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The Future of Medicine
Leslie Levin MD, FRCP (Lon), FRCPC
VP Evidence Development and Standards, Health Quality Ontario
Chief Scientific Officer MaRS EXCITE
Professor of Medicine, University of Toronto
Senior Staff Medical Oncologist, Princess Margaret Hospital
www.HQOntario.ca

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www.HQOntario.ca

3.
Hydraulic Health System
• Pressures within the sealed system are variable and dynamic but the
amount of fluid (money) is fixed and directed by need (valves) from a
reservoir. Relief in one area is redistributed via the reservoir to respond to
new needs
• Can health systems become hydraulic?
• Evidence is the backbone of the valves in a hydraulic health system
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Never Let a Good Crisis Go to Waste
• The crisis
– Fiscal constraint
– Demographic realities
– Environmental realities
– Changing public attitudes about health related decision
making
• The challenge
– Unprecedented opportunity for innovation that drives better
patient outcomes that are less invasive, efficient, cost
effective
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5.
Midurethral Slings v Colposuspension
6000
Volume of procedures
5000
4000
OHTAC
Recommendation
3000
2000
1000
0
2003
2004
2005
2006
Midurethral slings
2007
2008
Colposuspension
2009
Combined
2010
2011

6.
Evidence Driving Choice
• “For hundreds of years medicine was driven by anecdotes and
personal beliefs without the least supportive evidence” Kendrick.
Examples:
– Colectomies for anxiety, headaches, stomach pain (“toxic
colon)
– Coronary artery bypass – scaremongering and collaterals
– Back to sleep (Spock). Confounding variables
• Evidence driving choice in Ontario – PET scanning, drug eluting
stents
• What does this mean for innovation now?
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A New Reality - A New World
•
•
•
•
Intuitive decision making will become a thing of the past
The public will demand greater transparency and to be involved
increasingly
Evaluation of technology aimed mainly at regulatory approval will bleed
investors
– 48% rejection post market for licensed devices
– Increasing post market comparative effectiveness
– Recent panel on genetics – change the health system to
accommodate what genetics research will bring
– Drugs and some devices have been pre-market evaluation for >8
years – unsustainable
– The push and pull of evidence is changing e.g ECFA
Changing realities
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8.
Societal, Economic and Climate Change
•
Climate Change
– Tropical disease shift
– More COPD universally
– Agricultural changes could lead to malnutrition and poorer choices
•
Societal
– Increasing awareness of choice – public will expect more than marginal
benefits; increased attention to dignity and risk trade offs. “More and newer are
best” cannot be assumed to dominate the healthcare debate
– Increasing public expectation for compassionate care:
• “Health care is more about love than about most other things. If there isn't
at the core of this two human beings who have agreed to be in a
relationship where one is trying to relieve the suffering of another, which is
love, you can't get the right answer here” DB
• Aging population will create burden on the young. Could change the
conversation regarding end of life care
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Societal, Economic and Climate Change
(Cont.)
•
Economic
– Tough choices such as environmental control will decrease spending on
healthcare
– Increasing chronic diseases in developing countries e.g. diabetes, CAD,,
stroke, breast & colon cancer
– Chronic diseases will present a strain on developing country economies
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Genetics
1. Increasing use of genetic information to stratify risk prospectively:
– Advantages (treatment) - more selective targeted treatment.
• Unlikely that pharmacogenomics will cost less due to need to
cover developmental costs and for companion testing and need
for multimodal. NB treatment related predictive tests (Oncotype)
– Disadvantages (screening)
• inability to interpret risk
• creation of unwellness
• haphazard tests for those assumed to be at increased risk
2. As demand for genetic screening increases, disputed value of screening
could reduce enthusiasm. E.g., prostate, breast, thyroid ca., diabetes
3. Genetics based research is exciting and holds great promise. Need to
understand the risks and benefits and impact on quality of life and
longevity.
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Information Technology
IT will be increasingly scrutinized for effectiveness in improving patient
outcomes and in intelligence seeking regarding patient risk profiles and
treatment strategies. NB Based on associations rather than causality"
"
Investments by health systems into IT will be based on comparisons with
other technologies using existing evidence based methodologies"
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How Will Health Systems Respond to Changing Realities
1. Increasing emphasis on relevant, disruptive technologies
2. Increasing alignment between innovators, payers, academia and end users in
defining the pre market pipeline. Industry will become a true partner with
decreased need for post market policing. EXCITE
3. International harmonization of regulatory approval for health technologies will likely
not materialize but there will be increasing harmonization re- regulatory and
reimbursement processes - e.g. FDA and CMS parallel review, EXCITE
4. Increasingly rationalized health care. May lead to rationed health care. "There is
going to have to be a very difficult democratic conversation that takes place. The
decision is not whether or not we will have to ration care. The decision is whether
we will ration with our eyes open" (Donald Berwick)
5. Health systems will define their basket of services based on transparent criteria.
These decisions must be evidence based and represent the larger public interest
6. Health systems will continuously monitor services for obsolescence. $1 trillion
dollars wasted care out of a $2.7 trillion dollar health system in the US. In Ontario,
increased spending in healthcare is currently 2% per year compared to 7%
increase per year over the past 5 years.
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Inevitable Change on the Way
1.
Hospitals will increasingly become short stay high tech institutions with a critical
mass of highly specialized professionals.
2.
Specialties will change. Decreased demand for invasive procedures and need for
continuous re-training to cope with less invasive technologies. Likely to create
disruptive environment with changing and shared roles. Examples:
• coil embolistation
• draining intra abdominal abscesses, bleeding control etc.
• endocardial ablation
• replacing aortic and mitral valves
• removing renal calculus with ultrasound
• nanotechnology?
Increasing role for specialised nursing & interdisciplinary care in the community
3. Non drug technologies will increasingly replace drugs and will be used as front
ended treatment strategies e.g. bariatric surgery for diabetes, renal nerve
ablation, RTMS and deep brain stimulation for depression. There will be
increase in novel ways to deliver drugs with devices such as nanotechnology
and spinal infusion of analgesics
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Nanotechnology –
Multifunctional Dendrimer
From: http://nano.cancer.gov/resource_center/cancer_nanotechnology_brochure.pdf
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From Pill-Popping to Bionic Man
Condition
Example Drugs Used
Non-drug technologies as adjunct or replacement to drugs
Ventricular
arrhythmias
Amiodorone
Implantable cardiac defibrillator
Atrial fibrillation
Digoxin, coumadin,
ca+ channel blockers
Endocardial ablation
Obesity
Lipase inhibitors,
appetite suppressants
Bariatric surgery
Depression
Antidepressants
Deep brain stimulation/ RTCMS
Parkinsons
L-Dopa
Deep brain stimulation
Acute MI
Thrombolysins
Coronary stents
Heart failure
Inotropic drugs
Ventricular assist devices
Acute respirotary
failure
Mechanical ventilation
Extracorporeal life support

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Inevitable Change on the Way (2)
4. Surgical treatments will continue to become less invasive e.g. artificial
valves, aortic aneurysm, cholecystectomy, lithotripsy
5. Community based health care will assume better control of chronic
diseases. Community based care will be tracked more closely. More
surgical procedures will be performed in private not for profit community
clinics
6. Tracking data will increase but our ability to translate to information and
knowledge to shape policy and patient outcomes will be a constant
challenge
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What Does the Future Hold for Innovation?
• Huge opportunities for innovations that aim to reduce costs and/or
improve benefits for chronic disease and changing patterns of
disease attributed to e.g. climate change
• Pharmacogenomics and other genetic targeted therapies will make
large contributions but will increase in complexity and probably cost
in the treatment of cancer
• Research into decision making will become increasingly important
and especially how to involve the public. Need and relevance must
be re-defined from a societal perspective (e.g. absolute risk
reduction)
• The technology pipeline will be aligned to innovators, health systems,
public, climate and environmental change research, clinical trials
methodologists, epidemiologists and health economists.
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What Does the Future Hold for Innovation?
•
A matrix approach that responds to changes and prioritization will expand
the research agenda. This will change the nature of clinical research and
methodologies
•
Genetics research will be needed to better understand risk stratification
and KT so that results become an asset to health outcomes
•
IT will need to undertake outcomes based research based on proven
platforms. IT platforms alone will not provide a rationale for funding
•
Big data will grow but will need to go beyond capacity to cross link large
amounts of data. Could provide new approaches to clinical trials design
through prospectively collected patient outcomes
www.HQOntario.ca
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www.hqontario.ca!