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20140613 brn symposium

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Simposyum BRN Barcelona about personalized medicine Practical issues

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20140613 brn symposium

  1. 1. 1 Implications for the Health Care System Joan Escarrabill MD PhD Chronic Care Program– Barcelona Esquerra. Hospital Clínic (Barcelona) Master Plan for Respiratory Diseases (PDMAR) & Home Respiratory Therapies Observatory (ObsTRD). FORES. Ministry of Health (Catalonia)
  2. 2. Implications for the Health Care System 2 Sustainability AccessibilityOutcomes
  3. 3. 3 Am J Prev Med 2012;42:639–45 Balanced strategies that implement both population and individual-level interventions:  can best maximize health benefıts,  minimize harm,  avoid unnecessary healthcare costs. P5 = Population perspective Premature translation Lost in translation
  4. 4. 4 P4 Components Population perspectives Predictive Ecologic model of Health, integrating multilevel determinants of health Preventive Principles of population screening Personalized Principles of evidence based medicine Participatory Essential public health functions (assessment, policy development and assurance). Information system Am J Prev Med 2012;42:639–45 Common pratincole Grey heron
  5. 5. Personalization and Health Care: 5 elements to discuss 5 Variability Individual vs. population Business model Results Dissemination
  6. 6. 6 The requirements for variation Copious Small in extent Undirected Charles Darwin (1809-1882)
  7. 7. Variations in clinical practice 7 Science 1973;182-1102-09  There are wide variations in resource input, utilization of services and expenditures.  Variations indicate that there is a considerable uncercertaunty about the effectiveness of health services
  8. 8. Discharge ratio in surgical procedures 8 Source: Methodology of Atlas of Variations in Medical Practice Catalan Agency for Quality and Healthcare Assessment (AQuAS) http://goo.gl/wwI6jh
  9. 9. Long-term Oxygen therapy (LTOT) 2012/13 n: RV: CSV: EB: 26805 350 3704 5995 16756 5.44 9.79 25.59 11.10 7.51 0.34 3.18 0.44 0.47 0.41 0.27 0.94 0.31 0.30 0.29 -3 -2 -1 0 1 2 3 Tots 20-39 anys 40-64 anys 65-74 anys 75+ anys O2 concentrador+liquid Source: Catalan Agency for Quality and Healthcare Assessment (AQuAS) & Home Respiratory Therapy Observatory (ObsTRD / FORES) 9
  10. 10. Standardized rates LTOT 2012/13 p(14): 120.17 p(86): 367.99 Ciutat de Barcelona O2 concentrador+liquid 2012 10 Source: Catalan Agency for Quality and Healthcare Assessment (AQuAS) & Home Respiratory Therapy Observatory (ObsTRD / FORES)
  11. 11. Home mechanical ventilation by age-groups 2012/13 n: RV: CSV: EB: 3738 200 1138 1049 1351 22.94 6.20 14.35 19.90 62.14 0.37 1.08 0.96 0.54 0.59 0.34 0.72 0.50 0.33 0.47 -3 -2 -1 0 1 2 3 Tots 20-39 anys 40-64 anys 65-74 anys 75+ anys Vent. Mecànica Source: Catalan Agency for Quality and Healthcare Assessment (AQuAS) & Home Respiratory Therapy Observatory (ObsTRD / FORES)
  12. 12. Home mechanical ventilation Standardized rates 2012/13 p(14): 7.75 p(86): 56.22 Ciutat de Barcelona Vent. Mecànica 2012 12 Source: Catalan Agency for Quality and Healthcare Assessment (AQuAS) & Home Respiratory Therapy Observatory (ObsTRD / FORES)
  13. 13. 13 LTOT HMV The same accessibility No financial issues Social inequalities
  14. 14. 14 Ann Intensive Care. 2014;4(1):2. doi: 10.1186/2110-5820-4-2
  15. 15. Personalization and Health Care: 5 elements to discuss 15 Variability Individual vs. population Business model Results Dissemination
  16. 16. 16 Better value through population and personalised medicine. J A Muir Gray. Lancet 2013;382:200-1 Effectivity Quality Safety Value Presonalised Population medicine Customize evidence  Biomarkers  Personal values  Clinical situation  Context Responsibilities to the population to be served  Avoid inequalities  Distribution of resources
  17. 17. 17 Comparative effectiveness research • Overall benefits • Majority of patients • Establish population averages Personalized medicine • Subsets of patients • To exploit differences among subpopulations Improve health care outcomes Rationalize costs
  18. 18. 18 Even today, countries with more social provision of healthcare and less individualistic attitudes have better health outcomes across all social classes. How can we balance the role of the individual and the communal in healthcare?
  19. 19. Personalization and Health Care: 5 elements to discuss 19 Variability Individual vs. population Business model Results Dissemination
  20. 20. Disruptive business model Solution shop Intutive Medicine for unstructured problems Hypothesis testing until diagnosis can be made Value-added process Empirical medicine Standardization Facilitated network Patient groups with common needs Long-term care: adherence 20
  21. 21. Personalized medicine Focus on results 21 Precision medicine Care plan: adherence Disruptive business model • Changes in the role of health professionals. • Implication of new professions
  22. 22. 22 Lancet 2013;382:923-4 Increase (emergency) admission Reduction LOS Pts > 85 yrs Multimorbidity Cognitive impairementBalance
  23. 23. 23 Lancet 2013;382:923-4 Increase (emergency) admission Reduction LOS Pts > 85 yrs Multimorbidity Cognitive impairementBalance To identify the optimum care pathway for adults with medical illnesses
  24. 24. 24 Future hospital  Hospitals must be designed around the needs of patients  No “one size fits all” : Coordinated mangement of patients with multiple comorbidities  Specialist medical care will not be confined to inside the hospital walls.  Continuity of care  Illnes can occur in any time: 24/7/365.  Reorganisation of ‘front door’  Vulnerable patients.  Patient experience is valued as much as clinical effectiveness
  25. 25. Three elements 25 Acute care hub Clinical coordination center “Hub & spoke” Fast track Ann Intern Med. 2012;157:448-449.
  26. 26. Personalization and Health Care: 5 elements to discuss 26 Variability Individual vs. population Business model Results Dissemination
  27. 27. 27 Value = Outcomes Cost NEJM 2010;363:2477-81
  28. 28. 28 Int J Epidemiol. 2010;39:97-106  Factors at multiple levels may influence health and disease,  Interrelation among these factors often includes dynamic feedback and changes over time ObesityGenes Individual behavior Neighbourhood School level Health Policies food portions, dietary habits, exercise, television-viewing patterns availability of grocery stores, suitability of the walking environment, advertising of high caloric foods
  29. 29. 29 Int J Epidemiol. 2010;39:97-106 The impact of investing in good food stores on body mass index (BMI), Agent’s diet Availability of good food stores Her education level, The diet of her parents and friends Genetic predispositions Importance of friend networks
  30. 30. Chronic care related to patients’ needs 30 Health Affairs 2013;32:516–525  Identifying the needs of patients  Needs change over time Social & Health needs Technical complexity Cognitive disorders Multiple nedds (multimorbidity) Barriers to access Nursing home / Hospice Frail patients (“potential risks”) Post-discharge support Organ failure
  31. 31. Personalization and Health Care: 5 elements to discuss 31 Variability Individual vs. population Business model Results Dissemination
  32. 32. 32
  33. 33. 33 Alan Williams (1927-2005) Archie Cochrane (1909-1988) J Epidemiol & Community Health 1997;51:116-20  Evidence based medicine in not enough  Costs represent health gains that have been denied to others.  All health care activities which meet certain minimum cost effectiveness requirements, when provided for certain specified categories of people, should be provided free within the NHS.
  34. 34. 34 Lots of it, for a few Not much, to many
  35. 35. 35
  36. 36. Value for money JAMA. 2012;307(14):doi:10.1001/jama.2012.362
  37. 37. 37
  38. 38. To conclude: How many "P" are necessary? 38 Predictive Preventive Personalized Participatory  Population perspective P4 P5 Policy Productivity Precision. People (groups of persons with common needs) Peculiarities Payment. Purpose. Poverty. Palliative Proximity Plurality Planning Proactivity … P18 ?
  39. 39. 39 Thank you very much for your attention!!!

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