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

UCL SCHOOL OF LIFE AND MEDICAL SCIENCES

• Demography

• Economic− Recession− Tax earner : beneficiary ratio

• Technological capacity− Affordability v Productivity gains

• Public expectation

Supply and demand factors

Increments in life expectancy

UK Office for National statistics, 2010

Total deaths58 million

Projected main causes of death, worldwide, all ages, 2005

Preventing chronic disease a vital investment: World Health Organisation

• Cardiovascular disease, mainly heart disease

• Cancer

• Chronic respiratory disease

• Diabetes

Healthcare expenditure by age group (in % of GDP per capita)

Dormont et. al., Health expenditures, Longevity

and Growth, 2007Age group

% o

f G

DP

pe

r ca

pita

The impact of demographic shifts on healthcare:Tax earner:beneficiary ratio

AT Kearney, Healthcare out of Balance, Sept 2009

• Demography

• Economic− Recession− Tax earner : beneficiary ratio

• Technological capacity− Affordability v Productivity gains

• Public expectation

Supply and demand factors

Medical Technology: Economic impact

• Practice change• Substitution• Spread

• Cost efficiency• Economic productivity• Welfare

Cost drivers: ‘End-Stage Disease’

e.g.

• 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

• ~1.1 million patients are eligible according to NICE guidelines

• Studies suggest 25% would like surgery

• Only 3,600 operations were undertaken in 09/10

• 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.

• 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)

Yes! CVD-Risk DNA testing is ready now!

05

1015202530

Ave Patient

10

yr

CV

D r

isk

Genetic CRF

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

• 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’).

• This may be a critical determinant of the animal’s long-term cardiovascular health.

Systolic Blood Pressure of female rats exposed to 18% casein or low protein diets in utero and treated with catopril for 2 weeks.

9% casein control

9% casein catopril

18% casein catopril

18% casein control

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

Standard diet (n=83)

Nutrient enriched (n=70)

Diagnostic BP 61.3mm 64.5mm

P

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 adherence

• Better outcomes

• Long term cost benefits?

• More drug sales?

Technologies as solutions

• Refocusing on prevention

• Genetic risk

• Reprogramming

• Personalised therapeutics

• E-Health

E-Health

• Remote advice

• Social networking

• Remote diagnostics

• Empowerment

• Independent, subscription health-hotline operating in Mexico since 1998.

• Offers phone consults, drug information and discounts in certain medical facilities.

• 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.

• Two-thirds of cases are resolved over the phone.

Case studies: Medicall and CMO

• US provider of integrated healthcare management solutions.

• Network of 2,300 providers.

• Provides services to 179,000 health plan members using an experienced staff of well-trained nurse case managers

• Has dramatically reduced in-patient and emergency room visits

Addresses ACCESSIBILITY Addresses QUALITY

Case Studies: UCLPartners PRM

Paediatric diabetes Patient Relationship Management (PRM) project:

– Information and tools to empower the patient to manage their condition

– Microsoft – applying social networking to healthcare

Combines UCL and five of the UKs world-renowned

medical research hospitals, bringing together world-

class research and clinicians

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

Electronic Patient

Records

Cost Effective

Care

Personalised therapeutics

Involvement in trials / HTA

Synthesis of diagnostic information

Risk status

Side effects

Shared decision making

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