Paula Lorgelly is a health economist working as deputy director at the Office of Health Economics (OHE) in the UK. She has held posts at universities in the UK and Australia is visiting professor at King’s College London.
PMF Editor Mark Glover spoke to Paula about the economic value of precision medicine, the importance of stakeholder collaboration and the challenges facing low and middle-income countries trying to instigate diagnostic testing.
Could you tell me about your current role?
The OHE is a research organisation that also has a consulting arm called OHE Consulting. We undertake research across a range of programmes which including measuring outcomes and how you might use those outcomes can be used to make value judgements regarding value for money.
A theme that I lead is the economics of innovation; it covers research and development, drug development, early drug development as well as precision medicine topics.
As Deputy Director, I’m part of the leadership team, I have my own research stream and I also work on consulting projects.
How important a role does precision medicine now play in your research, compared to the work that the OHE were doing, say, ten years ago?
Precision medicine is interesting as it’s not your standard technology. Precision medicine is not just about the drug, it’s about the test or the diagnostic in the first place and then the choice of treatment, that’s what makes it interesting. The questions we were once asking about treatments we now need to ask of tests and test-treatment combinations.
What I also find is that we’re asking the same questions that we used to ask in other fields but we’re now asking them in precision medicine. Prior to working at OHE, I was doing work in public health and we’d ask questions about the value or outcomes of a public health intervention, it wasn’t just about health; many of these interventions tend to be broader in terms of people’s wellbeing. When we look at precision medicine there is a value to knowing if you don’t have a disease; if you were to measure somebody’s health you wouldn’t measure a change in their health at all as they don’t have the disease, but if you were measuring their wellbeing there could be something in the fact that they now have more information, which may actually have improved their wellbeing.
I often find that we are re-inventing the wheel, it’s just the same puzzle but in a specific area. So, if we’re working in public health or social care, it’s no different from working in precision medicine. The one area where that’s not true is when the you have to use your two technologies together. This could come up if you had a combination drug, it’s the same question: what is the value of each of them – what price do you place on the test versus what price do you place on the drug? If you had two drugs working together and they happened to be produced by different manufacturers, then they’ll be looking for two different prices in the market.
How important is collaboration in your current role?
It’s absolutely huge. There’s no point in coming up with a new way of informing a decision and then not working with decision makers!
It’s about making sure that what you’ve discovered and what you created can actually have an impact. It’s key to work with these decision makers in that sense but I step back from that because you’ve got to try and work with the people who are using it as well, the clinicians and health professionals.
A key issue now is when you tell a patient that they have something that you can’t do anything about (so called incidental findings) There’s ‘precision’ but it might not come with an actual ‘medicine’ to treat them. It means we are now going down a route where we are able to tell patients a lot more about what’s wrong with them and that’s opening up a lot more doors; we need to work out if the patients should even know some of this stuff.
Patients therefore are a key stakeholder because telling them this information completely changes their behaviour. There are consequences of telling people that they’re at risk of something and I don’t think we have thought that through enough as to whether or not that was a good idea.
Having conducted research in Ghana and Uganda do you think there will come a time where precision medicine is part of these country’s healthcare system, and if so what needs to take place?
A lot of precision medicine is aimed at chronic diseases in those low and middle-income countries they have the triple burden: high-rates of cancer and heart disease; as well as infectious disease and maternal issues; and accidents. The issue with testing is around pathology and the ability to make inference from the test. I think the consultants are very well trained and they can treat with what they’ve got available but it’s whether the testing is available.
I did some work in the Solomon Islands where they were doing cervical smears but they couldn’t test them there, so they were sending them to Australia. The tests actually sat in a cool box on the tarmac, with people crossing their fingers hoping the heat didn’t disintegrate the sample. These tests are so technology driven, more than the actual treatment, and even when I was doing work there, particularly with the high humidity, laptops just don’t work – that’s the kind of environment that people are working in.
There will have to be a change in the whole system before they can adopt these tests. It’s got to be about training; knowing what you’re testing and why you’re testing for it. Testing is only cost-effective if you target it, you can’t test everybody. In terms of the diagnostics, the PSA tests for prostate cancer is a good example of that. You can’t give it to everybody because it’s just not cost effective.
What inspires you?
I’m driven by making sure that the system is efficient and that decisions are made via the correct process. I was at an event recently and there was a politician speaking and she said she didn’t used to tell people that she was a politician. I introduced myself as “a card-carrying health economist”,I’m proud of what I do!
Nearly every minute of our lives we make decisions and a lot of the time they’re wrong but the fundamental thing about saving someone’s life and using money in the right way is that we’ve got the right information to make a good decision.
Sometimes you have to acknowledge you that you can’t help everybody, but you can make sure you help the right people.
Paula Lorgelly will be speaking at the Benelux Precision Medicine Forum in Utrecht which takes place from 12 to 13 June. You can register for the event here.