Darwin on Patient Evolution

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By Judith Philipps Otto

As the O&P profession adapts to dramatically changing economic environmental pressures, are patient needs changing as well? Is natural selection at work in a scenario that promotes survival of the fittest?

In the 1980s, exercise science recognized and predicted a problem in the developed world: hypokinetics-lack of stimuli to the human system due to a marked decrease in physical movement. "As greater technology replaces the need for human physical movement, people may become less fit, their bodies weaker and perhaps even fatter as their caloric input exceeds their output," explains Christopher Hovorka, MS, CPO, LPO, FAAOP, director of the master of science in prosthetics and orthotics program at the Georgia Institute of Technology (Georgia Tech). "We've seen this in the United States, and now other developing nations are seeing similar changes in the health of their populations.

"Thus our society's continuing problems with obesity, heart disease, stroke, diabetes, and arthritis appear to be increasing. From an orthotic/prosthetic perspective, persons with increasing body mass and fat composition may be at risk for a multitude of other system dysfunctions such as cardiovascular disease, diabetes, and musculoskeletal stresses, which create interesting challenges in device design and treatment planning."

Others also have noticed the alarming rise in obesity and diabetes in combination. Jim Rogers, CPO, FAAOP, president of the American Academy of Orthotists and Prosthetists (the Academy), notes that the dual problems of a largely obese society (both children and adults) and significant increases in Type 2 diabetes provide a serious challenge for public health systems in terms of prevention.

"Once the public health system is restored and our schools become a place where health awareness, proper nutrition, and exercise are once again emphasized, I think we will see a reverse in the trends, but this will take a generation or more. Comorbidities are an increasing concern for the practitioner who may be caring for someone with a very complicated medical history.

Dennis Janisse, CPed, president and CEO of National Pedorthic Services, has traveled the world studying diabetic foot issues. He points out that North America has the world's highest percentage of diabetes-not a leadership position to be proud of-and the numbers are multiplying hourly. Because of our lifestyles and diet habits, a lot of children are now being diagnosed with Type 2 diabetes.

"Since [many] people are not going to the doctor to get regular physicals," Janisse says, "there are a lot of people 50, 60, and 70 years old with Type 2 diabetes who don't know they have diabetes. The disease has dramatic effects on them in a very short period of time. So what we need is preventive care, but right now, nobody really wants to pay for prevention."

Thomas Kirk, PhD, CEO of Hanger Orthopedic Group, Bethesda, Maryland, also notes that the frequency and occurrence of diabetes and peripheral vascular disease that result in amputation is continuously increasing. "As patients get older, they're delaying the onset of the disease because they're taking better care of themselves-yet the numbers are still going up. We can expect to see higher numbers coming later in life and with a whole different set of needs that will require us to think about new delivery models for those services."

The Educated Patient

Patients are evolving not only in the type and complexity of the cases they present, but also in the amount of current and specialized knowledge they acquire before visiting their practitioner. The explosion of and access to online information has prepared patients to bring their prosthetist, orthotist, or pedorthist very targeted, informed questions about the products they are using or that they want to use. "The challenge for practitioners is to balance a patient's desire for the product that they just saw at the trade show, online, or in the magazine against the need to put the right product on them and to explain their rationale," points out David McGill, vice president of Legal Affairs for Ossur Americas, Aliso Viejo, California, and member of the Amputee Coalition of America (ACA) and National Association for the Advancement of Orthotics & Prosthetics (NAAOP) boards.

James Wynne, CPO, FAAOP, director of education and training, resident director, at Boston Brace International, Avon, Massachusetts, agrees. "Because that information is so readily available to them," he says, "patients are much better informed regarding options for their treatment. We as practitioners need to keep current with the evidence base so we can help filter the information available on the web, some of which has merit. The change in the patient population challenges us as clinicians; we want to make sure all members of the clinical team are providing similar information, each from his or her own perspective."

"I've got 90- and 100-year-old patients who are much more savvy on the computer than I am," Janisse admits. "As a result, they're much more knowledgeable. I spend a lot of time [educating] my patients.... If they understand what's going on with themselves, they're more compliant, and that saves us some time."

Kevin Carroll, MS, CP, FAAOP, vice president of prosthetics for Hanger Orthopedic Group, confirms that despite all the talk of baby boomers, it is the baby boomers' parents he is seeing more of. Carroll points out that because of their consciousness of the value of exercise, fitness, and preventive healthcare, patients are arriving at an older age than ever before for their orthotic and prosthetic devices. "This particular population is coming in as educated consumers," he says. "Their expectations are higher, which is a good thing because it holds us all accountable as clinicians. In a few years, we're going to have an even more advanced group of older adults. Today's 90-year-olds are still very active, and our population of those reaching 100-plus is very rapidly growing. By 2010, we can expect to have 125,000 people over 100 years old in the U.S."

Silver Lining for OP&P

So while some of the prognostications regarding the economy and its potential impact on the healthcare industry may look bleak, there is a silver lining in the rapidly growing clientele in need of OP&P services-including 20 years' worth of baby boomers about to follow in their aging parents' footsteps, Thomas Guth, CP, president of NAAOP, reminds us. "We also have diabetes on the rampage, with persons with diabetes living longer and having offspring who inherit the disease, resulting in a huge increase."

Thus, says Guth, "this industry is going to survive and do well because the demand is going to be huge within the next 20 years, and we have fewer practitioners coming [into the profession] than the number of people aging and needing us. It's going to be hard for decision makers to cut O&P from insurance groups and the VA [Veterans Administration], when the need is increasing.

"The benefit to the industry is going to be more evident as time goes on," he predicts.

All things considered, it sounds like the OP&P industry-and its patients-have a lot more to look forward to than to dread.

Judith Philipps Otto is a freelance writer who has assisted with marketing and public relations for various clients in the O&P profession. She has been a newspaper writer and editor and has won national and international awards as a broadcast writer-producer.