Health of a System

Managing health-care costs includes finding new ways to efficiently move research from the lab to the patient

Patients trickle in daily to Edmonton’s Cross Cancer Institute, on the southwest side of the University of Alberta campus. Inside, they find oncologists, nurses, psychologists and speech pathologists, not to mention nutritionists and spiritual care providers. The institute has a bone marrow and stem cell treatment office, imaging departments and 40 day care units. When a patient has a blood test or a mammogram, for example, the results are shared within the health-care team to avoid duplication. If patients from out of town need to stay overnight in Edmonton for treatment, a volunteer team will shuttle them to their hotel or bed and breakfast. The institute aims to treat the “whole person,” an important distinction in what can seem like a confusing and fractured health-care system.


But there’s another dimension to the Cross Cancer Institute that affects patients. The facility, and others like it in the province, is a physical link between research labs and the health-care consumer, because it collaborates with universities in Alberta on new techniques and therapies. Roger Palmer, who recently retired as interim dean of the University of Alberta’s School of Public Health, estimates that 15 to 20 per cent of patients at the Cross take part in clinical trials, meaning they get the best care, plus access to the latest therapies and surgical procedures. Closing the gap between the latest research and patient care – known as bench-to-bedside research – can make all the difference. If you’re looking for the intersection of high-level research and frontline care, you’ll likely find it in this squat brick building.

Bench-to-bedside research is often called translational research because it efficiently translates basic science into practical treatments. In essence, most successful health research eventually makes it to the bedside. Last year, however, Know, a publication of the University of Texas at Austin, reported that it takes as much as 24 years for research from the lab to reach your medicine cabinet. After scientists develop a new drug, for example, it goes through several often lengthy clinical trials, is commercialized by a drug company, winds its way through regulatory approvals and finally, eventually, reaches the market. Translational research, on the other hand, aims to remove as many barriers between disciplines as possible to bring innovative practical applications to patients
as quickly as possible.

Improving health care in Canada has been a decades-long discussion that typically centres around money.

This approach has become a hot topic in health care. YouTube is replete with short videos to help explain the concept. And it’s not only on the mind of Canadian health-care policy-makers and administrators. Last May, for example, a U.K. breast cancer tissue bank opened, one similar to the Alberta’s cbcf tumour bank in Edmonton, after an international survey found that researchers could advance their work more quickly if they had access to more tissue samples. In the United States, health centres such as Children’s Hospital Boston and educational institutions such as the University of California, San Diego, have established translational research departments.

In London, Ontario, the Children’s Health Research Institute, one of Canada’s largest children’s research organizations, created the Translational Research Centre with bench-to-bedside research programs such as tissue sampling and a bio-specimens repository. Like the U.K. tissue bank, the repository provides the infrastructure so researchers can easily access tissue samples – an espec-ially difficult challenge in pediatrics. In 2012, a new Alberta/Pfizer Translational Research Fund was launched to support projects with technology transfers and commercialization prospects. And the department of medicine at the University of Alberta recently created a $30,000 translational research fellowship.

The hype around a bench-to-bedside approach began around the time the Canadian Institutes of Health Research (CIHR), a Government of Canada health research outfit, launched a strategy to improve patient-oriented care. The goals were “to better ensure the translation of innovative diagnostic and therapeutic approaches to the point of care, as well as help the provinces and territories meet the challenge of delivering high-quality, cost-effective care.” The result, the strategy claimed, would be better health outcomes.

It’s about the Money
Improving health care in Canada has been a decades-long discussion that goes beyond quickly translating early innovations to the end user. The discussion typically centres on money. “Canada is made up of highly decentralized systems – 10 provincial, three territorial and one federal – with many points of decision-making and influence inside them,” the Canadian Institute for Health Information said in a 2011 report on the drivers of health-care costs. “Decisions in one system often influence other systems.” The CIHI released its report around the time Canada topped $200 billion in spending on health care – a historic milestone – and conversations around spending and health outcomes became more heated.

Health-care spending in Canada rose 7.5 per cent per year between 2000/2001 and 2009/2010, according to a study by the Fraser Institute. It predicts that, by 2028, eight provinces will spend half of their provincial budgets on health care. (Alberta, a big spender, is on track to reach this milestone by 2017.) “In most cases, health-care costs grow faster than provincial revenues, faster than population growth plus inflation and faster than economic output,” Jeffrey Simpson, a Globe and Mail columnist, wrote. Simpson, whose new book is Chronic Condition: Why Canada’s Health Care System Needs to be Dragged into the 21st Century, continued: “The Romanow Commission a decade ago naively argued that heaps of new money would ‘buy change.’ ”

Many in the health field freely admit that resource allocation is key to transforming the system. In a paper released last October, Herb Emery, the Svare professor of health economics at the University of Calgary, explored what implications an aging population would have on the financing of health care. The report, Can We Avoid a Sick Fiscal Future, was co-authored by David Still and Tom Cottrell, and called for reform in how services are delivered. “We’re basically pointing out that nothing about how we do things now is sustainable. If we want to make it sustainable,” Emery says, “we have to figure out how to reduce the cost of care for Canadians 65 and over without rationing care. In other words, prices of care have to come down.” Emery believes that if prices within the system were changed – if fees were lowered for surgeries that were once complicated and are now routine, such as many cataract surgeries, for example – money could be re-allocated to, say, new cancer drugs or long-term care. Discussions of money and efficient access to care are the backdrop to translational medicine.

People are Talking
Public discourse about cost and inefficiency of health care is what bolsters the case for optimized bench-to-bedside care.

Not surprisingly, the shifting economic landscapes impact innovation. In its 2011 study, the Canadian Institutes of Health Research found that, in a weak economic climate, “Funders of basic biomedical research … are anxious to see and to explain to taxpayers and donors the public benefit of the billions of dollars invested in scientific research.” Streamlining the research process and aligning the end-user more closely to the research process could offer one solution. “Patient-oriented research is not only about doing things better,” the CIHR study explained, “but also about being able to stop doing things that are known to be ineffective, unnecessary and often costly.”

Breaking down the roadblocks to sustainable health care is a systemic issue, but it’s not impossible. “The system has big challenges and they’re going to grow, but they’re not going to become fundamentally different from the challenges we’re managing now,” says Steve Buick, director of policy and communications at the Institute of Health Economics, an Edmonton-based non-profit that collaborates with government, academia and industry. Buick’s message means that the news is not grim. “The system doesn’t have to become fundamentally different to manage those challenges.”

When it comes to bench-to-bedside care specifically, the Canadian Institutes of Health Research identified two challenges, or “death valleys.” Valley one is a decreased capacity to commercialize health discoveries, a problem that impacts the country’s clinical knowledge base. Valley two is the ability to share and use research results at both the clinical and decision-making levels. “These two valleys must be bridged if Canada is to bring evidence to bear to enhance health outcomes and ensure a sustainable health-care system,” the CIHR reported.

But we have already come some of the way along the research-to-practice continuum. In a 2009 internat-ional ranking, Canada came in first for patient-oriented research, and was a leader, along with the U.K., Denmark and the U.S., in the impact of science on the health field.

On a provincial level, meanwhile, Alberta has introduced a new program that could impact how research reaches patients. Alberta Health Services launched six strategic clinical networks in late 2011 (a further six are scheduled for March). The networks bring together policy-makers, researchers, operations and strategy specialists, community leaders, along with patients and their families. The goal is to create a single, cohesive health-care delivery system. (The networks are part of a five-year strategic plan that participants hope will, among other things, reduce wait times for cancer patients to meet radiation oncologists. Planners expect that the wait times will drop from four weeks (in 2011/2012) to two weeks (in 2014/15).

Last October, Alberta Health Services appointed scientific directors for five of the strategic clinical networks to bridge the gap between research and clinical care. “It’s a golden window of opportunity to have practice-based evidence drive research and evidence drive practice,” Linda Woodhouse, one of the new scientific directors told a health-sciences media rep at the University of Alberta when the school announced the directorships in fall 2012.

For cancer care especially, drawing connections between research and leading technology might take the form of a clinical trial, a new way to deliver a service or a new technology. Recently, the Cross Cancer Institute and Calgary’s Tom Baker Cancer Centre received two new linear particle accelerators, or LINACS. The new machines, which deliver radiation therapy to cancer patients, are faster and rotate 360-degrees around the patient, leading to a decrease in delivery time from seven minutes to two minutes.

But pursuing efficiency is tricky. “Medicine is not cookie cutter,” Roger Palmer says. “Groups of oncologists in Alberta spend a lot of time designing the best ways to deal with particular tumour groups,” he offers by way of example, “but when it comes down to it, they might only use a technique in half the cases. That sounds strange, until you realize human beings don’t just have cancer, but may also have other things going on – diabetes, obesity, heart problems.”

Despite such challenges, many in Canadian health care see bench-to-bedside research as a key goal for the way research is completed.

Case in point: Dr. Gregory Cairncross, Alberta Cancer Foundation chair in brain tumour research, is the mind behind international clinical translational research studies to find the best approach to treating glioblastoma, a particularly devastating type of brain tumour. Cairncross’s research was the hallmark to doubling the lifespan of glioblastoma patients and improving their quality of life. Cairncross’s studies showed that glioblastoma patients did better with a drug called temozolomide in addition to radiation therapy. This research moved relatively quickly from the lab and is now the standard of care these patients.

It’s a breakthrough that would translate into any language.

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