The Future of Healthcare in Europe Technology drivers: Problems and Solutions

1. UCL SCHOOL OF LIFE AND MEDICAL SCIENCES The Future of Healthcare in EuropeTechnology drivers: Problems and Solutions Professor Sir John Tooke UCL Vice Provost (Health) Head of School of Life and Medical Sciences

2. Supply and demand factors • Demography • Economic • Recession • Tax earner : beneficiary ratio • Technological capacity • Affordability v Productivity gains • Public expectation

3. Increments in life expectancy UK Office for National statistics, 2010

4. Cardiovascular disease, mainly heart disease Cancer Chronic respiratory disease Diabetes Projected main causes of death, worldwide, all ages, 2005 Total deaths 58 million Preventing chronic disease a vital investment: World Health Organisation

5. Healthcare expenditure by age group (in % of GDP per capita) % of GDP per capita Dormont et. al., Health expenditures, Longevity and Growth, 2007 Age group

6. The impact of demographic shifts on healthcare:Tax earner:beneficiary ratio AT Kearney, Healthcare out of Balance, Sept 2009

7. Supply and demand factors • Demography • Economic • Recession • Tax earner : beneficiary ratio • Technological capacity • Affordability v Productivity gains • Public expectation

8. Medical Technology: Economic impact • Practice change • Substitution • Spread • Cost efficiency • Economic productivity • Welfare

9. Cost drivers: ‘End-Stage Disease’ e.g. • 2nd, 3rd, 4th… line cancer drugs • Sophisticated stents • Endoscopic procedures / robotics • Regenerative medicine etc.

10. 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.

11. Technologies as solutions Refocusing on prevention Genetic risk Reprogramming Personalised therapeutics E-Health

12. “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)

13. 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 £382mwithin 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.

14. Technologies as solutions Refocusing on prevention Genetic risk Reprogramming Personalised therapeutics E-Health

15. 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?

16. Yes! CVD-Risk DNA testing is ready now! 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) Humphries S, UCL Genetics Institute

17. 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

18. Technologies as solutions Refocusing on prevention Genetic risk Reprogramming Personalised therapeutics E-Health

19. 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. 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

20. 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) P 0.02 Diagnostic BP 61.3mm 64.5mm A Singhal et al., Circulation (2007); 115:213

21. Technologies as solutions Refocusing on prevention Genetic risk Reprogramming Personalised therapeutics E-Health

22. 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

23. Is ‘Personalised Medicine’ the key? Potential benefits: • Less adverse events • Less unnecessary treatment ? Better adherence • Better outcomes • Long term cost benefits? • More drug sales?

24. Technologies as solutions Refocusing on prevention Genetic risk Reprogramming Personalised therapeutics E-Health

25. E-Health • Remote advice • Social networking • Remote diagnostics • Empowerment

26. Case studies: Medicall and CMO • 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. • 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

27. Case Studies: UCLPartners PRM Combines UCL and five of the UKs world-renowned medical research hospitals, bringing together world-class 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

28. 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”

29. A transactional relationship – shared decision making Patient “no decision about me without me” NHS White Paper, ‘Equity and Excellence: Liberating the NHS’, July 2010 Physician

30. Personalised therapeutics Cost Effective Care Involvement in trials / HTA Synthesis of diagnostic information Electronic Patient Records Risk status Side effects Shared decision making

31. 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