In brain disorders, we need a paradigm shift towards value-based healthcare interventions
We have to educate people that a healthy brain is critical to a healthy body. As the Roman poet Juvenal wrote: Mens sana in corpore sano.
The VoT Project aimed to gather evidence to help us deal more effectively with brain disorders. The answer is to maximize the value of the treatments we already have, and to use our knowledge to develop the treatments of the future. We do have good treatments, but they are not being adequately used, Professor Nutt believes. In part, this is due to an overall lack of coordination and integration. Research shows us that the earlier we can diagnose a condition, the earlier we can intervene leading to better outcomes for patients and their loved ones.
The Project covered a range of neurological conditions including epilepsy, stroke, the dementias and Parkinson’s Disease and – in the realm of psychiatric health – schizophrenia. Many of its policy conclusions relate to brain disorders as a whole.
A comprehensive approach
With brain disorders in general,
- primary prevention is the ultimate goal
- in the absence of prevention, time matters: early intervention – including intervention in the prodromal phase -- results in objective gains in survival, reduced disability and improved quality of life, and lower overall treatment costs
- early intervention and the integration of healthcare are central to delivering sustainable models of management that provide good value in our use of limited resources under conditions of economic constraint
- although there are no curative treatments, technological innovation is moving at an unprecedented pace; and we struggle to adapt quickly enough to maximize the benefits to patients and society
- progress requires clear procedures for referral from primary to secondary and tertiary care and implementation of evidence-based guidelines
- patients’ needs embrace medical, psychological and social domains; and cognitive, educational and vocational concerns are common denominators that link many brain disorders.
The brain is the source of intellect, emotion and behavior; a source both of the person and of their participation in society.
The ECB’s VoT initiative adopted a bottom-up approach, starting with analysis of case studies and building towards policy recommendations. It assessed treatment gaps, and the cost of non-treatment or inadequate treatment. In this feature, we focus on its findings in relation to Alzheimer’s Disease (AD), Parkinson’s Disease (PD) and schizophrenia. You can read the full VoT report on EBC webpage.
Alzheimer’s Disease: the search for disease-modifying treatments
In Europe alone, there are currently over 10 million people with dementia.2 As a result of an ageing population, the burden of dementias – notably AD, which is by far the most frequent cause – is increasing. While there are symptomatic treatments, nothing yet has been shown to alter the natural history of the disease. However, the long prodrome offers potential opportunities for primary prevention.
Biomarkers are likely to have a positive impact on screening, diagnosis and the management of AD. Our ability to identify people with subjective cognitive decline or mild cognitive impairment (MCI), for example, should allow us to explore early intervention using disease-modifying agents to prevent or slow disease progression.
The ability to identify people with prodromal or pre-clinical dementia who have the highest likelihood of progression may allow us to delay the onset of clinically significant disease and extend their ability to live at home, delaying the need for institutional care.
Disease-modifying approaches are now being assessed in people who are asymptomatic but judged to be at high risk of developing AD on the basis of their genetic profile, results from PET imaging, or assessment of biomarkers.
Optimizing interventions in mental health and neurological diseases can bring both positive outcomes for patients and socio-economic gains for society
Potential economic impact of altering the natural history of AD
The greatest costs in managing AD arise from i) the need for the long-term institutional care of people who cannot live in the community, and ii) the burden on informal caregivers looking after those who can. Both these elements were included by Handels and colleagues in a model that assessed the impact of a hypothetical disease-modifying treatment in a virtual cohort of 10,000 people with normal cognition or MCI who tested positive for amyloid beta.3 It was assumed that the hypothetical agent would reduce progression to dementia by 50%.
Compared with usual care, the disease-modifying treatment would increase the length of time people spent with normal cognition or MCI, and increase life expectancy (since mortality is lower in pre-dementia states) (Fig 1). As a result, the number of quality-adjusted life years (QALYs) were higher over time (Fig 2).3 Since active treatment resulted in slower progression, healthcare costs were also reduced when compared with current care.