Simposyum BRN Barcelona about personalized medicine Practical issues

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. Implications for the Health Care System
2
Sustainability
AccessibilityOutcomes

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
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. Personalization and Health Care:
5 elements to discuss
5
Variability
Individual vs.
population
Business model
Results
Dissemination

6. 6
The requirements for variation
Copious
Small in
extent
Undirected
Charles Darwin
(1809-1882)

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. 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. 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. 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. 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. 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
LTOT HMV
The same accessibility
No financial issues
Social
inequalities

14. 14
Ann Intensive Care. 2014;4(1):2. doi: 10.1186/2110-5820-4-2

15. Personalization and Health Care:
5 elements to discuss
15
Variability
Individual vs.
population
Business model
Results
Dissemination

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
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
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. Personalization and Health Care:
5 elements to discuss
19
Variability
Individual vs.
population
Business model
Results
Dissemination

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. 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
Lancet 2013;382:923-4
Increase
(emergency)
admission
Reduction
LOS
Pts > 85 yrs
Multimorbidity
Cognitive
impairementBalance

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
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. Three elements
25
Acute care
hub
Clinical
coordination
center
“Hub &
spoke”
Fast track
Ann Intern Med. 2012;157:448-449.

26. Personalization and Health Care:
5 elements to discuss
26
Variability
Individual vs.
population
Business model
Results
Dissemination

27. 27
Value =
Outcomes
Cost
NEJM 2010;363:2477-81

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
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. 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. Personalization and Health Care:
5 elements to discuss
31
Variability
Individual vs.
population
Business model
Results
Dissemination

32. 32

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
Lots of it, for a few Not much, to many

35. 35

36. Value for money
JAMA. 2012;307(14):doi:10.1001/jama.2012.362

37. 37

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
Thank you very much for your attention!!!