SDOH’s Cube - Compliments of Peter Kongstvedt

By Clive Riddle, September 30, 2020

Dr. Peter Kongstvedt over a decade ago, before Social Determinants of Health rose to more recent prominence, developed an illustration of how complex and intertwined the multitude of determinants are that impact a consumers' state of health, using the famous Rubik's Cube design as model.

Peter Kongstvedt, MD, FACP is a highly regarded national authority on the health care industry with particular expertise in health insurance and managed health care, and was recently emailing with me on the topic of SDoH, and shared his graphic from the past that he told me he'd "created many, many years ago in my attempts to increase awareness of the issue, though it wasn’t called SDoH then, so I grafted that on to the slide – just for you."

I was so taken with how applicable his blast from the past was for Social Determinants of Health, that I asked for his permission to share the illustration with you, so here you go - and think about applying other current determinant items as well that are being discussed in the world of SDoH, and how complex the variables are for any individual outcome - and you'll see the Rubik's challenge in front of those on the front lines of SDoH.

WeChat to Many, But WeDoctor to Some

By Kim Bellard, September 23, 2020

You’ve probably heard about TikTok, especially lately. But you may have paid less attention to what’s been going on with WeChat, another China-based app. WeChat was part of the original proposed ban, which a federal judge blocked this weekend, hours before it was due to go into effect (the Commerce Department plans to appeal). The ban is on “transactions,” which, in WeChat’s case, covers a lot of ground.

WeChat is owned by Tencent Holdings, one of China’s internet giants. It has been described as a “Swiss Army knife” app, able to do many tasks — not just messaging and social networking, but also games, shopping, and payments.

It is also important to users’ health. WeChat is, according to CMI Media, “fast becoming the #1 online healthcare destination in China.” It offers, among other things, health content (some in partnership with U.S. firms), health products, telehealth, a network of “trusted” doctors, a form of health insurance, and WeDoctor. The latter “provides online health enquiry service, psychological support, prevention guidelines and real-time pandemic reports,” and is free to the user. It is available “24/7 for people all over the world.”

If we’re worried about what information China might glean from the video-watching habits of teenagers, think about how worried we should be about China having access to what health information users sought, what medical advice they got, and what health products they ordered.

China is famed for its “Great Firewall,” which restricts which outside internet platforms — like Google or Facebook — can be used within its borders. Equally important, the Chinese government monitors what happens on WeChat and other internet platforms/apps, and does not allow news or opinions it finds objectionable, or subversive.

There are estimated to be 19 million U.S. users, out of WeChat’s 1.2 billion users; most are people with family or friends in China, who rely on the app to stay in touch. The U.S. may argue it is worried about what financial and personal information might be going to the Chinese government, but it should be equally worried about what “information” is being served to U.S. users.

Think, for example, what it might tell U.S. users about COVID-19 vaccines.

The U.S. moves make some worry that we’re becoming more like China, leading to the “splinternet” where, as Vox explained, “your experience of the internet increasingly depends on where you live and the whims of the ruling parties there.”

It is the opposite of the open access, no borders version of the internet that most of us have believed in for the past thirty years. Aaron Levie, CEO of cloud-computing company Box Inc, warned in The Wall Street Journal: “U.S. tech companies have far more to lose if this becomes a precedent. This creates a Balkanization of the internet and the risk of breaking the power of the internet as one platform.”

Somehow, “optimal fragmentation” isn’t how I want to think of my internet experience; I suspect that fragmentation won’t be so optimal.

In discussing the effect of potential WeChat bans with The New York Times, Fang Kecheng, a professor at the Chinese University of Hong Kong, said: “Information is like water. Water quality can be improved, but without any flow, water easily grows fetid.” He didn’t carry the analogy further, but I will: information is like water, in that, eventually, it will get to where it wants to go.

We don’t have a U.S. platform as versatile as WeChat; we don’t even have a health platform as capable as WeChat’s health capabilities. But, if we’re not careful, WeChat might become that platform.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

The Ever-Growing Body of Evidence of Racial Disparities in COVID-19 Prevalence

by Clive Riddle, September 18, 2020

Kaiser Family Foundation has released a new study: COVID-19 Racial Disparities in Testing, Infection, Hospitalization, and Death: Analysis of Epic Patient Data, which adds to the evidence of disparities in COVID prevalence.

KFF reports that "the racial disparities in illness and death are not fully explained by differences in underlying sociodemographic characteristics and health conditions, finds the study, which analyzed Epic electronic health record data for roughly 50 million patients from 53 health systems representing 399 hospitals across 21 states." They conclude that "people of color may face increased barriers to testing that contribute to delays in obtaining testing until they are in more serious condition compared to White patients. They also demonstrate that people of color are bearing a disproportionate burden of negative health outcomes related to the COVID-19 pandemic at every stage."

Although testing rates differed little by race and ethnicity, among those tested, Hispanic patients were over two-and-a-half times more likely to have a positive result comparted to White patients, while Black and Asian patients were nearly twice as likely. COVID-19 infection rates among Hispanic and Black patients were over three and two times higher, respectively, compared to the rate for White patients. Hospitalization rates for Hispanic and Black patients with COVID-19 were more than four times and over three times higher, respectively, compared to the rate for White patients. Death rates for both groups were over twice as high as the rate for White patients.

COVID19 Positive Test Results:

• Hispanic: 311 per 1,000 tests
• Black: 219 per 1,000 tests
• Asian: 220 per 1,000 tests
• White:113 per 1,000 test

COVID-19 Infection Rates

• Hispanic: 143 per 10,000 population
• Black: 107 per 10,000 population
• White: 46 per 10,000 population

COVID-19 Hospitalization rates

• Hispanic: 30.4 per 10,000 population
• Black: 24.6 per 10,000 population
• White: 7.4 per 10,000 population

COVID-19 Death Rates

• Hispanic: 5.6 per 10,000 population
• Black: 5.6 per 10,000 population
• White: 2.3 per 10,000 population

KFF reminds us that their analysis, a joint project of the Epic Health Research Network and KFF, builds upon the findings of numerous other studies. In fact, just during the past 30 days, some of these studies have included:

The Color of Coronavirus: Covid-19 Deaths By Race and Ethnicity in the U.S.

APM Research Lab, September 16, 2020

Beyond the Case Count: The Wide-Ranging Disparities of COVID-19 in the United States

The Commonwealth Fund, September 10, 2020

'Enough is enough': Gilead-Morehouse study racial, ethnic disparity in COVID-19

S&P Global Market Intelligence, September 8, 2020

Racial/Ethnic Disparities in Hospital Admissions from COVID-19 and Determining the Impact of Neighborhood Deprivation and Primary Language

medRxiv, September 2, 2020

Community-Level Factors Associated With Racial And Ethnic Disparities In COVID-19 Rates In Massachusetts

Health Affairs, August 27, 2020

Racial Disproportionality in Covid Clinical Trials

New England Journal of Medicine, August 27, 2020

Disparities in Incidence of COVID-19 Among Underrepresented Racial/Ethnic Groups in Counties Identified as Hotspots During June 5–18, 2020

CDC Morbidity and Mortality Weekly Report, August 21, 2020

The Impact of Clinical AI: Four Questions for Jvion

By Claire Thayer, September 10, 2020

Recently, Jvion participated in a Healthcare Web Summit webinar discussion of how clinical AI differs from traditional predictive analytics and explored ways in which AI can improve patient risk trajectories while having positive impact on revenue, and identified key steps to implement adoption across organizations.  We caught up with Dr. John Showalter, Chief Product Officer, Jvion on four key takeaways from the webinar:

1. Why clinical AI? What’s the difference to other AI approaches?

Dr. John Showalter: Clinical AI focuses on an understanding of an individual patient and is designed to augment the actions and decisions of a care team. By understanding the individual drivers of risk and best actions to help a patient, an individual plan can be developed. Other AI approaches attempted to automate actions/processes, diagnose problems, or determine risk with a blackbox. The understanding of why and what to do is unique to Jvion.

2. What are the main gaps in traditional analytics like risk stratification and predictive modeling that leave healthcare organizations exposed?

Dr. John Showalter: The main gaps are predicting with non-modifiable risk factors, limited accuracy in risk predictions, population based protocols to respond to risk, and identifying too many individuals at risk. Current cohorting approaches frequently identify so many patients at risk that it is impossible to intervene on all of them effectively, especially when the individual gets an all or nothing population based protocol as an intervention.

3. What are a few of most pressing reasons for clinicians and healthcare organizations like payers to consider data augmentation in today's environment?

Dr. John Showalter: A few are: financial risk due to COVID-19, deferred care due to COVID-19, the aging population, increasing amounts of value-based contracts, increases in uncompensated care, increased consumerism, reducing health disparities.

4. What are the key things an organization should consider to ensure successful implementation and adoption of AI technology?

Dr. John Showalter: A commitment to adapting to the new insights, willingness to change workflows, identifying and tracking value attainment, identifying a need they are committed to fixing, full/broad stakeholder engagement.

If you missed this informative webinar presentation, Addressing the Iron Triangle of Healthcare With Clinical AI: Protecting Revenue While Improving Health Outcomes, we invite you to watch the On-Demand webinar video, short webinar re-cap video, or read the full Executive Brief.

Viscous Cycle: Pandemic Elevating Nation’s Blood Pressure, Which Increases COVID-19 Vulnerability

By Clive Riddle, September 3, 2020

The pandemic has increased our population’s stress levels, which has increased blood pressure levels, which creates a population more vulnerable to potential damaging effects of COVID-19. Livongo has released a paper: Tracking COVID-19’s Effect on the Nation’s High Blood Pressure, that examines their own national dataset in this regard.

Livongo refers to a August 14^th CDC Morbidity and Mortality Weekly Report article: Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic, which cites that “symptoms of anxiety disorder and depressive disorder increased considerably in the United States during April–June of 2020, compared with the same period in 2019”, and presents findings from their survey taken June 24–30, 2020 that include “40.9% of respondents reported at least one adverse mental or behavioral health condition, including symptoms of anxiety disorder or depressive disorder (30.9%), symptoms of a trauma- and stressor-related disorder (TSRD) related to the pandemic (26.3%), and having started or increased substance use to cope with stress or emotions related to COVID-19 (13.3%).

Livongo reminds us that “while anxiety and stress do not directly cause long-term hypertension, episodes of psycho-social stress and anxiety are well known to cause dramatic spikes in blood pressure (BP).” They note there was a 136% increase in utilization of their myStrength behavioral health solution in the period from January to May.

Livongo’s dataset in this case is driven by Livongo for Hypertension Members that “regularly measure their BP with a monitor and cuff that connect wirelessly with Livongo’s smartphone app. Readings are automatically transmitted to our Applied Health Signals platform where participants can view results.”

Their analysis did indicate a pandemic BP spike, and they report “until late January of this year the percentage of our Members nationally with high BP in any given week was on average 62%. At the end of January, however, we saw a rise in high BP roughly corresponding with the announcement of the first confirmed case of COVID-19 in the US (Jan 21) and the first mass quarantine of residents in the Chinese city of Wuhan (Jan 23). From that point forward, the proportion of our Members with high BP has mostly remained at a heightened level above 62%. An initial analysis of data at the state level shows that in 30 states the percentage of Members with high BP has increased between January and August. According to the data, high BP reached another significant peak in early to mid April when 68% of our Members nationally registered high BP.”

The implications? Livongo reminds us that “while no more susceptible to COVID-19, this population is more at risk of serious illness, hospitalization, and death from the virus. As our BP data reveals, the stress and anxiety and social isolation we have all experienced has had an outsized and measurable impact on this at-risk population.”

Livongo wasn’t the first to note this pandemic spike. Back in May, St. Luke’s Kansas City released an article in which their medical director discussed the trend: Doctors seeing more patients with high blood pressure amid coronavirus pandemic.

The American Heart Association has recently updated a guidance page: Keeping a lid on blood pressure during the coronavirus crisis, noting the need to manage stress, and cautioning that “high blood pressure might raise your risk of experiencing severe complications from the coronavirus. Nearly half of U.S. adults have high blood pressure, or hypertension, which is defined as consistent readings of 130/80 or above.”