Will the Internet of Things Transform Healthcare?

Emerging technologies like health apps on mobile computing platforms and wearable devices are believed to have the potential to improve individual and population health. Increasingly, however, attention should extend to a far larger cohort of connected devices known as the Internet of Things (IoT), an environment in which devices communicate with each other, health apps, and wearables. The resulting Internet of Health Things promises to do things conventional health providers either cannot do or do them faster and cheaper. First, services are always on, providing twenty-four/seven monitoring of the patient or pre-patient. Second, the multiple sensors contained in smartphones or second-generation wearables like the Apple Watch are professional grade. Third, our smartphones and wearables are highly context aware, with knowledge of place, environmental factors, and, increasingly, other people and things around us. Fourth, they are smart and capable of learning, often leveraging sophisticated, cloud-based analytics. However, the Internet of Health Things (IoHT) is, at least in comparison to conventional health care, unregulated or, at best, underregulated. This Article identifies and analyzes three areas of concern: (1) effectiveness and quality, (2) data protection (including pre-patient expectations), and (3) device safety and quality. The Article concludes by examining ways in which the IoHT can improve both traditional healthcare and create new, disruptive approaches to technologically mediated care

The impact of novel diagnostics on infectious disease epidemics

Diagnostic tests play a crucial role in the control and surveillance of infectious diseases, and to ensure effective clinical management. Novel diagnostic tests are traditionally evaluated in terms of their accuracy (sensitivity and specificity). Using mathematical models, I examine the impact of different novel diagnostic tests on the tuberculosis (“TB”) and severe acute respiratory syndrome coronavirus 2 (“SARS-CoV-2”) epidemics, and investigate how the context in which these tests are used may affect this impact. In chapter 3, I evaluate the use of a hypothetical biomarker test that can detect individuals at imminent risk of progressing to active TB disease (incipient TB) and subsequent TB preventive treatment (“TPT”) initiation in a high TB burden setting. I demonstrate that biomarker-led TPT can have a significant impact on TB incidence in a high TB burden setting; however, the cost of implementing such a strategy is likely to be prohibitive given the testing effort needed to identify those with incipient TB, even if testing is targeted to populations at high risk of TB. Next, in chapter 4, I evaluate the use of urine-based tests for active TB disease, in a high TB and HIV burden setting. Although current urine-based tests for TB suffer from poor sensitivity, these tests are continuously improving, and are essential for TB diagnosis amongst patient subgroups who struggle to produce quality sputum and who are therefore missed by traditional methods of TB diagnosis. I demonstrate that although urine-based diagnostic tests reduce mortality amongst people living with HIV, population-level epidemiological impact is not seen unless the tests are deployed outside of HIV care and into routine TB care. In chapter 5, I investigate the cost and epidemiological impact of expanding different TB publicprivate sector engagement services. My results reveal that services involving the use of Xpert, a highly accurate but costly test for diagnosing active TB disease are epidemiologically impactful, but costly, and thus have the highest cost per TB case or TB death averted than other services. Finally, in chapter 6, I explore the context under when cheap but less accurate rapid antigen diagnostic tests (“Ag-RDTs”) offer greater public health value than more accurate but costly nucleic acid amplification tests (“NAATs”) that often have high turnaround times. My results highlight that Ag-RDTs-led strategies, despite their imperfect sensitivity and specificity, are more impactful at a lower cost than NAATs under different use-cases. Overall, the context in which diagnostic tests are used is crucial in anticipating their impact. Factors, including but not limited to testing eligibility, levels of current testing and turnaround time, can affect 6 the potential epidemiological impact of a diagnostic test. Thus, future evaluation of diagnostic tests should move away from focussing exclusively on accuracy and move towards clearly defining different use-cases and investigating which factors other than accuracy, may affect the epidemiological impact of a diagnostic test.Open Acces

Economic potential of a point-of-care CD4 count diagnostic in Mexico : a case study for low-end disruption diagnostics in middle of the pyramid Latin America

Thesis (S.M. in Health Sciences and Technology)--Harvard-MIT Program in Health Sciences and Technology, 2012.Cataloged from PDF version of thesis.Includes bibliographical references (p. 92-95).Disruptive models of innovation are starting to appear in healthcare. In the US, for instance, retail medicine clinics are changing the way in which patients satisfy their basic medical needs. In Mexico, similar retail medicine models (e.g. Farmacias Similares) are also disrupting healthcare delivery for basic medical needs. Disruptive innovations, however, are not limited to healthcare delivery, but also change the face of devices and diagnostics markets. A low CD4+ T cell count is the primary clinical indicator for HIV/AIDS disease progression, and thus is used as the primary trigger to initiate antiretroviral therapy. An entire diagnostic industry has emerged around CD4+ T cell counts for the management and treatment of HIV/AIDS patients. The diagnostic gold standards of CD4+ counts are flow cytometers. These large, capital intensive devices are commonly located in central laboratory settings, typically in urban areas. In developing nations, particularly, suburban and rural regions have no access to flow cytometers and typically face logistical problems of blood sample transportation and loss to follow-up of patients. Point-of-Care (POC) diagnostics promise disruptive models in diagnostics that will increase access, enhance care, and help better allocate healthcare resources. The concept of POC embodies the trade-off of lower "quality" (usually in the form of lower specificity and sensitivity) in exchange for higher "convenience" (i.e. better accessibility and portability, and significantly lower cost). POC diagnostics promise typical low-end and new-market disruptions in medical diagnostics and devices. Cambridge-based Daktari Diagnostics is one of such companies focused in POC diagnostics. It has developed a CD4+ T cell count diagnostic device for the management and treatment of HIV/AIDS patients. It is hypothesized in this thesis that there exists a relevant unmet medical need for POC CD4 count diagnostics in the Mexican HIV/AIDS market. In order to evaluate this hypothesis, secondary sources were reviewed, as well as primary interviews conducted across the Mexican HIV/AIDS healthcare landscape. While this hypothesis was evaluated on a preliminary basis only, responses suggested a relevant, albeit not urgent, medical need for POC CD4 count diagnostics. This primary hypothesis evaluation is extended by and complemented with market size estimations, and competitive dynamic discussions, that arrive at the following preliminary conclusions: the current market opportunity in Mexico ranges from baseline of ~100,000 tests per year to an upper bound potential of ~200,000 tests per year. In the context of this potential opportunity, Daktari's CD4 count diagnostic device is well positioned, as defined by diagnostic quality, technological characteristics, and competitive offering, to obtain a portion of this estimated market opportunity in Mexico.by Mauricio Camargo Támara.S.M.in Health Sciences and Technolog

The Value Driven Pharmacist: Basics of Access, Cost, and Quality 2nd Edition

https://digitalcommons.butler.edu/butlerbooks/1017/thumbnail.jp

Mitigating Risk in a State Health Insurance Exchange

Describes how the Massachusetts HealthConnector designed a risk-mitigation program to stabilize insurance premiums. Offers lessons for federal reform efforts in implementing risk corridors, reinsurance, and risk adjustment

Towards improved detection, prevention and integrated control of scrub typhus in Central Vietnam

SUMMARY Background Scrub typhus is a zoonotic infectious disease caused by obligate intracellular bacteria Orientia spp, transmitted to humans by the bites of infected larval-stage trombiculid mites, which are found mainly on rodents of forests and rice fields across the Asia-Pacific region. Scrub typhus is a severe public health problem, with one billion people at risk globally, causes illness in an estimated one million people every year, and became a leading cause of treatable non-malarial febrile illness. Case fatality reports vary widely around a median mortality of 6.0% (range 0-70%) for untreated and 1.4% (range 0-33%) for treated scrub typhus patients. In Vietnam, after 40 years of neglect, scrub typhus (ST) is re-emerging as evidenced by expanding geographical distribution and increase in new cases. Unfortunately, both the clinical and laboratory diagnoses of ST remain challenging, even at the national hospital. Due to late diagnosis and late treatment effects, a severe case complication rate of 17% and a mortality rate of 1.2% among 251 infected and diagnosed patients was reported at the national hospital in 2003. Epidemiological and ecological information on scrub typhus is very scant in Vietnam, and there is no updated evidence on practical preventive measures and fostered case-detection. Dengue fever (DF) has made a substantial impact over the two past decades in Vietnam and is unequivocally the leading cause of febrile illness throughout the country. Dengue incidence per 100,000 population has steadily increased from 32.5 in the year 2000 (24,434 cases) to 149.9 in 2018 (141,927 cases), at the third rank among the 28 most common communicable diseases. Because of non-specific symptoms such as high fever, headache, skin rash or myalgia are common to both ST and DF, differential diagnosis is required to decide on the treatment strategies. The overall aim of the present PhD research was to contribute to a better understanding and improving case detection and practical prevention of scrub typhus in Vietnam. Specifically, the work aimed to i) differentiate scrub typhus from dengue fever using admission clinical manifestations and routine blood tests; ii) investigate behavioural and environmental related risk factors of scrub typhus; iii) evaluate temporal dynamics of DNA and serology-based assays and its efficacy in early diagnosis of scrub typhus in Vietnam. Methods First, a study including 221 and 387 confirmed acute cases of ST and DF, respectively, and use of multivariable logistic regression and classification and regression trees (CART), identified clinical and laboratory parameters differentiating ST from DF. Then in 2018/2020, a clinical hospital-based active surveillance study, and a retrospective residence-enrolment date-age-matched case-control study were conducted to investigate the risk factors of ST in Khanh Hoa, Vietnam. Finally, were used data of two hospital active surveillances of suspected ST patients that were done in Khanh Hoa in the periods of 2013-2014 and 2018-2020. The PCR, IgM ELISA, IgM rapid test (RDT) results and days of fever on admission of these patients were used to evaluate temporal dynamics of DNA and serology-based assays and their efficacies in early diagnosis of scrub typhus in Vietnam. Results The main variables to distinguish scrub typhus from dengue included i) the eschar; ii) regional lymphadenopathy; iii) an occupation in nature; iv) increased days of fever on admission; v) increased neutrophil count; vi) decreased ratio of neutrophils/lymphocytes; vii) increased platelet count; and viii) the higher age of patients. Sensitivity and specificity of predictions for scrub typhus based on these seven factors reached 93.7% and 99.5%, respectively, in multi. When excluding the “eschar” variable, the values dropped to 76.3% and 92.3%, respectively. Using the CART model, the corresponding values for the alternative decision tree model were 95.0% and 96.9% when including the variable “eschar” and 77.4% and 90.7% without eschar. Several factors were significantly associated with acquisition of scrub typhus, including sitting/laying directly on the household floor (adjusted OR=4.9, 95%CI:1.6–15.1), household with poor sanitation/conditions (aOR=7.9, 95%CI:1.9–32.9), workplace environment with risk (aOR=3.0, 95%CI:1.2–7.6), observation of mice around the home always (aOR=3.7, 95%CI:1.4–9.9), and use of personal protective equipment in the field (aOR=0.4, 95%CI:0.1–1.1). PCR buffy coat performed best from day 1 to day 6, compared to ELISA and RDT, with an overall positivity rate of 73% during this early phase. ELISA IgM and RDTs performed better after day 7 of fever, with positivity rates of 90% and 81%, respectively, in the later phase – but contributed to diagnosis from day 3 of fever. The combination of PCR buffy coat with an RDT detected 93% to 100% of all positive cases during the first 14 days of fever. Conclusions This work provides evidence for better understanding on fostered case-detection and practical preventive measures of scrub typhus in Vietnam. A combined package with clinical training, risk factors training, and RDTs should be implemented at primary health care level to promote accurate diagnostic for scrub typhus in the hotspot area. The findings from this study are useful for training courses at the community level, support the establishment of preventive measures, create better awareness among the public and inform regional surveillance, and promote much-needed effective public health responses against scrub typhus - this after many decades of neglect in Vietnam