Patients, particularly in Europe, the Middle East and Africa, have a very different view of how well their treatment went than the physicians who treat them and health care leaders who oversee healthcare delivery. Their main frustration is around their initial ignorance and the failure to diagnose early. We talk to Dr. Nick West, the Chief Medical Officer, Global Medical Affairs for Abbott’s Vascular business about the results from Beyond Intervention—a multi-year global research initiative that uncover the differing perspectives of the patient, the physician, and the healthcare leader.
HBI: I’ve just read your fascinating study on the different perceptions of 1,289 patients suffering from vascular disease, 408 physicians and 173 healthcare leaders across 13 countries. Several things jump out. The three groups really have a very different perception of the challenges that surfaced during the early stages of the patient experience.
NW: Yes. The patient experience simply isn’t as good as health leaders think it is. And the divide is worse for patients with peripheral artery disease than for patients with coronary artery disease, probably because they present with a wider range of symptoms and are less easy to diagnose.
Globally, only 38% of PAD and 44% of CAD patients agreed that their experience went as well as it could have. Yet 46% of physicians thought it was ideal and 64% of healthcare leaders. That was even more striking across Europe, the Middle East and Africa, where only 30% of patients with PAD and 44% of patients with CAD thought it went as well as possible, yet 70% of healthcare leaders, around double the patient number, thought it was ideal.
HBI: Wow! I suppose the further removed someone is from the patient, the more likely they are to not be aware of the problems. And I’m guessing that sort of situation almost certainly applies to any medical treatment, not just to vascular. It’s a real warning against complacency, isn’t it ?
NW: I suppose so.
HBI: So what appear to be the major barriers to getting treatment?
NW: Patients point to three factors. The most important is a lack of awareness of symptoms and treatment options, the second was difficulties getting diagnosis and the third was lack of coordination between primary and secondary care.
HBI: What is interesting about this is that all these barriers relate to diagnosis, not what eventually happened when they ended up in hospital.
NW: Yes. And the patient often feels in a position of real ignorance. Many people with vascular diseases are unaware of their condition; they tend to downplay their symptoms, and be confused about the next steps they should take for diagnosis and treatment. Half of patients globally struggled to recognise symptoms, 42% said they hadn’t realised the symptoms were a big deal and over a third didn’t know what to do next.
Interestingly, for “not understanding what to do,” Saudi Arabia was the highest-ranking country, at 57%, followed by the UK, at 43% of respondents.
Diagnosis, particularly for patients with PAD, was a real challenge. Roughly 1 in 5 patients state they were misdiagnosed on average three times before receiving a diagnosis for their symptoms!
Patients also cited a lack of communication between primary and secondary/tertiary care as a big issue. Roughly a third of patients with CAD and PAD cited “I constantly have to provide my medical history/ information, which I find inefficient” as one of the top challenges to early/accurate diagnosis. In addition, about a third of patients with PAD and nearly a quarter of patients with CAD cited “I felt like my different doctors weren’t talking to each other” as a top challenge.
HBI: And were there huge variations across patient populations? People who identified as struggling financially, or who identified as people of ethnic and racial backgrounds, as well as women, all claimed to have had worse experiences.
NW: Yes. Women consistently rated their experience as worse.
HBI: So how did that vary compared to physicians and healthcare leaders?
NW: Well, they recognised that not having standardized diagnosis was a major problem. One in three physicians and one in four health leaders saw that as an issue.
But for physicians, perhaps predictably, the biggest challenge was limited face-to-face time resulting in less comprehensive consultation (48% globally). EMEA was particularly likely to choose this at 56%. And the problem was seen as worse in the UK at 68%, Germany 66% and Spain 59%.
They also saw inefficient communications between primary care and specialists as a big issue 43% globally. That was particularly bad in Spain at 52% and Saudi Arabia 63%.
HBI: That is perhaps not surprising. Physicians and healthcare leaders may not be as focused on the early stages of screening and symptom recognition as well as diagnosis as they are on the later stages of the patient journey.
So at Abbott, how are you developing a platform that covers those early steps, that standardizes the diagnosis?
NW: We have a platform called Ultreon which uses AI and big data during intravascular imaging using our OCT technology to help physicians arrive at better decisions before selecting and placing the stents which are our core product. We’ve found that, almost 90 per cent of the time, use of this tool changes where the stent is placed by the physician and we have a trial underway which will show the real long-term impact of this on patient health.
More sophisticated imaging tools also enable the physician to look simultaneously at anatomy and physiology.
We are also now able to measure microvascular dysfunction in the vessels around the heart muscle. For a lot of people with angina this didn’t previously show up. Yet those organs are critical to the heart pump.
We are also beginning to appreciate the importance of advice after surgery. Patients really need to be told how to respond to further symptoms after a stent is fitted. This can dramatically reduce anxiety.
Aside from improvements in imaging we are also watching other ways of diagnosing illness. For instance we are looking for biomarkers of early onset. New research shows that a person’s voice changes as a condition worsens . That applies to Parkinsons and depression and possibly to vascular conditions as well.
HBI: So how far are patients willing to engage with digital before and after treatment?
NW: Smartphones are starting to come into their own. We are seeing cases where patients see a funny trace on their Apple watch as it detected an ischemia. This is only going to grow. You can get rings which detect oxygen saturation levels, for instance. So we need healthcare records which can incorporate and use patient generated data. Because some of this is really important. The number of steps a patient walks a day can be an important data point.
There is evidence that digital heath use can reduce readmission by 50% after a heart attack. But there is a problem. Medical adherence is weaker with drugs where the patient perceives no change in how he or she feels. Adherence to statins is therefore much lower than adherence to drugs which keep pain away for someone with arthritis.
And we have to acknowledge that different patients want different things at different stages in the journey. Many patients are not that keen on digital health trackers or digital medication adherence apps. And not all physicians and healthcare systems will want or be able to embrace these technologies .
We should also recognise that women are more likely to suffer negative clinical and economic consequences due to underdiagnosis or undertreatment. Yet they are also 75% more likely to use digital tools to track their health, often as a consequence of exactly these adverse experiences. Unfortunately, venture capital investments have yet to capitalize on this opportunity, with Femtech companies only accounting for 1.8% of total digital health investments ($254 million compared to the total annual investment of $14.5 billion in 2020).
Ultimately what all patients do want is the confidence of feeling that their condition has been adequately explained to them.
HBI: So how far has any of this research changed your approach as you build this much larger platform?
NW: One thing has astonished and saddened me at the same time. As we move into the AI-used tools you see physicians who like to use them and those who don’t. You find physicians who recognise the variability of treatment and say they would want that quashed if they were in treatment but who are not prepared to afford that privilege to patients who come to their door.
People have a way of doing things and there is a distrust of new technologies.
Drilling down to the patient experience is essential. But you then have to persuade payors of the value of a larger solution.
The acute costs of any type of procedure are not measured against the long-term costs. A recent report on patients with Ischemia and No Obstructive Coronary Artery Disease (INOCA) showed that in the USA estimated annual costs per patient were $9,819 due to absenteeism (patients unable to go to work) and $4,158 due to presenteeism (patients with productivity loss at work), for a total per-patient annual cost of $13,977. When this economic impact is applied across the estimated 1.5 million patients with INOCA in the U.S. workforce, the total estimated annual cost due to productivity loss from INOCA could be as high as $21 billion per year.