EH 1_2016

Copyright: everything possible/shutterstock.com EUROPEAN HOSPITAL  Vol 25 Issue 1/16 30 EH @ ECR Between revolution and slow-moving evolution Difficult to diagnose: interstitial lung diseases Digital Health in Germany A fan of pattern analysis Professor David Matusiewicz PhD, from the University of Applied Sciences for Economics and Management, in Essen, reflects on the current attitude to and future outlook for digital health Good teamwork, a pneumologist’s clinical data, and the use of HR-CT with very thin CT sections, high spatial resolution and specific algorithms for image reconstruction are essential ingredients for the successful diagnosis of rare interstitial lung diseases. Sylvia Schulz reports The spectrum of the Digital Health ranges from online information, to the digitisation of processes (e.g. clinical pathways in hospitals), the evaluation of big data (e.g. routine data/secondary healthcare data), Interstitial lung diseases (ILD) are rare – yet they are far more dif- ficult to diagnose and highly vari- able. Professor Julien Dinkel, con- sultant at the Institute of Clinical Radiology, Ludwig Maximilian University Hospital in Munich, deals with these rarities and presents ‘Systematic HR-CT Diagnostics, Part 1’. In October 2014, Dinkel was appointed as the newly created W2 Professor for Thoracic Imaging at the German Centre for Lung Research (DZL). ‘There is a series of basic prerequisites to making a good differential diagnosis,’ he emphasises. Those highly important prerequisites include clinical infor- mation provided by the referring pneumologist, he adds. Good team- work is essential. The second prerequisite is good technology. The technique used in this case involves HR-CT with very thin CT sections, high spatial resolution and the use of specific algorithms for image reconstruc- tion. ‘A section thickness of 1mm is almost always demanded in prac- tice’, Dinkel reports. The radiologist particularly argues the case for acquisition of CT images both during inhalation and exhala- tion, because the examiner thereby obtains additional information to assess the pulmonary window and to reconstruct the core of the lungs. ‘This is helpful, but not a must’, he notes. Above all, there is no Europe-wide standard for the use of this method. ‘One can obtain addi- tional information on minor respira- tory diseases; for example, whether bronchiolitis is present, which can be important for the differential diagnosis.’ Knowledge of microanatomy – especially with reference to the sec- ondary lobule – plays a decisive role in interstitial lung disease diagnosis. The secondary lobule is the smallest anatomical structure in the lung that is fully surrounded by connective tissue and has a diameter of 1-2.5 cm. ‘There is no chance at all of producing any images without high- resolution CT,’ Dinkel points out. Normally, only a few structures can be assessed in the secondary lobule, most of which become apparent due to pathologies. The third prerequisite for a good diagnosis is structured diagnosis. ‘I am the biggest fan of pattern-based analysis’, Dinkel states, with enthu- siasm. In structured diagnosis, the dominant pattern is identified using pattern analysis. In this process, the relationship to the secondary lobule and involvement of the lung must also be considered, and the prima- ry disease and secondary findings must be diagnosed. ‘Analysis of the HR-CT images is facilitated by consideration of four basic patterns: reticular and nodular patterns, cystic changes and den- sification of the lung parenchyma. Each pattern alone is not necessar- ily typical for a disease and they are commonly even present simultane- ously. The dominant pattern, loca- tion and the clinical data are key to the diagnosis.’ Dinkel will report on reticular and cystic patterns in his ECR lecture. For example, reticular patterns are dominant in idiopathic pulmonary fibrosis, sometimes in NSIP (non- specific interstitial pneumonia), lym- phangiosis carcinomatosa (LC) and in pulmonary-venous congestion. Purely cystic interstitial lung diseas- es, such as lymphangioleiomyoma- tosis or Langerhans cell histiocyto- sis, are recorded rather more rarely. The professor is fully aware of the fact that some colleagues have other diagnostic preferences, some excluding the most common, whilst others the most dangerous diagno- sis. ‘People with lots of experience will not go through every single pattern systematically,’ he points out. However, he recommends the ‘safe approach’ to those who are only rarely confronted with intersti- tial lung disease in practice. In such cases, however, a good differential diagnosis will only be possible at specialised centres. medical technology, diagnostics and therapy to billing procedures of pay- ers. A practical significance lies in increasing the compliance or adher- ence of patients regarding their medication (e.g. pill reminder) and prevention to care. A few years ago, the Digital Health scene was in an establishing phase. Currently the profiling phase has been initiated and market growth can be observed. The importance of Digital Health is also increasingly an important issue in health policy, health reporting, evaluation and control of the health- care system. In addition to this euphoria towards Digital Health there is also a more reserved attitude from the established actors, interest groups and health insurers. First venture capital donors lost money by sup- porting Digital Health start-ups and became more selective. According to the Federal Association of German Start-ups the proportion of start-ups under the heading Digital Health deal at 0.9% (in a market with a €314.9 billion spend on health and 5.1 million workers in 2013). Federal healthcare is a highly reg- ulated market with fewer degrees of freedom, in which existing fund- ing models have no direct relation to innovation provision (no pay- for-innovation). Since the (healthy) insured present a “contribution pref- erence” rather than a “performance preference” concerning their health- care insurance, the relative contri- bution of additional funds is more important than a better package of services given by statuary health insurance. Digital innovations are also uncertain expenditures, with- drawing money from the system that is needed to treat the sick. Calculating the return on invest- ment is not always straightforward. If Digital Health is used as a com- petitive tool to attract and retain patients/insured people, the ques- tion arises as to whether the real target was missed. Digital Health ranges between that mentioned euphoria among sup- porters and “German angst” among critics. Health economics evaluations will play an important role in the future. There is a lack of an overall strategy, which transfers lighthouse projects into standard care and inte- grates with the core business of health actors. A doctor will increas- ingly be a “transparent physician” and the patient will become an expert in his illness. The healthcare system will radically change in the next few years. Insurers and patients will vote with their feet. In the mean- time, we can hope that there is no excessive brain drain by the (good) start-ups in health and they will all have migrated to the USA. Professor David Matusiewicz PhD, from the University of Applied Sciences for Economics and Management, Essen Professor Julien Dinkel MD studied medicine at Louis Pasteur University, Strasbourg and gained his doctorate in 2010 from the Ruprecht Karl University of Heidelberg, based on research entitled ‘Four-dimensional multi-slice helical CT of the Lung: Qualitative comparison and reproducibility of small volumes in an ex vivo model’. Since October 2014 the consultant radiologist has been W2 Professor for Thoracic Imaging at the German Centre for Lung Research (DZL), LMU Munich. Pulmonary fibrosis Lymphangioleiomyomatosis ECR 2016 Friday 4 March 8:30–10:00 am. Room D1 Low dose and no-dose chest imaging: opportunities and limitations (RC 904)

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