Molecular diagnostics and personalized medicine: value-assessed opportunities for multiple stakeholders

Evaluation of optical detection platforms for multiplexed detection of proteins and the need for point-of-care biosensors for clinical use

This review investigates optical sensor platforms for protein multiplexing, the ability to analyze multiple analytes simultaneously. Multiplexing is becoming increasingly important for clinical needs because disease and therapeutic response often involve the interplay between a variety of complex biological networks encompassing multiple, rather than single, proteins. Multiplexing is generally achieved through one of two routes, either through spatial separation on a surface (different wells or spots) or with the use of unique identifiers/labels (such as spectral separation-different colored dyes, or unique beads-size or color). The strengths and weaknesses of conventional platforms such as immunoassays and new platforms involving protein arrays and lab-on-a-chip technology, including commercially-available devices, are discussed. Three major public health concerns are identified whereby detecting medically-relevant markers using Point-of-Care (POC) multiplex assays could potentially allow for a more efficient diagnosis and treatment of diseases.

Growth of molecular diagnostics and genetic testing in the USA, 2008-2011: analysis and implications

AIMS

Advances in genomics and molecular diagnostic testing are expanding, but national data on which to base clinical, regulatory and reimbursement policies in the USA are lacking. The study objective is to provide current estimates of utilization/spending trends for private and public payers.

PATIENTS & METHODS

Healthcare utilization/expenditure claims data for 32 million individuals across the USA in 2008-2011 were analyzed. Genetic testing and molecular diagnostic usage was categorized by major testing groups: infectious disease, cancer and inherited/other acquired conditions.

RESULTS

Per-person testing cost grew by 14% per year between 2008 and 2011, primarily resulting from increased utilization. Spending per person for Medicare and Medicaid was higher than for commercially insured patients. Expenditure across the USA was estimated at US$5.5 billion in 2011, up 13% from 2010.

DISCUSSION

Greater understanding of usage and technology diffusion requires increased data transparency and granularity. Conclusion & future perspective: The use of genetic testing and molecular diagnostics will grow over the next 5 years, with uncertainty about the precise diffusion trajectory. By strengthening the capacity to capture and analyze trends in this changing area of medicine, we increase our chances of promoting positive change to the benefit of patients.

Aligning the economic value of companion diagnostics and stratified medicines

The twin forces of payors seeking fair pricing and the rising costs of developing new medicines has driven a closer relationship between pharmaceutical companies and diagnostics companies, because stratified medicines, guided by companion diagnostics, offer better commercial, as well as clinical, outcomes. Stratified medicines have created clinical success and provided rapid product approvals, particularly in oncology, and indeed have changed the dynamic between drug and diagnostic developers. The commercial payback for such partnerships offered by stratified medicines has been less well articulated, but this has shifted as the benefits in risk management, pricing and value creation for all stakeholders become clearer. In this larger healthcare setting, stratified medicine provides both physicians and patients with greater insight on the disease and provides rationale for providers to understand cost-effectiveness of treatment. This article considers how the economic value of stratified medicine relationships can be recognized and translated into better outcomes for all healthcare stakeholders.

Stratified medicine and reimbursement issues

Stratified Medicine (SM) has the potential to target patient populations who will most benefit from a therapy while reducing unnecessary health interventions associated with side effects. The link between clinical biomarkers/diagnostics and therapies provides new opportunities for value creation to strengthen the value proposition to pricing and reimbursement (P&R) authorities. However, the introduction of SM challenges current reimbursement schemes in many EU countries and the US as different P&R policies have been adopted for drugs and diagnostics. Also, there is a lack of a consistent process for value assessment of more complex diagnostics in these markets. New, innovative approaches and more flexible P&R systems are needed to reflect the added value of diagnostic tests and to stimulate investments in new technologies. Yet, the framework for access of diagnostic-based therapies still requires further development while setting the right incentives and appropriate align stakeholders interests when realizing long-term patient benefits. This article addresses the reimbursement challenges of SM approaches in several EU countries and the US outlining some options to overcome existing reimbursement barriers for stratified medicine.

Highly-integrated lab-on-chip system for point-of-care multiparameter analysis

A novel innovative approach towards a marketable lab-on-chip system for point-of-care in vitro diagnostics is reported. In a consortium of seven Fraunhofer Institutes a lab-on-chip system called "Fraunhofer ivD-platform" has been established which opens up the possibility for an on-site analysis at low costs. The system features a high degree of modularity and integration. Modularity allows the adaption of common and established assay types of various formats. Integration lets the system move from the laboratory to the point-of-need. By making use of the microarray format the lab-on-chip system also addresses new trends in biomedicine. Research topics such as personalized medicine or companion diagnostics show that multiparameter analyses are an added value for diagnostics, therapy as well as therapy control. These goals are addressed with a low-cost and self-contained cartridge, since reagents, microfluidic actuators and various sensors are integrated within the cartridge. In combination with a fully automated instrumentation (read-out and processing unit) a diagnostic assay can be performed in about 15 min. Via a user-friendly interface the read-out unit itself performs the assay protocol, data acquisition and data analysis. So far, example assays for nucleic acids (detection of different pathogens) and protein markers (such as CRP and PSA) have been established using an electrochemical read-out based on redoxcycling or an optical read-out based on total internal reflectance fluorescence (TIRF). It could be shown that the assay performance within the cartridge is similar to that found for the same assay in a microtiter plate. Furthermore, recent developments are the integration of sample preparation and polymerase chain reaction (PCR) on-chip. Hence, the instrument is capable of providing heating-and-cooling cycles necessary for DNA-amplification. In addition to scientific aspects also the production of such a lab-on-chip system was part of the development since this heavily affects the success of a later market launch. In summary, the Fraunhofer ivD-platform covers the whole value chain ranging from microfluidics, material and polymer sciences, assay and sensor development to the production and assembly design. In this consortium the gap between diagnostic needs and available technologies can be closed.

Drug-diagnostic co-development: how to harness the value

Some years ago, we developed a value assessment process that was predicated on certain assumptions about how valuation might be influenced by drug development and marketing factors. Here, we discuss how our assumptions have held up particularly in light of regulatory and reimbursement changes. In addition, we assess how the relationship models derived from the value-assessment process have been substantiated by reviewing some recent cases of testing and stratification.

Biomarkers to improve the benefit/risk balance for approved therapeutics: a US FDA perspective on personalized medicine

This article highlights a current US FDA perspective concerning the use of biomarker-based diagnostics for personalized medicine. Specifically, current biomarkers that have application for improving the benefit/risk profile of already approved drugs are discussed. The success of biomarkers for use in personalized medicine depends on many factors, including proper evaluation of the usefulness of the biomarker for assessing the event of interest, and the safety and effectiveness of the diagnostic device used to measure the biomarker, which includes appropriate analytical and clinical validation. These points along with the many regulatory concerns regarding co-labeling of drugs and devices and future aspects, such as co-development, will be discussed in this regulatory science focus.

U-Health: an example of a high-quality individualized healthcare service

National Taiwan University Hospital (Taipei, Taiwan), which is one of the largest hospitals in Taiwan, is undergoing healthcare service reforms: it is combining the home healthcare service network and sensors network into a new service known as the Ubiquitous Healthcare (U-Health) service system in order to continually provide a personalized healthcare service to patients who live in remote areas. The U-Health service system is comprised of six service components that are introduced in an integrated manner: tele-education, telediagnosis, telemonitoring, teleconsultation, teletherapy and lifetime health. The target patient segments are postdischarge patients, patients suffering from cardiovascular diseases, patients suffering from chronic diseases and patients in hospice care. Since its launch in October 2009, the U-Health service system has effectively reduced the rehospitalization rate from 12% in October 2009 to 6% in May 2010 and the rate of visiting the emergency room from 21% in October 2009 to 9% in May 2010, during the 14-day postdischarge follow-up period.