Friday, February 28, 2014

Engaging patients in screening for colon cancer

Colon cancer runs in families. If you have a relative with colon cancer, your chances of getting the disease are markedly higher than if you don't. The good news is that if you get a screening test periodically, the disease can be found early, treated relatively easily, and you can go about your business. The bad news is that we don't do enough screening, especially of first-degree relatives and especially in rural areas where the long drive to colonoscopy is a barrier.
Anita Kinney, a nurse and epidemiologist in Utah, led a teem of researchers from five states in testing whether telephone outreach could get more high-risk patients screened. They found patients at elevated risk of cancer by recruiting the relatives of diagnosed patients. They either got a mailed brochure or a 40 minute telephone call with a genetic counselor plus a follow-up letter (with a copy to their primary provider). This was a carefully designed and executed randomized controlled trial with 481 subjects, so the improvement in colonoscopy from 16% to 25% is not only statistically significant (P<0.001), but unlikely due to bias or confounding. Interestingly, the effect of the telephone intervention was about the same in rural, urban, high income, and low income groups.
Although this is an impressive and clinically important effect, this intervention is a bit costly. The authors don't provide details, but these counselors are highly-trained and sophisticated providers and it takes a lot of their time to handle each case. I have to agree with the authors that this intervention should probably be part of a stepped strategy with the genetic counseling reserved for those who don't get screened after less expensive methods are tried first, especially since they had such a nice response from their brochure.
Now the challenge will be how to integrate this proven intervention into an ongoing delivery model, and that means, an ongoing business model. Who will pay for the outreach and the colonoscopy, especially if the index patient has different coverage than their relatives?

Kinney AY, Boonyasiriwat W, Walters ST, Pappas LM, Stroup AM, Schwartz MD, Edwards SL, Rogers A, Kohlmann WK, Boucher KM, Vernon SW, Simmons RG, Lowery JT, Flores K, Wiggins CL, Hill DA, Burt RW, Williams MS, Higginbotham JC. Telehealth Personalized Cancer Risk Communication to Motivate Colonoscopy in Relatives of Patients WithColorectal Cancer: The Family CARE Randomized Controlled Trial. J Clin Oncol. 2014 Mar 1;32(7):654-62. doi: 10.1200/JCO.2013.51.6765. Epub 2014 Jan 21.

Tuesday, February 25, 2014

The Power of Small Data

Big data is the uncharted territory of our time. Vast, multiple exabyte-sized data sets are like new continents that will, upon exploration, yield insights into all manner of human affairs. This is all well and good. But in the meantime, how about applying the latest tools and techniques of Big Data to much smaller data sets, say an insurer's chronic disease patients?

Today, with high speed data exchange and processing, it is possible to comb through millions of lab tests to find the results of eligible patients, monitor their timing and values, and provide nearly instantaneous feedback to patients and providers. This is the power of Small Data.

Small data connects people with timely, meaningful insights. It is organized and visually presented to be accessible, understandable, and actionable for everyday tasks.

Small data is the right data. You shouldn't need to be a data scientist to understand or apply it for everyday tasks.

Paraphrasing Joseph C. Kvedar, MD, the Founder and Director of the Center for Connected Health, Big Data will guide policy makers, but it's Small Data that will help patients get better.

Living with and managing a chronic disease, such as chronic kidney disease, is complicated. Small Data can deliver the right information to patients and providers at the right time so that they can do the right thing.

Wednesday, February 19, 2014

Using hand-held technologies to engage patients

Two recent articles take a look at how some small devices - smartphones and tablets - can be used to foster patient engagement.

The smartphone project tackled a tough problem  - supporting patients with chronic disease (in this case, HIV) and heavy alcohol use to reduce their drinking. Expanding on their previous approaches using Interactive Voice Response (IVR) telephone calls, Deborah S HasinEfrat Aharonovich and Eliana Greenstein from Columbia University enrolled 43 alcohol dependent HIV-infected patients and followed them for 60 days. The average number of drinks fell from 9.3 per day to 3.9. An impressive 25.6% were alcohol-free at the end of the two months. You can get all the details from their report in Addiction Science & Clinical Practice.

The second article provides the early experience with a tablet system that was given to 30 hospitalized patients at the University of California, San Francisco. The iPad2 tablets had an educational program about patient safety and a link to the hospital's patient web portal. The 30 patients were able to use the devices and liked having them. This preliminary report didn't address any changes in outcomes that wiring up inpatients might bring, so it is a little soon to endorse this approach, but they overcame the first hurdles (getting the machines in the hands of the patients and getting the patients to use them). The authors (S. Ryan Greysen, Raman R. Khanna, Ronald Jacolbia, Herman M. Lee, and Andrew D. Auerbach) do promise that they will investigate post-discharge outcomes in future work. You can find this in The Journal of Hospital Medicine.

These innovations have potential. I'm looking forward to some solid assessments (randomized clinical trials, anyone?) in the next few years to help us separate the effective approaches from the marketing chatter.