The U.S. ranks first in health spending, but only 26th in life expectancy. “I think we would all agree this is not a motto we’d be proud of, and we should be able to do better than this,” says NEJM Catalyst Patient Engagement Theme Leader Kevin Volpp.
Why is there such a discrepancy between the two rankings? The U.S. has access to new therapies and devices, notes Volpp, “but arguably we have much bigger challenges in terms of social and behavioral determinants in health. And we have to figure out, how do we get more health for all the money we’re spending on health care?”
Imagine you control all research spending in the U.S., and you want to use it to prevent as many heart attacks — the number one killer of Americans — as possible over the next 5 years. Would you put your budget into, a) developing more effective treatments, b) developing a vaccine, or c) increasing adherence to existing therapies?
Your answer might depend on how you answer another question posed by Volpp: What percentage of heart attack patients take all their medications in the year following an attack? In Volpp’s experience, very few people answer 85–100%; they recognize that it can be difficult to achieve full adherence to a daily medication. Some will answer 70–84%, while many more choose 50–69%. And, depending on the audience, either a small or large number of people will select 40–49% or below 40%.
“There is perhaps no other area in medicine where there are so many carefully done clinical trials that really highlight the efficacy of these therapies in both preventing heart attacks and saving lives,” says Volpp. “Yet despite that, in a number of studies, sadly, the answer is below 40%.”
With perfect adherence, we could reduce heart attack risk by as much as 62–88%, according to various experts, says Volpp. Perfect adherence is unlikely, of course, but we should still be able to do better. What if we designed a new care delivery model focused less on treating acute disease and more on prevention?
Volpp discusses several ways to achieve this new model: predictive analytics via natural language processing, social determinants of health, and wireless health devices; design principles — putting the patient in the middle of the health care system as opposed to the provider (e.g., reduced wait times, fewer unnecessary visits); leveraging patients’ social networks (e.g., friends and family, patient peers); and rapid cycle innovation — continuous testing of pilot ideas around lowering risk while refusing to accept mediocrity at scale.
“Imagine an alternative world in which patients at elevated risk had wireless devices and wearables to monitor their smoking status, their medication adherence, their physical activity. These data could be seamlessly uploaded into secure settings. We could have automated algorithms that give patients or their social supporters feedback on how they’re doing,” says Volpp. “And then for an exceptional handling process, we could have physician extenders reach out to patients who are not doing so well, help them figure out how to better navigate this system, help them figure out how to improve their medication adherence. And you can see how that would create both a more effective and more efficient way of allocating health care personnel.”
“In our current system, we wait until patients have a heart attack and go over the proverbial waterfall. We stop at nothing to try to rescue them. But imagine if we could divert the flow of water and really prevent patients from having those heart attacks in the first place.”
From the NEJM Catalyst event Hardwiring Patient Engagement to Deliver Better Health at Kaiser Permanente Southern California, April 13, 2017.