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Is FDA failing us Or are we failing FDA? Jonathan C. Javitt, M.D.,M.P.H Senior Fellow, Potomac Institute for Policy Studies Former Chair, Health Subcommittee,

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Presentation on theme: "Is FDA failing us Or are we failing FDA? Jonathan C. Javitt, M.D.,M.P.H Senior Fellow, Potomac Institute for Policy Studies Former Chair, Health Subcommittee,"— Presentation transcript:

1 Is FDA failing us Or are we failing FDA? Jonathan C. Javitt, M.D.,M.P.H Senior Fellow, Potomac Institute for Policy Studies Former Chair, Health Subcommittee, Presidents Information Technology Advisory Committee,

2 Jonathan C. Javitt, M.D., M.P.H.: NEI/FDA Endpoints Meeting. November 28, 2006 Dont take my word for it Our [FDAs] approach to risk management includes finding ways to help make sure that drugs we review are used safely once theyre approved. Too often, the drugs, devices, and other products we regulate are involved in preventable adverse events. As many as 20% of Americans have experienced some kind of medical error. Preventable errors and complications involving prescription drugs alone are responsible for thousands of deaths, millions of hospitalizations, and billions of dollars in additional health care costs each year, not to mention the unnecessary suffering. Mark McClellan, M.D., Ph.D.

3 A seemingly vicious circle Too few NMEs will be approved this year The cost of bringing new drugs to market is far too high and takes too long Congress and the public have labeled FDAs drug safety process as fundamentally flawed The more pressure that is brought to bear on FDA to improve drug safety, the more risk averse the agency becomes Nobody ever got fired from FDA for witholding approval on safety grounds Jonathan C. Javitt, M.D., M.P.H.: ASENT 2008

4 The other side of the coin The real threat to American lives is not dangerous drugs, but rather errors in the use of generally safe and effective drugs More Americans are harmed by their failure to receive a needed drug than will ever be harmed by administration of a harmful drug The problem lies in the disconnect between postmarketing surveillance, pharmaceutical risk management, and clinical practice Jonathan C. Javitt, M.D., M.P.H.: ASENT 2008

5 Jonathan C. Javitt, M.D., M.P.H.: NEI/FDA Endpoints Meeting. November 28, 2006 Todays question What is the best way to ensure public safety once drugs are introduced to the marketplace? Yesterdays answer anecdotal reporting Todays answer database analysis Tomorrows answer sentinel systems

6 A Unified Sentinel System: transforming a vicious circle into a virtuous one Jonathan C. Javitt, M.D., M.P.H.: ASENT 2008 A Sentinel System Continuously monitors all available sources of medical information in order to identify: 1.Common medical errors 2.Drug adverse events and interactions 3.Failure to comply with care 4.Threatening clinical parameters 5.Opportunities to improve care

7 Jonathan C. Javitt, M.D., M.P.H.: ASENT 2008 GAO Recognizes the problem However the proffered solution will add enormous cost to the regulatory process and provide far less benefit than might otherwise be achieved GAO does realize, however, that anecdotal reporting databases for drug complications are inherently flawed and that population surveillance is needed

8 Jonathan C. Javitt, M.D., M.P.H.: ASENT 2008 Drug Safety Health Plan Records Seen as Cost-EffectiveW ay to Identify Risks of Drugs on Market Analyzing large health plan databases to detect drug side effects would be a more cost- effective way to monitor drug safety than the risk-minimization plans proposed in a Senate bill (S. 484), a former head of the Food and Drug Administration said recently. Mark McClellan, the former commissioner of FDA, said that he supports S. 484, the drug- safety legislation sponsored by the chairman and ranking member of the Senate Health, Education, Labor, and Pensions Committee, calling it "the right foundation to build on." However, he and others who spoke March 21 at a Capitol Hill briefing cast doubt on whether the legislation makes use of the best type of postmarket drug-safety surveillance

9 Jonathan C. Javitt, M.D., M.P.H.: NEI/FDA Endpoints Meeting. November 28, 2006 As Safety concerns mount, sponsors have three basic alternatives 10,000 – 100,000 person safety trials prior to market approval Cost prohibitive Construction of ad-hoc registry programs for each newly launched drug Extremely expensive Deploy Sentinel Database systems in order to monitor drug safety and utilization $.50 pmpm

10 Jonathan C. Javitt, M.D., M.P.H.: NEI/FDA Endpoints Meeting. November 28, 2006 The drug safety paradigm must change While reporting databases can, and should be used to report rare, life-threatening events, moving to active surveillance systems enables us to: Actively keep drugs safe in the marketplace Improve patient safety by identifying those who would benefit from therapies they are not receiving Potentially launch new drugs much more quickly into a monitored environment

11 Jonathan C. Javitt, M.D., M.P.H.: NEI/FDA Endpoints Meeting. November 28, 2006 The Same Framework that addresses the most critical problems confronting patient care, also addresses the challenges facing postmarket surveillance and drug approval

12 Jonathan C. Javitt, M.D., M.P.H.: NEI/FDA Endpoints Meeting. November 28, 2006 The Active Health Care Engine® Hospital Claims Lab Results Pharmacy Claims Provider Claims RN Notes 7. Action by Doctor and Patient 4. Apply Medical Intelligence Clinical Rules 5. Create Recommendations 6. Communicate Recommendations Letters Automated Clinical Review System Communication Portal MD / RN Review 16 million covered lives

13 Jonathan C. Javitt, M.D., M.P.H.: NEI/FDA Endpoints Meeting. November 28, 2006 Can deployed Sentinel Systems save lives and save cost? 100,000 member midwestern managed care plan Selected all members with at least one physician visit and one pharmacy claim in preceeding 12 months 20,000 members selected per group Random allocation to Sentinel system with mailed clinical prompts or to watchful waiting Study period of 12 months

14 Jonathan C. Javitt, M.D., M.P.H.: NEI/FDA Endpoints Meeting. November 28, 2006 Implementation of Recommendations

15 Jonathan C. Javitt, M.D., M.P.H.: NEI/FDA Endpoints Meeting. November 28, 2006 Randomized Prospective Study: ControlStudyDifference Total Admissions %* Admits/ %* Hospital Bed-Days total %* ALOS3.89 days3.72 days4.5%* Days per %** Total paid$31.3 MM$29.6 MM5.5%** Inpatient paid$4.6 MM$4.1 MM11%** * p<.03 ** p<.005 Approximately 1,000 interventions issued in the intervention group and a similar number observed in the control group Overall cost saving of 6% - 8%

16 Jonathan C. Javitt, M.D., M.P.H.: NEI/FDA Endpoints Meeting. November 28, 2006 Sentinel Systems in Postmarketing Surveillance Reinventing the concept of drug safety –Keeping drugs safe in the marketplace through early detection of adverse events Enables early intervention Enables early implementation of monitoring Enables early labeling changes –Keeping drugs safe in the marketplace by avoiding interactions and proactive notifying caregivers –Keeping drugs safe by ensuring clinical monitoring –Keeping patients safe by increasing compliance with therapy –Keeping patients safe by identifying those in need of unprescribed therapy

17 Sentinel Systems will actually Increase appropriate sales of lifesaving drugs Half of those who would benefit from beta blockers post MI are not receiving them Half of those who qualify for ACE inhibitors under the HOPE trial criteria do not receive them And so on… Jonathan C. Javitt, M.D., M.P.H.: ASENT 2008

18 Jonathan C. Javitt, M.D., M.P.H.: NEI/FDA Endpoints Meeting. November 28, 2006 Keeping Drugs Safe in the Marketplace When Rezulin was approved for the treatment of diabetes, the possibility of liver failure was well recognized and all involved were confident that with proper laboratory monitoring patient safety could be assured When the first (predictable) cases of liver failure were reported, FDA determined that only 9% of physicians were following the rezulin label and obtaining LFTs. Therefore the drug was withdrawn on the grounds that safety could not be maintained in the marketplace

19 Jonathan C. Javitt, M.D., M.P.H.: NEI/FDA Endpoints Meeting. November 28, 2006 Frequency of pharmaceutical risk management recommendations: Clinical Issue Patients (N) Triggering (%) Need for LFTs on Rezulin15513% Need renal monitoring on Metformin32919% Need for INRs on Coumadin1537% Need for LFTs on Statins93110% In other words, 87% of physicians in this sample were monitoring their Rezulin patients (not 9% as FDA thought) and those who were not monitoring frequently complied with a single reminder letter.

20 Jonathan C. Javitt, M.D., M.P.H.: NEI/FDA Endpoints Meeting. November 28, 2006 Proven Results Sentinel systems are currently workable and deployable Sentinel systems can play a direct role in pharmaceutical risk management Sentinel systems suggest action that Physicians will accept and implement The costs of sentinel systems are more than offset by savings in health care

21 Are Sentinel Systems merely a Dream? 25 Million Americans already say NO! –However, these systems were engineered only for the purpose of patient safety and care improvement The next phase is the RHIO – Regional Health Information Exchange –First Gateways: 20 million lives this year –Indiana: 5+ million lives –New England: 5+ million lives –RHIOs are being engineered primarily for transportability of health information, driven by health systems economy, with patient safety as a secondary opportunity and postmarket surveillance not even a major topic of conversation. Jonathan C. Javitt, M.D., M.P.H.: ASENT 2008

22 The RHIO environment Draws together all known diagnoses, procedures, admissions, labs, and increasingly other findings under a common data umbrella. Privacy and security issues have been legislated and ironed out. Provides the ideal environment for post-market surveillance, in addition to patient safety The problem is the business model to support RHIOs – right now they are grant funded Jonathan C. Javitt, M.D., M.P.H.: ASENT 2008

23 Business Case for RHIOS Todays case –1 in 5 diagnostic tests is performed simply because the results of previous tests are not available during the time frame of the medical decision –1 in 8 hospital admissions is triggered by events resulting from failure of information flow in the outpatient environment Tomorrows case –New drugs will come to the market sooner –Drugs will be less likely to be withdrawn from the market because of unexpected and unmanageable toxicities –Patients will be more likely to be offered critical, lifesaving drugs Jonathan C. Javitt, M.D., M.P.H.: ASENT 2008

24 The future opportunity Reallocate current resources spent on episodic reporting to supporting RHIO initiatives Create a structure for earlier monitored drug launches in a RHIO environment with user fees paid by the sponsors –Instead of requesting a 10,000 person premarketing safety study, the safety results from 100,000 patients can be obtained in a RHIO environment at far lower cost Replace single product risk management programs with population based programs that work through and simultaneously support the evolving RHIO structure Jonathan C. Javitt, M.D., M.P.H.: ASENT 2008

25 Jonathan C. Javitt, M.D., M.P.H.: NEI/FDA Endpoints Meeting. November 28, 2006 Cost Effectiveness Sentinel systems cost approximately $10 per person / year to implement Cost represents < 0.5% of overall health care costs Direct savings exceed costs at least 10-fold, not including the benefits to industry and FDA of safer drugs, maintained in the marketplace Extrapolation of these implications to the nation suggest that a very modest level of IT investment (i.e. not universal EHRs) could readily save the country in excess of $70 Billion/yr

26 Jonathan C. Javitt, M.D., M.P.H.: NEI/FDA Endpoints Meeting. November 28, 2006 Think about the potential for doing better, more real-world clinical studies at a much more affordable cost. For example, post- approval studies could be much cheaper and easier to do, using clinical protocols administered over the internet via electronic records, with patients selected and results recorded directly from electronic medical records. Low-cost clinical trials to be performed more quickly and easily in real-world medical settings. And we can use the signals we obtain from our better surveillance system to work with health care providers, funding agencies, and health care payers to target these studies more effectively. Mark McClellan, MD, PhD Testimony to the Presidents Information Technology Advisory Committee


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