Consulo Indicium - 7/11/23

Consulo Indicium

Information for your Consideration…

A BEAD of Hope – The Biden Administration made a recent announcement that will have a profound impact on rural and underserved areas throughout the nation. The new program under the auspices of the US Department of Commerce has been titled the “Broadband Equity, Access and Deployment (BEAD Program (For details go here). In essence, the program will allocate over $42 billion in federal funds from the 2021 bipartisan infrastructure law to the states for support of high-speed internet access with the goal of creating equity in access across the entire nation and closing the digital divide. Specifically, the states will be charged with the responsibility for developing state-based plans and programs for how the funds will be allocated, deployed, and managed. In making the announcement, President Biden stated: “We’re talking today about a major investment that we’re making in affordable, high-speed internet, all across the country,” describing the program as “…the best thing that’s happened in rural America since the Rural Electrification Act.” As a long-time rural health advocate, I couldn’t agree more. The program has the potential for making high-speed infrastructure available on an equitable basis throughout the nation to support health care, education, communications, commerce and a host of other areas. It’s a policy I’ve been advocating for some time since eyes were opened to the inequities of care delivery for rural American when I served as the Founding Director of the Center for Rural Health at the University of North Dakota. From a health care perspective, the program will bring equity by allowing for better communication, monitoring, connectivity and actual care delivery for rural residents. Kudos to Biden for pushing this new initiative forward!

The Federal Communications Commission has been working to define the US households and business where high speed infrastructure is lacking and last month issued new maps that revealed at least 7% of US households and businesses with deficient infrastructure. The information will be used by the states as they develop their plans and program over the coming months. The states have been guaranteed a minimum of $100M in BEAD funding to support the initiative. For example, my home states of North Dakota and Maine will receive $130M+ and $271M+, respectively – a very respectable amount of start-up funds for initiating the new program. The next step will be in bringing the capabilities of the initiative to bear making sure the services are affordable as well as accessible. Congress approved the Broadband Equity, Access and Deployment program, or BEAD, along with several other internet expansion initiatives, through the infrastructure bill Biden signed in 2021.

A Cautionary Note On The Results Of Telemedicine: A Brief Analysis – When the pandemic hit in 2019, it seems that we finally saw the uptick in use of telemedicine technologies that some of us had been predicting for some time. The disappointing factor was that it took a pandemic to see it come about ☹. Regardless, the use of telemedicine and telecare has become far more normative in a relatively short period of time. However, the recent research on the effectiveness or reliability of these tools for enhancing care delivery has been mixed. Why? At least for starters, it appears that a focus on selected problems appears to offer better outcomes than on those individuals with a panoply of clinical problems. In a study on blood pressure management from Mass General Brigham researchers, there was a 22% increase in the number of patients who reached their goal which due in large measure to the fact that there was a 71% increase in home B/P measurements during the course of the study. But, it’s not just chronic problems. It also applies to acute problems such as at-home treatment for COVID-19 infections as reported in three separate studies[1]. However, the results are inconsistent as reported in the literature. Other studies have shown little correlation to the use of remote management. So, why the difference? The US Department of Health and Human Services did a review to assess the reasons for the differences in outcomes from these studies. Their analysis along with other studies can be found is here. Long story short, there seem to be several important factors, including:

• Infrastructure – As a long-time rural health equity advocate I’ve been making this argument for far too long. Without bandwidth, capacity, connectivity and a host of other issues related to “access”, people cannot be expected to use telehealth and telecare models for care delivery! In part, that’s why I was so excited about the recent announcement by the Biden Administration to establish the BEAD Initiative (SEE first item in this blog, “A BEAD of Hope”).

• Workflow Management – Simply adding in the use of technology without reassessing and redesigning the workflow of the clinical care approach is creating an incompatibility. As a clinician, I can tell you that managing face-to-face clinical work with patients is vastly different than virtual work. Trying to do the two together requires a modification of how clinicians do their work. Without such an approach, far too many workflow items simply fall to the flow and “use” of these systems will decline over time.

• Scaling – While an initial “small” cohort of patients might benefit substantially from use of the tools, how and what resources are used in scaling up to care for larger numbers of patients is an important element. I will argue that simply assigning these scaled up tasks to the very busy clinical office for following up will create a major obstacle (back to “workflow management”).

• Collaborative Capability – It is important to consider how the entire “team” of care providers in the continuum of telecare/telehealth/FTFcare will be integrated. In short, rethinking the care delivery model is required so that effective “team” with internal as well as external communication capacity are developed, supported and sustained.

• Integration of AI/ML – There are any number of evolving tools that need to be considered as part of the capacity for deploying effective telehealth and telecare tools that will require a focus on all four of the above items. For a good review of “guidelines and guardrails” on this topic, go here.

A Leading Cause of Injury Can Be Abated – As an individual who suffers from peripheral neuropathy (the diminished ability to “feel” one’s hands and feet – for starters), I recently read an article that more than a couple of my readers might find of interest. It relates to engaging in “balance exercises” for diminishing the risks associated with the falling. I was sensitized to the problem more recently not because of my own problem but because of a colleague who fell and ended up with a total hip and some other medical sequelae. It sensitized me to the problem that I was already “not feeling”. The data shows clearly that nearly 1 in 4 adults will experience a fall. In fact, for those over the age of 65 (hmmm – that’s me!), a fall is the leading cause of injury. In fact, every time I visit one of my many physicians, he always asks me first up, “Where’s your cane?” I finally relented and then discovered more recently that for those over the ae of 65, the most common cause of hip fractures and traumatic brain injuries is a fall!! So, why the problem? It’s not only the result of decreased balance from problems like peripheral neuropathy. It’s also from decreased visual acuity and muscle weakness. So, for the last couple of years, I’ve engaged the help of an exercise guru who once worked with professional athletes to help them stay in tip top condition. The only problem was their attitude – which he did not like. So, he turned to the “elder community” – which is growing by leaps and bounds ,where attitudes are more forgiving (ahem!). His approach includes some critical areas of focus training.

1. Improved coordination through balance training. When we first started, I could not for the life of me do heel-to-toe walking or stand one leg. Now I perform much better through a combination of focused exercises and practice. These types of exercises, reduce the rate of falls by 24%.
2. Selective and focused weight-lifting along with use of resistance bands. The muscles in the core, hips and legs are critical areas of focused training.

3. Tai chi and yoga exercises have been shown to be an effective approach. Through the use of controlled, slow movements with shifts in body weight a person can increase their strength and balance, demonstrating a 20% reduction in falls.

4. Flexibility training to improve one’s range of motion and reduce stiffness. These types of exercises clearly add to us older types ability to move around much more effectively and efficiently.

5. Find someone with expertise and follow their advice. As an increasingly seasoned elder this is probably the most important part of the program. And, don’t dabble. Get into it. Regular exercise does – in fact – make a difference!

Then, There’s Sleep… - Boy, you can sure see what’s been on my mind of late 😊. I noticed this article from the Sleep Disorders Center at Beth Israel Lahey Health the other day and wanted to pass along the information. It’s especially important for those of us who are burning both ends of the candle trying to “make health care better” (my personal mantra for the last 50 years). Sleep is one of the most basic of human functions the over the millennia (and before) has been fine-tuned to help us with all of our body’s daily functioning, In our modern society we face significant intrusions into the rhythm of life – intrusions like increasingly variable work lives that are no longer confined to the office but seek out time at home as well. Then there are the usual intrusions like always on smartphone, computer messages, messages from whoever to say nothing of the impact of travel through multiple time zones to get to a place like Greece 😊. According to the National Heart, Lung, and Blood Institute, sleep disruption affects an estimated 50-70 million people or just over 20% in the USA alone. If we extrapolate that number to the world, it means that roughly 1.5 billion+ people across the world are affected by sleep deprivation.

Finally – The Targeted Bans Show Results With E-Cigarette Sales Tapering Off in 2022! – The New York Times recently reported that the sale of e-cigarettes increased by “nearly 47% from January 2020, just before the pandemic hit the United States, to December 2022” according to research conducted by the US Centers for Disease Control and Prevention. The decline was attributed to several factors including the increasingly ubiquitous e-cigarettes which seemingly give the user immediate nicotine fixes with hundreds and hundreds of puffs from a single device, to state and local bans on flavored tobacco products and other government policy initiatives designed to curb tobacco use. The impact on e-cigarette use through such initiatives as the “flavor ban” was clear. During the study period, tobacco flavored products decreased from 28.4% to 20.1%; and, mint flavored productions, from 10.1% to 5.9%. If you need more information on how best to curb your patients’ use of e-cigarettes, a good sourced is available on Familydoctor.org. 

An Ominous Trend – Price Waterhouse Coopers (PwC) is projecting a potential increase of 7% in health care costs according to a report recently released by the consulting firm. Labor shortages and inflation were described as the primary culprits. The trend is ominous for several reasons. First, in the decade prior to the onset of COVID-19 health care costs had generally been on a gradual decline in comparison to overall costs for other goods and services. Health care was not the only area affected. COVID-19 was generally a culprit across the board throughout society and across all sectors. For health care the pandemic; however, saw a spike in costs due to the two factors mentioned above. The other issue inflationary factor was from the pharmaceutical side of health care where the average cost for introduction of a new medicine was in the neighborhood of $200,000. That’s a major cost factor that affects everyone. The burden for these costs will likely fall on the uninsured, the underinsured as well as those with insurance with significant deductible plans like middle-class workers private insurance and elders with Medicare Advantage plans offered by employers. Now, the big question is: Will the inflationary increases continue or abate in the next couple of years? If they continue their upward spiral – health care will no doubt consume even more of the overall Gross Domestic Product (GDP) and the federal and state budgets. Now, that’s not good for the health care delivery community! 

[1] Kaiser = https://www.thepermanentejournal.org/doi/10.7812/TPP/20.281#ref; Mayo = https://www.aha.org/aha-center-health-innovation-market-scan/2021-09-14-studies-find-remote-monitoring-advanced-care; and, VHA = https://telehealthandmedicinetoday.com/index.php/journal/article/view/281/444