How technology could help to identify hidden patients and offer potentially life-saving preventative care to reduce deaths from heart attack and stroke.
Could a culture change, coupled with better use of technology, give family doctors the tools to reach patients who are ‘hiding from health care’ − and prevent them from falling victim to Australia’s biggest and silent killer?
Inverse Care Law
Hidden patients become victims of a theory known as the Inverse Care Law. First coined by Welsh doctor Julian Tudor Hart in the Lancet in 1971, it states that the “availability of medical care tends to vary inversely with the need for the population served”.
It is a challenge that still faces primary health care today.
“The problem hasn’t gone away,” says Professor Zwar, who spent a decade working as a GP in Sydney’s inner west and as a medical educator at the Royal Australian College of General Practitioners. “The people who most need preventive care, are the ones who are least likely to come to get it. We know that Aboriginal people, for example, are not getting, to the extent that is needed, the benefits of good quality health care.”
The people who most need preventive care, are the ones who are least likely to come to get it.Professor Nick Zwar
He is calling for a change in culture among general practitioners to bridge the gap, with the help of technology. “Firstly, a mindset change is required,” Professor Zwar says, with a new take on the old philosophy of a general practitioner providing cradle to grave care for their patients.
“As a general practitioner, is your responsibility to the people who come to see you that day, week or month, or is your responsibility to everyone who regards you as their GP?” he asks.
“The idea of a practice population is that you have some degree of responsibility for and have organised your service so you can reach out to patients and try to provide services where they are most needed.”
Technology can bridge the gap
Where previously a small town, single-handed GP might have been able to keep a good track of patients and the time to talk about underlying health concerns, larger practices, greater time pressures and complex communities have made this more challenging.
This is where the technology comes in, to bridge the gap. We have become used to Google maps being able to guess the address we are about to type based on the email we just read, or a Facebook ad tempting us with a product we recently ‘liked’. And Professor Zwar says we should be using similar algorithms in health care to search out high-risk hidden patients to be targeted with preventive medicine.
The idea of a practice population is that you have some degree of responsibility for and have organised your service so you can reach out to patients and try to provide services where they are most needed.Professor Nick Zwar
The system he is proposing, involves using standard general practice software to search digital medical records for particular factors to identify patients. It could be adapted to scan for many chronic diseases, but it is being trialled in the first instance to help combat a risk factor for the nation’s leading cause of death − heart disease.
In a pilot study for the program, called ImPress, medical records at eight general practices in Sydney were scanned to identify patients at risk from unmanaged high blood pressure.
Six million Australians with high blood pressure
Hypertension – or high blood pressure – is the leading risk factor for heart disease, which in turn is the leading cause of death in Australia. Left unmanaged, high blood pressure can lead to heart attack, stroke and kidney disease.
Close to six million Australians have high blood pressure – which can have no symptoms – and many have no plan to manage their condition. As many as two in five Australians have unmanaged hypertension. It impacts more on people living in rural and remote areas and those from households with lower incomes, according to data from the Australian Bureau of Statistics.
Even when there are no symptoms, high blood pressure damages the body. It can be managed using medication, but lifestyle factors like regular exercise, maintaining a healthy weight, limiting alcohol intake and not smoking, can all help to lower high blood pressure.
In the pilot study, around 500 patients were identified and were invited to see a practice nurse and then offered help with lifestyle changes or medication to help to reduce their risk of heart disease and stroke.
The study showed reductions in weight and waist circumference and, on average, the systolic blood pressure was decreased by 14mm of mercury − that equates to the kind of reduction that you might expect to see from using three different hypertensive medications. This was coupled with positive feedback from nurses and participants.
“In the case of high blood pressure, the people who have the most to gain, with reductions in risk from heart attacks and strokes, are those at highest risk,” Professor Zwar says. “You can also show a difference reasonably quickly with hypertension, within months rather than years.”
Larger randomised controlled study
Professor Zwar hopes next year to lead a larger randomised controlled study, to provide further evidence to take to policy makers in a bid for the approach to be adopted on a wider scale.
“We know from very big studies that if you can reduce high blood pressure and address cardiovascular risk factors, there is no doubt you will reduce strokes and heart attacks,” he explains.
“So, there is clearly a health benefit both in terms of preventing death, disability and sickness, but also an economic benefit because people don’t need to be treated in hospital, so there’s less pressure on the system.”