Transcript Technology drivers - problems and solutions

UCL SCHOOL OF LIFE AND MEDICAL SCIENCES
The Future of Healthcare in Europe
Technology drivers:
Problems and Solutions
Professor Sir John Tooke
UCL Vice Provost (Health)
Head of School of Life and Medical Sciences
Supply and demand factors
• Demography
• Economic
− Recession
− Tax earner : beneficiary ratio
• Technological capacity
− Affordability v Productivity gains
• Public expectation
Increments in life expectancy
UK Office for National statistics, 2010
Projected main causes of death, worldwide,
all ages, 2005
Chronic respiratory, 7%
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Cardiovascular disease,
mainly heart disease
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Cancer
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Chronic respiratory
disease
•
Diabetes
Cancer, 13%
Other chronic, 9%
Diabetes, 2%
Injuries,
9%
Total deaths
58 million
Cardiovascular,
30%
Communicable
maternal & perinatal
conditions, &
nutritional deficiencies,
30%
Preventing chronic disease a vital investment: World Health Organisation
% of GDP per capita
Healthcare expenditure by age group (in % of GDP per capita)
Age group
Dormont et. al., Health
expenditures, Longevity
and Growth, 2007
The impact of demographic shifts on healthcare:
Tax earner:beneficiary ratio
AT Kearney, Healthcare out of Balance, Sept 2009
Supply and demand factors
• Demography
• Economic
− Recession
− Tax earner : beneficiary ratio
• Technological capacity
− Affordability v Productivity gains
• Public expectation
Medical Technology: Economic impact
• Practice change
• Substitution
• Spread
• Cost efficiency
• Economic productivity
• Welfare
Cost drivers: ‘End-Stage Disease’
e.g.
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•
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2nd, 3rd, 4th… line cancer drugs
Sophisticated stents
Endoscopic procedures / robotics
Regenerative medicine etc.
NICE cost effectiveness guidelines
• National Institute for Health and Clinical Excellence (NICE) - a
special health authority of the NHS.
• A standard and internationally recognised method is used to compare
and measure the clinical effectiveness of drugs: the quality-adjusted
life years measurement (QALY).
• Cost effectiveness is expressed as ‘£ per QALY'.
• Each drug is considered on a case-by-case basis. Generally,
however, if a treatment costs more than £20,000-30,000 per QALY,
then it would not be considered cost effective.
Technologies as solutions
• Refocusing on prevention
• Genetic risk
• Reprogramming
• Personalised therapeutics
• E-Health
“It’s my genes/glands doctor”
• A common variant in the FTO
gene is associated with BMI and
predisposes to childhood and
adult obesity.
• The one in six adults
homozygous for the risk allele
weighed 3kg more and were
1.67 times more likely to be
obese.
Frayling T. M. et al., Science (2007)
Gastric banding: economic benefits
Report : Office of Health Economics, Shedding the pounds, 2010
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~1.1 million patients are eligible according to NICE guidelines
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Studies suggest 25% would like surgery
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Only 3,600 operations were undertaken in 09/10
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If 5% of patients eligible had surgery the economy would gain £382m within
3 years through reduced NHS burden, reduced benefits expenditure and
income tax generated by those back in work.
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If 25% had surgery, £1.3bn would be realised within 3 years, even taking
into account the cost of the surgery itself.
Technologies as solutions
• Refocusing on prevention
• Genetic risk
• Reprogramming
• Personalised therapeutics
• E-Health
Classical risk factors and cardiovascular
events
• Most cardiovascular events occur in men with ‘average’
risk scores
• 86% of 10 year events not predicted by risk score
• Can we improve by genotyping?
A CVD-Risk DNA Test : Fact or Fiction
Fact
Using several genes  predictive over-and-above other risk factors
Based on statistically robust accurate and reproducible risk estimates
MUST use WITH CRFs to risk stratify in e.g. CHD risk clinics
Genotyping is affordable and accurate
No evidence for negative psychological impact (with pre-test counselling)
Genetic
10 yr CVD risk
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CRF
30
25
20
15
10
5
0
Ave
Patient
Yes! CVD-Risk DNA testing is ready now!
Humphries S, UCL Genetics Institute
Identifying diabetic patients prone to renal
failure
• 30% Type 1 DM
• 40 – 50 x mortality rate
• Greater incidence of all complications
• Familial predisposition but ~ 10 years before physiological
phenotype detectable
Technologies as solutions
• Refocusing on prevention
• Genetic risk
• Reprogramming
• Personalised therapeutics
• E-Health
Programming of hypertension
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A study on rats demonstrated that raised
blood pressure associated with foetal
exposure to the mother’s low-protein diet,
was prevented by the early administration of
medication (ACE inhibitor ‘catopril’).
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This may be a critical determinant of the
animal’s long-term cardiovascular health.
9% casein control
9% casein catopril
18% casein control
18% casein catopril
Systolic Blood Pressure of female rats exposed to
18% casein or low protein diets in utero and treated
with catopril for 2 weeks.
Source: Sherman, R et al. ClinSci (1998); 94:373
Infant feeding trials
• A nutrient enriched diet (formula feeds) in small for
gestational age infants increases later blood pressure
Diagnostic BP
Standard diet
(n=83)
Nutrient enriched
(n=70)
P
61.3mm
64.5mm
0.02
A Singhal et al., Circulation (2007); 115:213
Technologies as solutions
• Refocusing on prevention
• Genetic risk
• Reprogramming
• Personalised therapeutics
• E-Health
Refill adherence to oral hypoglycaemic
drugs…
• Good ‘persistence’ (>80%) seen in only 52% of 56,000
veterans
• Good ‘persistence’ associated with achieving good
glycaemic control (HbA1c </= 7.0%)
Kim N et al ANN Pharm 2010;44:800
Is ‘Personalised Medicine’ the key?
Potential benefits:
• Less adverse events
• Less unnecessary treatment
• Better outcomes
• Long term cost benefits?
• More drug sales?
? Better adherence
Technologies as solutions
• Refocusing on prevention
• Genetic risk
• Reprogramming
• Personalised therapeutics
• E-Health
E-Health
• Remote advice
• Social networking
• Remote diagnostics
• Empowerment
Case studies: Medicall and CMO
• Independent, subscription health-hotline
operating in Mexico since 1998.
• US provider of integrated healthcare management
solutions.
• Offers phone consults, drug information and
discounts in certain medical facilities.
• Network of 2,300 providers.
• Members have access to a referral network of
6,000 physicians and 3,200 health service
providers.
• Hotline receives average 90,000 calls a month.
• Provides services to 179,000 health plan
members using an experienced staff of welltrained nurse case managers
• Has dramatically reduced in-patient and
emergency room visits
• Two-thirds of cases are resolved over the
phone.
Addresses ACCESSIBILITY
Addresses QUALITY
Case Studies: UCLPartners PRM
Combines UCL and five of
the UKs world-renowned
medical research hospitals,
bringing together worldclass research and clinicians
Paediatric diabetes Patient Relationship Management (PRM) project:
– Information and tools to empower the patient to manage their condition
– Microsoft – applying social networking to healthcare
Case Studies: iStethoscope for iPhone
• Dr. Peter Bentley, UCL Department of
Computer Science, invented the
iStethoscope application, which monitors
heartbeat through sensors in the phone.
• Downloads have averaged up to 500 a day
• "Smartphones are incredibly powerful devices
packed full of sensors, cameras, high-quality
microphones with amazing displays”
A transactional relationship – shared
decision making
“no decision about
me without me”
NHS White Paper, ‘Equity and
Excellence: Liberating the NHS’,
July 2010
Personalised therapeutics
Involvement in
trials / HTA
Electronic
Patient
Records
Synthesis of diagnostic
information
Risk status
Side effects
Shared decision making
Cost
Effective
Care
Conclusions
• Unfettered, technologies focussed on end stage
chronic disease threaten the affordability of
healthcare
• Retargeting on prevention, more accurate
diagnosis, and patient empowerment/concordance
may provide solutions that rebalance the economic
arguments