Chapter 27 PERSPECTIVES IN PERSONAL HEALTHCARE

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Chapter 27

PERSPECTIVES IN PERSONAL HEALTHCARE

Towards Patient Centric Care Thomas Zaengel, Eric Thelen, Jeroen Thijs

Philips Research, Aachen, Germany

Abstract: Future healthcare scenarios will increasingly extend from acute care towards prevention and from institutional points-of-care into personal environments.

Individuals will take increasing responsibility for managing their own health.

We present and analyze trends towards personal healthcare and describe current approaches as well as future visions for healthcare in the 21st century.

Keywords: Aging population, chronic diseases, risk factors, major diseases, prevention, disease management, remote monitoring, aftercare, rehabilitation, activity

1. VISION

Future healthcare scenarios will more and more include elements of monitoring and therapy outside institutional points-of-care, i.e. healthcare will continue to extend into personal and private environments both for managing risk factors (primary prevention) as well as chronical conditions (secondary prevention). Personal healthcare will take place in the patient’s home and will still accompany the patient by means of mobile solutions when on the move.

With prevention becoming increasingly part of the overall healthcare strategy, everyone will regularly be involved – as a ‘consumer’, before ever becoming a ‘patient’. The responsibility of the individual for his or her health status will continue to grow.

This vision is supported by several major worldwide trends:

• Increased life expectancy results from continuous advances in healthcare. Today, we are likely to survive many diseases that still were life threatening before. This not only implies that we will live longer, but also that we will acquire more (often chronic and/or degenerative)

© 2006 Springer. Printed in the Netherlands.

439-462.

G. Spekowius and T. Wendler (Eds.), Advances in Healthcare Technology,

440 Chapter diseases over time, increasing the overall load on our healthcare systems

and requiring new ways of effective long-term disease management.

• The availability of more advanced healthcare options comes at a price.

Optimum healthcare continues to become ever more expensive with the consequence that healthcare systems will have to seek more cost- effective solutions, without compromising the quality-of-care. Lower acuity settings including increasing participation of the individual in managing his or her own health status will become mandatory.

• More information than ever on health related matters (e.g. risk factors, symptoms, treatment options and progression expectations) has become available through the modern media, including the Internet. Today, the average person is also much better informed about health issues, leading to pro-active consumer behavior and the development of consumer driven healthcare markets.

• Effective prevention and management of many health problems of today require a change in lifestyle. This will have to take place in the individual personal environment at home and away, by conscious adaptation of consumer behavior, supported by proper technologies.

Personal healthcare represents a wide space of opportunities and applications. After looking into some relevant trends and statistic in more detail we will give in the final section of this chapter a first outlook on this opportunity space. The following chapters will then address a number of specific opportunities and technologies in more detail.

2. TRENDS & STATISTICS

In this section, a number of trends related to personal healthcare are presented together with illustrative data points.

2.1 Aging population

The average age of the population is increasing significantly, not only in the developed countries. Figure 27-1 shows the percentage of the world population aged 60 years and older.

The most prominent reasons for this development are:

• Better working conditions.

• Better nutrition.

• Better health care delivery for a broad population.

• Behavioral/lifestyle changes (e.g. reduction in smoking).

Figure 27-1. Percentage of population aged 60 years and older, between 1950 and 2050

.

In addition to the increase in life expectancy the decrease of birth rates especially in Europe and Japan increases further the ratio between retired population and working population. In China, this ratio is also expected to increase further due to the introduction of the one-child policy in 1979.

The following facts about the aging population provide a remarkable challenge to the worldwide healthcare systems:

• Population aging is unprecedented in history; the 21

century will witness even more rapid aging than the previous century.

• Population aging is enduring. We will not return to the young populations that our ancestors knew.

• Population aging is pervasive; it is a problem of all world countries, developed as well as non-developed.

• The proportion of older persons is projected to more than double worldwide over the next half century.

• In 2050, up to 33% of the population will be 60+ in developed countries.

In Figure 27-2 the world map shows the development of the percentage

of the population aged 60 and older on a per country basis until 2050.

442 Chapter

Figure 27-2. Percentage of population aged 60 years and older

.

2.2 Growth of chronic diseases

As a result of the aging population and the limitations to fundamentally/

completely cure degenerative diseases (but rather turn them into manageable conditions), the world will see an increase of chronic, non-communicable diseases in the coming decades. Chronic diseases are the major cost drivers in the current healthcare system. Therefore cost of and spending on healthcare will substantially increase.

A chronic condition is defined as a health problem that lasts a year or

longer, limits what one can do and may require ongoing care. According to

the Partnership for Solutions

, a US based policy research program based at

Johns Hopkins University, more than 125 million Americans have at least

one chronic condition and 60 million people have multiple conditions. In

terms of the American workforce, this translates into a full 40% of employees

having at least one chronic health condition. Furthermore, it is projected that by the year 2020, 25% of the American population will be living with multiple chronic conditions, and costs for managing these conditions are estimated to reach $1.07 trillion. The number of people with chronic diseases is expected to increase by more than one percent each year through 2030, as shown in Figure 27-3.

Figure 27-3. Projection of the number of people with chronic conditions in the US

.

By 2020, over 70 percent of the global burden of disease in developing and newly industrialized countries will be caused by non-communicable diseases, mental health disorders and injuries. Figure 27-4 shows the most prevalent chronic disease is hypertension, followed by arthritis, respiratory diseases and heart diseases.

2.3 Inappropriate lifestyle

The remarkable technology developments of the 20

century have had

their inevitable impact on people’s lifestyles, especially in the more

developed countries.

Figure 27-4. Most prevalent chronic diseases in the US

.

The availability of new means of transportation has reduced our need for moving based on our own abilities. In addition, modern communication and media technologies have motivated an even more sedentary lifestyle. The abundant availability of food – also in many new forms – has altered our nutrition habits. And the ever-increasing pace of our professional lives has raised more attention to the phenomenon of stress. These are just examples.

The evolution of the physiology of our bodies has been unable to follow those developments at the same pace. As a consequence, we are experiencing an increase of ‘lifestyle diseases’. Reversing this trend cannot be exclusively realized by managing the resulting diseases – thinking about re-adjusting our lifestyles is required even more importantly. Personal healthcare technologies can support this process.

2.3.1 Physical inactivity

Our current society limits the need for physical activity in our daily lives.

However, in order to maintain our health status, our body requires us to make use of our abilities to move. This implies that it is necessary to create additional opportunities for movement, e.g. by means of regular exercising.

In common statistics, the term physical inactivity is used for persons,

who report no leisure-time physical activity. A recent World Health

Organization (WHO) report recommends at least 30 minutes of regular

moderate-intensity physical activity on most days.

The annual estimated cost for diseases associated with physical inactivity (see Table 27-1) in the US in 2000 was $76 billion

.

Table 27-1. Physical inactivity in the US

.

Total prevalence Total males Total females

Physical inactivity 38,6% 35,8% 41,0%

Data on levels of physical inactivity across Europe is poor. In general Southern countries have lower levels of physical activity than Northern and Western countries.

In 2002, over 40%

of adults in Europe reported no moderate-level physical activity in the past week. Only 15% reported daily moderate-level physical activity, the frequency the WHO suggests is required to reduce the risk for cardiovascular diseases.

2.3.2 Nutrition

Bad nutrition habits have a direct and significant impact on the development of obesity and other important diseases that increase the cardiovascular risk. A high level of cholesterol is widely accepted as an extra risk factor for cardiovascular diseases.

High cholesterol is defined as a total cholesterol level of 200 mg/dl and higher, where levels between 200 mg/dl and 240 mg/dl are considered borderline. A distinction is made between High Density Lipoprotein (HDL,

‘Good’) and Low Density Lipoprotein (LDL, ‘Bad’) cholesterol. The higher the level of HDL cholesterol the better, less than 40 mg/dl is considered as a risk factor. For LDL cholesterol levels of 130-159 mg/dl are considered borderline, whereas levels above 160 mg/dl are considered high.

In Europe, cholesterol levels are converted to mmol/l. The threshold for high cholesterol is defined at 6.5 mmol/l.

Roughly half of the U.S. population has an increased level of cholesterol (see Table 27-2), largely caused by bad nutrition habits.

Table 27-2. High cholesterol in USA

.

Total population

with high cholesterol

LDL cholesterol 130mg/dl or higher

HDL cholesterol less than 40 mg/dl Prevalence 106,900,000 95,000,000 54,700,000

% of total population 50,7% 45,8% 26,4%

In Europe there are no uniform statistics on LDL and HDL cholesterol levels. Levels vary widely among countries and for men and women. Some examples are listed in Table 27-3.

Generally, Mediterranean countries (Spain, Italy, Greece) have a lower

prevalence of high cholesterol.

Table 27-3. Population with high cholesterol in Europe

. Prevalence of levels 6,5 mmol/l and above in men

Prevalence of levels 6,5 mmol/l and above in women

Germany 36% 37%

Northern Sweden 45% 35%

UK-Scotland 35% 36%

Italy 28% 26%

2.3.3 Stress

Stress response describes the condition caused by a person’s reaction to physical, chemical, emotional or environmental factors. Stress can refer to physical effort and mental tension. Precise ways of measuring the levels of emotional or psychological stress are not available. Most people feel stress, but they feel it in different amounts and react to it in different ways.

More and more evidence suggests a relationship between the risk of cardiovascular disease and environmental and psychosocial factors. These factors include job strain, social isolation and personality traits. How stress contributes to heart disease risk is at this time subject to further research.

There are not many statistics about stress, as objective measures for diagnosing do not exist.

A number of surveys have however been conducted. A survey by Roper Starch Worldwide

states that globally, 23% of women executives and professionals and 19% of their male peers, say they feel ‘super-stressed’.

According to the National Institute for Occupational Safety and Health,

$300 billion, or $7,500 per employee, is spent annually in the U.S. on stress- related compensation claims, reduced productivity, absenteeism, health insurance costs, direct medical expenses (nearly 50% higher for workers who report stress), and employee turnover

.

2.3.4 Smoking

Smoking is usually defined as cigarette use during the preceding month.

This definition includes the complete range of smokers from irregular to heavy smoking. Smoking is a major risk factor for cardiovascular diseases and for cancer. In the U.S., more than 20% of the population (almost 50 million citizens) smoke

. Prevalence is shown in Table 27-4.

In European statistics, smoking is often defined as regular daily smoking.

The average smoking prevalence in Europe is 30%

. The strongest

deviations are found in the former Yugoslavia (48%), Albania (39%),

Greece (38%) and Germany (37%). Lower prevalence is found in Sweden

(18%), Portugal (21%), Romania (21%) and Iceland (22%). The numbers

date from 1999 to 2002.

Table 27-4. Prevalence of smoking in the US

.

Total Male Female

Prevalence 48,500,000 26,300,000 21,200,000 Percentage of total

population

22,5% 25,2% 20,0%

2.4 Relevant diseases

In this section, we discuss the major disease types in the context of personal healthcare scenarios.

2.4.1 Obesity

Obesity is defined by using the Body Mass Index (BMI). This is calculated as

)

(height weight BMI =

In the definition of obesity a difference has to be made between obesity and overweight. Persons with a BMI between 25 and 30 are considered to be overweight, whereas a person with a BMI greater than 30 is defined to be obese.

Table 27-5 lists the NIH (National Institute of Health) classification of obesity and, combined with waist circumference, the associated disease risk for type 2 diabetes, hypertension and cardiovascular diseases.

Table 27-5. Obesity risk factors

. Classification of

obesity

BMI Obesity Class Disease risk, waist circumference men <102 cm Women <88 cm

Disease risk, waist circumference men >102cm Women >88 cm Underweight <18.5

Normal 18.5-24.9

Overweight 25.0-29.9 Increased High

Obesity 30.0-34.9 I High Very High

Obesity 35.0-39.9 II Very High Very High Extreme

Obesity

>40 III Extremely High Extremely High

In Table 27-6 the prevalence of obesity and overweight for the United

States is depicted. Figure 27-5 shows the percentage of overweight and

obese people in the US.

Table 27-6. Prevalence of overweight and obesity in the US (data from 2002)

. Overweight and obesity in

adults (BMI>25)

Obesity in adults (BMI>30)

Prevalence 134,750,000 63,120,000

Percentage of total population

65.1% 30%

Figure 27-5. Prevalence of obesity and overweight in the US

.

In Europe, the latest statistics date from the beginning of the 90’s

. These show that overweight rates in Europe are overall around 50% of the population. Obesity has a prevalence of 15-20% of the population.

2.4.2 Diabetes

Diabetes mellitus is a chronic disease caused by inherited and/or acquired deficiency in production of insulin by the pancreas, or by the ineffectiveness of the insulin produced. Such a deficiency results in increased concentrations of glucose in the blood, which in turn damages many of the body’s systems, in particular the blood vessels and nerves. If diabetes is acquired due to obesity or bad nutrition habits, it falls into the category of ‘lifestyle diseases’

as described above.

More than 194 million people have diabetes worldwide

and the number may well double by the year 2025. Much of the increase will occur in the developed countries. In the U.S., the following numbers are known about diabetes prevalence:

Table 27-7. Diabetes prevalence in the US

.

Diagnosed diabetes Undiagnosed diabetes

Prevalence 13,900,000 5,900,000

Percentage of total population 6,7% 2,8%

The values in Table 27-8 accumulate diagnosed and undiagnosed (estimated) diabetes prevalence.

Table 27-8. Diabetes prevalence in Europe

.

Undiagnosed and diagnosed diabetes

Prevalence 48,378,000 Percentage of total population 7,8%

In 2002 the direct and indirect cost of diabetes in the US was $132 billion

. Diabetes has a broad background and is segmented in a number of types and complications that can occur. An analysis of the needs of diabetics shows the three most important unmet needs of diabetics being painless

burdens of diabetes management, reducing long-term complications and generally improving the quality of life for diabetics. Chapter 31 discusses diabetes and the management of this disease in more detail.

2.4.3 Hypertension

Hypertension or high blood pressure is defined by the American Heart diastolic blood pressure of 90 mm Hg or higher. There is a definition for pre- hypertension, which is defined as a systolic pressure of 120-139 mm Hg or a diastolic pressure of 80-89 mm Hg.

Studies have recently shown that for adults aged 40-69 years, each 20 mm Hg increase in systolic blood pressure or 10 mm Hg increase in diastolic blood pressure doubles the risk of death from coronary heart disease.

Nearly 1 in 3 adults has hypertension in the US (see Table 27-9). It is more prevalent in men than in women. The estimated direct and indirect cost of hypertension in 2005 is estimated to be $59.7 billion.

Table 27-9. Prevalence of hypertension in the US

.

Total Male Female

Prevalence 65,000,000 29,400,000 35,600,000 Percentage of total

population

32,3% 31,5% 32,8%

The only reliable data on the prevalence of hypertension in Europe was collected between 1989 and 1997. In these studies hypertension is defined as having a systolic blood pressure over 160 mm Hg. It varies widely from 2%

in the south of France and Spain to 17% in former Eastern Germany and techno- glucose monitoring, decision support and lifestyle support. New

unmet logical solutions in these fields have the potential to fulfill these needs. This will make meaningful contributions by reducing the daily

Association (AHA) as a systolic blood pressure of 140 mm Hg or higher or a

21% in the north of Finland. Since different definitions of hypertension are used, these figures are not comparable to the figures from the US.

Figure 27-6 shows the results of a study conducted in 6 European countries and the US

in 2003 on the prevalence of hypertension in major European countries and the US:

Figure 27-6. Prevalence of Hypertension, ages 35-64yr, USA and Europe compared

.

This study also used the 140/90 threshold and can therefore be compared to the US figures. According to this study, hypertension is generally higher in European countries, compared to the US.

2.4.4 Asthma

Worldwide between 150 and 300 Million people suffer from asthma

and the number is rising. In Western Europe, the number has doubled in the last 10 years. The international patterns of asthma prevalence are not explained by the current knowledge of the physical backgrounds of asthma.

Research into these backgrounds and the efficacy of primary and secondary

intervention strategies represent key priority areas in the field of asthma

research. The rate of asthma increases as communities adopt western

lifestyles and become urbanized. With the projected increase in the

proportion of the world’s population that is urban from 45% to 59% in 2025,

there is likely to be a marked increase in the number of asthmatics

worldwide over the next two decades. It is estimated that there may be an

additional 100 million persons with asthma by 2025.

The map in Figure 27-7 shows the world prevalence of asthma.

Figure 27-7. Worldwide prevalence of asthma

.

The economic cost of asthma is considerable both in terms of direct medical costs (such as hospital admissions and cost of pharmaceuticals) and indirect medical costs (such as time lost from work and premature death). In the US, asthma had an economic impact of $14 billion in 2002.

It is estimated that asthma accounts for about 1 in every 250 deaths worldwide. Many of the deaths are preventable, since they often result from suboptimal long-term medical care and delay in obtaining help during the final attack. Annually 180,000 deaths are caused by this condition.

The lack of symptom-based rather than disease-based approaches to the management of respiratory diseases including asthma is one of the major barriers to reduce the burden of asthma. It is therefore needed to develop and promote cost-effective management approaches, which have been proven to reduce morbidity and mortality, and to ensure that optimal treatment is available to as many asthma patients as possible worldwide.

2.4.5 Sleep disorders

A sleep disorder is defined as any difficulties related to sleeping,

including:

• Difficulty falling or staying asleep.

• Falling asleep at inappropriate times.

• Excessive total sleep time or abnormal behaviors associated with sleep.

Physicians and sleep specialists typically categorize sleep disorders into four main categories specified by the International Classification of Sleep Disorders

. These include:

• Dyssomnias: These are disturbances in the amount, timing, or quality of sleep resulting in excessive daytime sleepiness or insomnia.

• Parasomnias: These are disorders of partial arousal or disorders that interfere with sleep stage transitions, e.g. abnormal events occurring during sleep.

• Medical / psychiatric disorders.

• Proposed sleep disorders: Proposed sleep disorders encompass sleep problems for which there is not enough information available to positively establish them as distinct disorders.

Sleep disorders range from the bothersome to the serious. Insomnia (problems falling or staying asleep) affects 15% of the population.

Furthermore, 30% of people will experience short-term insomnia at some point in their lives. The most common types of sleep disorders are discussed in the following.

Sleep apnea: A breathing problem during sleep that creates a sleep disorder. Sleep apnea occurs when a person's breathing is interrupted during sleep. Three types of sleep apnea are obstructive sleep apnea, central sleep apnea and mixed sleep apnea. In obstructive sleep apnea there is an obstruction in the airway. In central sleep apnea the brain signal that instructs the body to breathe is delayed. In mixed sleep apnea, both types are present. Sleep apnea and snoring are a related and common disorder that can lead to serious health problems such as high blood pressure, heart disease, stroke, and may cause a significantly greater mortality risk if untreated.

Snoring can be irritating, but can also be a sign of sleep apnea, a more serious disorder where one actually stops breathing during sleep. Sleep apnea affects up to 20% of middle-aged men and 10% of all age groups.

Restless legs syndrome and periodic limb movement during sleep:

A neurological disorder characterized by uncomfortable, tingly or creeping sensations in your legs, which create an uncontrollable urge to keep them moving. Restless legs and periodic limb movements are very common, affecting between 15% and 50% of the population, increasing with age.

These conditions may lead to difficulty falling asleep or sleepiness due to

disrupted sleep.

Narcolepsy: A chronic neurological disorder that impairs the ability of the central nervous system to regulate sleep. Narcolepsy often causes uncontrollable sleep attacks. These may occur while driving, at work or during normal daytime activities. Onset usually occurs during the teenage years and early adulthood.

Parasomnias: Abnormal sleep behaviors are called parasomnias. Two common examples of parasomnias are sleepwalking and bad dreams. Less common parasomnias are nocturnal seizures and REM Sleep Behavior Disorder. Parasomnias are evaluated when there is a suspicion of an underlying medical condition or if the activity is potentially injurious to the patient or others.

2.4.6 Cancer

Cancer is a group of diseases characterized by uncontrolled growth and spread of abnormal cells. If the spread is not controlled, it can result in death.

Cancer is caused by both external factors (tobacco, chemicals, radiation, infectious organisms etc.) and internal factors (inherited mutations, hormones etc.). These causal factors may act together or in sequence to initiate or promote carcinogenesis. Cancer is treated by surgery, radiation, chemotherapy, hormones and immunotherapy.

An estimated 9.8 million Americans have a history of Cancer

(2001).

Worldwide 11 million new cases of cancer are reported every year. In the US, these are about 1.4 million, in Europe 2.7 million. Table 27-10 shows leading sites for new cases of cancer are found to be in the US.

Table 27-10. Leading sites for new cases of cancer in the US

.

Men Women Prostate 33%

Lung and Bronchus 13%

Colon and Rectum 10%

Breast 32%

Lung and Bronchus 13%

Colon and Rectum 11%

Cancer in lung & bronchus is the leading cause of death related to cancer.

Worldwide around 7 million people die of cancer yearly. In 2005, 570,000 people in the US are expected to die of cancer, meaning more than 1,500 people per day. This makes it the second leading cause of death in the US, exceeded only by heart disease. Overall costs for cancer in the US were estimated at $189.8 billion in 2004.

2.4.7 Cardiovascular diseases

In the United States over 70 million people are suffering from one or

more types of cardiovascular diseases (CVD)

. This corresponds to more

than 1 in 3 persons. Almost half of this population is estimated to be age 65 or older. The highest contributors to this number are:

• Coronary heart disease (including myocardial infarction and angina pectoris): 18%

• Congestive heart failure: 7%

• Stroke: 7%

The average annual rates of first major cardiovascular events rise from 7 per 1000 men aged 35-44 to 68 per 1000 men aged 85-94. For women, comparable rates occur 10 years later in life.

An estimated 17 million people die of CVD worldwide every year.

Cardiovascular diseases accounted for 1 of every 2.6 deaths in the US in 2002. Since 1900, CVD has been the number one killer in the US and Europe. In the US, 1.4 million people die of CVD every year (1 death every 34 seconds). In 2005, estimated direct and indirect costs of CVD (in the U.S.) are $393.5 billion.

2.4.8 Depression

Depression is a common mental disorder that comes with depressed mood, loss of interest or pleasure, feelings of guilt or low self-esteem, disturbed sleep or appetite, low energy, and poor concentration. These problems can become chronic or recurrent and lead to substantial impairments in an individual’s ability to take care of his or her everyday responsibilities.

Depression affects about 121 million people worldwide

. Fewer than 25% of those affected have access to effective treatment. Depression can be reliably diagnosed in primary care. Antidepressant medications and brief, structured forms of psychotherapy are effective for 60-80% of those affected and can be delivered in primary care. However, fewer than 25% of those affected (in some countries fewer than 10%) receive such treatments.

Barriers to effective care include the lack of resources, lack of trained providers, and the social stigma associated with mental disorders including depression.

2.5 Challenges for healthcare systems

The trends described above pose significant challenges to the healthcare

systems all over the world. In general, it is acknowledged that a public

healthcare system is an important part of the social welfare system of any

country. However, with the currently visible developments, an insurance

model will eventually no longer be sustainable. With a larger portion of the population achieving a high age and with major diseases becoming rather chronic than lethal, adjustments within the healthcare systems will become necessary. Examples that are already visible in some countries and in some areas of healthcare may include bonus systems for a healthy lifestyle and the increasing responsibility of the individual with respect to private financing of healthcare options.

In this context, technology providers are often asked to enable cost reductions. While this may be possible for certain areas, where the effectiveness of healthcare delivery can still be optimized, it is historically, however, more likely that new healthcare options will even further increase the cost requirements for optimal medical care instead of solving the financing problem.

2.5.1 Global cost structure

Healthcare spending continues to rise at the fastest rate in history. Over 2002, healthcare expenditures increased by 7.7%, four times the inflation in 2003.

In 2003, total healthcare spending in the US was $1.7 trillion

. This accounts for about 15% of the Gross Domestic Product (GDP). In 2015, more than 18% of GDP will be spent on healthcare. In the US, the out- of-pocket spending is also rising. In 2003, total out-of-pocket spending was

$230 billion, an average of more than $750 per citizen.

Healthcare spending in Europe is shown in Table 27-11.

Table 27-11. Healthcare spending in Europe in 2003

.

Healthcare expenditure, % of GDP Switzerland 10.9%

Germany 10.7%

France 9.5%

Main cost drivers in healthcare are shown in the Figure 27-8 for the US.

Main cost drivers are hospital care and physician services. As can be seen

from the figure, the cost share for hospital care is continuously going down

to eventually 27.9% in 2010. At the same time, the cost share for

prescription drugs increases.

Figure 27-8. Cost structure of healthcare in the US

.

Healthcare costs are mainly dominated by the costs for chronic conditions

. 83% of healthcare spending in the US is spent on chronic diseases. Figure 27-9 shows what share of the offered services people with chronic conditions make use of. People with chronic conditions are the heaviest users of healthcare services and the major costs for the services are accounted to chronic patients.

Figure 27-9. Percentage of healthcare services used by chronic patients in the US

.

3. APPLICATION SCENARIOS

In this section, we discuss typical personal healthcare application scenarios.

We will see that personal healthcare concepts can be applied in all phases of the care cycle (from prevention to rehabilitation) and for various medical conditions.

A common aspect for personal healthcare solutions is that they usually realize a ‘closed feedback-loop’ between the acquisition of data on the personal health status and the recommended action that should be taken. The following three phases can be distinguished in this context.

Acquisition and pre-processing: Pertinent physiological parameters need to be accurately measured. The measuring methods should be unobtrusive and convenient (e.g. body-worn solutions). For some applications, the availability of continuous readings is beneficial. Due to the special measurement situation, the obtained data will not be directly comparable to data gathered in a clinical environment. While mishandling by the user should be avoided by means of suitable interaction design, movement artifacts and other challenges of the mobile solution need to be dealt with on a signal processing or algorithmic level.

Interpretation: The pre-processed data needs to be automatically interpreted in order to generate higher-level information. For ECG monitoring, e.g., various parameters have to be extracted from the signal in order to enable a proper analysis of the function of the heart.

Feedback & therapy (recommendation): Based on the results of the interpretation step, possibly taking also further higher level information into account from other sources, feedback and therapy will be initiated:

• Either in a closed local loop providing recommendations and/or treatment directly to the patient (by means of home/portable/wearable/implanted equipment).

• Or by invoking professional interaction in an outer loop as needed, which may also be invoked for longer-term surveillance/remote patient management. The hand-over between these two loops is the most critical design parameter of the personal healthcare solution.

The ‘feedback loop of personal healthcare’ (see Figure 27-10) is closed

by monitoring the success of the actions that were triggered by the system

response, which implies starting over again with the data acquisition step.

Professional Care Self

Care Transition Point

Home Platform

Telemedicine Platform

Figure 27-10. The feedback loop of personal healthcare.

3.1 Primary prevention

The individual lifestyle plays the most important role in preventing diseases. The medical community has already developed recommendations on how to effectively prevent diseases, clearly e.g. in the field of cardiovascular diseases. Within the care cycle, the balance continues to shift towards more investments into preventive lifestyles. But although prevention is known to be a very efficient approach to fight diseases, it has not been consistently and successfully implemented so far. We talk about ‘primary prevention’, if preventive measures are taken prior to a first acute event and the actual outbreak of a disease.

The following personal healthcare application scenarios support primary prevention:

• Sports & fitness: Encouraging a more active lifestyle; motivating more frequent and more regular exercise.

• Weight management: Supporting active management of weight and avoiding overweight and obesity.

• Health monitoring: Allowing regular monitoring of the true health

status and enabling to take early action in case of irregularities

• Elderly care: Assistance for daily activities in order to avoid negative consequences of age-related problems (e.g. falling).

3.2 Emergency support

The ability to take quick and confident action often determines the difference between life and death in acute medical emergencies. Personal healthcare technology can help to empower people in the environment of the victim to take action. The most prominent example is the Heartstart home defibrillator, which can save the life of a patient in the event of a sudden cardiac arrest. The device is designed to be used by anybody and guides the user through the procedure by means of step-by-step voice instructions.

Chapter 29 discusses home defibrillation and the Heartstart product in more detail.

3.3 Early discharge from hospital

An ambition of personal healthcare towards cost-saving for the medical system is to reduce the number of days that patients have to stay in the hospital by enabling a sufficient level of care also in the home environment.

The following examples illustrate how personal healthcare scenarios can influence the decision to release patients from hospital earlier than before.

Drug titration: Continuous monitoring of health parameters related to (onset of) drug therapy; adjusting the regular dose to the individually suitable level (today, patients are often kept in the hospital during this drug titration phase).

Relapse detection: Enabling an effective and early detection of relapses with an accuracy that previously would have required observation in hospital.

Depression management: Allowing a close supervision of the disease state for depressive patients, so that acute depressive episodes can be detected sufficiently early in order to take appropriate action, even when the patient is not in the hospital.

3.4 Rehabilitation and restoration

‘Rehabilitation’ describes the process of recovering from a disease or another event step-by-step by regaining prior strength or potentially learning alternative skills. ‘Restoration’ means the repair, enhancement or replace- ment of ability via an intervention or with the help of technology.

Rehabilitation or restoration programs can be run for a large variety of

health problems, e.g. related to brain, heart, eyes, ears, skin, muscles or

bones. During rehabilitation programs, many patients experience a severe drop in performance after they are released into their home environment.

This often occurs due to a lack of guidance and patient awareness and compliance. While most programs still require a significant amount of professional interaction, scenarios that extend into the personal environment can already be envisioned:

• Stroke rehabilitation: Making use of the plasticity of the human brain in order to retrain specific (e.g. mechanic or linguistic) abilities after a stroke that has caused neurological deficiencies; extending the rehabilitation exercises from the rehabilitation center into the home environment without loss of quality.

• Heart rehabilitation: Running and monitoring a program dedicated to increase the strength of the heart muscle, e.g. after suffering from a severe cardiac event.

• Eye care: Providing the most appropriate type of glasses or directly removing the visual deficiency by means of laser surgery

• Ear care: Providing optimized hearing aids in order to compensate for a loss in hearing ability with the help of miniaturized acoustic signal processing technology.

• Skin care: Treating a variation of skin problems, from strictly medical conditions (e.g. after a burn injury) to mostly beauty related aspects (e.g.

avoiding or removing wrinkles).

3.5 Secondary prevention

After a first health-related event (e.g. a heart attack or a stroke), special measures have to be taken, in addition to fighting the root causes, in order to avoid reoccurrence.

Such ‘secondary prevention’ can usually rely on higher motivation and compliance rates, since the patient now knows exactly what is at stake and that the risk is not negligible.

Personal healthcare application scenarios can support secondary prevention in various ways:

• Continuous monitoring: Providing the confidence that everything is alright and under control at any given moment and that a new major health event will be detected immediately; reducing the patient’s stress of continuously being afraid.

• Lifestyle adaptation: Offering (interactive) guidance after a major e.g.

cardiovascular event, e.g. encouraging useful exercising on just the right

level, in combination with continuous monitoring.

• Educational programs: Reducing the fear of reoccurrence by keeping the patient informed about the disease and raising the awareness e.g. of early symptoms.

3.6 Disease management

After a chronic disease has been diagnosed, two major objectives become an element of everyday-life for the affected patient: Preventing the disease from further progressing and living with the consequences of the disease in its current state. It becomes important to ‘manage’ the disease.

The person most directly involved in any long-term disease management effort is the patient himself. Self-care, ideally based on well-defined and evidence-based guidelines and supported by easy-to-use tools, always is an important element, supported by interactions with professional caregivers.

This implies that disease management is another important application area for personal healthcare:

• Heart failure management: Preventing critical conditions by early detection of decompensation (accumulation of water in the lung due to insufficient heart activity).

• Diabetes management: Preventing a worsening of the condition by regular monitoring of blood glucose levels and aiming at adjusting towards a balanced value (diabetes care is discussed in more detail in Chapter 31).

• Asthma management: Adjusting the amount of medication to the current need and avoiding strong asthma attacks by early warning.

• Pain management: Offering quick and effective relief in situations of recurrent acute pain (e.g. migraine).

Philips has developed a telemedicine platform for disease management applications. Chapter 30 discusses this system (called Motiva) in more detail.

REFERENCES

1. United Nations, Report on world population aging 1950-2050, ch2, 11 (United Nations, New York, 2002).

2. United Nations Programme on Ageing, World Population 2002 Wall Chart (September 15, 2005); http://www.un.org/esa/population/publications/ageing/Graph.pdf.

3. Johns Hopkins University, Partnership for solutions, Web factbook: Chronic conditions:

Making the case for ongoing care, September 2004 Update (September 15, 2005);

http://www.partnershipforsolutions.com/DMS/files/chronicbook2004.pdf.

4. American Heart Association, Heart Disease and Stroke Statistics – 2005 Update, (American Heart Association, Dallas, 2004).

5. S. Petersen, V. Peto, M. Rayner, J. Leal, R. Luengo-Fernandez and A. Gray, 2005 European cardiovascular disease statistics (British Heart Foundation, London, 2005).

6. Roper Starch Reports Worldwide, Global Consumers 2000 study (Roper-Starch, New York, 2000).

7. Stress Directions Inc., Website on Stress Statistics (September 15, 2005); http://www.

8. International Diabetes Federation, Diabetes Atlas 2

edition (International Diabetes Federation, Brussels, 2003).

9. K. Wolf-Maier et al., Hypertension, Prevalence and Blood Pressure Levels in 6 European Countries, Canada and the United States, JAMA, 289, 2363-2369 (2003).

10. M. Masoli et al., Global Initiative on Asthma GINA, Global Burden of Asthma (September 15, 2005); http://www.ginasthma.com/download.asp?intId=29.

11. Diagnostic Classification Steering Committee, M.J. Thorpy, Chairman, ICSD – International classification of sleep disorders: Diagnostic and coding manual (American Sleep Disorders Association, Rochester, 1990).

12. American Cancer Society, Cancer Facts and Figures 2005 (American Cancer Society, Atlanta, 2005).

13. World Health Organization, Fact sheet mental and neurological disorders, 2001 (September 15, 2005); http://www.who.int/mediacentre/factsheets/fs265/en/.

14. National Coalition on Health Care, Facts on the cost of healthcare (September 15, 2005);

http://www.nchc.org/facts/cost.shtml.

15. OECD, Organization for Economic Co-Operation and Development, Health at a Glance OECD indicators 2003 (OECD, Paris, 2003).

16. Center for MediCare and MediAid Services, Office of the Actuary, Fact sheets (September 15, 2005); http://www.cms.hhs.gov/charts.

stressdirections. com/corporate/stress_organizations/stress_statistics.html.