A Look at An Emerging Frontier in Healthcare and Other Relevant Issues
The Academy of Pediatrics has designated the month of October as Child Health Month. The Academy strongly feels that newborns, infants, children, adolescents, and young adults up to the age of 21 years in the United States should have access to comprehensive healthcare. The statistics released reveal that 40 million Americans do not have access to the healthcare system when needed, and of these Americans, 11 million are children. Our ranking when compared to other developed countries with reference to Health status is unacceptable. We are placed 17th in comparison with peer countries in terms of infant mortality at 6.7 deaths per 1000 live births. In birth outcomes, the U.S. ranks poorly with low birth weight at 8.2 percentage of live births, weight below 2500 Grams. In fact, 27 countries outperform the U.S. on life expectancy at birth. The cost does not justify the outcomes pertaining to certain diseases and the health status of certain segments of the population.
When one considers the emerging trends within the segment of the population of newborns to young adults, the prevalence of obesity and overweight status has steadily increased within the last few decades. In some U.S. demographic subgroups, like non-Hispanic whites and those of higher socioeconomic status, the rates have plateaued recently. The prevalence of asthma in children and the increasing awareness of Attention deficit/hyperactive disorder are quite alarming.
AN EMERGING FRONTIER IN HEALTHCARE
The Healthcare industry is presently undergoing a major transformation with the introduction of the affordable care act. The budget sequestration and the fiscal constraints that are imposed on publicly funded programs and the increasing emphasis on cost constraints and accountability for privately funded programs has a profound effect on the provision of healthcare in the country. And induces the healthcare providers to formulate innovative methods of providing cost effective, compassionate quality care in a timely manner. This brings us to an emerging frontier in healthcare called “Population Health.”
Population Health refers to the distribution of health outcomes within a population, the health determinants that influence the distribution, the policies, and the interventions that impact the determinants. To implement such a program and to monitor the health status of any population requires participation of various segments of the community to qualitatively assess the status and the perceived needs of the target population. The utilization of trained, licensed experts and the identification of fiscal resources within the locality of the population are of paramount importance to implement and maintain a successful healthcare continuum of service.
The rapid evolution within the field of Bio-Medical-Informatics further enhances the transformation of the Healthcare industry. Opportunity exists to capture the tremendous amount of data that is generated on a daily basis in the healthcare field. If the data generated is analyzed appropriately, certain inferences could be made about our own patient populations (such as responses to treatments), and identify if there are variances among gender and various ethnic groups, etc. From a business point of view, the health information generated at the patient encounter should be integrated with the revenue cycle management, to provide information regarding the feasibility of providing services/procedures. Cost estimates should be done on each line item of service/procedures, which enables organizations to negotiate with contractors of healthcare for appropriate compensation and sharing of cost savings.
A LOOK AT TRENDS IN OBESITY
Pertaining to the current trends facing the pediatric population, obesity has been an issue for the past several decades. Obesity is measured by estimating the Body Mass Index (BMI), which is calculated by dividing the weight of the patient in kilograms by the height in meters squared. The BMI does not measure body fat mass directly, but is a rough estimate. The child’s weight status is determined using the age/sex specific percentiles for BMI. Charts published by the Centers for Disease Control (CDC) are available for ages between two to 19-years-old. Overweight is defined as BMI at or above the 85th percentile and lower than the 95th percentile. Obesity is defined as BMI at or above the 95th percentile for the children of same age and sex. In the U.S., the prevalence of overweight and obesity in children and adolescents is 32 percent. In a prospective pre-birth cohort, the prevalence of overweight and obesity among black and Hispanic children at 7-years-old was almost double that of white children. About 19-20 percent of black children and eight to 10 percent of Hispanic children from the ages of two to five years are obese. These children are likely to remain obese during their childhood and adolescence. The obesity rates have decreased in 19 of the 43 states studied, while 3 states have increased and 21 states remain the same.
The work published by the Department of Population Medicine at the Harvard Medical School and the Harvard Pilgrim Healthcare Institute states there is growing evidence that the risk factors in the pre-natal period and early childhood are crucial to the development, thus the prevention of obesity and its consequences. Adverse experiences like intra-uterine exposure to maternal smoking, excessive weight gain during the intra-uterine period, and elevated glucose levels are some associated factors. In the early childhood period rapid weight gain in the infant, poor feeding practices like early introduction of cereals, excessive TV watching, and short sleep duration may increase the short and long term risk for obesity. The racial, ethnic, and socio-economic disparities across most of the known risk factors for childhood obesity from the prenatal period through to childhood has also been demonstrated by research publications.
During the past several decades, research including the seminal Cochrane review emphasizes the impression that a strategy engaging a family based intervention to achieve weight loss rather than child focused program is more effective, and has less chance of having rebound weight gain. Evidence also suggests that the best times to intervene with optimizing efficiency and effectiveness to prevent obesity is during infancy and early childhood, when behaviors are easily modifiable and physiologic characteristics are plastic. In addition, the parents have the access to primary care providers, child care, and agents of early childhood education. Since habits and tastes develop early in children it is important to implement a healthy life style initiative, establishing a behavioral pattern to choose a blend of healthy foods, recreation activities, and good sleeping habits. For those organizations providing outpatient services, opportunity exists to identify individuals who are at risk and intervene appropriately, utilizing the concept of maternal-child heath integration of service and minimize the long term consequences of obesity.
A LOOK AT TRENDS IN ASTHMA
Respiratory diseases account for a significant portion of morbidity and mortality in Pediatric medicine. Asthma contributes its fair share. Asthma is a heterogeneous, multi-factorial, genetic disorder with no single etiology but the outcomes determined by many trigger factors. According to the CDC, the prevalence rate of asthma in U.S. children less than 17 years of age is about 4.6 million (8.5 percent) of the population. The age distributions are from zero to four years (6.3 percent), five to nine years (10 percent), 10-14 years (9.4 percent), 15-17 years (nine percent). The gender difference shows that males are higher at 10 percent, while females show a prevalence rate of seven percent. The racial/ethnic differences exhibit a marked disparity in the prevalence rates, with black children showing 14 percent, multi-ethnic Hispanics have a rate of 13.2 percent, while the white children have a rate of 7.4 percent. An important fact to note is that research indicates children who live in low socio-economic backgrounds and whose parents did not attain higher education skills have poorer outcomes.
Asthma is a chronic inflammatory disorder of the small airways characterized by airway narrowing, due to increased responsiveness of the smooth muscles, of the small airways, and excessive mucous production from the mucous membranes leading to reversible airway obstruction. The symptoms associated are coughing, wheezing, and chest tightness. These symptoms are variable, and can lead to impairment of the lives of children and families when it’s not well controlled. The goal of therapy in asthma is to reduce the impairment imposed on the child and prevent the onset of exacerbation. The National Asthma Education and Prevention program defines goals of asthma control as night cough less than two nights per month, daytime symptoms and rescue inhaler use to less than two days per week (not including use before exercise), and no impairment in daily activities from asthma symptoms.
At each visit it is important to assess the state of asthma control, medication use technique, dosage adherence, and parent/patient concerns. Reliable assessment of symptoms is necessary to determine the optimal therapy to control the patient’s asthma status. Self-management is the key in prevention of exacerbation of the symptoms, but the most important factor is the level of asthma literacy of the parents of the children. The economic impact of asthma-related costs is about 56 billion dollars per year. The average yearly cost of care was $1,039 per child in 2009. In 2008, it was estimated that there were 10.5 million missed school days for children, and 14.2 million missed days of work for parents.
A LOOK AT TRENDS IN ADHD
The other area of importance in early childhood diseases is neurobehavioral disorders, of which Attention Deficient Hyperactive Disorder (ADHD) occupies a significant portion. This disorder is usually diagnosed in early childhood and may last into adulthood in some who are affected. The children who are effected by ADHD may present symptoms of inattentiveness, impulsivity, and are overly active. The children may manifest predominantly with inattentiveness. The other presentations being hyperactivity and impulsivity or a combined manifestation. It’s usually the teachers who make the initial observations in the classrooms and make the parents aware about the child’s behavior patterns.
Several studies are looking at the risk factors associated with ADHD presently. Genetics may be associated with ADHD. The children of the parents who had ADHD in childhood are more likely to manifest signs and symptoms of the disorder. Other factors that may have an association to this disorder are environmental exposure to lead, as well as alcohol and tobacco indulgence during pregnancy (intra-uterine exposure). Prematurity and low birth weight are also considered as risk factors to ADHD.
When one considers the disease burden of ADHD in the country, the estimates of children diagnosed with ADHD has changed over time depending on the diagnostic criteria changes and treatment modalities. Parents report apparently 9.5 percent children between ages four to 17 years (5.4 million) have been diagnosed as having ADHD as of 2007. The rates of ADHD diagnosis increased by an average of three percent per year between 1997 and 2006. And an average of 5.5 percent increase per year from 2003 to 2007. In terms of the gender representation, the boys at (13.2 percent) were more likely than girls at (5.6 percent) to be diagnosed with ADHD. In looking at the geographical distribution of the prevalence rate, parents reported ADHD diagnosis had a substantial variance between states, from 5.6 percent in Nevada to a high of 15.6 percent in North Carolina. The cost of illness using the prevalence rate of 5 percent, a rough estimate of the annual societal cost for childhood and adolescent treatments to be 42.5 billion dollars with a range between 36 to 52.4 billion dollars. ADHD creates a significant financial burden with reference to the cost of medical care and work loss for parents and family members.
Considering all these issues, you could say that our children are the under-appreciated treasures of this country. We must formulate policies to invest in their future, so that they may be nurtured in a disease-free environment with the opportunity to acquire intellectual enrichment and become productive citizens of the land and future leaders. The policy makers of today should embrace this simple concept.
As Pediatricians, it is incumbent upon us to redirect the health status of future generations by addressing the current trends within our own patient populations, in a collaborative effort with integration of services of all people involved. With the expanding racial/ethnic diversity within our populations, we should be able to identify individuals at risk for certain diseases and monitor their progress to maintain status of wellness on a continual basis, rather than providing episodic curative care after the onset of the morbid state. Applying the principle of predictive analytics to populations at risk, we should be able to monitor their health status and provide appropriate interventions in a timely manner. The concept of “predict and prevent” is more cost effective than “diagnosis and cure.” For those cases who have gone beyond the preventive phase, the concept of prescriptive analytics could be applied to enhance the effectiveness and the efficiency of curative care, thereby improving the outcomes. With the research that is ongoing in Genomic medicine, Pharmco-genomics, and Proteonomics, the information could be inter-phased at the clinical decision support level within the clinical work flow at the point of care to further improve outcomes. We must stand up to the challenges and embrace the opportunities that are given to us for the sake of quality medical care, and most importantly, for the patients.
ABOUT THE AUTHOR: Dr. Ranjit Silva is a Polk County Medical Association member and a board-certified pediatrician with the Children’s Division of Gessler Clinic in Winter Haven.
story by RANJIT J. SILVA, MD, FAAP