In Western medicine, especially the U.K. and U.S.A., mandatory screening for cardiac disease in young people doesn’t exist.
The NHS currently offers screening for the following:
Newborns (blood, cardiac, hearing tests, and physical examination)
Pregnancy (foetal abnormalities, blood tests, and infectious disease)
Diabetic eye testing (annual follow-ups for cases confirmed in >12 year olds)
Cervical (every 3 years for 26-49 year olds, and every 5 years for 50-64 year olds)
Breast cancer (50-70 year olds, 70+ individuals can self-refer)
Bowel cancer (55-74 year olds)
Abdominal Aortic Aneurism (65 year old men. Over 65s can self-refer)
These tests are designed to aid in patient healthcare and to alleviate the long-term financial burden on the heath service, but as you can see, they’re fairly narrow in their scope. Aside from newborns, the vast majority of the screening programmes cater to individuals in later life, or after index presentation/diagnosis. If one suspects an abnormality, then of course, there are many private options available, and in fact, cardiac screening for precursors to sudden cardiac death (such as hypertrophic cardiomyopathy) is in place for young athletes. Given that the estimated number of young people with the abnormality currently stands at 1 in 500, it has been theorised with this and other cardiac diseases in mind, that mandatory screening for young people could ease the cost on the NHS, enhance patient treatment/safety and the emotional fallout that comes as a result of the morbidity associated with serious cardiac conditions.
The results of a nationwide U.K. screening programme known as Cardiac Risk in the Young imply that mass-screening that also encompasses ECG in addition to the standard physical exam and history increases the likelihood of early diagnosis and actually saves money.
The results are the endpoint of a 4-year process, involving roughly 30,000 young persons who were screened using the above methods, all of which were performed and interpreted using the relevant professionals and governing body guidelines.
8.1% of the 30,000 were deemed to produce an abnormal 12-lead ECG, 3.5% had an abnormal physical exam and/or history, and 0.5% showed abnormality in all three areas. 11.7% underwent echocardiography to confirm or deny the presence of dysfunction, 0.9% were referred for cardiac MRI, 1.7% were moved on to longer-term ECG monitoring, and 1.7% had exercise stress testing.
87 abnormalities associated with SCD syndrome were positively diagnosed at the 2-year follow up mark, accounting to 0.3% of the cohort, and 83% of this number was done so using the ECG alone. Interestingly this 83% was found in individuals who presented as asymptomatic, and would likely go undiagnosed otherwise.
The cost of this screening and subsequent treatment of a positive identification is estimated to be 20% lower than the cost of treatment and screening using current requirements, due to its lowering of false positives from 21.8% to 4.3%. This, in turn, lowers the amount of unnecessary follow ups, so this study may have great implications for young athletes, and non-athletes alike in helping to spot these potentially fatal conditions, many of which can be managed.
Beyond Verbal, an Israeli company leading the market in voice/emotion analysis software are making headlines thanks to their study with the Mayo Clinic, that shows that voice analysis can indicate the presence of coronary artery disease (CAD).
CAD is responsible for one of the highest cardiovascular mortality rates in developed countries globally, and whilst lower in developing countries, this figure is quickly rising. With this in mind, inexpensive, low-risk and non-invasive screening methods are a very desirable prospect. Currently, ECG, Exercise Tolerance Testing (ETT), Radionuclide testing and Pharmaceutical Stress Testing are the most common procedures used to screen for CAD, but, aside from ECG, each has contraindications, and/or is fairly invasive. Again, aside really from a simple ECG, each has a middling to significant associated cost attached to it. Technology that could reduce these costs and the potential for unnecessary testing presents a possible alternative to patients being referred to chest pain clinics and such, without a sure fire reason to do so.
Beyond Verbal have already used their vocal analysis software to find audio characteristics associated with Parkinson’s disease and autism, and have now turned their technology to CAD.
The Beyond Verbal/ Mayo Clinic study hypothesised, due to the association coronary atherosclerosis has with other systemic pathologies, that vocal processes and the structures responsible may also be affected.
150 patients, 120 of which presented for angiography of the coronary arteries and 50 healthy, or non-cardiac control patients had their voice recorded prior to the test. Beyond Verbal then used a variety of their analytical software to record three 30 second voice clips from each patient; the first (R1) was a predetermined script, R2 was a description of a positive experience, and R3 was personal like R2, only a negative experience.
The analysed results show a 19-fold increase in the likelihood of CAD in R3, the negative voice clip, irrespective of traditional cardiac risk factors such as age, suggesting there is indeed a link between CAD and voice.
BV hope that future development of this technology can be used to screen patients telephonically.
On the 10th of November, after a long process of meetings between local council members, healthcare union staff and members of the public, Bath and North East Somerset council voted in favour of Virgin Care for its delivery of adult services in the area, rejecting the rival bid from ousted former controllers, Sirona CIC.
B&NES council have given their reasons for preferring Virgin Care for this role, citing their transforming services across the country and positive collaboration with GPs, care centres and charities as two of those at the forefront of the decision.
It is important to note that B&NES has made this decision with deep input from the local Clinical Commissioning Group and community champions over two years, so it is the culmination of a number of differing viewing perspectives and backgrounds.
The vote, which was 35/22 in favour of the Richard Branson-owned healthcare firm, marks the first time a for-profit organisation has been in charge of NHS contracts in the B&NES area. It has been met with vehement opposition from numerous individuals and local organisations since the bid was announced, and the company itself has previously been under scrutiny for its use of tax havens, quality of care, and alleged mistreatment of staff.
National outlets have lambasted VC in the not too distant past
In 2012, a Dispatches documentary revealed how under-target a Virgin Care centre was regarding Chlamydia screening, exposed a memo asking staff to take test kits home with them, in order to increase the number of screens executed and keep them in line with national targets.
A year later, emergency department medics and the CQC expressed deep concern with practice policy, after a VC-run centre triaged a patient using a receptionist as oppose to a healthcare professional. This proved fatal, but Virgin still defended their actions at a hearing, saying that the patient was appropriately treated.
Despite only being in the market since 2010, Virgin Care currently has NHS contracts worth a reported £1bn, and provides services across the country. It being a Virgin subsidiary and having its head offices in the British Virgin Islands, means it is exempt from corporation tax, but, tax aside, the company has said that all profits made by its B&NES services are to be re-invested into local healthcare delivery. At the same time, however, it has been made clear by the company itself and from other sources that Virgin Care are not looking to make profit from this deal.
Confused yet? I am.
With this deal citing a new precedent in the volume of healthcare services of which Virgin Care have control in the UK, confusion isn’t something that benefits patients, and the majority of middling to major news networks have sensationalised this to the point of farce;
The Canary used the headline “While We’re Still Recoiling from Trump, Branson Quietly Buys up the Biggest Chunk of our NHS…”
Given that this deal has been featured in local and national news for well over a year, spawned public and political backlash (acclaim too, in fairness), and has only now reached a conclusion, the word “quiet” isn’t even slightly appropriate in this case. Headlines such as these only serve to stoke the fire.
In order to try to cut through media Chinese whispers and rhetoric, I spoke to Liberal Democrat Councillor for Oldfield Park, Bath, Will Sandry. Will attended, and was an active part of the B&NES meeting, so I asked him for his thoughts on the deal itself, and what he thinks this means for service users in the Northeast Somerset area.
Cllr Will Sandry (Lib Dem)
Virgin Care have never had charge of a number of the services, such as social work, which are contained under this Adult Services umbrella. As I see it, this makes service users guinea pigs in this case. Would it be fair to say that this is something of a risky move on B&NES’ part?
It’s fair to describe service users as “guinea pigs” because some of the services have not been provided by a private company before, and a key element of Your Care Your Way is a redesign of services so the services themselves will change during the contact. I don’t think this is “risky” because I have faith that the wellbeing of service users will remain paramount.
During the meeting you were, along with one of your Labour counterparts, in favour of moving for a deferral of the vote so as to further scrutinise numbers you felt didn’t “stack up”, appearing to cite distraction techniques and I quote, “Jedi mind tricks”. What about the numbers and overall proposal sounded alarm bells for you?
In our meeting papers the costs of the services were listed as remaining static for 7 years. I did not have confidence that was achievable. The papers were glossy but had scant financial detail. I had also asked for details of the Virgin Care management team that would deliver the contact, but I could not get a clear answer as to how much of their time would be allocated to delivering the B&NES contact. These are the main reasons I wanted more time for scrutiny.
The most vocal reactions from the public have been almost unanimously negative; a petition, anti-privatisation websites and protest marching, as well as cries of “shame” from those who attended the meeting. We know from recent referenda and elections that small samples of public opinion may not represent the view of the community, so with that in mind, what have you and your colleagues heard from service users on the street?
Apart from the vocal reactions you describe I’ve not had any direct concerns raised by service users. I suspect that the vast majority of people don’t know or mind who delivers their care as long as it remains available to them and free at the point of use.
Conservative councillor Anthony Clarke assured the meeting that Virgin Care were not looking to make profit from this deal. I personally find it strange, and indeed improbable that a for-profit organisation isn’t looking to make a profit from a £700m deal. How is the proposed budget going to monitored and how will it be enforced by the council?
I don’t know, but would presume it will be by the Council’s Health Scrutiny Panel or the B&NES Heath and Wellbeing Board. Profit is an interesting thing. An organisation can have legitimate costs (for example the cost of using the “Virgin” brand) but not record any profits for accounting purposes. I don’t know what (if anything) Virgin Group will be charging Virgin Care for the use of the Virgin brand.
What happens if this figure is exceeded? Comparing news reports from this year, it already appears to have increased by £200m, so how does the council aim to allay concerns and potential indignation that a for-profit organisation (who controversially escape corporation tax) may possibly have a future need to utilise tax payers’ money in order to do its job?
Savings can also be made by redesigning a service to deliver the same outcomes – this was always the aim of Your Care Your Way. Ultimately if that doesn’t work I imagine that the tax payer (local or national) will pay or there will be a reduction in the levels of service available.
Has anyone shed any light on how Virgin Care plan to reinvest profits that they have assured us they aren’t trying to make?
No
We in healthcare treat patients using a risk:benefit ratio, wherein the potential risks of a treatment should be less than the benefits they could provide in order to make them viable. Given that the issues surrounding Virgin Care’s practices have been documented nationally, were these problems taken into account and considered to be outweighed by the benefits a VC-driven service could provide?
As an opposition Councillor who voted against the deal, this is a question for those who voted in favour of it. In B&NES we have good Heath and Social Care, in part because we don’t play a political game over it. Nobody would thank us for that. If it could have been proven to me that the deal was the best for our residents I would have supported it despite any personal political concerns about privatisation. Let’s hope it is a good deal for service users, but I could not be convinced about the finances of it.
Finally, Will, our whole healthcare system hinges on its patient-centred approach. Given the vote for Virgin Care, despite the vocal opposition to it, it can be logically assumed that the majority of the council feel it will bring about positive changes. What sort of changes can service users expect to see under Virgin Care? What has been proposed that betters the existing system?
I can’t speak for those who voted for the deal, but it is logical to assume they did feel it would bring about positive changes. The contact is too big to list what specific changes might be made, but I imagine any changes will attempt to keep the same beneficial outcome for service users while reducing costs.
These represent the thoughts and opinions of Cllr Sandry himself, and are not necessarily indicative of those held by his associates, or by Bath and North East Somerset Council
Fitbit, the wearable fitness tracker, has gone from strength to strength since its launch. The company recorded a record $1.858 billion (!) in revenue at the close of the 2015 financial year, and, due to its affordable price tag, everyone from we regular folk, to soon-to-be ex-P.O.T.U.S. Barak Obama can be seen wearing one. That said, Fitbit are known to court controversy; in 2015, it was suggested that the advertised “sleep-tracker” in the company’s Flex model was inaccurate, and over-logged sleep. This case is still ongoing, but it is important to note that it is not suggesting negligence with regards to health; rather that the product itself was falsely advertised. It remains to be seen how this case will play out, but as if that wasn’t enough, at the beginning of the year, a multiple-plaintiff class action lawsuit was filed, with a study showing evidence that Fitbit’s PurePulse technology was woefully inaccurate during exertion.
The study, performed by a team at California State Polytechnic, compared exertional heart rates acquired via the wearable device and from an ECG. After exercising 43 individuals for 65 minutes, it was noted that the various Fitbit models displayed a heart rate that differed by up to 22bpm compared to that on the ECG, and that some didn’t display a heart rate at all.
According to the study’s team, there exists a distinct lack of rigorous, scientific testing in the wearables market (this is further suggested by lawsuits filed against other, similar product developers), but Fitbit have dismissed both this statement and the study itself, citing bias and, perhaps humorously for reasons I shall soon disclose, a lack of scientific methodology. Fitbit have stated that they perform extensive testing during development, and have pointed towards another study which purports to have found PurePulse products to be highly accurate, although it is important to note that this particular study tested a sample size of two (yes… two).
Wearable devices aren’t anything new, but with technological advances, they are no longer being seen as simply fitness trackers and companies are exploring their application in healthcare. As this gains further traction, accuracy will be incredibly important. In fact, one of the plaintiffs in this case, an 82 year old woman, has alleged that her device underestimated her heart rate by such a margin, that were she to have tried to reach her supposed target heart rate, she would have likely done serious damage to her health, so it is already having a potential impact.
The company’s financial growth since the launch of this generation of devices is thought to be largely due to PurePulse, what with it being the most heavily marketed new feature, so Fitbit’s request that the case be dismissed has last week been denied. Judge Susan Illston has decided that the plaintiffs case has sufficient merit, with regard to fraudulent claims about Fitbit’s accuracy, so it will be considered in court. This does not necessarily give an indication as to the outcome, however.
The Student Physiologist 