Medicine Unplugged: Bringing the Solution to the Problem through Mobile Health

January 22, 2014 Steve Steinhubl, MD

Improvements in Healthcare Over Time 80% Decline in CV Death Rates

Thompson D. Atlantic Monthly March 19, 2012

But at a Cost….

Thompson D. Atlantic Monthly March 19, 2012

Physician

Sources of Solutions: Hospital

ED Doctor’s Office

Healthcare Today: Primarily Sickness Care that Requires Traveling to the Solution

Patient

Can mobile health (mHealth) technologies transform

healthcare by bringing the solution to the consumer, and in

so doing, improve satisfaction and decrease costs?

Medicine Unplugged: Bringing Solutions Problem 1. Wellness

₋ Activity & Weight Loss - Stress Management

₋ Sleep Optimization - Cancer Prevention

2. Acute Disease Diagnostics

₋ Common Infections

3. Chronic Disease Management

₋ Hypertension - Diabetes

4. Medication Adherence

Medicine Unplugged: Bringing Solutions Problem 1. Wellness

₋ Activity & Weight Loss - Stress Management

₋ Sleep Optimization - Cancer Prevention

2. Acute Disease Diagnostics

₋ Common Infections

3. Chronic Disease Management

₋ Hypertension - Diabetes

4. Medication Adherence

How “Well” are We Relative to Other Countries? Obesity Rates

% Obese Adults

http://www.oecd-ilibrary.org/sites/health_glance-2011-en/00/02/index.html

Walking and Cycling Rates Worldwide

Bassett DR. J Physical Activity Health 2008;5:795-814

Life Expectancy Relative to Health Care Expenditure per Capita

Thompson D. Atlantic Monthly March 19, 2012

How Well Does the Current Healthcare System Perform in Meeting Consumers Wellness Needs?

• 83 million adults spend $33.9 billion annually, mostly out-of-pocket, on complimentary or alternative medicine.

• In addition we spend another $11 billion out-of-pocket for vitamins and mineral supplements.

• It is estimated that ~108 million Americans dieters spent ~$66 billion in 2013, almost all out-of-pocket, on weight loss programs.

NCCAM July 2009: http://nccam.nih.gov/news/camstats/costs/costdatafs.htm.

MarketData Enterprises. U.S. Weight Loss & Diet Control Market (12th edition). April 2013

$111 billion annual out-of-pocket wellness care ≈ Total fast food sales 2013

The DNA of Hunter-Gatherers: Immobility

Leads to a Stress Response • Our hunter-gatherer relatives are thought to have travelled

on average ~20 km per day.

• When we achieve 30 minutes of brisk walking everyday (which < half of US citizens do) that corresponds to only ~2.5km per day.

Charansonney OL. Nature Rev Card 2010;7:468-72

Dose-Response Relationship to

Increasing Physical Activity

Individuals considered in the low volume activity group exercised at a moderate level (brisk walking) for an average of 92 min/wk (~15 min/day) had a 14% reduced risk of all-cause mortality and had a 3 year longer life expectancy compared to inactive participants. Every additional 15 min of daily exercise beyond 15 min a day further reduced all-cause mortality by 4%

416,175 individuals with ~8 years of follow-up. On the basis of the amount of self reported weekly exercise association between activity and mortality was

determined

Wen CP. Lancet 2011;378:1244-1253

Screen-Based Entertainment

Time and Mortality • TV watching is second only to sleep as the behavior that occupies

the most time at home.

• Observational study of ~4,500 had screen time assessed and 4 years follow-up.

Stamatakis E. J Am Coll Card 2011;57:292-9

HR All-Cause

Mortality

HR CV Disease

<2hr/day 1.00 1.00

2-4 hr/day 1.13 2.20*

>4 hr/day 1.77* 2.76* * p<0.05

Does Tracking Activity Improve Activity?

Systematic review of 26 studies (8 RCT, 18 observational, total of 2767 participants) studying the association between pedometer

use and physical activity.

Randomized Trials

of 2491 steps

Bravata DM. JAMA 2007;298:2296-3204

Change in Daily Ambulation and CV Events in People with Impaired Glucose Tolerance

9306 individuals with IGT followed up for an average of 6 years. Ambulatory activity was assessed at baseline and 12 months.

Yates T. Lancet - Online Dec 20, 2013

Both baseline activity and change in activity were independently and inversely associated with a decrease in CV events with an ~ 10% relative reduction per 2000 steps per day.

Accelerometers and Digital Coaching to Improve Activity

235 inactive adults, age 60-70. Randomized to a 3 month intervention with (1) an accelerometer-based activity monitor, (2) a personal website, and (3)

a personal e-coach, who provided regular updates of the individual’s physical activity status by email and gives advice to increase physical

activities, or control.

Wijsman CA. J Med Internet Res. 2013;15:e233

Need Help Losing Weight? Just Exhale

Martinez-Lozano Sinues P. PLoS One 2013 8(4): e59909.

We each have individual breath phenotypes. The overall breath-mass spectrum to breath-donor

recognition score was 76% over 193 samples.

10 October 2012

Breath Analysis can Potentially Aid Dieters by Providing Real-Time Fat-Burning Information

Samudrala D. Obesity 2014 Jan 11. doi: 10.1002/oby.20696

“Insufficient Sleep Is a Public Health Epidemic” - CDC Jan 2014

• About 70 million Americans suffer from chronic sleep problems.

• 18 million ,~5% adult population, suffer from sleep apnea.

• Sleep problems are critically under-addressed contributors to a number of chronic diseases and conditions, including diabetes, cardiovascular disease, obesity, and depression

http://www.cdc.gov/sleep/about_us.htm

Diagnosing Sleep Disorders - Today

• Over the last 10 years the number of accredited sleep labs has quadrupled.

• Each night in a sleep lab is ~$1,900 (mostly covered by insurance)

• Medicare payments alone for sleep testing were $235 million in 2009

Kaiser Health News Jan 2012

The Future of Diagnosing Sleep Disorders

Pollak CP. SLEEP 2001;24:957-65

• Actigraphy is the continuous recording of body (often wrist) movement.

• Allows for sleep-wake information to be gathered, but not sleep stages.

• In head-to-head testing against polysomnographic predictive value for sleep was 87%.

Ballistocardiography Systems for Enhanced Monitoring and Improving Sleep

• Under mattress sensor that monitors movement, heart rate and breathing .

• Monitors room environment (temp, noise).

• Sleep stage awakening.

http://www.beddit.com/ and http://www.withings.com/en/aura

Depression & Anxiety • Depression affects 9.1%

of the US population at any one time.

• Major depressive disorder is the leading cause of disability in US for ages 15 to 45.

• Only 50% of individuals with major depression receive treatment.

• Anxiety disorders are most common mental illness in US affecting 40 million.

• Total annual cost related to anxiety ~ $42 billion.

http://www.cdc.gov/features/dsdepression/ and http://www.nimh.nih.gov/

Triggers of Anxiety/Depression are Different in Everyone, and Often Subconscious

Objective measures of autonomic nervous system activity can help individuals recognize stress triggers and what helps minimize them.

Electrodermal Activity (EDA) is a sensitive measure of sympathetic nervous system activity

Heart rate variability (HRV) varies based on autonomic nervous system activity. The less stress, the greater parasympathetic activity, the greater the variability.

mHeath Tools for Checking and Tracking HRV

mHealth Tools for Checking and Tracking EDA

http://www.cs.rochester.edu/hci/pubs/pdfs/FoodMood.pdf

Other Methods of Stress / Mood Tracking

http://pac.cs.cornell.edu/pubs/ubicomp2012_StressSense.pdf

Clmtrackr: Face tracking technology to track mood

StressSense: Algorithm analyses the tonal expression of the human voice to help people track and monitor their moods

MyBreath: Records 1-3 minutes of breathing and then measures, analyzes and trains your breathing.

Cancer Detection Guidelines – American Cancer Society

• Yearly mammograms are recommended starting at age 40 and continuing for as long as a woman is in good health.

In 2011 only 53.6% of women reported having a mammogram in the last year.

• Beginning at age 50, both men and women should have a flexible sigmoidoscopy every 5 years, or colonoscopy every 10.

~50% of the US population receive recommended colon cancer screening tests.

• For high risk individuals age 55-74 low-dose CT scan screening is recommended.

Pace LE. Cancer 2013;119:2518–2523

Hudson SV. J Am Board Fam Med 2012;25:782-791

Passive or Active Screening of Multiple Cancers Through Breath Analysis

Lung, breast, colon and others have been studied.

Peng G. Nature Nanotechnology 2009;4:669-73

Mhealth Tools for Simplified Population Screening for Cancer

Simple attachment to a mobile phone turns it into a multimodal imaging device for screening for cervical cancer.

Two billion women worldwide are un-screened

for cervical cancer

http://www.mobileoct.com/

Oral cavity cancer is amongst the most prevalent cancers worldwide

Consumer / Provider Platforms to Empower and Engage (e.g. Tictrac)

Medicine Unplugged: Bringing Solutions Problem 1. Wellness

₋ Activity & Weight Loss - Stress Management

₋ Sleep Optimization - Cancer Prevention

2. Acute Disease Diagnostics

₋ Common Infections

3. Chronic Disease Management

₋ Hypertension - Diabetes

4. Medication Adherence

Upper Respiratory Tract Infection (URI) – Treating the Common Cold

1. Viral respiratory tract infections, “colds” are the most common acute illness in humans and the most common reason for an urgent office visit. 1

2. Adults average 2-4 colds annually.

3. The estimated total annual economic impact of non-influenza viral URIs is ~$40 billion in the US alone.2

4. There is no role for radiologic or lab studies in the diagnosis or treatment of URIs.

1. Cooper RJ. Ann Intern Med. 2001, 134: 509-517 2. Fendrick A. Arch Intern Med 2003;163:487-94

Potential mHealth Solutions for the Common Cold

• Thermometer that measures temperature, and…

Tracts symptoms

Informs you of others in same community (school, workplace) with similar symptoms.

Can send information to provider’s office

• In the near future, POC tests will allow for home diagnosis of exact pathogen.1

1. Lodes MJ. PLoS One 2007; 2(9): e924.

Scanadu Scout

Urinary Tract Infections

1. Most common bacterial infections in adults. 1

2. Accounts for roughly 7 million office visits, 1 million ER visits and 100,000 hospitalizations annually. 1

3. UTIs are responsible for an estimated cost of $2 billion dollar annually. 1

4. Only ~50% of women presenting with symptoms concerning for UTI are actually diagnosed as having one after evaluation.2

1. Foxman B. The American Journal of Medicine. 2002;113:5-13. 2. Bent S. JAMA. 2002;287(20):2701-2710.

mHealth Solutions for the Home Diagnosis of UTI • Several mobile devices are designed

for at-home urinalysis with analytic, tracking and transmission capability.

• Future advances will likely allow for the detection of both the presence of infection and the exact pathogen via a mobile electrochemical biosensor .1

1. Mohan R. PLoS One 2011;6(10):e26846.

Otitis Media 1. Recurrent ear infection is the most common

acute complaint of children leading to ~30 million pediatrician visits annually.1

2. Responsible for annual costs over $5 billion dollars, not including lost work time by family caregivers. 1

3. For every 100 children utilizing a healthcare service because of their parent’s suspicion for an acute ear infection, only 50 are actually diagnosed to have an ear infections.2

1. Bondy J. Pediatrics 2000;105(6):e72. 2. Laine MK Pediatrics 2010;125(5):e1154-e1161.

Home Diagnosis of Otitis Media – Smartphone Otoscope

•By giving parents the ability to digitally image their child’s tympanic membranes at home with a smartphone-based otoscope a substantial percentage of office visits could potentially be prevented with remote image transmission and diagnosis

Medicine Unplugged: Bringing Solutions Problem 1. Wellness

₋ Activity & Weight Loss - Stress Management

₋ Sleep Optimization - Cancer Prevention

2. Acute Disease Diagnostics

₋ Common Infections

3. Chronic Disease Management

₋ Hypertension - Diabetes

4. Medication Adherence

Hypertension (HTN): Scope of the Problem

1. One of every 3 adults in America have HTN. 1

2. Nearly $100 billion in total costs are attributed to HTN annually in the US. 2

3. Nearly 40 million office visits every year in the US have a primary diagnosis of HTN making it the single most common reason for an office visit.3

4. Less than half of all hypertensive individuals have their blood pressure under control. 1

1. MMWR. Morbidity and mortality weekly report 2011;60(4):103-108. 2. Heidenreich PA. Circulation 2011;123(8):933-944. 3. National Ambulatory Medical Care Survey: 2010 Summary Tables.

Improving HTN Management Through mHealth

• Home BP monitoring alone is already known to improve BP control, although only slightly.1

• When home monitoring is couple with provider feedback and patient engagement there is much greater BP control than with monitoring alone.2

• Cuffless and continuous non-invasive BP monitoring devices will soon allow for a substantially greater depth of understanding of BP and its control.

1. Uhlig K. Annals of Intern Med 2013;159(3):185-194.. 2. Green BB. JAMA. 2008;299(24):2857-2867

mHealth in Diabetes 1. Over 25 million US adults have diabetes, roughly 8% of

the adult population, while an additional 79 million are pre-diabetic. 1

2. The total cost of diabetes in the US for 2012 was $245 billion, with $176 billion in direct costs. 2

3. Interventions that train patients in self-management and improve their communication channels with providers can significantly improve outcomes and decrease costs. 3

1. CDC. National diabetes fact sheet: 2011. 2. ADA. Diabetes Care. Apr 2013;36(4):1033-1046. 3. Aubert RE. Annals of internal medicine. Oct 15 1998;129(8):605-612.

The Next Generation of Glucose Monitoring

Medicine Unplugged: Bringing Solutions Problem 1. Wellness

₋ Activity & Weight Loss - Stress Management

₋ Sleep Optimization - Cancer Prevention

2. Acute Disease Diagnostics

₋ Common Infections

3. Chronic Disease Management

₋ Hypertension - Diabetes

4. Medication Adherence

Medication Non-Adherence

1. Only 51% of Americans treated for hypertension are adherent to their long-term therapy. 1

2. About 25% to 50% of patients discontinue statins within one year of treatment initiation. 1

3. Non-adherence causes ~30% to 50% of treatment failures and 125,000 deaths annually. 2

4. Direct cost due to medication non-adherence are estimated at $100 billion to $289 billion annually.2

1. Choudhry, NK Pharmacoepi Drug Safety 2008;17:1189-1196 2. Ho PM. Circulation 2009;119(23):3028-3035.

mHealth Tools for Non-Adherence

mHealth Tools for Non-Adherence – Ingestible Sensor (Proteus)

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What will mHealth Technologies Mean for Healthcare Providers?

Medicine Unplugged – Good News for More than Just the Healthcare Consumer

1. In general, physicians are unsatisfied with their careers:1

Physicians rate the morale of 80% of their colleagues as poor to very poor.

Two-thirds of physicans would not recommend it as a career to younger individuals

2. ~80% of physicians rate the doctor-patient relationship to be the most satisfying aspect of their work.1 However,

Today, average face-to-face time with a patient is ~10 minutes2

It would take between 11-18 hours daily for a PCP to provide all of the preventative and chronic disease management required for a typical patient compliment. 3,4

1. http://www.physiciansfoundation.org/ 2. Gottschalk A. Annals of family medicine 2005;3(6):488-493. 3. Yarnall KS. American journal of public health 2003;93(4):635-641 4. Ostbye T. Annals of family medicine 2005;3(3):209-214

What mHealth can Mean for Healthcare Providers

1. mHealth technologies will dramatically change the practice of medicine, which, at first blush is very concerning to physicians.

2. However mHealth will eventually free physicians of being directly involved in precision, algorithmic medicine that currently takes up a majority of their day.

3. Instead providers will regain their primary role as a diagnostician and educator allowing for longer and more rewarding interactions for both patients and providers.

Healthcare Team -Physician

-Nurse -Pharmacist

-Dietician

Unplugged Medicine: Bringing Solutions to the Consumer

Medicine Unplugged: Bringing the Solution to the

Problem through Mobile Health- Summary

1. Healthcare in the US is unsustainably expensive and does not provide consumers with the kind or quality of care they require.

2. mHealth technologies provide a starting point for the complete re-engineering of healthcare that engages and empowers consumers, improves outcomes, lowers costs and improves satisfaction for all involved.

3. Real world, large-scale demonstration projects and/or pragmatic clinical trials are greatly needed.