BACKGROUND AND MOTIVATION


The western world is facing a major shift in its demographic composition, and this constitutes a potential threat to the economy of the existing healthcare systems. This change is a result of many factors all related to the increased wealth and social security in the industrialized world which have been established in modern time. This increased wealth has lead to major advances in sanitation and other public health related engineering areas, access to an abundance of healthy food and clean drinking water, and not the least in broad public access to ever better and more efficient and relevant medical treatment, including a wide range of pharmaceuticals counting amongst others a range of different antibiotics and vaccines, as well as advances in medical technology and surgery. These advances and others have resulted in a dramatic increase in the overall expected lifespan of a western world citizen, allowing more children to survive to become adults, and allowing adults to live far longer lives than previous generations.

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Figure 1. Distribution of Danish population of age and gender 2008 to 2050. Source Danmarks Statistik

On Figure 2. to Figure 5. demographic data and data projections are shown from two very different but yet comparable western world countries, the United States of America with a partly private healthcare insurance based system, and Denmark with an almost exclusively publicly funded healthcare system. Denmark with a total population of 5.3 million with an average life expectancy of 76.7 and the US with a total population of 282.3 million in the year 2000, and an average life expectancy of 76.6 years. These figures should be compared to a world average of 63.8 years and 62.4 in the group of less developed countries [1]. At the same time, in 2000 the US spent 13.3% (16% in 2005), of its gross domestic product per capita on health expenditures, or $4,588 USD compared to Denmark spending just 8.3% or $2.555 USD per capita, and with the same life expectancy as a result. For a comparison, Turkey had a mere $459 USD per capita in 2000, which still constitutes 7.4% of their gross national product.

The U.S. Census Bureau has collected projections on the demographic composition of the future. According to their figures, the percentage of the population in the US over 65 years will rise from 12.4% in 2000, to 18.2% in 2025 and to 20.7% in 2050 - or almost a doubling in 50 years. The same numbers in Denmark are 14.8% in 2000, 21.2% in 2025 and 24.7% in 2050, or roughly the same percentage increase as in the US.
The percentage of the population becoming older than 80 years will in the US increase from 3.3% in 2000, to 4.5% in 2025, to 8% in 2050. The equivalent Danish numbers are 4% in 2000, 5.9% in 2025 and a staggering 9.7% in 2050. For both countries this amounts to an estimated increase of almost 2.5 times as many citizens at or above the age of 80.

Heart and circulatory conditions increase from being 0.53% at the ages 18-44, to 2.53% ages 45-54, to 6.6% in age 55-64, climbing to 9.67% for ages 65-74, 15.35% ages 75-84 and 22.07% by 85 and over. This shows a significant rise in the group of people over age 64.
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Figure 2. Distribution of Danish population of age and gender 2000. Source U.S. Census Bureau, International Database[1]
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Figure 3. Distribution of Danish. population of age and gender 2050. Source U.S. Census Bureau, International Database[1]

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Figure 4. Distribution of U.S. population of age and gender 2000. Source U.S. Census Bureau, International Database[1]

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Figure 5. Distribution of U.S. population of age and gender 2050. Source U.S. Census Bureau, International Database[1].

The same tendency is seen with other chronic conditions, for instance is non-insulin requiring Diabetes (type 2) increasing from 1.32% in the ages 45-54 to 4.06% by ages 65-74, or almost a four time higher incident rate in a 20 year interval only.

Americans over age 65 thus incur considerable higher medicine expenses than their younger countrymen, requiring more caretaking staff, equipment and facilities [2], [3]. It is estimated that over 600 million people worldwide have chronic diseases, and the spending on chronic diseases is expected to increase [4]. In the US alone, spending is expected to increase from $500 billions a year to $685 billions by 2020 [4].

At the same time that the number of elderly citizens requiring a higher degree of caretaking and service is growing rapidly throughout 2000 to 2050, the number of people traditionally considered within the working-age, that is, below 64 or 70 depending on culture and regulation in individual countries, is decreasing accordingly. In the US, in the year 2000 there was approximately 59% of the population within the working–age of 20-64, and only 12.4% in the older adult group, which is not considered part of the working force by today’s norms. This is around 4.7 working men and women for every retired or elderly adult. By 2025 this will have changed to 55.4 vs. 18.2 or 3 workers for each elderly. And in 2050 we end up at 53.5 vs. 20.7 – or merely 2.6 active workers for each elderly. The same ratio numbers for Denmark today (2000) are 4.2, and 2.7 for 2025, and as low as 2.2 active workers for each Danish elderly by 2050. This is a half of the workforce compared with the year 2000, and they will thus be facing at least twice the workload for each caretaking professional by the year 2050.

We may increase the potential active work force available by different means and incentives. This includes importing young and educated caretaking workers from third world countries, which do not suffer from the same bleak demographic scenarios. Or we may offer incentives for caretaking staff to work more hours, shortening duration of the healthcare educations and finally by keeping healthcare workers longer on the job market through incentive programs and other. Also, the workers may increasingly come from other sectors, as these no longer requires the same number of workers (for example from the heavy industry, and other industries being increasingly automated or outsourced).

These issues are, however, not investigated further in this paper, although they are of course most relevant as alternatives or supplement to a solution focusing on technical advances.

The other path suggested in this paper, is through the use of technology in order to increase the efficiency of the limited staff resources. This process is not in any way new, and the use of computers and electronic medical equipment has long been a major growth area.

The new paradigm within healthcare technology has been dubbed pervasive healthcare [7] (see section III on pervasive healthcare) and hails a new approach to supporting caretaking staff, patients and relatives. The area includes both the primary and the secondary healthcare sector.

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Figure 6. Limittation of acitivity caused by selected chronic health conditions among working-age adults by age: United States, 2004-2005 [5]

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Figure 7. Limittation of acitivity caused by selected chronic health conditions among older adults, by age: United States, 2004-2005. [6].

The primary sector consisting of home and community-based healthcare, including the home nurses, nursing homes and general practitioners, while the secondary sector mainly consists of small to large seized hospitals (depending on the healthcare organization of the individual country or region). The secondary sector receives a great deal of attention, and it might appear to be the most relevant sector to focus on, trying to achieve a heightening of efficiency here. It is however very likely that focusing the effort on the primary sector, by helping people in their own homes, including monitoring their condition (ECG, heart rate, blood sugar etc), and making sure they take their prescribed medication, might prevent them from ever being admitted to a hospital, and as such it will decrease the expenses incurred of a hospitalization.

As suggested by [8] the price for a hospital bed for one day amounts to a mean of $1,237 USD, varying between $2,401 USD for critical or intensive care days, to $1,122 USD for regular care (2005 numbers for the state of Michigan). The estimated average cost in a Danish public sector hospital is around $1,104 USD per day [9].

Of course, these figures may vary to a large degree between different healthcare systems, depending on wages and level of facilities, but they do indicate the overall level of the cost of being hospitalized. If we can avoid just a few days of hospitalization by increasing the quality of home care, we may achieve significant savings for each day of hospitalization avoided. This could easily finance the technology needed, while at the same time save the expected future scarce manpower available.

Also, the vast majority of Americans over the age of 65 live independently in single family homes [10] and [11]. They spend a major part of their time in the home, including around 6 hours spent sleeping [11]. It is thus most likely, that it is in the home where the realization that someone is sick first occurs, as well as where the elderly feels the most at home and confident. The earlier we might be able to help the occupant understand his current condition and what to do next, the easier it will be to keep him out of hospital.

The OpenCare Project is primarily focusing on the primary sector, the home and community-based health area. Of course, hospital staff may also use some of the information from the system, but the main objectives include early warning, information, reminders, help and guidance, as well as collecting data for better decision making for the caretaking staff, the elderly themselves and their relatives.

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