To Prevent or to Treat? 11/3/12

I’m on plane traveling back from California. I never really like to travel on Friday nights, but sometimes it seems unavoidable. Either way, I’ll only be home for 30 hours before hitching a flight back to California. I think I get more work done when I traveling than when I’m at home or at my office.

I was having a discussion with a friend in California about what I consider to the be the Wisconsin equivalent of Chik-fil-A, a place called Culver’s. To me, Chik-fil-A represents the alternative drive-through option to places like McDonald’s and Burger King. The impression, at least among my relatively health-conscious friends and parents, is that Chik-fil-A is a decent enough alternative for a fast meal with kids. These are people that would never eat at McDonald’s, Burger King, or Taco Bell. Chipotle also makes the healthy fast food (or good food fast) list.

Anyway, back to Culver’s. I think of Culver’s as being very Wisconsin because it has a different custard flavor each day — which seems to be standard for Wisconsin custard places — and offers fried cheese curds as a substitute for fries. Cheese curds are fantastic without being fried, but frying them makes them superb. The best fried cheese curds I’ve ever had were at the Wisconsin State Fair, another event worth attending (though I think the Minnesota state fair is even more of an experience).

My point in all this rambling is that the subject of fast food and cheese curds got me thinking about strategies of prevention vs. strategies of treatment for chronic conditions, and if there is a reason to distinguish between the two. Prevention and treatment aren’t mutually exclusive, but I’ve always thought of them as distinct from one another because: 1) it seemed like goals of each are likely different, 2) perceptions are different for patients, and 3) we always seem to exaggerate preventative strategies and prevention (makes more sense to prevent something than to try to reverse something).

The reason this is relevant is that a lot of both prevention and treatment is lifestyle, as is all health and wellness. Mobile and connected health is a powerful and unrealized force for either.

One classic example is prediabetes (PSA video above). Patients who are at risk for diabetes might not have reached the glucose levels in testing to meet classification for diabetes, but often have levels and trends which clearly indicate they are heading that way and are above normal. This is definitely a group that should be targeted. It’s also a group that’s very hard to target because they don’t really have any clear diabetes-related problems, meaning they don’t really have a ton of motivation to change behaviors because it’s not immediately apparent to them how bad the end result of their trajectory could be.

Even once people progress to a formal diagnosis of diabetes, it’s hard to see it as more than a condition that, in and of itself, is not the danger. The fear is really the dreaded complications associated with poorly managed diabetes, namely those of the eyes, kidneys, peripheral nervous system, and vascular (small vessel vascular problems actually lead to most of the other issues).

Another example is childhood obesity, or just childhood nutrition, more broadly speaking. Kids (including teens) don’t usually think about nutrition and often model lifestyle and eating habits after what they’ve seen at home and in school. The lessons learned, habits formed, and health status of youth typically caries over to adulthood. Changing it, or preventing poor lifestyle choices, is a great target to prevent lots of the issues we see as epidemics in adulthood. The problem again is that kids are another group that’s very hard to get to change behavior and to engage in their health.

You could probably add a long list of other conditions like cholesterol and hypertension to the list of conditions that should be the focus of prevention strategies. There are tons of apps out there to track things glucose and blood pressure, made for people that already have the conditions and really for treatment more than prevention. Tracking glucose and blood pressure are important, especially as medications are added to gauge efficacy, but aren’t we missing a bigger piece related to lifestyle and more closely in line with what we think of as prevention strategies?

I’ve come to think that it seems like strategies and apps, whether they be for prevention or for treatment, should be mostly the same. There are minor differences once somebody officially has a diagnosis and is on medications, but the goals remain the same, namely to prevent progression. Before somebody has a diagnosis, it’s about preventing progression to diagnosis. After somebody has a diagnosis, it’s about preventing worsening of disease and preventing complications like cardiovascular events.

It’s all really the same spectrum, though and less about the milestones and more about the reasons people progress to being more and more unhealthy. I don’t think medication adherence, glucose tracking, blood pressure tracking, or weight tracking are the main reason that people get sicker. It’s bigger than that and it’s related to the same underlying issues, namely a lack of engagement and awareness of the patient with their health.

But what sucks is this all comes back to engaging patients, or at least getting them to take baby steps towards better health. The reason that sucks is because I think it’s very hard and I think it involves creative strategies with bought-in, vested, and reimbursed members of the healthcare team. It also involves a mix of technology and human touch. And it certainly makes me look more at some of the companies trying to do effective prevention in otherwise healthily, or pre-diagnosed, patients.

I don’t pretend to have the answer, and I’m sure there isn’t only one answer, but I’ll at least throw out one potential strategy for prevention, one that I’m sure is being used or tested but I haven’t heard much about. It involves leveraging technology — and I think mobile is overwhelmingly the form factor of choice — to connect identified cohorts of local at-risk, but still early-stage (pre-diabetes, for example), patients.

I remember in medical school spending time observing small groups of patients recently diagnosed as pre-diabetic. Attendance was incredibly high and members of the group actively brought in journals of things they’d eaten and activities they’d done. I was surprised to see how smoothly and effectively the whole thing seemed to work and how excited everybody was about it. I’m not sure what the ultimate findings were in terms of effectiveness.

The sessions were funded by a grant and it wasn’t exactly large scale. If an organization — like a payer or an ACO – was motivated to do this, they could do the same thing with almost any at-risk group. Mobile technology could enable them to scale cheaper and faster and also to continually engage the users. If the users are engaged and connected, it also makes it easier to make more informed decisions. I’m sure gaming and social components play a role, though these seem to be becoming the norm rather than they exception, so there isn’t really a need to go into detail.

This is one example. I’m sure there are many others and I’d love to hear about them.

Travis Good is an MD/MBA involved with health IT startups. More about me.

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