Baby Boomers: The Radiological Outlook

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 - Lighthouse

The retirement of the baby boomers will have an unparalleled impact on the delivery of health-care services in the United States. The anticipated explosion of costs, the bulk of which will be shouldered by taxpayers, was a key driver in the development and implementation of health-care reform, and it continues to be an issue of paramount concern to legislators and providers alike.

Richard Gunderman, MD, PhD, says, “It’s going to challenge us even further to attract more resources to health care—in this case, health care for the elderly—or to find ways to achieve further reductions in costs and increase the efficiency with which we work.” Gunderman, a bioethicist and vice chair of radiology at the Indiana University School of Medicine, is a professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy.

Demographically, the baby boom covers a broad swath of the population, Louis G. Pol, PhD, stresses. He is coauthor of The Demography of Health and Healthcare (Plenum Press, 2013) and is John Becker dean of the College of Business Administration at the University of Nebraska Omaha.

“A lot of people think of the baby boom as a group of people who were born around the same time and who have very similar ideas and preferences,” he says. “That couldn’t be further from the truth.”

He notes that the baby boom following World War II is actually defined as including those born from 1946 through 1964, and that 1964 was chosen as the cutoff date because 1965 was the first year since 1954 in which there were fewer than four million births in the United States. “Some baby boomers are just turning 50, while some are getting close to 70,” Pol says. “That makes them a very diverse group, when it comes to health-care needs.”

Nonetheless, many demographers, futurists, and physicians agree that the baby-boom generation can be expected to bring with it more obesity- and smoking-related chronic conditions, cancers, dementia, and bone loss than previous generations brought to their golden years. Some of these conditions are partly attributable to lifestyle, while others are the result of increased life expectancy. “Not only will we see more cases, or at least a higher number of studies per patient, but the mix of cases we see is likely to change,” Gunderman says. “It will be more weighted toward the diseases of the elderly.”

Demographic Trends

Jeff Goldsmith, PhD, coauthor of The Sorcerer’s Apprentice: How Medical Imaging Is Changing Health Care (Oxford University Press, 2010) and associate professor of public health sciences at the University of Virginia, anticipates certain general trends from the retirement of the baby-boom population—currently numbering 77.3 million people—as it unfolds over the next 15 years. “A third of us are obese, and another third are overweight,” he notes. “That’s really the overwhelming difference between us and prior generations. We have a cluster of risk factors that are really quite unique.” As a result, he anticipates a higher incidence of diabetes, as well as an increased demand for joint replacement.

Complex comorbidities, though, are not the only changes for which health-care providers should be bracing themselves. Leon Rybak, MD, assistant professor of radiology and vice chair of operations, radiology department, at NYU Langone Medical Center (New York, New York), has observed significant differences in attitude between this generation of incumbent retirees and the generation that preceded it.

“It’s not just that the population is aging or that life expectancy has increased,” he notes. “It’s that members of this generation have greater expectations of what life should be. They’re active. They play sports. I’ve had older patients undergoing ultrasound-guided shoulder injections whose biggest concern is getting back out on the tennis court or golf course. They expect to live an active life into their later years. It’s a whole different ball game.”

Robert Vogelzang, MD, an interventional radiologist at Northwestern Memorial Hospital (Chicago, Illinois), concurs that the baby-boom generation’s lifestyle expectations will be elevated—and that radiology stands to be disproportionately affected. “We’ve been really exceptional at developing image-guided, minimally invasive procedures, and this generation will be seeking those,” he says. “Quality of life is going to be a big issue, and minimally invasive procedures offer that—in everything from cerebrovascular treatment to interventional oncology.”

Gunderman adds that members of this generation are likely to be more informed, when it comes to the utilization of health-care resources, than their forebears. “They may be more tech savvy and better able to access information online than we’ve traditionally assumed the elderly to be,” he says. “It’s conceivable that they may have higher expectations for the level of care they’re going to receive. As people become increasingly aware that good physicians sometimes disagree with one another, they may be more likely to seek second (or even third) opinions, and if they have unsatisfactory experiences, they’re likely to go out and tell their friends and relatives.”

Goldsmith counters, however, that lack of access to financial resources could put a damper on that enthusiasm. “We may be more demanding, but we’ll have less money with which to make our demands known,” he says. “One quarter of our generation has no retirement savings at all. The average amount saved is $29,000. If you assume that one way or another, we’re going to be asked to pay more of the cost for our health care, we’re just not going to have the cash.”

Pol emphasizes the potential for significant change as younger baby boomers learn lessons from those retiring ahead of them. “There’s plenty of hope for those at the tail end of this cohort,” he says. “If you take into account that this generation is very diverse, you can see large groups that are very aware of their health status. For a while now, these groups have lessened their intake of saturated fats; they’re not eating at McDonald’s three times a week, and they’re out on the bike trails or hitting the gym.”

Pol continues, “Among those who are retiring now, we may see a mentality, from some, saying that this is the way it is; they do things the way they want to do them, and they are not going to change their lifestyles in any way that inconveniences them. People at the tail end of the baby boom, however—with the right information and the right tools—can make better choices.”

Obesity and Its Consequences

People of all ages are experiencing obesity in unprecedented numbers, and this is especially true of the current generation of US retirees. Scott C. Goodwin, MD, FSIR, says, “Baby boomers are less healthy than the generation ahead of them.” Goodwin is Hasso Brothers professor and chair of radiological services at the School of Medicine of the University of California–Irvine and president of the Society of Interventional Radiology (SIR).

He continues, “The primary reason for this is that one-third of baby boomers are obese. Obesity is, of course, associated with increased heart disease and increased cancer risk, so not only are we facing more elderly patients in the future, but we are facing more elderly patients who will not be as healthy.”

The consequences of this trend are wide-ranging. Goldsmith points to a prediction by George Halvorson, former CEO of Kaiser Permanente, that the diabetic population will double by 2050. Rybak predicts an increase in back problems and joint injuries. Goodwin notes that not only can the incidence of cancer be expected to increase, but utilization of imaging resources related to cancer is likely to rise as well.

“Traditionally, even if a patient had multiple lesions, you would biopsy the first and then assume the rest were the same cancer,” Goodwin says. “Now, it’s understood that the genetics of the disease change over time: Even different metastases in the same body can have different genetic profiles. As therapies become even more specific to the genetics and the targets that derive from those genetics, it will be more and more important to rebiopsy.”

Though joint replacement has been available for decades, Rybak notes that there is an ongoing imperative to create better and longer-lasting prosthetics, given the increase in life expectancy. “Anyone who studies history realizes that there was no need for this technology 100 years ago—because people didn’t usually live long enough to wear out their joints,” he says. “In a similar way, it was considered a success if the first generations of arthroplasties lasted five to 10 years. Now, the push is for better materials and designs that will last as long as the joint is needed.”

Initially, these implants were all cemented into place, but it was discovered that the cement could cause breakdown of the bone around the prosthetic components. The creation of cementless designs and the use of special plastics to line the joint surfaces helped with some of the mechanics, but this material was also susceptible to wear, Rybak says.

More recently, special metal-on-metal designs have been created, but they have had their own adverse effects, in many cases. “Now, not only are we imaging patients to detect arthritis and to determine when to do these procedures, but we’re also imaging them to look for complications indicating that we need to swap out the arthroplasties,” Rybak says. “Imaging the early complications of arthroplasty to help determine the need for reoperation has become increasingly important.”

Goldsmith concurs that the demand for joint replacement will explode, but believes that diabetes will be the number-one health issue for baby boomers in retirement. He thinks that other diseases of aging—such as heart disease and chronic obstructive pulmonary disease (COPD)—might actually decline. “The smoking rate is down, compared with that of prior generations, so that bodes well for reduced lung-cancer and COPD prevalence,” he notes. “Thanks to the use of statins, we see that the interventional-cardiology and bypass-surgery rates will be down significantly from the previous generation as well.”

As a result, Goldsmith believes, on balance, the baby boomers might actually be better off than their forebears. “On the negative side, you have diabetes and obesity, but on the positive side, you have sharp declines in the death rates for the major US killers: stroke/cerebrovascular disease, cardiovascular disease, and cancer,” he says. “I think the ledger, taking both sides into account, is still mildly positive, particularly if we can reduce diabetes prevalence with more aggressive prevention.”

By contrast, Pol observes, the implications of obesity might be more far-reaching than anyone anticipates, owing to the effects of some of its comorbidities over time. “Most members of this population are expected to live into their early 80s, compared to a life expectancy of the late 60s, a couple of generations ago,” he says. “That’s another 15 years of impact from an unhealthy lifestyle, and we don’t know exactly what that will mean. High blood pressure affects the functioning of all organs, not just the heart. With our lifestyle choices, we create health realities for ourselves that we’re going to have to live with for a very long time.”

Additional Impact on Imaging

Other effects and diseases of aging stand to affect the utilization of imaging as well. Rybak points to cartilage loss as one area of promise. “Once cartilage wears down or chips away, there’s no way to replace it, and you never grow it back,” he says. “Imaging in the musculoskeletal world may actually be ahead of treatment, in this area. We can image early cartilage degeneration and visualize the biochemical process at work. We can see where cartilage is sick and going to fail. The holy grail, for us, would be to be able to do something with that information. Right now, we can’t, but there is a lot of ongoing research.”

Vogelzang cites an emerging technique for treatment of benign prostatic hyperplasia as a potential future blockbuster procedure. “We’ve done a trial of prostate artery embolization, and already. our phone is ringing off the hook with people who are interested in avoiding surgery (which involves the possibility of incontinence),” he says. “This generation is already seeking out treatments that will cause the least disability, allowing people to maintain their lifestyles.”

Goodwin observes that there are many lines of research that are particularly promising for incumbent retirees. “An area discussed at the recent SIR Annual Scientific Meeting was developing an alternative to vertebroplasty and kyphoplasty,” he says. “Osteoporosis is often an issue of age, obviously. We’re looking for ways to treat compression fractures that don’t involve the use of medical cement alone.” So far, the use of a polymeric device to restore the height and stability of the vertebral body, he adds, appears to have worked as well as (if not better than) balloon kyphoplasty.

Goodwin also mentions targeted therapies for metastatic breast cancer. “When the disease metastasizes to the liver, patients see their quality of life and longevity affected,” he says. “With radioactive beads delivered directly to metastatic liver tumors in breast-cancer patients, the disease can be treated with minimal side effects.”

Gunderman notes, however, that in the case of slower-progressing cancers, imaging utilization might actually decline as detection and intervention become less critical concerns. “The vast majority of older men who have microscopic evidence of prostate cancer probably won’t get very sick from it, and they are likely to die of something else before it has an impact on them,” he says. “There also may come a point in the life of women when they choose to stop screening with mammography—because the disease, if they have it, will develop so slowly and cause so few problems that undergoing treatment for it will be more of a loss than a gain.”

Goldsmith adds that there is emerging evidence to suggest that Alzheimer disease will be less prevalent than previously anticipated. “Some people are now revising their forecasts downward and saying this might not be as serious a problem as we once thought,” he says. “There is apparently a socioeconomic gradient associated with Alzheimer-disease risk; wealthier countries are showing significantly lower rates of Alzheimer disease than were predicted. We’re still seeing a rising curve here in the United States, but the numbers aren’t as scary as people had suggested they might be.”

Prevention and Cost Containment

Prevention will be key to mitigating future health-care costs, Pol says. “I’d make the case that in some ways, this is the first older generation truly to be concerned about prevention,” he says. “Advances in health-care research have led to a clearer understanding of the relationship between lifestyle and health outcomes. We’ve been having public conversations about the effects of inactivity, of smoking, of carcinogens in our workplaces, and of the foods we eat.” He adds, “Prevention often seems to work in our minds more successfully than it works in practice,” however.

Any conversation about prevention necessarily becomes a dialogue about population-health management, Gunderman says. “We shouldn’t be focusing primarily on expanding the human lifespan,” he explains, “but rather, on keeping people healthier and more functional until they reach life’s limits. If we can prevent, delay, or otherwise mitigate the progression of key diseases and spread that over the growing aging population, there are major implications for the cost of care as a whole.”

Rybak observes that imaging can assist with cost containment in health care by identifying opportunities to use less costly modalities. “In South America and other parts of the world where health-care systems couldn’t support the cost of an explosion in advanced-imaging utilization, people got quite good at doing with ultrasound what we might do with MRI,” he says. “We should identify where we can use ultrasound for image-guided procedures or to diagnose early arthritis or other conditions.”

Goodwin adds that attention should be paid to the nature of procedures in order to limit downstream costs, where possible. “The less invasive the medical treatment, the more cost effective, in the long term, you can expect it to be,” he says. “I think interventional radiology can play a big role in helping to curtail costs, as we go forward, by continuing to develop and improve minimally invasive treatments.”

From his perspective as a sociologist, Goldsmith predicts that increasingly stringent appropriateness criteria will be implemented in order to blunt the escalating costs of care. “So far, 40% of each baby-boomer cohort has chosen Medicare Advantage when retiring,” he notes. “That’s 2.5 million enrollees in 2012 and 2013, and 700,000 already this year. I view these plans as significant future mediators of imaging demand. I’m not sure epidemiological characteristics will drive volume as much as the prevalence and use of appropriateness guidelines.”

End-of-life Care

Vogelzang highlights an emerging cost center that crosses specialty, modality, and procedure lines: end-of-life care. “As unpleasant as it is, this is a discussion we have to have,” he says. “As an interventional radiologist, I see a lot of care rendered excessively at the end of life, to no net benefit. In the future, we will not be able to afford to do that.”

He points to a 2013 newspaper article1 in which many physicians agreed that at the end of life, they would decline the very interventions that are routinely recommended to patients and their families: resuscitation, intubation, and dialysis. “As a profession, we advocate things we wouldn’t want used on ourselves,” Vogelzang says. “I think that’s a very telling discrepancy.”

Debates about the bioethics of end-of-life care can quickly turn heated—a tendency against which Gunderman cautions providers. “The shouting heads on television attempt to polarize these matters,” he says, “but any sober observer of the interplay between human aging and health care would say that we do not want to keep every person’s heart beating until the last possible moment. There comes a time when death is no longer a defeat for medicine. We need a paradigm shift that recognizes that we are all going to die, and that in some cases, we might not want to expend our life savings (or devote too much of other people’s resources) in postponing our death.”

Like Vogelzang, Gunderman thinks that radiologists can contribute most meaningfully to the conversation about how best to care for the next generation of retirees by considering what, as experts, they would want for themselves. “These aren’t just matters for patients,” he says. “Eventually, all of us—radiologists, technologists, and administrators—will become patients ourselves. We need to be prepared to offer our informed standpoints on these choices.”

Reference:

  1. Gorenstein D. How doctors die: showing others the way. New York Times. Published November 19, 2013. Accessed April 5, 2014.