There's no question that our health-care system is inefficient and costly, and there are many views about the direction(s) reform should take. Some academic physicians have become enamored of the possibilities of ultra-high-tech medicine, including innovations that embrace variations of "telemedicine," including real-time personal monitoring and reporting of data to healthcare providers. However, there is a place for innovative, low-tech approaches as well.
Dr. Eric Topol, a cardiologist at the Scripps Research Institute in La Jolla, California, wrote recently that "real progress in containing costs and improving care will require transforming the practice of medicine itself . . . to move much more aggressively into the era of smart medicine, using high-tech tools to tailor more precise and economical care for individual patients."
He describes an example of his vision of the future this way:
Last week in my clinic I saw a 59-year-old man with hypertension, high cholesterol and intermittent atrial fibrillation (a heart rhythm disturbance). Before our visit, he had sent me a screenshot graph of over 100 blood pressure readings that he had taken in recent weeks with his smartphone-connected wristband.
He had noticed some spikes in his evening blood pressure, and we had already changed the dose and timing of his medication; the spikes were now nicely controlled. Having lost 15 pounds in the past four months, he had also been pleased to see that he was having far fewer atrial fibrillation episodes, which he knew from the credit-card-size electrocardiogram sensor attached to his smartphone.
Some progressive health-care organizations are already incorporating telephone and Skype visits and home monitoring, approaches that will likely gain currency gradually as patients, newly-trained physicians and other healthcare workers become comfortable with the new technologies.
In the meantime, however, innovative, low-tech, inexpensive approaches that can markedly improve Americans' health are available. A colleague recently told me about specialized flooring in a home for seniors in Denmark.
Not only was the flooring cushioned, but it also contained electronic sensors every few inches, so that an attendant sitting at a central console could tell if there was any sudden change in distribution of weight — for example, going from standing on two legs to weight distributed evenly over a broad area of floor. If a senior fell in his unit with the door closed, an attendant could detect the fall and be in the room in a matter of seconds.
To measure the potential benefits of this sort of approach in a rigorous way, a research group in New Zealand compared rates of falling and injuries from falls on low-impact flooring (LIF) compared with standard vinyl flooring on an "older person's health ward." Falls were prospectively monitored with written reports of all incidents, noting the location and consequences of each fall. The frequency of falls and injuries on LIF and those occurring on standard vinyl flooring (controls) were compared.
The investigators found that over the 31 months of the study, there were 278 falls (among 178 persons who fell). The rate of falls was indistinguishable in the two groups, but "fall-related injuries were significantly less frequent when they occurred on LIFs (22 percent of falls versus 34 percent of falls on control flooring)." And many of those averted injuries were serious: "Fractures occurred in 0.7 percent of falls in the LIF cohort versus 2.3 percent in the control cohort."
Falls are both a cause and effect of declining health in the elderly. They are the leading cause of injury-related visits to emergency rooms and the primary cause of accidental deaths in Americans over the age of 65. Thus, the New Zealand study provides a compelling rationale for adding low-impact flooring to housing for seniors, along with other modifications.
A recent article in the New England Journal of Medicine illustrates how a low-tech, low-cost nutritional supplementation approach might reduce the likelihood of a genetic predisposition to preterm birth, at a time when highly sophisticated gene therapy approaches are impractical and premature (no pun intended).
Preterm birth (defined as birth before 37 weeks of gestation) affects almost 10 percent of pregnancies in the United States and is the leading cause of death in neonates and children under the age of five years. The study, in 43,568 women of European ancestry, found that "six maternal genomic loci that were robustly associated with gestational duration and that contained genes in which the established functions are consistent with a role in the timing of birth. Three of these loci were also associated with preterm birth."
Because of the multiple genes involved and the fact that the results show only an association with preterm birth, not causation, gene therapy is beyond scientists' capabilities.
However, the study did suggest a simple, low-tech, low-cost solution — selenium supplements during pregnancy. The rationale is that one of the genes identified is involved in the incorporation of the element selenium into proteins that serve a critical role in the body and have been linked to birth and preterm birth. In addition, as noted by the authors, "Malawi, the country with the highest global risk of preterm birth, has a high prevalence of selenium deficiency." Thus, the monitoring of selenium levels and selenium supplementation in pregnancy should certainly be studied.
The high-tech miracles of modern medicine — ranging from gene therapy and breakthrough pharmaceuticals to the personal monitoring and telemedicine favored by Dr. Topol — certainly have their place, but so do simpler and relatively inexpensive interventions.
Henry Miller, a physician and molecular biologist, is the Robert Wesson Fellow in Scientific Philosophy and Public Policy at Stanford University's Hoover Institution. He was the founding director of the Office of Biotechnology at the FDA.