Proactive Medicine Is Helping Us Live Longer. Could It Make Those Years Better?
Thanks to screenings, labs, vaccines, imaging and earlier interventions, many of us who, in previous generations, would have died in middle age from heart or lung disease, cancer, infections or a host of other disorders are living well into old age.
However, the proactive approach that is helping us live longer hasn't caught up to the long arc quality-of-life disorders that have such a negative impact as we age.
Take osteoarthritis, for example. Think back to the last time you went to your physician for a checkup. Review vital signs and listen to heart and lungs-check. Labs for A1-C and lipids--got it. Maybe a flu shot. But has anyone ever checked the wear pattern on the bottom of your shoes? Have they watched you walk for signs of a patella misalignment or looked for a biomechanical problem in your back that is putting extra pressure on your joints?
Irfan Asif, MD
"Up until recently, health care has been paid on a fee for service basis, like taking your car to a garage when it's running rough, or going to a lawyer in a contract dispute. Most healthcare coverage has been oriented toward fixing a problem rather than preventing it," Irfan Asif, MD, chair of UAB's Department of Family and Community Medicine, said. "That is beginning to change as we move toward a new model that rewards physicians for keeping patients well rather than just treating a disease.
"We're already seeing progress toward reimbursement for preventive medicine and screenings. Eventually, the system is likely to become more proactive in early detection and intervention in correctable factors that contribute to chronic conditions that cause pain, limit function and increase health care expenses."
Two other major barriers stand in the way. Much can go wrong with the human body, and there isn't enough time in physician training for everyone to learn everything. As research uncovers more information about biomarkers for earlier detection of disorders like Parkinson's Disease, Alzheimer's, depression, cognitive decline and the effects of stress, there will be much more to learn and then to implement that knowledge in patient care.
"We are moving toward working more closely as a team, especially in primary medicine. This can give physicians the support of other disciplines to care for patients as incentive turn toward rewarding providers for keeping people healthy," Asif said.
As reimbursement moves toward a value-based system, it may become common to send patients to physical therapists or orthopedists for a baseline assessment to check for biomechanical issues that might be correctable to prevent the need for surgery or medications that might come with side effects that can complicate care. Instead of just telling patients to lose weight, we may be able to send them to a nutritionist and trainer.
Instead of worrying about the physical effects of stress and depression on patients, physicians can refer them for the support they need. This assumes that there are enough psychiatric and social support professionals to provide care and reimbursement resources to cover it.
It also brings up the second major barrier to a more proactive approach to chronic diseases. There aren't enough primary care providers now to care for patients and not enough time in a doctor's day to do proactive extras.
"Across the country, we have a shortage of primary physicians and one of the worst shortages is Alabama," Astif said. "If nothing changes, the shortage is expected to be more than 600 by 2030. That is only 11 years away. Part of this shortage grew out of a system with more incentives for treating a disease rather than preventing it. The shift toward a value based system aimed at keeping patients healthy should help, but we also have to look at the rewards that will attract more providers now in training to primary care."
Even if the shift to more proactive care happened tomorrow, it would only be half the equation. It takes a partnership between physician and patient to build a lifetime of better health. The day-to-day efforts required depend on the patient. Unfortunately, bodies don't come with an owner's manual and education has been limited.
Sports medicine orthopedic surgeon Amit Momaya, MD, is a team physician for UAB athletics and for John Carroll High School.
"Mineral density in the bones peaks at age 25 and then begins to decline," Momaya said. "I try to make sure that young athletes understand the importance of continuing to move after they graduate. Bodies need both aerobic and strength-building exercise slow the decline of mineral density and to keep muscles strong to support joints. In later years, it is important to keep muscles strong to aid balance. A fall and broken hip can lead to a devastating decline in health.
"The type of work we do can have a major effect on our joints and bones later. If people do a lot of standing or lifting, they need to have the right footwear and equipment and know the right way to do it. And long hours at a desk can lead to lower back problems. People need to stand up every 15 minutes or so, stretch and walk around a bit. Try a standing desk to see if it feels better. Also think about nutrition. Too many people are just not getting enough vitamin D and calcium."
Whatever people can do to delay or prevent the need for surgery later can be a good investment.
"We have come a long way in joint replacements, but they don't last forever," Momaya said. "If you need a replacement early, you may need another replacement later. Revision surgery is often more complicated and may not be as successful. It may also be needed at an age when you have other conditions that makes surgery difficult."
UAB researchers are looking for a way to use stem cells to regenerate cartilage and prevent the need for surgery. That goal is yet to be achieved, but some studies are offering hope for relief of symptoms. Other injectables, including steroids, platelet rich plasma, and hyaluronic acid are being used with other conservative treatment to postpone surgery.
UAB rheumatologist Laura Hughes MD, MSPH, joins Astif and Momaya in agreeing that the course of osteoarthritis and mobility in later life depends greatly on patients following through with positive health behaviors.
"There are genetic influences in some types of osteoarthritis, but we usually find that in the hands, neck and upper body," Hughes said. "Hips and knees are primarily a load issue, either the weight of the body or how that weight is aligned. Patients should be encouraged to control their weight. Every pound they avoid can save four pounds of wear on their knees.
As healthcare turns toward a more preventive approach to chronic conditions like osteoarthritis, what can physicians do here and now to help patients?
"There are some observable clues that patients may be having alignment issues," Momaya said. "If they stand with one knee bent more than the other, have an unusual gait or a knee that tends to turn inward or outward more than usual, you may want to take a closer look. There may be pain or swelling. If there are unusual wear patterns on the soles of shoes, they may need orthotics."
Although physical therapy can help with these issues, some patients might not be able to afford it. Are there alternatives?
"Free handouts for physical therapy exercises are available from professional associations related to rheumatology and joint surgery," Hughes said. "And medical centers and physical therapy groups put videos online demonstrating how to recognize problems and the right way to do exercises to ease them. It could be helpful to get recommendations of video sources from physical therapists and list them on handouts available to patients."
Astif is working on an outreach program to bring the benefits of activity to a broader population and hopes to involve civic groups like the YMCA. By starting young, perhaps we can spare future generations from the pain and limitations.
