Meet the Solutionists, with Mark Scott

Cardiovascular disease is one of the leading causes of death worldwide – thankfully, we’re getting better at treating it, and more people than ever are surviving major events like heart attacks. But it’s a double-edged sword: with more people living for longer with cardiovascular disease, our hospital system is overburdened. 

Cardiologist Dr Clara Chow says this imbalance is only going to get worse, because the rate of new cardiologists and other health professionals won’t match the rate of patients visiting hospitals. So, what do we do? 

Clara is committed to finding frugal solutions for problems like these: efficient, cost-effective approaches that could have massive impact. One example is text messages. That’s right – a good old SMS could be the key to recovering from a heart attack...

Mark Scott  00:01

This podcast is recorded at the University of Sydney's Camperdown campus on the land of the Gadigal people of the Eora nation. They've been discovering and sharing knowledge here for tens of thousands of years. I pay my respects to Elders past and present, and extend that respect to all Aboriginal and Torres Strait Islander people.

Mark Scott  00:29

There's a problem at the heart of Australian Health. Cardiovascular diseases are one of the country's leading causes of death. Nearly 18% of Australia's population lives with cardiovascular disease, and every second, someone is hospitalised because of it. We're getting better at saving lives, but that success has created its own challenge. More survivors means more pressure on hospitals already stretched to the limit.

Mark Scott  00:57

Could the solution be modern technology? And I'm not talking about medical technology. I'm talking about something as cheap and simple as a text message.

Mark Scott  01:09

This is The Solutionists, and I'm Mark Scott. Professor Clara Chow is a cardiologist and the Academic Director of the Westmead Applied Research Centre at the University of Sydney. She's at the forefront of using digital tools to transform how we prevent and treat cardiovascular disease.

Mark Scott  01:30

Clara, as a cardiologist, one of your primary concerns is treating heart attacks. What happens when someone comes to hospital suffering from a heart attack?

Clara Chow  01:40

Mark, firstly, they've got really bad chest pain, usually, and symptoms, and we react immediately. We want to get them treated. So these days, in a city like Sydney, we take them to the cath lab and we try to open up that vessel immediately. And we then start them on a whole bunch of medicines to hopefully keep that artery open, and then we do some tests to see how much damage has been done to the heart, and then we let them go home. 

Mark Scott 02:08

So if all goes well and the person survives, what happens say over the next six months? What does that look like after a person's first heart attack? 

Clara Chow 02:18

The thing about heart disease is that once you've got heart disease, it doesn't go away. And a person who's had a heart attack is at pretty high risk of having another heart attack. It used to be, we would quote that if you've had a heart attack, your chances of having another one in the next five years is about two in five. So 40% of people could have another heart attack in a pretty, pretty short period of time. The great thing is that a lot of treatments have been developed over the years, medicines that we can give them and that can actually really reduce that risk to reduce by nearly 80%. So, you know, go from like 40% chance to more like two or 3% chance. But the difficult thing is that they've got to take these medicines. They've got to change their lifestyles, their behaviours. They've got to change their diets, they've got to become more active. They have to do all of these things to be able to achieve those much lower risks of getting a repeat heart attack. So I suppose to your initial question, what happens in the next six months? I would love to see them change all of these things and take all these treatments.

Mark Scott  03:32

Clara, could you take us through what your average work week looks like? How does your work bring you into contact with heart health and the patients and the research that you're doing. 

Clara Chow  03:42

I think I'm pretty lucky that I get a week that is, I suppose, broadly half teaching and education and research, and probably research is a big part of that, and half being a cardiologist and seeing patients and looking after them at Westmead Hospital. So that kind of looks like alternate days, actually, though a lot of it intermingles in each other. So as a clinician, I'll see patients, whether it's in the emergency department or in the wards or the clinics, and I'll often talk to them about things like their presentation and how we manage them better and their treatments, and I try to explain to them all of these ways that they can prevent them from worsening their heart condition or getting heart disease in the first place. Through my research, I get to be quite I suppose, complimentary to that, because my focus of my research is on preventing heart disease, and I have been working to develop different digital health solutions to be able to support my patients and other patients now prevent and learn how to prevent heart disease. So that involves supervising students on specific projects and asking specific questions, like, is a patient able to use digital health tools? Is it going to work for a whole lot of patients doing clinical trials, those sort of things.

Mark Scott  05:12

And you're a great example of what we see a bit of at the university. You're seeing patients, you're doing research, you're teaching students, to what extent has your experience with patients informed you of areas you really want to dig into, on your research, particularly around the prevention end of heart disease and helping people who've had this shock remain well rather than further deteriorate. 

Clara Chow  05:33

Yeah, look, I think the day to day kind of clinical experience is very important in me working out what questions I want to ask and what sort of research I do. I mean, we started realising patients were surviving from their heart attacks, which is amazing, right? I mean, actually, cardiology has changed massively over the last 20 or 30 years. It used to be people, you know, could die from this. Now they're living with this. But you know, and notice that actually, instead of the people presenting to our hospital as being people with their first heart attack, they were coming back in after their heart attack, with repeat heart attacks, trying to work out, okay, why do they keep coming back in? Realising actually it's because they're not taking their medicines. They're not doing the things we tell them that to do. Then I realised that actually it's hard to do all of those things, and so those sort of experiences have very much informed what research I do now. 

Mark Scott 06:25

It's clearly a magnificent achievement that more people survive that first heart attack, but it puts real pressure on the hospital system, doesn't it, too, and particularly return. Tell us about the scale of that change and that systemic pressure it's putting on our hospital systems. 

Clara Chow 06:35

I mean, look, you know, in kind of big numbers, if we stand back, everybody is ageing, and it's expected in the next 25 years, we're going to double the number of people over the age of 60, and we're probably, we're going to double the number of people with heart disease. Now, if people with heart disease have a higher chance of coming into hospital, we're just going to have more, I don't want to say customers, but we are going to have more people needing the hospital system to support them after their heart disease. I mean, they do need additional procedures, additional treatments, and they're more likely to get heart attacks. So I worry that the way we practice health care now, you know, the hospital and the clinic, will not be able to manage I suppose that increasing number of patients, and I worry that we won't be able to deliver as good care to those patients as we are now. So, I mean, we are on a daily basis, seeing more patients coming to hospital. I can't see us doubling our medical workforce in 25 years.

Mark Scott 07:50

Nor doubling number of hospital beds.

Clara Chow 07:52

Nor doubling the number of hospital beds. 

Mark Scott  07:55

So what are we going to do? So take us through you've seen already great changes in your career. If, in fact, you throw it forward, what is, in a sense, the practical solution of sending more people home quickly after heart attacks and trying to get into this preventative state with them, so it's not tragically reoccurring and reoccurring again. You said earlier that the discipline involved in making the lifestyle changes has proven to be considerable. So what are the clues and insights that your research has given you about helping the prognosis for people? 

Clara Chow 08:35

I think that that is absolutely that changing mindset to be more prevention focused. We're already pushing patients out of hospital quicker, regardless whether that's a good thing or not. We're pushing them out. But I also think we need to kind of transform the way we deliver health care. I think we should be able to deliver kind of support and care when people are still at home. We need to be able to monitor and identify those people that are at risk before they fall and have another event, and we need to treat them earlier, which is all that kind of prevention thing. I mean, some of the things we've been starting to do is use digital health solutions to support people after hospital discharge and to reach out to them all with personalised support, trying to help them in their journey around learning about heart disease and changing their diet and providing that education a little bit more bite sized chunks along the way. So explain to us how you do that. How do you use text messages to help someone change their lifestyle?

Clara Chow 09:42

Yeah, it seems a little bit far fetched, doesn't it? Okay? So how we do it? Okay, so on Monday, after the last week, we send an outreach to by text message to all the patients that were in hospital in the last week. 

Mark Scott  09:59

So I've gone home. I've had a heart attack. You've looked after me, but you've sent me home, and on the following Monday, I get a text message. 

Clara Chow 10:09

Yep, something like Hi. This is Westmead Hospital. You've just recently been in Westmead Hospital with heart disease, and the Westmead Department of Cardiology would like to continue supporting you. If you'd like that, please enrol in this programme, and then they click on a link and they can enrol in the programme. 

Mark Scott  10:24

Yeah, and if I enrol in the programme, which I hopefully do, what are you going to do for me?

Clara Chow  10:31

We've developed a programme, and it's mainly delivered all via text message. It contains bite sized chunks of information there's been, you know, carefully selected by our clinicians and our researchers and also reviewed by patients to make sure that it's reasonable for patients. We send them information about their diet, their exercise. If they're a smoker, we'd send them information about smoking cessation. If their diet is vegetarian, we wouldn't, you know, we'd send customised - so we can personalise the messages. 

Mark Scott 11:09

What is the personalisation like? 

Clara Chow 11:10

So we personalise things like risk factors, so clinical risk factors, so if you've got diabetes or hypertension, or if you don't have diabetes.

Mark Scott 11:20

You'll get different messages.

Clara Chow 11:22

You’ll get different information. If you're a smoker, if you're vegetarian, if you tell us you want to speak another language, we can deliver it in other languages. So all of those things we use to personalise the content, but we also say, Hi Mark. This is from Westmead Hospital, so we add that too. 

Mark Scott 11:41

And what kind of things are you encouraging me to do? 

Clara Chow 11:44

So we're trying to let you know about the medicines and give you reassurance that, yes, you've been started on a bunch of medicines, but this is what each of these medicines do. We acknowledge that it's really hard for you to take medicines regularly, and we give you some tips about how to be more regular about your medicines. We give you information about, if you have a side effect, what to do and how you can reach back out. We give you an option to text back and ask a question if you need to. 

Mark Scott 12:11

So is there a multidisciplinary approach to this kind of medical intervention and support? And what other experts are you drawing on to try and get this preventative medicine approach to heart disease in place?

Clara Chow 12:23

So the text messages aren't just the ones that I write. They are a team of people that write them. You know, we've got clinicians and researchers to make sure the content is correct, but we also work with patients and consumers, people that have heart disease and people that don't have heart disease, their families and their relatives to make sure we get the language right. We work with health literacy people to make sure we get the language right for the different types of patient populations. We work with behavioural psychologists and people that are more familiar with how to change behaviours to make sure that the way we say the message gets people or nudges people to change their behaviours. So yeah, it's absolutely a multidisciplinary approach. 

Mark Scott  13:04

Do you see AI chatbots as a possible variant of this, and, in a sense, a more live and interactive variant? And how do you, how do you evaluate the potential and the risk of that? 

Clara Chow  13:15

Yeah, we're actually running a programme we call Chat AF. It's a conversational AI programme where we are trying to coordinate healthcare with, I suppose, bots. So let me walk you through that. So these are patients with atrial fibrillation, a slightly different cardiovascular condition. After they leave hospital, we want to have follow up visits, but we programme these with IVR, which is voice technology, so it rings up and says hello, but it's not a person. Hello, this is Westmead Hospital cardiology calling for Mr. Smith. Is this Mr. Smith? Mr. Smith, we want to check in on you after your event. You know, how are you? And so it then goes through a series of questions to ask how they are, depending on the answers to these questions. If they're all good, that's good, that's the visit. But if they're not good, or they flag up risk, then we send a real visit, so we have a real person connect to them. And we're running this as a trial at the moment, where we programme a number of visits across a six month period to see whether patients are okay with being supported by, I suppose, this kind of digital chatbot type system, and to see if we're actually improving their quality of life and their health outcomes in that. So it's a randomised clinical trial again.

Mark Scott  14:38

It's interesting, whilst that sounds tailored and sophisticated in design, when it comes to execution, it's kind of pretty simple. You're sending out text messages every day. What results are you seeing from that kind of almost, you know, low touch intervention? Rather than a kind of medically highly sophisticated intervention?

Clara Chow 15:05

Well, I would say it's low touch for the patients, but it's still relatively complex for the algorithms. But we've done a number of randomised clinical trials, and that's when we randomly assign half of the patients to receive the programme and half of them to not receive the programme, and then we've compared health risk factors and outcomes in the people that received the programme and didn't. Now, the people that received the programme were more likely at six months to have lower blood pressure, more likely to quit smoking, more likely to have lower cholesterol and more likely to report a better diet and more be more physically active compared to the controls that didn't receive the programme. So that's one type of evaluation we've done for the programme. More recently, we've also looked at comparing the people that received the programme to those who didn't enrol in the programme, and we've looked at their likelihood of re hospitalisation or coming back to the hospital, and we found that the people that receive the programme are less likely to come back to the hospital or come back to our emergency department compared to the people that haven't received the programme. And we're pretty excited about those sort of things, right? They're kind of the things that we do look for in medical treatments, or many, you know, more sophisticated technology treatments, and it's, I suppose, as you say, a light touch, but it's a service level intervention.

Mark Scott  16:26

And terribly exciting outcomes. The extent to which people are really paying attention to that, and the extent to which you could see this scaled around the country?

Clara Chow  16:36

Look, we're excited to say that we have delivered this in our 10,000 patients out of Westmead Hospital. And you know, I'm proud that we have been able to do that. I am also kind of proud that we've been able to pitch it to our local district, and they're going to support this as a service in an ongoing way, so we can spread it to more people in Western Sydney. But the solution we've developed, and we've worked in partnership to develop this, because I am still a cardiologist and a researcher, and I don't, you know, do complex kind of programming and stuff, so we have partnered with good engineers to create now a robust and secure platform. So I'm pretty confident now that this platform could support rolling out this programme to multiple hospitals in multiple places. Now I need to work out how to convince, I suppose, other parts of government, health systems, countries, states, etc. 

Mark Scott 17:41

It's interesting, though, with a layman's perspective on it, I appreciate it's sophisticated and tailored in its design, but it's pretty frugal in its implementation. You know, the cost of text messages, compared to the costs of drug development, new treatments and therapies, the cost of hospitalisation and intensive care, I would have thought almost the economic modelling behind this would make it a compelling case for scaling. 

Clara Chow 18:09

Yeah, we've actually also partnered with health commerce to evaluate the programme from an economics point of view, and they've told us it's cost effective. Actually, they've told us it's cost saving. So yes, it does seem to make sense from an economic viewpoint.

Mark Scott 18:27

You described earlier, that the part of the pressure that health systems are under comes with an ageing population, and you're using a digital solution. You know, a stereotype would be that older people are not as comfortable with technology, not as comfortable with digital solutions, if you like, to a range of things in life. How do you deal with a clientele that may not be as tech literate as their children or grandchildren in this?

Clara Chow 18:53

I think that we have learnt that actually older people often are quite open to these type of solutions. We have kept the bar relatively simple, though, with a text message as being the main entry and exit. We have started creating more complex solutions so they could download an app and they could get more information and interact more and you know, some of our more complex solutions. Now we're pulling in wearable data and other monitoring data to further customise and create more complicated algorithms, but we found through our research that older people are able to engage with this. Often they're more excited to do that. And actually, in our evaluation, like our analyses, we found that older people actually benefit more, as in, they have a greater reduction in the likelihood of hospital representation compared to younger people. I mean, that might just be because older people are at more risk, but it kind of indicates, though, that it's just as helpful for older people as younger people. 

Mark Scott  19:55

Why has frugal innovation been important to you as a researcher and a cardiologist?

Clara Chow  20:00

Well, I did a little bit of an odd thing as a PhD student. I did a PhD in international public health, and partly that was just an opportunity that came up. My PhD programme was based in rural India and developing a cardiovascular prevention programme suitable for scaling into rural India. Then, even earlier than that, I was interested in programmes to improve equity and health in many different areas. So I suppose that lens I can't get rid of, and that's something that continues to be important to me. But I also think that to make things scalable, if we are frugal and we only have a certain amount of resources in the world, I get that, so, you know, if it is frugal, we can do high value with, you know, lower cost care, why not?

Mark Scott  20:55

Clara, you've described the kind of intervention that happens when someone comes into an emergency room with a heart attack. And I think we're all kind of familiar with that from television. You know, it's kind of dramatic and bold interventions, but as I hear you talk about how this is changing, there'll probably be less of that and more management of patients on an ongoing basis, because, mercifully, many of them are surviving that first encounter. So if you're a young cardiologist now if you're just training now, how do you think the shape of your discipline, the shape of your profession, might change through your career, given what you're seeing happening now?

Clara Chow  21:41

I think it is interesting. Cardiology previously attracted a lot of people that wanted to, one be involved in acute medicine, but also in the procedural side of medicine, of which, you know, I think there will still be, you know, things to do, but you're right. You know, as I see patients getting very sophisticated implanted devices, and us getting lots of not only simple, but really complex data coming in remotely from all of these devices, I think cardiologists are going to have to learn how to manage larger numbers of patients well and interpret this information that is coming in well, really, I don't think we've seen an era where we've got this much information. We can get daily information about patients. And being able to prioritise. I mean, it's very easy if they tell you you've got a chest pain, but if you want to pick up the things before they have chest pain, I think the patterns are in the data. 

Mark Scott  22:36

So just explain that a bit more. I mean, you would have once responded to someone who was presenting with a heart attack. Now with a device implanted on them, in a sense, you can get live feeds or regular data insights from patients that give you greater insight as to what is going on, greater capacity to assess risk in advance.

Clara Chow  22:59

So we can now, today, we're already getting alerts off these devices. But actually, we're struggling with understanding all of these alerts at the moment, because we don't kind of know what all of these measures mean. We've got some understanding. So even now, trying to juggle, I suppose, seeing the patient in the emergency department, but also hearing that Mr. B got an alert for this, and do I pull them in? Or should I give them a call? Or, you know, how I manage those sort of things? That is just going to get a whole lot more in the future. And I think we're going to need to get better at understanding all of that remote information and data. Hopefully there'll be tools that are able to help us work through that. Things like the artificial intelligence algorithms and all of these sort of things will help us sort through some of that information, but it will still take other things for us to be able to evaluate people, I suppose, in a more virtual sense or remote sense, than the one sitting in my emergency department.

Mark Scott  23:59

And still with the behavioural changes that are required, this kind of medicine is still going to be kind of deeply personal and, in a sense, behavioural in how you're engaging with patients so they make the changes they need to make. 

Clara Chow  24:15

Yeah, and I think it's also about how we maintain our relationships with patients, because the personal relationship is one that we've all learned to develop, and how some of the things I've seen in this delivering Digital Health Solutions is we've been able to maintain a connection using digital tools with all of these patients. And that's excited me as well. I mean, we do what we call detailed qualitative evaluations, which these detailed interviews of patients to understand why did this work for you? And a lot of the feedback that comes back from this is because I still feel connected to you. I still feel you are caring about me and that you're there to keep an eye on things, and that sort of thing that we're able to do with the help of technologies is very useful when I think about how I need to manage more patients into the future well.

Mark Scott  25:15

That's Professor Clara Chow, cardiologist, Academic Director of the Westmead Applied Research Centre at the University of Sydney, and perhaps you might hope that Clara isn't texting you anytime soon. If you're interested in how technology is transforming our approach to health, make sure you listen to our episode with Professor David James, who's working towards more and more precise medications.

Professor David James  25:37

I would like to see is if we could do a test on people right at the get go, and that test would tell us you should be taking Drug Y, so that you immediately prescribe Drug Y, save all those problems, and you save the potential dangerous adverse effects from taking four medications instead of one.

Mark Scott  26:00

You can listen to that episode of The Solutionists right now and make sure you're following the show so you don't miss an episode.

The Solutionists is podcast from the University of Sydney, produced by Deadset Studios. Keep up to date with The Solutionists by following @sydney_uni on Facebook and Instagram, and @sydney.edu.au on Bluesky.

This episode was produced by Liam Riordan with sound design by Jeremy Wilmot. Supervising producer is Sarah Dabro. Executive editors are Kellie Riordan, Jen Peterson-Ward, and Mark Scott. Strategist is Ann Chesterman.

This podcast was recorded on the land of the Gadigal people of the Eora nation. For thousands of years, across innumerable generations, knowledge has been taught, shared and exchanged here. We pay respect to elders past and present and extend that respect to all Aboriginal and Torres Strait Islander people.