When an economist gets a heart monitor

The following originally appeared on The Upshot (copyright 2015, The New York Times Company).

At rest, I could feel my heart pounding out a double beat. It felt like falling in love, only I wasn’t.

My cardiologist explained that one of my heart’s lower chambers — a ventricle — sometimes pumped when it shouldn’t, causing a sensation of an overly strong double beat. “I’m 99.9 percent certain it’s benign,” he said.

Confident in his diagnosis, my doctor advised against further tests and visits. I thus avoided the unease I always have about medical tests. As a health economist, I know that many aren’t necessary. As a patient, I’m not confident I know which ones.

As my palpitations persisted, so too did my concern. By not ordering additional testing and follow-up, was my doctor using health care resources wisely or too wisely? Was I the patient for whom additional tests would be beneficial or wasteful?

The health economists Amitabh Chandra and Jonathan Skinner tell a cautionary tale about medical technologies like advanced imaging and testing. Some are valuable for some people but are used in a great many more for whom it is wasteful. When applied to the population with the right risk factors, various tests of the heart can save lives. When applied to a population at very low risk, a great deal of it does little but add to our health care bill, waste patients’ time and lead to unnecessary procedures, which carry their own risks.

After the exchange of a few emails, my doctor ordered an at-home, 30-day heart monitor. It’s a marvel of modern technology. Electrodes on my chest fed my heart’s rhythm, over wires, to a recorder on my belt, which wirelessly communicated the data to my physician. With onboard software, it continuously monitored for signs of a heart attack.

As amazing as this technology is, it wasn’t amazing enough. The wires tickled my torso and puffed out my shirt. The bulk of the recorder on my belt poked my waist, hampering movement. I felt concerned looks whenever the monitor was in plain view. It was hard to forget I was a patient. I felt tethered to, not freed by, technology. These inconveniences were like small physical and psychological co-payments, increasing the cost of the test to me, the patient.

The cost proved too high, particularly since I was uncertain that I even needed 24/7 monitoring. (I mean the psychological costs, although my insurance company was billed about $2,200, of which it only paid about $100. My copay was $40). Within a day, I unplugged and immediately felt liberated. (Have no fear, I subsequently plugged back in when I felt the double beat and captured the recording that would confirm my doctor’s original diagnosis: benign.)

Technology improvements will reduce inconveniences like these to patients. Eric Topol, a cardiologist and director of the Scripps Translational Science Institute, imagines such a future. Technology will advance so that we will soon be able to unobtrusively monitor a wide range of our bodies’ processes — heart rhythm, blood pressure, blood sugar and more — generating streams of personal health data. Even today, my heart’s rhythm could have been assessed with a Band-Aid-like patch, requiring no wires or bulky monitor.

If the physical, mental and financial cost of collecting data about one’s body falls, more will take advantage of the technology. Out of curiosity, an abundance of caution, or for fitness reasons, people will monitor their hearts’ rhythms not just when their doctors order them to, but all the time. The data such widespread monitoring would generate might enhance researchers’ ability to learn early cues to potential problems. It might save lives.

This is not so far-fetched. Already, wearable heart monitors for stroke patients can more reliably diagnose irregular heartbeats so doctors can intervene to decrease the risk of subsequent strokes. Other wearable devices not only monitor conditions, but also deliver lifesaving treatment. For instance, implantable defibrillators decrease risk of mortality for some patients with heart failure by shocking their heart back into normal rhythm.

But, notice: These examples are for technology targeted to specific groups with significant heart problems, the people we know will benefit most. What happens when millions of healthy people start recording their hearts’ rhythms just because they can? Even though the devices that enable this may be cheap, collectively we may pay a lot if doing so leads to over-diagnosis and unnecessary procedures. People who need wearable health monitors the least may be among those most likely to use them.

Are advances in medical technology like this worth it? There are no easy answers in medicine. New technology is amazing. It frequently improves lives and even saves them. But we often overuse it, inviting the familiar concern about waste. Then ever newer technology comes along and we hear renewed claims that it will, at long last, bring us better care at lower costs.

Each time it feels right, but so often it doesn’t last. It’s like falling in love.


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