Advancing Long-Term Care Through Precision Medicine

The current state of precision medicine in long-term and post-acute care, and potential future advancements, are discussed with Dr Joel Diamond, CMO of Aranscia.  

Please share your name, title, and a brief overview of your professional history.  

I am Joel Diamond, chief medical officer for Aranscia and the companies that are part of the Aranscia family. I've been practicing family medicine for about 30 years and continued to do so despite also working in medical technology. I practice medicine outside of Pittsburgh, Pennsylvania.  

I started with a company called 2bPrecise, a precision medicine software platform that allows transformative diagnostic solutions at the point of care in electronic medical records. Aranscia encompasses several other companies such as a laboratory called AccessDx, which provides diagnostic laboratory services aligned with patient outcomes, particularly in the field of precision medicine. SinguLab is a lab diagnostic services platform that helps organizations with their testing needs. A recent acquisition of ours is a company called YouScript, which is sort of the gold standard of helping people with evidence-based medicine that involves drug responses, including pharmacogenetic testing. 

Please explain what precision medicine is and why it seems to be a growing area of interest in health care? What are some of the key challenges of implementing precision medicine?  

People have used the term precision medicine in lots of different ways. When I was in medical school, we admired the doctors who taught things from their personal experiences treating patients that we wouldn’t find in a textbook. The problem with that is that many of those personal treatment choices were just opinions.  

When we started implementing evidence-based medicine, it was a significant change to the status quo. Evidence-based medicine means applying real standards, looking at clinical studies critically, and deciding if a particular medication, treatment, or diagnostic study should be used broadly or have some unique standards. Now, we apply this one-size-fits-all model to every patient, and we must recognize that many people fall outside the mean. Within any class of medications on the market for treating depression or for high blood pressure, et cetera, there are many medicines available because all our bodies may respond differently. The root cause of those differences is often because of genetics.  

Many pieces make up precision medicine, but a couple of areas that people may be more familiar with include cancer treatment. We used to treat cancer by how it presented anatomically, such as breast cancer or colon cancer, and we thought of it in a way that was specific to anatomy. We now recognize that there are amazing new treatments that depend on that cancer’s molecular nature instead of its anatomical location. This new treatment approach is based on genetic markers, among other things.  

We're exploring pharmacogenomics so that instead of just pulling a drug out of a hat, we’re really applying specific rigor to why a medicine may work better for one person than another. We've been in this in-between zone in medicine where you go to the eye doctor, and they say to try on a pair of glasses, come back in 2 weeks if they aren’t working, and we’ll try a different pair. But we can't do that same trial-and-error approach in other areas of medicine. We have an adolescent health crisis in behavioral health right now, and clinicians don't have months to find the correct treatment. We’re moving very rapidly towards more precise treatment plans and getting patients on the right medicine quicker. This means we will find cures quicker and, in some cases, get them feeling better quicker.  

Why is precision medicine especially important in a long-term care setting to personalize care when treating infection and disease? 

Many of the problems in long-term care have to do with, again, this notion of one size fits all. The major areas in long-term care affecting reimbursement, rehospitalizations, and quality of life like cognitive problems, infections, emotional care, etc. All of these have a precision medicine component.  

When it comes to infectious diseases, because of COVID-19, most people have now heard of polymerase chain reaction (PCR) testing. PCR is a DNA test that can diagnose a particular strain of COVID-19 and other infectious diseases. This testing has been a marked change from how we used to do microbiology, and we're now recognizing we can do this with bacterial diseases as well. This testing leads to a much quicker and more accurate diagnosis. This may also alleviate and predict antibiotic resistance trends, which is a big problem in nursing homes.  

What clinical best practices and tools are essential for personalizing long-term care, improving patient outcomes, and enhancing facilities’ efficiency?  

The best way to introduce new technology is not to force it immediately into patient care. That approach is very difficult because it doesn’t address the huge information gap. This science has grown more rapidly than anything else in my entire career, and keeping up with it is hard. Most doctors had a very short course in genetics in medical school, and what's happened in genetics in the last two decades has been astounding. So, in my opinion, the best practice is to evaluate existing programs for quality improvement.  

In long-term care, for instance, we have initiatives around reducing falls. Another initiative is to recognize infections quicker because they're associated with mental status changes, falls, and hospitalizations. Another initiative is to recognize that certain drugs may be metabolized poorly or may have more side effects based on individual genetic responses to medicines and can lead to increased cognitive problems.  

Clinicians tend to add more prescriptions on top of existing prescriptions. If a patient experiences a side effect of a medicine, they often are given a new medication to address the side effect, and so on. Because of this pattern, de-prescribing is another important initiative.  

Some other treatment initiatives in long-term care is to consider are to address urinary incontinence in this population, post-hospital or post-surgical infection rates, and accessing what drugs we are prescribing. We must study existing programs to identify ways of improving quality and patient outcomes and see where precision medicine fits in instead of using precision medicine as a blanket solution for the long-term care population.  

What are your recommendations for other health care professionals and leaders to enhance their long-term care knowledge and team training?  

Education is key. It is difficult for clinicians, caregivers, and staff to stay current on important health care developments. Our biggest health care threat in long-term care is the growth of antibiotic resistance and antibiotic stewardship. We use the phrase antibiotic stewardship, but it takes time to implement. Clinicians want to keep patients out of the hospital, creating an incentive to prescribe broad-spectrum antibiotics very quickly. However, we're overprescribing. This is creating more antibiotic resistance in the long-term care population. To pick the appropriate antibiotic, not just the strongest antibiotic, we must quickly and precisely diagnose infections.  

Another piece of this puzzle is emerging infections. Many people are now familiar with Candida auris (C. auris), which is a new fungal infection that sounds like science fiction because it is resistant to almost every drug we have and seems to be able to live for a very long time on surfaces. If we use molecular techniques to recognize infections better, we can figure out how to isolate infected patients in long-term care to slow the spread of infections.  

How do you see precision medicine evolving in the next 5-10 years regarding long-term and post-acute care? What do you anticipate being the major breakthroughs? 

People's perception of testing is evolving quickly. You will see ads on TV for treating almost every disease now, not just cancer drugs. For autoimmune diseases like arthritis, psoriasis, or Crohn's disease, we're increasingly using biologic, molecular-based therapies. I think we're going to see a lot more of that.  

One of the “black holes” in medicine has been neurological diseases and psychiatric diseases. In common long-term care diseases like Parkinson disease or psychosis, we also haven't made a lot of progress in treatment to date. However, treatments for these diseases are probably right around the corner, and I am sure they will be precision medicine and molecular-based treatments.  

I think we will make bigger strides in treating and mitigating infectious diseases on a population level and better understanding antibiotic resistance. I also think the cost of reimbursement for genetic testing and the perception of genetic testing being extraordinarily expensive will change as well. Already, the cost of this type of testing has come down faster than any other technology that I've experienced. Genetic costs have beaten Moore's Law every single time and will probably continue to.  

We're starting to see some real reimbursement for pharmacogenomic testing. California recently passed a rule that in addition to Medicare, Medi-Cal will also start paying for pharmacogenomic testing. I think that ruling will be a bellwether for the rest of the country. 

I encourage people to put some time in and start reading about these advancements and getting excited. Some people may perceive that precision medicine is far from becoming the standard of care, but I think we're really at that tipping point right now. My biggest disappointment is seeing people who would benefit from precision medicine testing go without. Whether that's young women with a family history of cancer that haven't had testing, or elderly patients being mismanaged because their potential drug and gene interactions weren’t identified. I’d encourage health care professionals to increase their awareness and education around precision medicine and recognize that we're already well into this revolution in medicine.