Precision medicine, tailored care, personalized medicine—these catch phrases all have been used over the last decade to represent similar visions for fundamentally changing the way health care is provided. The goal, in the broadest sense, is to move away from delivering care based on population-centered guidelines and instead target care based on the individual patient’s situation.
In his keynote Heart & Stroke Foundation Lecture, John Spertus, MD, of St. Luke’s Mid America Heart Institute in Kansas City, framed the issue this way. Guidelines are generalized, averaged recommendations, but there is no such thing as an average patient. In practice, following guidelines helps some patients, doesn’t help others, and even harms some.
Each patient has their own personal risk profile based on physiological, genetic and behavioural/lifestyle factors. Their overall health, the various conditions they suffer from, their genetic predispositions and their diet, physical activity and everyday habits can all impact the appropriateness, likelihood of success and potential for side effects of a particular course of treatment. Patient preferences and personal priorities must also be considered.
Dr. Spertus is an outspoken proponent of incorporating individual risk profiles into care processes. The potential advantages of this approach are compelling: more effective care and better outcomes, fewer complications and better patient safety, and substantial cost savings.
As an example, he cited a study he and colleagues conducted across nine top cardiac centres in the United States looking at angioplasty. The researchers found that when information on individual patient risk for bleeding was highlighted for interventional cardiologists during the treatment process, these physicians were more likely to take steps to avoid bleeding in high-risk patients. The result was a 45% drop in bleeding events. Dr. Spertus stressed that this significant improvement was achieved among centres known for providing top-tier care. In terms of the financial bottom line, one centre reported annual savings of $3.6 million from implementing these measures.
Dr. Spertus also suggested that providing patients with clear and understandable information about their personal risk can aid in shared decision making. For a patient with angina, for example, this information could help them clarify their preference among angioplasty, bypass surgery or management with medication.
The challenges in developing information systems to make relevant risk information available to doctors and patients at appropriate decision points and in useable formats are substantial. But, he explained, looming changes to the health care system are forcing the issue in the United States.
Legislation, known by the acronym MACRA, will bundle all healthcare provider reimbursement covered by the US Medicare system for a given care event. This means that when a person has a heart attack all physician, hospital and other associated allied health costs must come out of a single, pre-determined lump sum. Bundling for heart attack care is set to begin in 2018.
If costs aren’t controlled, said Dr. Spertus, providers will go broke.
This payment model shifts the emphasis from quantity of care to quality. Poor outcomes and complications—such as bleeding events—are expensive, as are inappropriate tests and procedures. He argues that precision medicine, with its potential to reduce complications, tailor care appropriately for each patient and keep costs in line with the pending reimbursement model, can no longer remain an unrealized vision for future.