnose a bacterial sore throat?  
 
Without such a device to determine whether minor ailments require antibiotics, doctors will continue to prescribe them, and thereby contribute to the steep rise in Antimicrobial Resistance (AMR). In 2016 the National Institute for Health and Care Excellence (NICE), the UK government’s NHS watchdog, reported that as many as 10m prescriptions for antibiotics are handed out in England every year to patients who do not need them. According to a 2016 report on AMR, by 2050 a staggering, “10m people will die from AMR each year . . . . The world needs rapid diagnostics to improve our use of antibiotics,” says the report.
 
Sore throat
 
Acute throat infections are among the most common infectious diseases presented to primary healthcare and A&E departments and are frequently misdiagnosed. They are responsible for 2 to 4% of all primary care visits. Viruses cause 85% to 95% of throat infections in adults and children younger than 5. For those aged 5 to 15, viruses cause about 70% of throat infections, with the other 30% due to bacterial infections, mostly group A β-hemolytic streptococcus (GAS), which can cause 0.5m deaths a year. There are challenges in diagnosing GAS because its signs and symptoms are often indistinguishable from viral and other causes of sore throat.
 
If a doctor intends to treat suspected GAS pharyngitis, it is generally recommended that laboratory confirmation of the presence of GAS be sought to limit unnecessary antibiotic prescription. The gold standard laboratory investigation is of a bacterial culture of a throat swab. However, this is expensive, and there is a relatively long lag time between the collection of the specimen and final microbiological diagnosis: so doctors tend not to it. 
 
Rapid antigen diagnostic tests (RADTs) are an alternative to the gold standard laboratory test for GAS. However, widespread use of RADTs has been hindered by low sensitivity for most commonly used RADTs (immunoassays). Reviews of RADTs performance have identified significant variability in the diagnostic accuracy, especially sensitivity, between different test methodologies.
 
Urgent need for rapid and accurate diagnostic test
 
A principal recommendation of a 2016 report on AMR is to ban doctors from prescribing antibiotics until they have carried out rapid tests to prove the infection is bacterial. The report also stresses that doctors need urgent help to temporise their use of antibiotics if AMR is to be reduced.

Notwithstanding, the AMR challenge is bigger than doctors overprescribing antibiotics. Farmers feed antibiotics to livestock and poultry, and spray them on crops to make our food supply ‘safer’. We dump antibiotics in rivers, and even paint them on the hulls of boats to prevent the build up of barnacles. However, it seems reasonable to suggest that successfully reducing doctors’ over prescribing antibiotics would represent a significant contribution to denting the burden of AMR. To do this, “We need a step change in the technology available . . . Governments of the richest countries should mandate now that, by 2020, all antibiotic prescriptions will need to be informed by up to date surveillance and a rapid diagnostic test,” urges the AMR report.
 
The technological ‘step change’, which the report says is essential, has already been achieved, says Roger Kornberg, Professor of Medicine at Stanford University and Nobel Laureate for Chemistry. “Advanced biosensor technology enables virtually instantaneous, extraordinarily sensitive, electronic detection of almost any biomarker (protein, nucleic acid, small molecule, etc.). With relatively modest resources it would only be a matter of months to develop a simple, affordable handheld device, which not only would tell you immediately and accurately whether a sore throat requires antibiotics or not, but would also tell you which antibiotics you require, and for how long you should take them,” says Kornberg. See videos below in which Kornberg describes how tried and tested biosensor technology could facilitate rapid and accurate diagnosis of a sore throat.
 
 
Bionsensors in diagnosing a sore throat
 


Instant diagnosis of a strep throat
 
Serious and growing threat
 
Each year, millions of people throughout the developed world present themselves to their doctors with minor ailments, such as a sore throat. 97% of these patients demand antibiotics although 90% of their ailments are viral and therefore do not require antibiotics. 90% of doctors, who do not have the means to rapidly and accurately determine whether a minor ailment requires antibiotics, feel pressured by patients to prescribe them.
 
A 2014 study of four million NHS patients from 537 GP practices in England found that more than 50% of those presenting with a minor ailment were prescribed antibiotics, despite warnings that the medication will not help, but increases their risk of developing resistance. The study, by scientists at Public Health England and University College London, published in the Journal of Antimicrobial Chemotherapy, found that antibiotic prescriptions for minor ailments increased by some 40% between 1999 and 2011. 70% of GPs surveyed said they prescribed antibiotics because they were unsure whether patients had viral or bacterial infections, and 24% of GPs said it was because of a lack of an easy-to-use, rapid and accurate diagnostic device.
 
Superbugs will kill millions and cost trillions
 
Concerned about the rising levels of drug resistance whereby microbes evolve to become immune to known drugs, in 2014 the UK Government, in collaboration with the Wellcome Trust, commissioned a review of the large and growing global burden of AMR. Jim O’Neill, a former Goldman Sachs chief economist who coined the phrase “BRICS”, was appointed to lead the endeavour and propose actions to tackle AMR. In 2015 O’Neill was elevated to the House of Lords, and appointed Secretary to the UK government’s Treasury.

During the 18 months it took O’Neill to complete his final report, one million people worldwide died from AMR. At least 25,000 people die each year in Europe from AMR. According to the Centers for Disease Control and Prevention (CDC), more than 2m people in the US become infected with resistant bacteria every year, and at least 23,000 of them die. According to O’Neill, “If we don't do something about antibiotic resistance, we will be heading towards a world with no-antibiotic treatments for those who need them.”
 
A threat to modern medicine
 
O’Neill’s findings are congruent with warnings from the World Health Organization (WHO), which suggests AMR is a crisis worse than the Aids epidemic – which has caused some 25m deaths worldwide – and threatens to turn the clock back on modern medicine. The misuse of antibiotics has created, “A problem so serious that it threatens the achievements of modern medicine. A post-antibiotic era, in which common infections and minor injuries can kill, far from being an apocalyptic fantasy, is instead a very real possibility for the 21st century,” says a 2014 WHO report. “Superbugs risk making routine surgery potentially lethal, killing millions and costing the world economy US$100 trillion a year by the middle of the century,” says O’Neill.
 
These dire warnings are supported by a case study of AMR published in Antimicrobial Agents and Chemotherapy in 2016, which suggests that we might be closer to a "post-antibiotic era" than we think. A particular group of bacteria (Gram-negative) have become increasingly resistant to currently available antimicrobial drugs. Colistin is one of the only antibiotics that still show some effectiveness against such infections, but the study suggests that even Colistin may no longer be effective.
 
Takeaways
 
AMR is widely recognized as a serious and growing worldwide threat to human health. New forms of AMR continue to arise and spread, leaving doctors with few weapons to bring potentially life-threatening infections under control. The injudicious use of antimicrobials, and the proliferation of AMR pathogens are compounded by the inability to rapidly and accurately diagnose minor ailments such as sore throats. Professor Kornberg has an answer.
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8 years, 5 months ago

Lung cancer and cutting edge stem cell therapy

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Directory:
Cancer
Tags:
cancer reasearch
cell-gene therapy
commentary
lung cancer
stem cell bank
stem cells research
stem cell therapies
  • Stem cell study aims to improve prospects for lung cancer sufferers
  • Professor Sikora suggests that lung cancer is associated with poverty
  • Current therapies for lung cancer extend life by only a few months
  • Lung cancer kills more people than any other cancer

Lung cancer and cutting edge stem cell therapy

In 2015 a combined stem cell and gene therapy for lung cancer started its first clinical study in the UK. Professor Sam Janes of University College London, the study’s leader, said: “This will be the first UK cell therapy for lung cancer, and the biggest manufacturing of cells of its kind.” 

Dr Chris Watkins, director of translational research at the Medical Research Council, which is funding the study, said: “Lung cancer kills more men and women than any other cancer, and improving the outcome for patients with this terrible disease is one of the biggest challenges we face. This new therapy, which uses modified stem cells to target the tumour directly is truly at the cutting edge.”
 
Few studies
 
The use of stem cells for treating lung diseases has increasing appeal, but as yet, little is known about the effects of administering stem cell therapy to patients with lung diseases. Currently, there are only a small number of approved clinical studies in the US and Canada investigating cell therapy approaches for lung diseases. Patrick O’Brien a consultant obstetrician and gynaecologist at University College Hospital, London describes an initiative to create a national stem cell bank in the UK: 
 
       
 
Lung cancer
 
Lung cancer is the most common cancer worldwide, accounting for 1.8 million new cases and 1.6 million deaths in 2012. This year, an estimated 224,210 adults in the US, 40,000 in the UK, and 169,000 in India will be diagnosed with lung cancer, 90% of which are and caused by smoking. Of those diagnosed, 95% will die within ten years, although early stage lung cancer has a much better survival rate. Professor Karol Sikora, a world respected oncologist, and campaigner for better universal cancer treatment, suggests that lung cancer is associated with poverty:
 
    

Traditional therapies
 
Cell-gene therapy holds out new hope. “Lung cancer is very difficult to treat because the vast majority of patients are not diagnosed until the cancer has spread to other parts of the body. One therapy option for these patients is chemotherapy, but even if successful this treatment can normally only extend lives by a handful of months,” says Janes. Current therapeutic strategies of chemotherapy, radiation therapy, and clinical studies with new-targeted therapies have only demonstrated, at best, extension in survival by a few months.
 
Innovative approach
 
“We aim to improve prospects for lung cancer patients by using a highly targeted therapy using stem cells, which have an innate tendency to home in on tumours when they’re injected into the body. Once there, they switch on a ‘kill’ pathway in the cancer cells, leaving healthy surrounding cells untouched,” says Janes. His study will test the treatment in human volunteers, firstly to check that the treatment is safe, and then in 56 lung cancer patients to see how effective the gene-cell therapy compares with standard care. Each patient in the study will receive three infusions comprised of billions of cells in parallel with chemotherapy.
 
Takeaways

A key advantage of Janes’ proposed treatment is that the cells do not have to be closely matched to a person’s tissue type or genetic profile. They are simply taken “off the shelf” from existing bone marrow supplies. This is because the cells have relatively few proteins on their surface, and do not induce an immune response in the recipient.
 
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8 years, 5 months ago

Can the obesity epidemic learn from the way Aids was tackled?

HealthPad
Directory:
Diabetes
Tags:
behavioural techniques
chronic disease prevention
commentary
diabesity
healthcare costs
healthy lifestyle
obesity
Type 2 diabetes

 
  • Obesity is common, serious and costly
  • Obese adults in the UK will soar by a staggering 73% to 26m by 2030
  • Obesity generates an annual loss equivalent to 3% of the UK’s GDP
  • Obesity cost NHS England £8bn in 2015
  • The obesity epidemic will only get worse unless we take effective action
  • Innovative research to control appetite could provide a cheap and scalable answer to the obesity epidemic
  • The UK’s obesity crisis should learn from the way AIDS was tackled 

Can the obesity epidemic learn from the way Aids was tackled?
 
Obesity is a common chronic health challenge, which is serious and costly.It is one of the biggest risk factors for type-2 diabetes (T2DM) and together - obesity and T2DM - form a rapidly growing global diabesity epidemic, which today affects some 9m people in England.
 
Experts forecast the incidence rate of obesity will rise sharply, and bankrupt the NHS. Conventional strategies to reduce obesity and prevent T2DM have failed. According to the Mayo Clinic it is common to regain weight no matter what weight loss treatment methods you try, and you might even regain weight after weight-loss surgery. This Commentary suggests that extra resources are urgently needed to accelerate and broaden innovative obesity research.
  
Efforts to tackle obesity are low priority and fragmented
 
Overweight and obesity lead to adverse metabolic effects on blood pressure, cholesterol, triglycerides and insulin resistance. Risks of coronary heart disease, ischemic stroke, and T2DM increase steadily with raised body mass index (BMI). High BMI also increases the risk of osteoarthritis; sleep apnoea, gallbladder disease, and some cancers. Cancer Research UK predicts that obesity related cancers are expected to increase 45% in the next two decades, causing 700,000 new cases of cancer. Mortality rates will increase with increasing degrees of obesity. It is therefore important that obesity is treated aggressively. According to a 2014 McKinsey Global Institute study, the UK’s Government efforts to tackle obesity are ''too fragmented to be effective'', while investment in obesity prevention is ''relatively low given the scale of the problem''.
 
A multi-generational problem
 
The 2014 Health Survey found that 61.7% of adults in England (16 years or over) are either overweight or obese, and the prevalence of obesity among adults rose from 14.9% to 25.6% between 1993 and 2014. The number of obese adults in the UK is forecast to soar by a staggering 73% to 26m over the next 20 years.

In 2014-15, there were 440,288 hospital admissions in England due to obesity: 10 times higher than the 40,741 recorded in 2004-5. In England one in five children in their first year at school, and one in three in year 6 are obese or overweight. Also, in the past 10 years there has been a doubling of children admitted to hospital for obesity. Over the past three years 2,015 overweight youngsters needed hospital treatment, and 43 of these have had to undergo weight-loss surgery to reduce the size of their stomachs. Today, diabesity is a multi-generational problem, which suggests that far worse is still to come.
 
Costs and spends
 
The UK spends less than £638 million a year on obesity prevention programs - about 1% of the country's social cost of obesity. But the NHS spends about £8bn a year on the treatment costs of conditions related to being overweight or obese and a further £10bn on diabetes.
 
Obesity is a greater burden on the UK’s economy than armed violence, war and terrorism, costing the country nearly £47bn a year, the 2014 McKinsey study found. Obesity has the second-largest economic impact on the UK behind smoking, generating an annual loss equivalent to 3% of GDP. The current rate of obesity and overweight conditions suggest the cost to NHS England alone could increase from £8bn in 2015 to between £10bn and £12bn in 2020.
 
19th century technologies for a 21st pandemic
 
A year after the publication of the McKinsey study, the UK government launched a national Diabetes Prevention Program (DPP) led by NHS England, Public Health England (PHE), and the charity Diabetes UK (DUK). The program offers people at risk of T2DM an intensive personalised course in weight loss, physical activity and diet, comprising of 13 one-to-one, two-hour sessions, spread over nine months, and is expected to significantly reduce the estimated five million overweight and obese people in England, and thereby prevent them from developing T2DM. A previous Commentary predicted that the DPP would fail because it is using a 19th century labour intensive method to address a 21st epidemic.
 
This suggests that the diabesity epidemic will only get worse unless we take more urgent and effective action. A view supported by Majid Ezzati, Professor of Global Environmental Health at Imperial College, London, and the senior author of the most comprehensive review of obesity ever undertaken, and published in The Lancet in April 2016. According to Ezzati, “The epidemic of severe obesity is too extensive to be tackled with medications such as blood pressure lowering drugs or diabetes treatments alone, or with a few extra bike lanes”.
 
Radical action: weight loss surgery
 
The gravity of the UK’s obesity epidemic is demonstrated by the National Institute for Health and Care Excellence (Nice) 2016 suggestion to lower the threshold at which overweight people are offered weight loss surgery. The UK lags behind other European countries in this regard, and experts argue that lowering the threshold would mean the number of people who qualify for weight loss surgery would increase significantly.

According to a report prepared by English surgeons, weight-loss surgery would make people healthier and save the NHS money. The report concluded that after weight loss surgery obese people are 70% less likely to have a heart attack, those with T2DM are nine times more likely to see major improvements in their condition, and also the surgery has a positive effect on angina and sleep apnoea. If all the 1.4m most severely obese people in the UK had weight loss surgery, which costs the NHS around £6,000 per operation, the total cost would be £8.4bn.
 
Weight loss surgery and the brain
 
Initially it was thought that weight-loss surgery worked by reducing the amount of food that can be held by the stomach. However, some patients were found to have elevated levels of satiety hormones, the chemical signals released by the gut to control digestion and hunger cravings in the brain. Patients who had undergone surgery were also found to prefer less fatty foods, which supports the thesis that the hormones also change the patients’ desire to eat, and reinforce the gut brain relationship. This finding reinforces the important link between the gut and the brain on which some of the most promising obesity research is predicated.
 
Gut brain relationship
 
Dr Syed Sufyan Hussain, Darzi Fellow in Clinical Leadership, Specialist Registrar and Honorary Clinical Lecturer in Diabetes, Endocrinology and Metabolism at Imperial College London describes the gut-brain relationship and explains why we eat and why we stop eating:
 

 
Cheap, safe and scalable treatment for obesity
 
The person who has spent most of his professional life searching for cheap, safe and scalable alternatives to weight loss surgery and ineffective weight loss therapies is Professor Sir Steve Bloom, Head of Diabetes, Endocrinology and Metabolism at Imperial College London. Bloom believes that the answer to the UK’s obesity epidemic lies in the gut-brain relationship, and is working on two innovative methods of appetite control, which he and his colleagues believe could significantly reduce the burden of obesity.
 
Method 1: an implantable microchip
 
One method is comprised of a small implantable microchip attached to the vagus nerve to suppress appetite in a natural way. The chip reads and processes both electrical and chemical signatures of appetite within the vagus nerve, and then sends electrical signals to the brain to either reduce or stop eating. Bloom has proven the method’s concept, and in 2013 was awarded €7m from the European Research Council to continue his research. Early findings suggest that chemical rather than electrical impulses are more selective and precise, and the chip reduces both consumption and hunger pangs. All things being equal, it will take another 10 years before this treatment gets to market.
 
Method 2: naturally occurring hormones
 
Bloom is also working on another method to treat obesity, which uses naturally occurring hormones that reduce appetite. Early clinical studies suggest that people will consume 13% fewer calories when they eat a meal after taking the hormones. In 2013 Bloom received £2m from the Medical Research Council to develop this research. One of the significant challenges he faces is hormones normally last only a few minutes in the human body. To overcome this Bloom and his colleagues have had to develop versions of the hormones that can last up to a week before they start breaking down. This suggests that patients could take a single weekly injection to control their appetites. Another approach would be to develop a device, which delivers the hormones continuously. While promising, this method too will take 10 years to get to market.
 
Takeaway: treat obesity the same as Aids
 
Bloom believes that if we approached obesity as we did Aids, the time to develop a cheap, effective and scalable drug for weight control could be cut by half. "The obesity pandemic is the biggest disease that has hit mankind ever in terms  [of] numbers. It is killing more people than anything else has ever killed, . . . . . . . in terms of disease [there are] more deaths from obesity than anything we have known about. The time needed to develop an effective drug could be cut by more than half if conservative checks and balances were loosened. I think we might need to treat obesity in a hurry, and we are being held up. The Aids lobby forced Aids’ drugs on to the market before they had finished testing, but they turned out to be useful and lives were saved. Something similar should be considered for obesity,” says Bloom.
 
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8 years, 6 months ago

Behavioral scientists not doctors will prevent CVD

HealthPad
Directory:
Vascular Disease
Tags:
behavioural science
behavioural techniques
cardiovascular disease
Cardio vascular risks
commentary
CVD
risk calculator
 
  • 90% of the 17m heart related deaths each year are preventable
  • Not preventing heart disease will cost US$47 trillion over the next 20 years
  • UK and US cardiovascular disease (CVD) risk calculators found to be faulty
  • Doctors play a leading role in CVD prevention
  • Doctors well equipped to diagnose and treat CVD, but ill equipped to prevent it
  • Behavioral scientists not doctors should spearhead CVD prevention strategies


Behavioral scientists not doctors will prevent CVD
 
Should we trust clinicians to devise and implement preventative healthcare strategies?
No!
Behavioral experts with knowhow and experience in techniques that successfully nudge people to initiate and maintain healthy lifestyles, rather than doctors should lead chronic disease prevention strategies. Clinicians are programed to diagnose and treat according to strict guidelines, and preventing disease is not in their DNA.
 
What is in this commentary?
 
This Commentary focuses on CVD, but its message applies to any disease prevention strategy. It reviews a number of high profile CVD tools from the UK, USA and India, and found that a CVD risk calculator developed by world-renowned UK cardiologists is over engineered, and its inventors show little appreciation of the significant practical challenges associated with its implementation via UK GPs, who are in crisis. Another CVD risk calculator, which has been used extensively by British GPs since 2009 has been found to have a software glitch, which may have led to thousands of patients being misdiagnosed and wrongly treated. A similar software problem was found in a US CVD risk calculator popular among primary care doctors, which overestimated the risk of a CVD event, and led doctors to unnecessarily prescribe cholesterol-lowering drugs called statins. A more successful CVD prevention calculator has been introduced in India by a former cardiologist and healthcare entrepreneur. The calculator’s success is associated with its simplicity, accessibility, and the fact that it effectively engages and influences people’s behavior. The Commentary describes behavioral techniques, which are necessary to engage at risk people, and nudge them towards permanently adopting healthier lifestyles.
 
Overall our review suggests that doctors are well equipped to diagnose and treat CVD, but ill-equipped to prevent it.
 
An English academic approach to preventing CVD
 
The Joint British Societies Risk Calculator, the JBS3, was launched in 2014 as a tool for the prevention of CVD. It was the result of a collaborative effort of 11 British cardiovascular societies chaired by Professor John Deanfield, the British Heart Foundation Vandervell Professor of Cardiology at the University of London. The calculator embodies the UK’s national guidelines for the prevention of CVD, and is managed by the British Cardiovascular Society, and supported by the British Heart Foundation. Although available as an app, the calculator is designed for use by doctors and practitioners with their patients.
 
Unlike conventional risk assessment devices, which focus on high-risk patients, the JBS3 emphasises lifetime risk of CVD events, such as a heart attack, ischemic stroke or dying from coronary artery disease. To achieve this, the calculator’s algorithms are predicated upon a large data pool of people who have a relatively low 10-year risk of a CVD event, but who nevertheless have a high lifetime event risk.
 
The JBS3 allows doctors to assess a person's heart age compared with a person of the same age, gender and ethnicity with optimal risk factors. It also generates estimates of 10-year CVD risk, and average CVD event-free survival.  Results are intended to facilitate an informed discussion with patients in which doctors can show, in different graphical formats, how lifestyle modifications and other interventions, such as drug treatment, can increase a patient’s years of healthier life. Such discussions are expected to motivate patients to make lifestyle choices, which help them prevent future CVD events.
 
A cautionary note
 
Developing a risk calculator mediated by GPs is no guarantee of producing a significant reduction in the vast burden of CVD. It is too early to assess the effectiveness of the JBS3 Risk Calculator, but it appears to have underestimated the challenge associated with getting overstretched and demoralized UK primary healthcare professionals to use a new tool to engage large numbers of people at risk of CVD.
 
Previous Commentaries have described the UK’s primary care crisis. Over the past decade GPs’ workloads have increased significantly, as a result of the government’s decreasing investment in primary care, and the increasing prevalence of chronic multi-morbidity lifetime conditions, such as CVD. Trainee GPs are dwindling, newly trained GPs are seeking employment abroad, and increasing numbers of experienced GPs are taking early retirement. “GPs in the UK are so fatigued and overworked that they are at risk of harming patients by misdiagnosis”, says Dr. Maurine Baker, chair of the Royal College of General Practitioners.
 
A software glitch in a popular British CVD calculator
 
In May 2016 about 33% of UK doctors were instructed by the government’s Medicines & Healthcare Products Regulatory Agency (MHRA) to warn thousands of patients that their treatment plans, developed from the results of a computer algorithm embedded in a CVD risk calculator could be wrong, and people at risk of a CVD event may have been mistakenly prescribed or denied statins.
 
The risk calculator, called the QRISK2, was introduced in 2009 by the IT company TPP to calculate the risk of CVD, and currently is used in some 2,500 primary care surgeries throughout the UK to help GPs to determine which patients are at risk of CVD. The calculator is embedded in another TPP product; SystmOne, which is a software system extensively used by GPs to access a single source of information, detailing a patient’s contact with the health service across a lifetime.
 
A faulty American CVD risk calculator
 
Recently, a widely recommended American risk calculator for predicting a person's chance of experiencing a CVD event was found to overestimate the actual five-year risk in adults overall, and across all socio-demographic subgroups, leading doctors to unnecessarily prescribe statins. The study, by Kaiser Permanente, was published in the Journal of the American College of Cardiology in May 2016.  It suggests that the incidence of heart disease over the period between 2008 and 2013 “was substantially lower than the predicted risk in each category". According to Dr Alan Go, a lead author, "Our study provides critical evidence to support recalibration of the risk equation in 'real world' populations, especially given the individual and public health implications of the widespread application of this risk calculator.”
 
An Indian entrepreneur’s approach to preventing CVD
 
Billion Hearts Beating  is an open, and easy-to-use website launched in 2010 by Dr. Prathap Reddy, an Indian cardiologist turned entrepreneur who founded the Apollo Group of hospitals, with the mission of bringing world-class affordable healthcare to India. Reddy is mindful that there are some 65m people in India with CVD, but each year only about 100,000 of these receive specialist treatment. Unsurprisingly, about 2.4 million people die each year in India from CVD related events. The Billion Hearts Beating website identifies five simple solutions for lowering the risk of CVD: (i) cessation of smoking, (ii) a healthy diet, (iii) increased physical activity, (iv) a reduction in stress, and (v) regular heart checks.
 
The Billion Hearts Beating campaign fares better than the British JBS3, not least because it employs a simpler way to engage at risk people directly and encourages them to follow recommended solutions to reduce their overall CVD risk. To date, over 505,000 visitors to the Indian website have used its embedded risk calculator and importantly, pledged to improve their diets and lifestyles in order to reduce their risk of CVD.  
 
 
CVD a leading silent killer
 
CVD is often asymptomatic, caused by atherosclerosis, and represents a family of conditions linked by common risk factors, and includes coronary heart disease, stroke, hypertension, hypercholesterolemia, diabetes, chronic kidney disease, peripheral arterial disease and vascular dementia. Many people who have one CVD condition commonly suffer from other related conditions.
 
According to the World Health Organization (WHO), each year CVD accounts for more than 17.5m deaths worldwide, despite the fact that 90% are preventable. Deaths from CVD are projected to grow to some 24m by 2030. Direct and indirect costs of CVD total more than US$316.6bn. The economic costs of not preventing CVD are estimated to be US$47 trillion over the next 20 years.
 
CVD is the UK’s single biggest killer. There are seven million people living with CVD in the UK. Annual healthcare costs associated with CVD amount to some US$14bn, while the UK’s annual economic burden of CVD, including indirect costs from premature death and disability, is over US$20bn. About 85.6m Americans are living with CVD, which is responsible for killing over 370,000 Americans a year. By 2030, 40.5% of the US population are projected to have CVD. Between 2010 and 2030, total direct US medical costs of CVD (2008 US$) are projected to triple, from US$273bn to US$818bn. CVD is the leading cause of morbidity and mortality in India, where an estimated 65m people suffer from the condition.
 
Despite the improvements in outcomes for CVD in the UK and US over the last 20 years, it remains the major cause of morbidity and mortality in population throughout the world. More patients are surviving their first CVD event, and they remain at high risk. Further, levels of certain risk factors such as obesity, and diabetes are increasing. More focus on effective prevention is therefore required.
 
 
How “nudge” can prevent CVD
 
CVD prevention strategies are too important to be left to clinicians. To be successful prevention strategies have to nudge people to change their lifestyles, and this requires experts in behavioral techniques. Over the past decade behavioral scientists have revolutionized the way we encourage people to change entrenched behaviors, which are not in their interest.
 
It all started in 2008 with the ground-breaking publication on behavioral economics, Nudge: Improving Decisions About Health, Wealth and Happiness, written by US academics Cass Sunstein and Richard Thaler. The authors argue that by simply making small changes to the way options are framed and presented to people - “choice architecture” - provides a cheap and easy way to “nudge” people to change their lifestyles without actually restricting their personal freedoms. Politicians loved the thesis, and ‘Nudge’ became compulsory reading among policy makers. President Obama and Prime Minister Cameron set up “nudge units” in the White House and 10 Downing Street to improve public services and save money by tackling previously intractable policy issues.
 
Small personal touches make a big difference
 
One of the first tasks Cameron gave the Downing Street nudge unit was to encourage more unemployed people to turn up for job interviews. The unit found that the standard impersonal written request to attend a job interview only yielded an 11% response rate.  Adding the person’s name, for example, “Hi John”, increased the response rate to 15%. But when the request was ended with a personal phrase and signed off such as, “I’ve booked you a place, Good luck, (signed) Margaret”, the response rate jumped to 27%. These small personal touches were so successful that now they are used in every job center in the UK.
 
Understanding human behavior is key
 
Under the leadership of David Halpern, the UK’s nudge unit has quadrupled in size since it was spun out of government in February 2014. Now a private company of 60 people jointly owned by its employees, the Cabinet Office, and Nesta, the nudge unit permeates almost every area of government policy, and also is working with Bloomberg Philanthropies on a US$42m project to help solve some of the biggest problems facing US cities. The UK’s Revenue and Customs (HMRC) has set up its own behavioral insights unit, and nudge teams are being established throughout the world in Australia, Singapore, Germany and the US.
 
Halpern’s unit has, among other things, signed up an extra 100,000 organ donors a year, persuaded 20% more people to consider switching energy provider, and doubled the number of army applicants. Also, it has implemented behavior change strategies that motivate individuals to initiate and maintain healthy behaviors that fit their lifestyle in approachable and convenient ways. The unit’s behavior change strategies that have demonstrated self-efficacy and self management are examples that can be incorporated into lifestyle change programs, which could help people maintain healthy habits even after a program ends, and thereby be a significant element in CVD prevention strategies.
 
Takeaways
 
If the UK’s nudge unit has discovered anything, it is that an understanding of human behavior is vital for almost all public policy, and this includes healthcare and CVD prevention strategies. Clinicians leading CVD prevention programs understand the disease, but they do not understand the psychology of the people with the disease. Clinicians are well equipped to diagnose and treat CVD, but ill equipped to prevent it. The sooner David Halpern is tasked with preventing CVD, the sooner the devastating personal and economic burden of CVD in the UK will be reduced.
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8 years, 6 months ago

Will the UK’s diabetes prevention program work?

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  • National diabetes prevention program (DPP) uses 19th century methods
  • 60% of adults in England are either overweight or obese
  • 5m adults in the UK are at risk of developing T2DM
  • T2DM devastates the lives of millions and costs billions to treat
  • NHS to offer personal trainers to obese people at risk of T2DM
  • There is no evidence that exercise alone can reduce obesity
  • Public Accounts Committee warns that the DPP is insufficient
 
Will the UK’s diabetes prevention program work?
 
Should we entrust the UK’s clinical establishment with preventing type-2 diabetes (T2DM)?

In March 2015 a consortium spearheaded by NHS England, Public Health England (PHE) and Diabetes UK (DUK) - the UK’s clinical establishment - launched the Diabetes Prevention Programme (DPP). A year later, it has come up with Healthier You, an evidence-based program which it hopes will make a significant contribution towards preventing the 5m people in England at risk of T2DM from developing the disease.
 
What will Healthier You achieve?
 
Previous Commentaries have warned that diabetes will not be prevented by repeating past failures. Despite the fact that we know how to avoid and treat T2DM, and despite the fact that over the past decade some £110bn have been spent on diabetes care and education, the incidence rate of the condition has increased by a staggering 65% over the same period. And still each year In England, there are more than 22,000 avoidable deaths, from diabetes-related illnesses.
 
Because the size of the English population at risk of T2DM is so vast, and because Healthier You is using a variant of past diabetes education programs that have failed, it seems reasonable to suggest that while the DPP may have some limited success, it will fail to make a significant reduction to the overall burden of obesity, which devastates the lives of millions and costs billions.
 
Obesity and T2DM are global epidemics

Currently, in England alone some five million people are either overweight or obese, and therefore at high risk of developing T2DM. The economic cost of obesity is £6.3bn, and expected to rise to £8.3bn in 2025 and £9.7bn in 2050. However, this only reflects costs to the health service, and not wider economic consequences for society. In England in 2014, pharmacies dispensed just over half a million items for treating obesity with a net ingredient cost of £15.3 million. All of these prescriptions were for Orlistat, which prevents the body from absorbing fat from food.
 
If current obesity trends persist, one in three people in England will be obese by 2034, and 1 in 10 will develop T2DM. T2DM is a leading cause of preventable blindness, and is a major contributor to kidney failure, heart attack, and stroke. Each year about 120,000 people in the UK are newly diagnosed with diabetes, and there are about 22,000 avoidable annual deaths from diabetes-related causes. In addition to the human cost, T2DM treatment currently accounts for almost 9% of the annual NHS budget: about £8.8bn a year.
 
Similar trends can be seen in the US, where 86 million people are either overweight or obese and therefore have a high risk of developing T2DM. One in every three American adults has prediabetes, a condition that arises when blood glucose levels are higher than normal, but not high enough for a diagnosis of diabetes. There are 30 million Americans living with T2DM, resulting in two deaths every five minutes.

Obesity is a global epidemic. A study published in The Lancet in 2016 found that in the past four decades, global obesity has more than tripled among men and doubled among women. The study says that if current trends continue, 18% of men and 21% of women worldwide will be obese by 2025. According to Majid Ezzati, Professor of Global Environmental Health at Imperial College London, and the study's senior author, “We have transitioned [to] a world in which  . . . .more people are obese than underweight”. 

Diabetes is a global epidemic. Over the past 35 years 314m more people, making a total of 412m, are now living with the condition: 8.5% of adults worldwide. In 2012, 1.5m people died as a result of diabetes, and 2.2m additional deaths were caused by higher that optimal blood glucose.
 
In England, the rising prevalence of obesity in adults has led, and will continue to lead, to a rise in the prevalence of T2DM. This is likely to result in increased associated health complications and premature mortality, with people from deprived areas and some minority ethnic groups at particular risk. Modelled projections indicate that, all things being equal, costs to the NHS and wider costs to society associated with overweight, obesity and T2DM will rise dramatically in the next few decades.
 
Roni Sharvanu Saha, Consultant in acute medicine, diabetes and endocrinology at St Georges Hospital NHS Trust, London describes prediabetes:
 

 

DPP in the news
 
The launch of Healthier You triggered headlines such as, “Personal trainers on the NHS in war on diabetes”, which raised eyebrows and attracted criticism. Despite mounting evidence to suggest that physical activity alone cannot reduce obesity, and despite being attacked by the National Audit Office (NAO) and the Public Accounts Committee (PAC), the NHS, PHE and DUK are convinced that their DPP will be successful. Professor Jonathan Valabhji, national clinical director for diabetes and obesity at NHS England, and one of the leaders of the DPP, says, “The growing body of evidence makes us confident that our national diabetes prevention programme will reduce the numbers of those at risk of going on to develop the debilitating disease”. Is Valabhji right?

Despite a year of planning and the optimism of the DPP leaders, the UK’s Public Accounts Committee has expressed serious doubts about the way the DPP is setting about its task, and has warned that, "By itself, this [the program] will not be enough to stem the rising number of people with diabetes".
 
Successful pilot studies
 
Behavioral interventions, which nudge people to adopt and maintain a healthy diet and lifestyle, can significantly reduce the risk of developing T2DM. Over the past year, seven demonstrator sites set up by the DPP in England have been testing innovative diabetes educational programs, and have reported the reduction of at-risk people from developing T2DM. One pilot that offered two exercise classes a week, and classroom sessions on diet and lifestyle, found that 100% of its participants lost weight, with more than half reducing their diabetes risk. Intelligence from these studies has informed Healthier You. Three quarters of England’s 211 clinical commissioning groups (CCGs) have already joined forces with local authorities, and will now work with four designated providers to offer personal care to those at high risk of developing T2DM.
 
The service providers
 
The four service providers are: (i) Momenta, which offers weight management for adults, and is part of the Reed Partnership that has already delivered over £0.6bn of publicly funded UK contracts, (ii) Pulse Healthcare, which is part of the ICS Group, an established healthcare service provider that offers health and wellbeing services to local authorities, CCGs and employers, (iii) Health Exchange, which was launched in 2006 as a local authority partnership to provide healthy living advice to local community groups, and (iv) Ingeus, which has evolved from a small Australian rehabilitation company in 1989 to an international provider of employment, training and support services.
 
US has similar diabetes prevention program
 
Healthier You is similar to a US diabetes prevention program, which was developed to improve the health of people at risk of T2DM through improved nutrition and physical activity.  In 2011, through funding provided by the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) awarded the National Council of YMCA America more than $11.8m to enrol eligible Medicare beneficiaries at high risk of developing T2DM in a program that could reduce their risk.
 
Participants in the American program attended weekly meetings with a lifestyle coach who trained them in strategies for long-term dietary change, increased physical activity, and behavior changes to control their weight and reduce their risk of T2DM. After the initial weekly training sessions, participants could attend monthly follow-up meetings to help maintain healthy behaviors.
 
Over the course of 15 months, participants lost about 5% of their body weight, which, if maintained, is enough to substantially reduce their risk of future diabetes. Over 80% of participants attended at least four weekly sessions. When compared with similar people not in the program, Medicare estimated savings to be $2,650 for each participant over the 15-month period, which was more than enough to cover the cost of the program.
 
In 2016, independent experts found that the American program saved money and improved peoples’ health, and recommended its expansion into US Medicare. "This program has been shown to reduce health care costs and help prevent diabetes, and is one that Medicare, employers and private insurers can use to help 86 million Americans live healthier,” says US Health Secretary Sylvia Burwell.
 
The results of the US diabetes prevention program are promising, although there is no recognized evidence to suggest that exercise alone reduces obesity. Further, not enough time has elapsed to assess whether the program permanently changed the behavior of participants, and whether they maintained their initial loss of weight.
  
No evidence to suggest exercise can tackle obesity

Despite Healthier You’s emphasis on personal trainers, there is no evidence to suggest that exercise has a role in tackling obesity. A 2015 British Journal of Sports Medicine editorial suggests that it was time to “bust the myth” about exercise. According to the Mayo Clinic, “Studies have demonstrated no or modest weight loss with exercise alone, and that, an exercise regime is unlikely to result in short-term weight loss”. The benefits of exercise are on insulin sensitivity and aerobic fitness, not weight loss. Exercise is a good way to keep weight off, but a bad way to lose weight. To put it in perspective, exercise burns calories, but substantially less than people often think. For example, 1lb of fat is 3,500 calories, and to burn 1lb of fat you would need to run about 40 miles.
 
19th century methods for a 21st century epidemic

The US experience and the English pilot studies suggest that Healthier You is likely to produce some improvement in the overall situation, but research suggests that this will more likely come from diet rather than exercise. The logistics and scale of the problem are so great that Healthier You is unlikely to have more than a relatively small impact. One-to-one life coaches are expensive, difficult to scale, and costly to administer. Successfully engaging a substantial proportion of the vast and rapidly growing English population at risk of developing T2DM, and nudging them to change their diets and lifestyles will require 21st century technologies. That the DPP has chosen 19th century labour-intensive methods to deal with a 21st century epidemic raises doubts about its efficacy.  Let us explain.
 
Not well planned

Healthier You’s 2016 objective is to identify 22,000 people at high risk of T2DM out of a population of 26m across 27 geographic regions of England, and offer them an intensive personalised course in weight loss, physical activity and diet, comprising at least 13 one-to-one, two-hour sessions, spread over nine months, which is estimated to cost £320 per person, or some £7m each year for the cost of the coaches alone.  

By 2020, the DPP expects to have rolled out Healthier You to the whole country, and each year thereafter expects to recruit 100,000 at-risk people found to have high blood sugar levels. At this rate, it will take 50 years, at a minimum annual cost of some £35.2m, to provide 26 hours of personal coaching for the 5m people at risk of T2DM in England. In addition to the cost, the logistics of effectively delivering and accounting for such a program is a significant challenge. The four designated service providers are expected to join forces with the 211 English CCGs, which are the cornerstone of NHS England, and with several thousand local authorities to deliver each year 2.6m hours of one-to-one personal coaching to 100,000 people at risk of T2DM drawn from an adult population of some 50m, and spread across nearly 60 geographic regions in England. A significant percentage of the beneficiaries will be in full time employment and therefore have time constraints. Another complexity is that each CCG commission’s primary care for an average of 226,000 people, and there are some 8,000 GP practices, which ‘own’ the patient data.

Moreover, the £35.2m annual cost estimate does not include the administrative costs associated with identifying and triaging the 5m at-risk people to recruit annually 100,000 people most at risk who will be offered personal coaching, and monitoring the impact this will have on patient outcomes. It seems reasonable to suppose that Healthier You will be difficult to manage, given that the current NHS primary care infrastructure is at breaking point, with a shrinking pool of overworked and demoralised GPs. It will also be extremely expensive as well as wholly inadequate for the scale of the problem. Recently, Dr Maureen Baker, chair of the Royal College of General Practitioners, said: “Rising patient demand, excess bureaucracy, fewer resources and chronic shortage of GPs [are] resulting in worn-out doctors, some of whom are so fatigued that they can no longer guarantee to provide safe care to patients.”
 
Simple arithmetic
 
Did the leaders of the DPP not only over emphasize the potential impact of exercise on obesity, and their ability to manage the program and underestimate the program's costs; but also get their arithmetic wrong in planning the roll out of Healthier You? The DPP leaders must have known that each year for the past 10 years there have been some 100,000 new diagnoses of T2DM. Even if we assume that: (i) there will be no future increase in the incidence rates of obesity and T2DM, (ii) by 2020 Healthier You will be 100% effective in recruiting its annual target of 100,000 at risk people, (iii) Healthier You will be 100% successful in changing the diets and lifestyles of the 100,000 people it recruits each year, and (iv) the annual death rate from diabetes-related causes will remain constant; the conclusion is unavoidable that although the DPP will be spending a minimum of £35m a year to deploy personal trainers, there will still be millions of overweight and obese people, and the incidence rate of T2DM will still be vast and escalating. The T2DM epidemic will not have been dented.
 
 Accountability
 
The UK’s Secretary of State for Health says, “We will be looking closely at the results of this programme.” Does this mean that its leaders will be accountable? To date, the UK government’s record on making people accountable for diabetes care and education is poor.

An earlier Commentary drew attention to the fact that UK diabetes agencies responsible for spending millions each year on diabetes education and awareness programmes which fail, only report on the distribution of services, rather than on the impact those services have had on patient outcomes, which is the most appropriate way of measuring the Healthier You’s effectiveness.  See, The importance of measuring the impact of diabetes care. 
 
Takeaways
 
What will Healthier You achieve?  Given the success of the English pilot studies and the success of the similar American diabetes prevention program, it seems reasonable to expect Healthier You to produce some improvement in the overall situation. However, the scale of the problem is so vast, its management infrastructure so weak, and the impact of exercise on obesity so little, that Healthier You is unlikely to have more than a relatively small impact. The size of the UK population at risk of T2DM is so great that much more modern and efficient tools are needed to get to grips with the problem and make a real difference. A future Commentary will be devoted to describing some of the technological advances being made to tackle obesity and T2DM.
 
Preventing T2DM is too important to be entrusted to our well-resourced clinical establishment that has failed to dent the large and rapidly rising burden of the condition. Preventing T2DM requires leadership and an efficacious strategy, which in the short term, innovates and leverages the use of mobile technologies to engage millions of at-risk people, and nudge them to become permanently enthusiastic about changing their diets and lifestyles; in the medium term, recruits corporates, educational establishments, restaurants, and faith groups into the overall prevention strategy; and in the long term, promotes changes in our environment so that we are obliged to live healthier lives. 
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8 years, 7 months ago

Cost-effective asset to relieve growing pressure on GPs

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Cost-effective asset to relieve growing pressure on GPs

Can the escalating primary care crisis in England be helped with a new and innovative online dashboard, which automatically sends short videos contributed by clinicians to patients’ mobiles to address their FAQs?
 
Dr Seth Rankin, Managing Partner of the Wandsworth Medical Centre, and co-chair of Wandsworth CCG’s diabetes group, who has spearheaded the dashboard, thinks it can. Click on the photo below to view a short video that describes how health professionals can use the dashboard:
 
 
 
New and innovative dashboard
 
A 24/7 fully automated service that never wears out
“We were motivated to do something about the increasing pressure on GPs, and the impact this has on the quality of our care. Patients may have to wait a couple of days for an appointment with a GP, but they can receive our videos within minutes of their request,” says Rankin. He continues: “A pilot study we carried out in two London primary care practices suggested that video is a patient’s preferred format if they can’t see a GP. Further, patients often don’t retain what you tell them in a 10-minute face-to-face consultation, and they tend not to read pamphlets, which also are expensive to produce. 53% of patients regularly search the Internet for healthcare information, but 81% can’t differentiate between good and bogus information. 72% prefer healthcare information from their GP, and like healthcare videos delivered directly to their mobiles. 70% want access to healthcare information at any time, from anywhere, on their mobiles.
 
“Unlike the Internet, our dashboard provides premium reliable information, which can be easily consumed and shared among family, friends and carers. Also, the videos can be viewed many times, from anywhere, and unlike pamphlets and doctors, they never get tired, never wear out, and are available 24/7, 365 days a year. The dashboard is fully automated [see figure below], relieves GPs of a lot of unnecessary work, and, importantly, reports on how our patients’ are using the different videos.”
 
Automated system that encourages engagement behaviours
 
Local experts
“We used local medical experts in our videos because we were keen to increase their connectivity with our patients. The videos provide 60 to 80 second talking-head answers to patients’ questions, and are designed to increase patients’ knowledge of their condition, propel them towards self-management, slow the onset of complications, and reduce face-time with GPs, while enhancing the quality of our care,” says Rankin.
 
Diabetes
He continues: “Although the dashboard easily can be used for any disease state, we started with T2DM as it represents our largest group of patients. Also, we know that: (i) T2DM is preventable with effective education that encourages diet and lifestyle changes, (ii) current diabetes education fails, and over the past decade, the incidence rate of the condition has increased by 65%, (iii) only 16% of the 120,000 people diagnosed each year with diabetes in England are offered structured educational courses, and (iv) only 2% of those offered courses actually enrol in them. So, we created our own bespoke dashboard and content library of about 120 videos, which we organised under 10 headings that we know interest our patients. Each heading has a cluster of ‘essential’ and ‘in-depth’ videos. We use the dashboard to relieve some of the pressure on our health professionals.”
 
Unprecedented crisis
 
Saturation point
A 2016 study published in The Lancet suggests that between 2007 and 2014 the workload in NHS general practice had increased by 16%, and that it is now reaching saturation point. According to Professor Richard Hobbs of Oxford University and lead author of the study, "For many years, doctors and nurses have reported increasing workloads, but for the first time, we are able to provide objective data that this is indeed the case . . . . . As currently delivered, the system [general practice in England] seems to be approaching saturation point . . . . . Current trends in population growth, low levels of recruitment and the demands of an ageing population with more complex needs will mean consultation rates will continue to rise.”
 
More than 1m patients visit GP every day
A 2014 Deloitte’s report commissioned by the Royal College of General Practitioners (RCGP) suggests that the GP crisis in England is the result of chronic under-funding and under-investment in primary care at a time when the demand for GP services is increasing as the population is ageing, and there is a higher prevalence of long term conditions and multi-morbidity.
 
According to the RCGP, over the past five years the number of annual GP consultations has increased by 60 million to around 370 million, while over the same period the number of GPs has grown by only 4.1%. More than one million patients a day visit their GP surgeries, with some GPs now routinely seeing between 40 to 60 patients daily.
 
GPs are extremely stressed
Deloitte’s findings are confirmed by a 2016 comparative study undertaken by the prestigious Washington DC-based Commonwealth Fund, which concludes that increasing workloads, bureaucracy and the shortest time with patients has led to 59% of NHS GPs finding their work either “extremely” or “very” stressful: significantly higher stress levels than in any other western nation. GP stress levels are likely to increase. In a speech made in June 2015, the UK’s Secretary of Health said, “Within 5 years we will be looking after a million more over-70s. The number of people with three or more long term conditions is set to increase by 50% to nearly three million by 2018. By 2020, nearly 100,000 more people will need to be cared for at home.” According to Dr Maureen Baker, chair of RCGP, “Rising patient demand, excessive bureaucracy, fewer resources, and a chronic shortage of GPs are resulting in worn-out doctors, some of whom are so fatigued that they can no longer guarantee to provide safe care to patients.”
 
Causes and consequences
 
GP exodus
Trainee GPs are dwindling and young GPs are moving abroad. According to data from the General Medical Council (GMC), between 2008 and 2014 an average of 2,852 certificates were issued annually to enable British doctors to work abroad. We now have a dangerous situation where there are hundreds of vacancies for GP trainees. Meanwhile, findings from a 2015 British Medical Association (BMA) poll of 15,560 GPs found that 34% of respondents plan to retire in the next five years because of high stress levels, unmanageable workloads, and too little time with patients.
 
Suggested solutions
 
5,000 more GPs by 2020
In the run up to the UK’s 2015 General Election the Secretary of Health pledged “to train and retain an extra 5,000 GPs by 2020” to ease the primary care crisis, but doctors’ leaders did not see this as a solution. Dr Maureen Baker said, "Even if we were to get an urgent influx of extra funding and more GPs, we could not turn around the situation [the GP crisis] overnight due to the length of time it takes to train a GP,” And Dr Chaand Nagpaul, chair of the BMA GPs’ committee, warned later that, “delivering 5,000 extra GPs in five years, when training a GP takes 10 years, was a practical impossibility that was never going to be achieved.” After the election the Health Secretary softened his promise and suggested that it would be ‘a maximum' of 5,000 by 2020.

In 2016, Pulse, a publication for GPs, suggested that the Health Secretary knows he cannot deliver his promise of 5,000 new doctors by 2020, and is negotiating with Apollo Hospitals, an Indian hospital chain, to bring 400 Indian GPs to England.
 
A more innovative approach

Better and smarter solutions needed
While searching for an immediate temporary solution to the GP crisis the Secretary of Health seems to understand that a more innovative approach is required for the medium to long term. In his June 2015 speech he said, “If we do not find better, smarter ways to help our growing elderly population remain healthy and independent, our hospitals will be overwhelmed – which is why we need effective, strong and expanding general practice more than ever before in the history of the NHS. Innovation in the workforce skill mix will be vital too in order to make sure GPs are supported in their work by other practitioners.”
 
Pharmacists in GP surgeries
In July 2015 the NHS launched a £15m pilot scheme, supported by the RCGP and the Royal Pharmaceutical Society (RPS), to fund, recruit and employ clinical pharmacists in GP surgeries to provide patients with additional support for managing medications and better access to health checks.
 
Dr Maureen Baker said, “GPs are struggling to cope with unprecedented workloads and patients in some parts of the country are having to wait weeks for a GP appointment yet we have a ‘hidden army’ of highly trained pharmacists who could provide a solution”. Dr David Branford, former Chair of the RPS said, “It’s a win-win situation . . . .  We will be doing everything we can to support the GPs and make sure this pilot is successful. In time, I hope pharmacists will be working in every GP practice in the country.” Ash Soni, president of the RPS suggests that it makes sense for pharmacists to help relieve the pressure on GPs, and says, “Around 18m GP consultations every year are for minor ailments. Research has shown that minor aliment services provided by pharmacists can provide the same treatment results for patients, but at lower cost than at a GP surgery.”
 
Progressive and helpful move
The efficacy for an enhanced role of pharmacists in primary care has already been established in the US, where retail giants such as CVS, Walgreens and Rite Aid have led the charge in providing convenient walk-in clinics staffed by pharmacists and nurse practitioners. Over time, Americans have grown to trust and value their relations with pharmacists, which has significantly increased adherence to medications, and provided GPs more time to devote to more complex cases. Non-adherence is costly, and can lead to increased visits to A&E, unnecessary complications, and sometimes death. According to a New England Healthcare Institute report, Thinking Beyond the Pillbox, failure to take medication correctly, costs the US healthcare system $300 billion annually, and results in 125,000 deaths every year. 
 
Takeaway
 
Introducing pharmacists into GP surgeries is a progressive and potentially helpful move forward, because, as Dr Maurine Baker suggests, “It is in everyone’s best interests to be seen by a GP who is not stressed or fraught and who can focus on giving their patients the time, attention and energy they need”. However, even more could be achieved if the dashboard described by Dr Seth Rankin were more widely introduced. “Videos play a similar role to practice-based pharmacists. Both deal with simple day-to-day patient questions, and relieve pressure on GPs, which allows them to focus their skills where they are most needed,” says Rankin.
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8 years, 7 months ago

Can AI reduce medical misdiagnosis?

HealthPad
Directory:
Health Policy
Tags:
AI
artificial intelligence
commentary
misdiagnosis
virtual reality
 
  • Misdiagnosis means unnecessary suffering and the loss of life
  • 15% of all medical cases are misdiagnosed
  • 44% of some types of cancers are misdiagnosed
  • Misdiagnosis results from the way doctors are trained

Can AI reduce medical misdiagnosis?
 
Inaccurate or delayed medical diagnosis is more widespread than often thought, and results in a staggering toll of harm and patients’ deaths.
 
Unnecessary suffering
Each year, in the US an estimated five per cent of all medical cases are misdiagnosed. ‘Not bad’, some might say given the millions of Americans who visit their doctors’ each year presenting thousands of different disease states each with multiple symptoms. But five per cent translates to 12 million annual misdiagnoses in the US alone, which is, “the tip of the iceberg” according to Professor Graham Neale, an expert in misdiagnosis from the Centre for Patient Safety and Service Quality at Imperial College London.
 
A 2012 study reported in The American Journal of Medicine suggests that 15% of all medical cases in developed economies are misdiagnosed. Professor Neale suggests that 15% of all UK cases are also misdiagnosed. The Mayo Clinic Proceedings suggest that misdiagnosis could be as high as 26%, and according to The Journal of Clinical Oncology, a staggering 44% of some types of cancers are misdiagnosed.
 
Misdiagnosis means unnecessary suffering, the loss of life, and unnecessary costs. For example, 33% of the $3trillion spent each year on healthcare in the US is considered “wasted” because of medical misdiagnoses. And data released in 2015 by NHS England’s Litigation Authority in response to a Freedom of Information request show compensation paid to people misdiagnosed rose from £56 million in 2009-10 to more than £194 million in 2013-14.

According to Sebastian Lucas, former Professor of Clinical Histopathology at King’s College London, the most common misdiagnosis found through post-mortem examinations are the over diagnosis of cardiac disease, the under diagnosis of pulmonary-embolism, the over and under diagnosis of cancer, and the under diagnosis of significant infections.
 

What are the most common misdiagnosis found through autopsy? By Sebastian Lucas
 

Medical misdiagnosis occurs when either a condition is undiagnosed, or where an incorrect diagnosis is made. An example of the former is when a patient with a health problem has visited their doctor over a period, and the doctor fails to diagnose the illness.  An example of the latter is when, say, a fracture is diagnosed as a sprain.

 

Why misdiagnosis occurs
Reasons given for misdiagnosis include the fragmented nature of healthcare systems, and the over burdened, demoralised and scarce supply of primary care doctors. See, Curing the Problems of General Practice. In 2008 Eta Berner and Mark Graber published a paper in the American Journal of Medicine entitled, ‘Diagnostic Error: Is Overconfidence the Problem?’ which suggests that both intrinsic and systemically reinforced factors lead doctors to be over confident in their ability to diagnose, and once a diagnosis is made and a treatment pathway started, a momentum occurs, which is difficult to change.
 
Doctors trained to take short cuts
At the root of misdiagnosis is the way that doctors are trained, says Jerome Groopman, Professor of Medicine at the Harvard Medical School, and Chief of Experimental Medicine at Beth Israel Deaconess Medical Center.
 
Groopman’s thesis is predicated on the concept of the availability heuristic developed by Nobel Laureate Daniel Kahneman, notable for his work on the psychology of judgment and decision-making. In his book How Doctors Think, Groopman suggests that doctors are trained to recall similar recent cases when making a diagnosis. For example, common infections picked up by children at school often affect entire communities. Once a doctor has seen, say, nine such cases, the information about them is immediately available in his subconscious, and creates a tendency for the tenth patient presenting similar symptoms to be diagnosed the same although the actual illness might be different.
 
Such mental shortcuts are indispensible in a medical setting. In A&E, for example, doctors are encouraged to use mental shortcuts to help them make rapid decisions often on incomplete information; failure to do so could mean the difference between life and death.
 
Will misdiagnosis increase?
Structural reasons suggest that misdiagnosis will not be reduced in the near term. According to the Royal College of General Practitioners the shortage of doctors in the UK is the worst it has been for 40 years. Established GPs are retiring early, and a significant proportion of newly qualified GPs are moving abroad where pay and working conditions are better. One hundred primary care practices, serving 700,000 patients across Britain, are facing closure, and the number of doctor-patient consultations is estimated to rise from 338 million in 2013 to 441 million by 2017.

Similarly in the US, the Association of American Medical Colleges predicts increasing shortages of doctors: 130,600 by 2025. One reason for the shortage is the aging of both doctors and their patients. According to a 2012 Physicians Foundation survey, nearly half of the 830,000 doctors in the US are over 50, and approaching retirement.

Thus, fewer doctors in both the UK and US face having to diagnose an increasing number of aging patients presenting complex conditions, at a time when the volume of medical data are doubling every 73 days. Under such conditions it seems reasonable to assume that the incidence of misdiagnosis will not decrease.

Increased role for cognitive computers in medicine
Will the increased pressure on doctors to diagnose more accurately be helped by artificial intelligence (AI)? Although there are some challenges for AI in a medical setting, it is well positioned to play an increased role in diagnosis. This is confirmed by Google’s DeepMind AlphaGo computer’s landmark defeat of Lee Sedol, a 33-year-old grandmaster of the ancient Asian game GO in March 2016. Let us explain.
 
AI: the complex algorithms that analyze and transform electronic medical data, into clinically relevant medical opinions for health professionals has developed significantly as the demand for healthcare increased, healthcare costs escalated, and the supply of doctors decreased.
 

What is the next "big thing" in healthcare? By Devi Shetty
 
The relationship between the game GO and medical diagnosis
For some time, cognitive computers have been able to defeat the world’s best human players of games such as draughts and backgammon by enumerating every possible move, and drawing up rules for how to guarantee that a computer will be able to play to at least a draw. Although more complex, chess computers rely on a modified version of the same tactic. In 1997 for example, when IBM’s Deep Blue computer defeated former world chess champion Garry Kasparov, it could evaluate 200 million possible moves in a second.
 
But GO is different: its simplicity belies its astonishing complexity. There are more legal board states for a game of GO than there are atoms in the universe, and just like in medical diagnoses, reaction and intuition are important. These intangible aspects of the game GO, and diagnosis, make them resistant to the tactic by which games in the past have been “solved” by computers. Experts predicted that it would take another 10 years before a computer program would stand a chance even against a weak GO player. This is why a computer’s defeat of Lee Sedol, signaled a landmark moment for AI, and has implications for medical diagnosis.
 

GOis played by two people on a 19-by-19 grid-board, with 361 black and white stones, 181 black and 180 white. Each player takes turns placing their stones in an attempt to surround and capture their opponent’s pieces. The player who controls more territory is the winner. The first move of a game of chess offers 28 possibilities; the first move of a game of GO can involve placing the stone in one of 361 positions. An average game of chess lasts around 80 turns, while on average GO game lasts for some 150 turns, which leads to a staggering number of possibilities.


Cognitive computing and diagnosis
Cognitive computing systems that understand, reason, and learn, also are able to see health data that were previously hidden, and do more than we ever thought possible. Doctors have access to such computers, which provide them with collective knowledge gathered from thousands of healthcare providers, millions of patients’ records, and millions of treatments other doctors have prescribed to people presenting similar symptoms and disease states. Such computers are capable of analyzing in seconds these data and identifying patterns that humans cannot.

Further, unlike doctors, computers work 24-7, 365 days a year, they never get tired or demoralised, and they never leave. Also, computers are faster and more thorough than doctors, and can analyse vast amounts of patient data, identify trends in seconds and consistently make more accurate diagnoses. One example is IBM’s Watson, a computer, already being used in medicine, which can attain high levels of cognitive behaviour. Watson uses natural language processing to analyse structured and unstructured data common in clinical notes and reports, and can read 40 million medical documents in 15 seconds, understand complex questions, and identify and present evidence based solutions and treatment options. In the US similar computer programs have stopped making clinical recommendations based on the most popular therapies prescribed by its users, to providing doctors with clinical recommendations based on patient outcomes.
 
Challenges for AI in medical diagnosis
Despite the fact that AI systems are getting smarter there are still significant challenges associated with the compatibility of computer systems, the integrity of medical data; and data security and access. Further, as AI systems get smarter so the line between computers recommending and deciding becomes blurred. Healthcare providers are wary not to allow their AI systems to make clinical decisions because this would mean that they would be viewed as “medical devices”, and require FDA approval, which can be a costly and lengthy process to obtain.
 
Doctor’s resistance to AI systems
A doctor’s raison d'être has been to diagnose and treat illnesses, which ordinary people cannot do because it requires expertise, intuition and interpersonal skills. Some doctors argue that computers will never be able to provide such skills. But medical knowledge, which previously resided in the minds of the few doctors, has become readily available to everyone over the Internet, and doctors have changed from being the sole processors of that knowledge, to being the interpreters of such knowledge; in this scenario AI has an important role.

Takeaway
Professor Stephen Hawking and other leading scientists have warned of the dangers of AI becoming “too clever”. There are also concerns about data security and privacy, and some doctor’s fear cognitive computers could diminish their role. However, the defeat of Lee Sedol by AlphaGo has demonstrated that computers can attain high levels of intelligent behavior, and this has significant implications for medicine in general and diagnoses in particular.
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8 years, 8 months ago

The Future of Healthcare

HealthPad
Directory:
Health Policy
Tags:
3D printing
artificial intelligence
big data
cancer genomics
commentary
communication technology
healthcare unplugged
human genome project
virtual reality
 

The Future of Healthcare
 
Fahad Aziz
Co-founder of Caremerge, which provides comprehensive web and mobile communications and care-coordination solutions for senior living communities. Fahad is the author of several technical papers, and the recipient of Pakistan’s prestigious Performance Excellence Award.
 
  • How will machine learning, virtual reality, the Human Genome Project, and the Internet of things change healthcare?
  • Will technology result in a healthier future full of empowered patients?
  • Will big data strategies help physicians perform their jobs better?
  • Will 3D printing be used to replace tissue and organs?
  • Will VR allow scientists to experience physical and psychological challenges rather than observe them?

 
Living in Silicon Valley I have a front row seat to the in technology poised to reshape the future of humanity. Machine learning, Virtual Reality, the Human Genome Project and the Internet of things will undoubtedly impact our lives in general, but they can also have a major impact on the Healthcare industry in particular.

To visualize the future of healthcare, I took a look at what’s trending in Silicon Valley and applied them to the healthcare industry. If the possibilities seem farfetched today, remember the iPhone is less than a decade old and has spawned countless industries that have shaped our daily existence, and will continue to do so. Technology moves fast and these four trends can potentially disrupt all aspects healthcare.

Machine learning
Artificial Intelligence (AI) is not new to the technology world, but with machine learning, AI has taken on an open-ended form rife with endless opportunities for technology in general and healthcare in particular.

Machine learning enables computers to identify patterns and observe behaviors based on empirical data, and use all that to ‘learn’. In other words, machine learning is a set of self-learning algorithms that can eventually become smarter than any human being on this planet.

In 2012, Vinod Khosla, an American businessman and a co-founder of Sun Microsytems, predicted that in time, “Technology will replace 80% of what doctors do”; sparking outrage and umbrage within the healthcare industry. Physicians overlooked what Khosla was really saying: that big data, properly harnessed and utilized, had the potential to help physicians perform their jobs better. Farfetched at the time, big data and machine learning have come far enough in just four years to provide levity to Khasla’s argument.

When given access to a trillion gigabytes of patient data collected from devices, electronic health records (EHRs), laboratories, and DNA sequencing - alongside surrounding factors such as weather, geo-location, and viral outbursts - computers learn quickly, and they learn everything. The depth of information provided at such a scale suggests patients will not need to consult with various specialities to figure out what’s ailing them in the future. Instead, consolidated data will create and provide a fully coordinated treatment plan.

If you are thinking this sounds crazy, consider the fact that IBM acquired Truven Health for $2.6 Billion in early 2016. Truven delivers information, analytic tools, research, and services to the healthcare industry, and gives IBM access to data of some 200 million patients to feed Watson, which is IBM’s machine learning product that is a powerful question answering computer system capable of answering questions posed by natural language.

I can only imagine what Watson will offer after digesting this massive data, but one thing is for sure: the result is nothing but good news for patients and their care plans.

The Internet of things
Gartner, a US IT research and advisory firm, estimates six billion devices will be “connected” by 2020; collecting data for consumption, analytics and a whole lot more.

Healthcare has historically been a sucker for devices, embracing hardware that captures data, provides diagnostics and even treats patients. Previously, these devices have been in use only at hospitals and other healthcare locations, but in the future this technology has the potential to become a part of every single home; marking a new era in care.


How can the NHS innovate? - Mike Farrar, former NHS Confederation CEO

In the future, doctor’s visits will begin before we even head out the door. Our vitals will be captured at home and sent to our doctor. In some cases, we may even receive treatment in the comfort of our home. Further, once treatment begins, a real-time feed of our vitals and conditions will be shared and analyzed automatically via set protocols, which will trigger alerts if our health declines and requires a change in treatment.
 
The Internet of things has implications elsewhere for the healthcare industry. Pharmaceutical research could bid farewell to clinical trials once they can access millions of patients’ data to accurately analyze behaviors and outcomes.

Challenges facing immunizations could also be solved using simple, digitized solutions. Currently, vaccinations are rendered ineffective by temperature changes during their transport; a simple tracking device with a thermometer could solve that problem. Similar challenges with manufacturing, delivery and tracking of vaccination can also be digitized to make the immunization programs successful globally.

Last but not least, I foresee nano devices embedded within the human body to monitor glucose, blood pressure, temperature, and more; to allow for swifter, more effective decisions to be made so treatments can begin as soon as needed, significantly increasing positive outcomes.

The Human Genome Project
One of the greatest breakthroughs in healthcare this last decade was decoding the human genome to understand the DNA sequencing. It took over 10 years and a staggering US$2.7bn to crack the code of one human being. Just a decade later, it takes US$1,500 and a couple of hours to run the genome for any person.

The more we learn about DNA and its sequencing, the more accurately we can treat patients for their illnesses. There will be no guesswork involved, instead, a complete technical report will show exactly what went wrong since last time, and what can be done to fix it.

The future is closer than we think. I suspect human genome machines will be deployed at healthcare locations in the near term. The appetite for this type of information will grow, and eventually, we may live in an age where small genome devices are installed under your sink or inside your toilet seat to analyze changes in your DNA sequencing several times a day.

Today, researchers in Europe are using 3D printers and DNA sequencing to create human body parts that can potentially replace limbs or ailing organs. Prototypes already exist. DNA sequencing will help people take more control over their bodies, allowing them to make better informed decisions about their lifestyle, illnesses and treatments. This means that doctors’ roles will change, potentially allowing for a complete shift in the healthcare paradigm.

Virtual reality in healthcare
Mark Zuckerberg, chairman, CEO and co-founder of Facebook, takes every opportunity he can to promote his latest US$2bn acquisition, Oculus VR, an American virtual reality company, whose product, Oculus Rift, is a virtual reality (VR) headset. I had the opportunity to try Oculus Rift, and was blown away. Market analysts say Zuckerberg was crazy to bet on this, but I know he has discovered a platform with the potential to be larger than Facebook.

Virtual reality transports you into another world by creating an artificial environment, deceiving your sense of sight and touch, so your mind believes you are part of that environment. At a recent Aging2.0 conference, I watched a man in his 30s struggle to walk while wearing an Oculus Rift headset. A moment after putting it on he experienced the physical shortcomings of someone in there 80s. These types of experiences open up a new world for researchers by providing them with the ability to directly experience physical and psychological challenges rather than rely on observations.


Doctors' resistance to change - Devi Shetty,  founder of Narayana Hrudayala, Bangalore, India

The environment created by VR is artificial and programmed, at least for now. But fast forward three to four years, and you will likely be in a real environment. Consider this: a doctor could be transported to a hospital in Kenya while sitting in the relative comfort of his clinic in San Francisco. VR would allow the user to move around and interact with people enabling participation in treatments, research or even surgery.

I suspect Zuckerberg will combine social networking and virtual reality, allowing people from any part of the world to meet up with one another, to visit places they have previously only dreamed of, and go on adventures their body would never allow in the real world.

In healthcare, innovators are already leveraging VR for treating post-traumatic stress disorder (PTSD), autism, social cognition, meditation, and help with exposure therapy and surgical training. And this is just the beginning.
 
Takeaways
The day is fast approaching when I will be able to virtually go to hospital to meet with doctors and specialists, share my vitals through various devices and a video camera to gain assessment and treatment plans from the comfort of my own home.

Healthcare information and management systems (HIMSS) have never disappointed me in terms of their participation and size, and I am hopeful that innovations will continue to shock, whispering promises of a healthier future full of empowered patients.
 
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