Wednesday, July 15, 2009

Heart disease, prevention - Eureka! Measuring Physical Fitness to Bridge Gap between Wellness and Sickness Systems of Care

In the course of writing Obama, Doctors, and Health Reform, I’ve become acutely aware of huge differences between how physicians practice in the worlds of wellness and sickness.

Many reform activists have observed that the only sure way to reduce costs is for physicians to practice and teach wellness to their patients rather than concentrating strictly on treating disease and for patients to take responsibility for their health to achieve a state of wellness and health.

Easier Said Than Done

This, of course, is easier said than done. Physicians are trained and reimbursed for treating sickness, patients may not comply with physicians’ orders, wellness is a patient responsibility conducted beyond the reach of physicians and the health system, and wellness tends to be subjective rather than objective and varies with the beliefs of the beholder.

The Eureka Phenomenon

In a 2006 essay, the late Isaac Asimov observed that the Eureka phenomenon , conceptual breakthroughs, usually come while one is relaxed and distracted rather than when one is under stress.

My particular Eureka moment came when I was visiting an amiable and perceptive cardiologist during a follow-up. During our relaxed conversation, he asked, seemingly off-hand but intently, “All symptoms aside, are you feeling well? Do you have a sense of well-being? In my experience, that’s the important thing?”

Measuring Well-Being

The thought flashed through my mind, “If only we doctors could measure well-being, that would be a breakthrough. A sense of well-being, of course, is an amalgam of emotional , situational, and physical well-being – not easily reduced to a single measurement and not reimbursable in the current climate of reducing health costs.

On the other hand, physical well-being is closely linked to emotional well-being, a sound mind in a sound body. If you’re in sound physical shape, you’re likely to have a feeling of emotional well-being.

With Chronic Disease, a Sense of Mal-Being

It’s well-known that 5% to 10% of chronic diseases take 70% to 80% of total health costs. If you give the matter any thought at all, you’ll realize the major chronic diseases - coronary artery disease, heart failure, diabetes, obesity, chronic obstructive lung disease, asthma, even depression – occur in individuals in suboptimal physical condition. Those afflicted with these conditions often have a sense of mal-being – an un-ease, or dis-ease.

If only, I thought, we had some objective measure of physical capacity to use as a baseline measure of physical wellness, understood by patients, physicians, nurses, and other caregivers, that measurement could bridge the gap between the worlds of wellness and sickness. For the physician that measurement would have to reimbursable, for there is no such thing as a free lunch, or a free doctor visit, or a free measurement to gauge a state of well-being.

Talk of Prevention as Part of Health Reform

There’s a lot of idle and often unproductive talk these days about prevention as a health reform means of saving money and resources, the ounce of prevention is worth a pound of cure philosophy. There’s some dispute whether prevention can save money for the system, or if merely postpones cost to inevitable end-of-life illnesses, which are more expensive than earlier-in-life preventable illnesses.

Nonetheless, prevention – through the right diet, the right dietary supplements, right exercise, controlling blood lipids and blood pressure, and ceasing smoking and excess drinking – is the right thing to do and is the fundamental foundation of most wellness programs. Many businesses are going to the extreme of rewarding or punishing or hiring or not hiring based on health or non-health or taking or not taking corrective health measures.

Brother, Can You Paradigm?

During the Great Depression, a popular saying was “Brother, can you spare a dime?” I would like to suggest that, during this, the Great Recession, we might alter that saying to be “Brother, can you paradigm?” In other words, why can’t we, as medical professionals in the greater health system, adopt a new medical mindset devoted to measuring wellness rather than just talking about it in theoretical terms. This is not as radical as one might think, for sickness would represent a deviation from that measurement and would be treated in a traditional fashion.

The Heart (and Lungs) of the Matter

This brings me to the heart (and lungs) of this discussion. I’ve been working with and writing about a company in St. Paul, Minnesota, called Shape Medical Systems( Off and on over the last 30 years, and more intently on the last three years or so, the principals of Shape have been working on a device, or perhaps more accurately a low-risk approach, to evaluate and measure heart and lung fitness, hence the name SHAPE, an acronym of System of Heart and Pulmonary Evaluation.

This device or approach consists of a one-step staircase, an electrocardiogram, a snorkel-like device with an attached breath gas analyser, and an attached lap top computer with a database of thousands of patients and a predictive modeling algorithm capable of predicting levels of fitness and statistical risks of hospitalization and/or death.

The FDA has approved the Shape system, and the Mayo Clinic and others have tested it on thousands of patients. Shape is portable, can be easily carried from one site to another, including the home, can be set up and conducted by minimally trained personel, carries no risk, and can be repeated often to measure the effect of drugs, heart monitoring devices, the progression of a disease.

Perhaps most important, Shape is acutely sensitive to the early onset of preventable diseases heralded by decline in physical fitness. In their early stages, many chronic diseases are reversible, or their progression can be halted. Because of its easy to interpret reports, Shape lends itself to common understanding by all engaged in the health system, in health reform, and those in ill health and of the physiological state of health that contribute to a “sense of well-being” – and how to measure it, maintain it, and interpret it in the trajectory of from onset of disease to shortness of breath to death.

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