Latest / Becker’s Healthcare Podcast / Bioelectronic Medicine’s Potential to Transform Rheumatoid Arthritis Treatment with Dr. John D’Angelo

Transcript

Bioelectronic Medicine’s Potential to Transform Rheumatoid Arthritis Treatment with Dr. John D’Angelo · Becker’s Healthcare Podcast

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  - This is Scott Becker with the Beckers Health
• 1:01
  - Care Podcast.
• 1:02
  - We're thrilled today to be joined by doctor
• 1:04
  - John D'Angelo.
• 1:05
  - John is the CEO and leader president at
• 1:08
  - Northwell Health. Northwell Health has become the largest
• 1:11
  - health system in the state of New York
• 1:13
  - And in a lot of ways, the most
• 1:15
  - important health system in the Greater Tristate Area
• 1:18
  - is it takes care of a larger part
• 1:19
  - of the population
• 1:20
  - than anybody else at this point. It's really
• 1:23
  - remarkable the growth that that Northwell Health has
• 1:26
  - been on. We're gonna talk specifically today
• 1:28
  - about some of the areas that that doctor
• 1:31
  - D'Angelo himself is an expert in and and
• 1:33
  - spends a lot of time in. And we'll
• 1:35
  - get him back on to speak about Northwell
• 1:37
  - more generally at some point as well because
• 1:39
  - the entire trajectory
• 1:41
  - over the last couple decades has been remarkable.
• 1:43
  - John, can you take a second, doctor D'Angelo,
• 1:45
  - before we get started on speaking about rheumatoid
• 1:48
  - arthritis and specialty pharmacy and some of the
• 1:50
  - different issues here? Can you take a moment
• 1:53
  - and introduce yourself and tell the audience a
• 1:54
  - little about you and your background?
• 1:56
  - Sure. Thanks for having me. John D'Angelo. I'm
• 2:00
  - an emergency physician by by background. So I'm
• 2:02
  - by no means the expert in bioelectronic medicine
• 2:05
  - or rheumatoid arthritis, but I've learned quite a
• 2:07
  - bit in my tenure at Northwell. I've been
• 2:09
  - here twenty six years, and doctor Kevin Tracy,
• 2:12
  - who's been a real pioneer in that... In
• 2:14
  - this space,
• 2:15
  - has, has really brought a lot of us
• 2:17
  - up to speed on
• 2:19
  - on the science and the possibilities of the
• 2:21
  - future.
• 2:23
  - Northwell is a, as you said, largest,
• 2:25
  - health care organization in the Northeast. We are
• 2:28
  - 28 hospitals at this point, close to a
• 2:29
  - thousand per axis, 108,000
• 2:31
  - team members.
• 2:32
  - We've had a a remarkable journey and incredible
• 2:35
  - culture and one we're very proud of. But
• 2:37
  - one of the things we're very proud of
• 2:38
  - is our center for bioelectronic
• 2:39
  - medicine
• 2:40
  - at the Feinstein Institute for Medical Research, which
• 2:43
  - gets to the topic
• 2:44
  - of today.
• 2:45
  - And to answer your question, yeah, this focus,
• 2:48
  - the initial focus and use case for what
• 2:50
  - we're gonna talk about is rheumatoid arthritis, which
• 2:52
  - affects about one and a half million Americans
• 2:54
  - a year. And from
• 2:56
  - a a pharmaceutical
• 2:57
  - spend,
• 2:59
  - rheumatoid arthritis ranks in one of the top
• 3:00
  - five,
• 3:01
  - conditions of payer specialty pharma... Pharmaceutical
• 3:04
  - spend in the country. And it's about 30,000,000,000
• 3:07
  - annual,
• 3:08
  - spent on the drugs to treat...
• 3:10
  - Biological drugs to treat, rheumatoid arthritis,
• 3:14
  - and about sick... 13 to $14,000,000,000
• 3:16
  - in Medicare part d spending.
• 3:18
  - And, these are drugs that have
• 3:22
  - very powerful. These biological drugs also come though
• 3:25
  - with a large spectrum of potential side effects.
• 3:28
  - They're costly.
• 3:30
  - And, most people have to switch drugs every
• 3:32
  - few years because of efficacy.
• 3:35
  - And that's,
• 3:36
  - been the focus of doctor Tracy's research all
• 3:38
  - these years of how we can modulate the
• 3:40
  - immune system
• 3:42
  - in chronic inflammatory disease like, rheumatoid arthritis
• 3:46
  - from almost like hacking the nervous system rather
• 3:49
  - than through pharmaceutical,
• 3:51
  - intervention.
• 3:52
  - And and it it is remarkable how much
• 3:54
  - inflammation
• 3:55
  - and inflammatory
• 3:57
  - causes
• 3:58
  - have become such a focus, and it makes
• 4:00
  - great sense. I know at Cleveland Clinic, it's
• 4:02
  - become one of their primary focuses of research
• 4:04
  - because
• 4:06
  - inflammation affects so many other conditions and is
• 4:08
  - such a a vast impact on on the
• 4:10
  - human condition.
• 4:12
  - Could you just tell me really quickly, rheumatoid
• 4:14
  - arthritis versus traditional arthritis that we always think
• 4:17
  - about, like people aging and have arthritis,
• 4:20
  - Are those different things... And, again, I'm... You're
• 4:23
  - a physician
• 4:24
  - leader.
• 4:24
  - I'm not. But tell us the distinction between
• 4:26
  - rheumatoid arthritis and arthritis that we all talk
• 4:29
  - about as we're aging. Yeah. I mean, there's
• 4:31
  - there's different types of arthritis, and that's the
• 4:33
  - the whole specialty of rheumatology kind of focuses
• 4:35
  - on. There's
• 4:37
  - there's arthritis that a lot of people suffer
• 4:40
  - from that's just wear and tear in our
• 4:41
  - joints over a lifetime of activity and work
• 4:43
  - and pounding and things of that nature on
• 4:45
  - one extreme, which is one extreme. But on
• 4:48
  - the other extreme are these inflammatory causes of
• 4:50
  - arthritis and rheumatoid arthritis being the most prominent
• 4:53
  - of those. And one of the more debilitating
• 4:55
  - where your body's inflammatory response,
• 4:59
  - starts to attack the linings of our joints,
• 5:01
  - and break down, you know, the joint surfaces
• 5:04
  - and bone, through this chronic,
• 5:08
  - unregulated,
• 5:09
  - immune,
• 5:10
  - inflammatory cells that that that kinda
• 5:14
  - high concentrate in the joints.
• 5:16
  - And it leaves people,
• 5:18
  - in extreme in extreme cases and in a
• 5:20
  - lot of cases,
• 5:21
  - unable to do simple activities of living such
• 5:23
  - as, like, brushing their teeth or or walking,
• 5:26
  - depending on the joints that are affected, and
• 5:28
  - it's extremely debilitating for folks.
• 5:31
  - And unlike
• 5:32
  - some of the more acute arthritic conditions that
• 5:35
  - people have gout and other causes of of
• 5:38
  - inflammation in a joint where you treat it,
• 5:39
  - it goes away. Maybe you have an episode
• 5:41
  - or two over your lifetime, maybe you don't.
• 5:43
  - This is a chronic
• 5:45
  - ongoing and often progressive,
• 5:48
  - condition.
• 5:49
  - Thank you. That makes tremendous sense. And you
• 5:52
  - talk a little bit about how
• 5:55
  - the challenges to treating rheumatoid arthritis
• 5:58
  - and the other conditions like it. And talk
• 6:00
  - a little bit also about
• 6:02
  - why there's a constant need to periodically change
• 6:05
  - medicine with people that suffer from rheumatoid arthritis
• 6:10
  - and and and why there's not just a
• 6:11
  - standard treatment all the way through. It's it's
• 6:13
  - that you're... Talk a little bit about both
• 6:15
  - those things. Yeah. Part of it is it's,
• 6:17
  - these are biological medications, and they have an
• 6:20
  - impact to get at the at the at
• 6:22
  - the air... The point of inflammation and trying
• 6:24
  - to bring down inflammation.
• 6:26
  - And everybody's body kinda reacts different. Some never
• 6:28
  - work at all for certain individuals.
• 6:30
  - Some work for a while, and then the
• 6:32
  - efficacy, whether the body becomes more tolerant of
• 6:35
  - it or whatever the drivers are, are less
• 6:37
  - efficient over time. People often on... In this
• 6:40
  - particular case, people, I believe, switch their drug
• 6:43
  - on average every two, three years. They're switching
• 6:45
  - to a different biologic or they're compounding multiple
• 6:48
  - biologics to kinda get the right level of
• 6:50
  - relief. So it's one of those
• 6:52
  - conditions where it's it's in flux.
• 6:56
  - And that's the beauty of of some of
• 6:58
  - the alternatives that are now available
• 7:00
  - is
• 7:01
  - trying to get the same benefit without, again,
• 7:04
  - side effects, cost, and other things related to
• 7:06
  - these drugs.
• 7:09
  - Fascinating. And and and talk about this because
• 7:12
  - I did not understand this. There's this concept
• 7:14
  - that there's a lot of upfront cost in
• 7:17
  - treating rheumatoid arthritis
• 7:19
  - and that the drug spend is quite expensive.
• 7:21
  - Can you give us some insight into that?
• 7:24
  - Why is there so much cost upfront versus
• 7:26
  - later?
• 7:27
  - And and and what does that look like?
• 7:29
  - And how do you think about that trade
• 7:30
  - off? Yeah. The cost is on average,
• 7:33
  - for the drugs themselves, average between 16 to
• 7:36
  - $90,000
• 7:36
  - a year per patient.
• 7:39
  - And, that does not include,
• 7:41
  - the trial and error with finding the right
• 7:43
  - drug that works for the patient, the visits
• 7:45
  - that are detailed, all the workups, and and
• 7:47
  - all the all the stuff that goes on
• 7:48
  - early treatment until people get to, hopefully, a
• 7:51
  - form of remission
• 7:52
  - where then it's less frequent checks, less frequent
• 7:54
  - modulation of the different drugs, compounding different drugs
• 7:58
  - on top of each other, which adds to
• 7:59
  - the effect.
• 8:00
  - So, early on, it's a lot of that
• 8:02
  - trial and error that leads to a lot
• 8:03
  - of the cost. And then, hopefully, over time,
• 8:05
  - you find that right steady state for the
• 8:06
  - patient.
• 8:08
  - And and, again, these drugs are not cheap.
• 8:11
  - Granted, there's a lot of research and development
• 8:13
  - that goes into creating these drugs, and there...
• 8:15
  - There's a a cost associated with that. And
• 8:17
  - then you have all the other, you know,
• 8:19
  - drivers of of drug costs that all kinda
• 8:21
  - compound here.
• 8:23
  - And so if you're talking about a million
• 8:24
  - and a half people a year diagnosed with
• 8:26
  - rheumatoid arthritis
• 8:27
  - Yep. And and the cost of treating them,
• 8:29
  - 60,000 to 90,000 when somebody's on full track
• 8:32
  - of of medication
• 8:33
  - Right. That's that's a really expensive condition.... Our
• 8:35
  - lifetime. Yep.
• 8:37
  - Yep. And and doesn't stop. That's remarkable.
• 8:40
  - And and when you talk about the patient
• 8:42
  - outcomes
• 8:43
  - and the total cost of their care, what
• 8:45
  - what... I mean, you you you mentioned this
• 8:46
  - just a moment ago, but talk about some
• 8:48
  - of those additional costs besides those medication costs,
• 8:51
  - which are very, very high. Yeah. No. It's
• 8:53
  - frequent specialist visits. It's... And it... There's direct
• 8:57
  - costs, which are the the cost of care.
• 8:59
  - So,
• 9:00
  - specialist visits, imaging,
• 9:02
  - you know, you name it. All of those,
• 9:05
  - dynamics that go into care, especially at the
• 9:07
  - more acute,
• 9:08
  - more labor intensive early stages of care.
• 9:11
  - You add to that the overall economic impact
• 9:14
  - of people's inability to maintain their livelihood
• 9:17
  - and all the other driver. You know, if
• 9:18
  - this is something that's preventing people from being
• 9:20
  - able to function in their day to day
• 9:22
  - life, it has greater toll on the overall
• 9:24
  - economics both to them, their family, and so
• 9:26
  - forth.
• 9:27
  - And that... That's what, again,
• 9:29
  - the goal of therapy is to bring these
• 9:31
  - people back to an... A,
• 9:33
  - not only a stage of enjoying their lives,
• 9:35
  - but getting back to work, getting back to
• 9:37
  - productivity,
• 9:38
  - and so forth.
• 9:39
  - So I'm sure you'll talk to,
• 9:42
  - whether it's doctor Tracy or turn off from
• 9:43
  - set point or other ex... Experts in the
• 9:45
  - field. But from my emergency medicine lens, that's
• 9:48
  - where I see most of the cost being
• 9:49
  - is on that upfront acute care cost.
• 9:53
  - Literally,
• 9:54
  - remarkable.
• 9:55
  - And and and and talk for a second.
• 9:56
  - When when you look at sort of,
• 9:59
  - what you're most excited about in this area,
• 10:02
  - potential changes,
• 10:04
  - evolutions,
• 10:05
  - What are you seeing here that could be
• 10:06
  - impactful both rheumatoid arthritis and potentially to other
• 10:10
  - chronic conditions?
• 10:11
  - So if we if we step back for
• 10:13
  - a second, the the the the lead...
• 10:16
  - The the novel therapy that we're talking about
• 10:18
  - is, you know, again, kept doctor Tracy's work
• 10:21
  - over decades
• 10:23
  - of how do we stimulate the nervous system
• 10:26
  - and almost, like, trick the nervous system to
• 10:28
  - turn down the inflammatory
• 10:30
  - response.
• 10:32
  - And what he's discovered decades ago is if
• 10:35
  - you stimulate one of the largest nerves in
• 10:36
  - the body, the vagus nerve,
• 10:38
  - at a certain level,
• 10:40
  - that
• 10:41
  - auto,
• 10:42
  - regulates, turns down inflammation in areas of high
• 10:45
  - concentration of inflammation.
• 10:47
  - SetPoint is a company that ran a lot
• 10:49
  - of the clinical trials and was the, company
• 10:52
  - to bring this through the first FDA approval
• 10:54
  - for this type of treatment. And now there's
• 10:57
  - an FDA approved
• 10:58
  - device that's about the size of a vitamin
• 11:01
  - that a neurosurgeon in what is a fifteen,
• 11:04
  - twenty minute ambulatory procedure can put on that
• 11:06
  - nerve in the neck, the vagus nerve.
• 11:08
  - And with
• 11:10
  - signals just impulse several times a day,
• 11:14
  - turn down that inflammatory response. And what the
• 11:17
  - the remarkable piece of this is, more than
• 11:20
  - fifty percent of these patients are remaining,
• 11:24
  - drug free after a year.
• 11:26
  - A majority of them, seventy five... I'm sorry.
• 11:29
  - Seventy five percent are managing their disease without
• 11:31
  - the without the drugs at a year end,
• 11:33
  - and more than half have lower disease activity
• 11:36
  - or remission that are that are using this
• 11:37
  - novel therapy.
• 11:39
  - And from my perspective, one of the exciting
• 11:41
  - things about that is it's not,
• 11:45
  - electronic stimulation or it's not attacking the joint
• 11:47
  - itself. It's turning down inflammation in the entire
• 11:50
  - body. Right? So you can think about how
• 11:52
  - that same
• 11:53
  - regulation of the inflammatory response could affect other
• 11:56
  - diseases like inflammatory bowel disease, Crohn's, ulcerative colitis,
• 12:00
  - how it could affect lupus, how it could
• 12:02
  - affect, you know, potentially
• 12:04
  - some of the other processes
• 12:07
  - pulmonary hypertension, and the list goes on and
• 12:09
  - on.
• 12:11
  - So I think if you think about the
• 12:12
  - role that you opened up with at the
• 12:14
  - beginning of this conversation, inflammation plays
• 12:17
  - in so many disease entities.
• 12:19
  - This could be the start of a... Of,
• 12:22
  - a new evolution of therapy that could have
• 12:24
  - really meaningful impact on on the cost of
• 12:26
  - care and on people's lives.
• 12:28
  - So, I mean, it's similar on the autoimmune
• 12:30
  - diseases where the immune system kicks in, like,
• 12:33
  - with with with chemotherapy, then it overkicks in.
• 12:35
  - It overkicks out. And so then you're constantly
• 12:38
  - fighting the battle between what's
• 12:40
  - helping versus what's causing too much harm as
• 12:42
  - a response to it. And and and similarly,
• 12:45
  - if we could find different ways to keep
• 12:47
  - the inflammation,
• 12:48
  - the responses in check so they balance each
• 12:51
  - other out Right. Then you've gone a long
• 12:52
  - way on chemotherapy, on autoimmune diseases, on inflammatory
• 12:56
  - diseases,
• 12:57
  - across the board.
• 12:58
  - Doctor James, let me ask you another question.
• 13:00
  - You've been at Northwell now for twenty six
• 13:02
  - years, I think you said, which is Yep.
• 13:04
  - Incredible.
• 13:05
  - Did you ever envision that Northwell would become
• 13:07
  - such a leader in not just community health
• 13:09
  - care between the different suits to put together,
• 13:12
  - but in research and in in helping to
• 13:14
  - fund these types of efforts in in trying
• 13:16
  - to take medicines a whole different level
• 13:19
  - compared to what Northwell was when you started
• 13:22
  - compared to what it is today. Does that
• 13:24
  - ever just an issue? It really is amazing.
• 13:27
  - If you think about it, Northwell,
• 13:29
  - initially started with,
• 13:31
  - a tertiary hospital and a lot of community
• 13:33
  - hospitals that came together in our early days.
• 13:35
  - And it was more around to your point,
• 13:37
  - optimizing care delivery in the communities we serve.
• 13:40
  - And over time, that tertiary hospital and then
• 13:43
  - subsequent,
• 13:44
  - hospitals and health... You know, that came as
• 13:46
  - part of the system,
• 13:47
  - the academics really,
• 13:49
  - has come a long way. We're really proud
• 13:51
  - of being what we refer to as a
• 13:52
  - modern,
• 13:54
  - academic,
• 13:55
  - organization, modern academic medical center, where not only
• 13:58
  - do we have cutting edge research at Feinstein
• 14:00
  - Institute, and we have really strong affiliations with
• 14:02
  - Cold Spring Harbor and other world renowned, research
• 14:05
  - facilities.
• 14:07
  - The amount of discovery that's going on here
• 14:09
  - is incredible. In our bioelectronic,
• 14:11
  - institute, for example, we're talking about vagus nerve
• 14:13
  - stimulation today,
• 14:14
  - But we have other scientists like Chad Booten
• 14:17
  - who was just recognized in time as one
• 14:19
  - of our top innovators of our time, who
• 14:21
  - has discovered... You know, we have the first
• 14:22
  - human in history who was paralyzed from the
• 14:24
  - neck down that has movement feeling back in
• 14:26
  - their arm from a neuro brain bypass. I
• 14:28
  - mean, there's really incredible science happening here. And
• 14:31
  - you add that to the medical school and
• 14:33
  - all the things that it's... It... Northwell
• 14:35
  - and this health system has really come a
• 14:37
  - long way. We are the number two or
• 14:38
  - three in the country. I believe I just
• 14:39
  - saw the stat. We're now number two in
• 14:41
  - the country for graduate medical education.
• 14:44
  - 2,600
• 14:45
  - residents and fellows. And you think about the
• 14:47
  - training of the next generation of doctors and
• 14:49
  - scientists, it's it's really incredible.
• 14:51
  - We we have a, you know, one of
• 14:53
  - our daughters is long term partners is a
• 14:57
  - is a young man
• 14:58
  - who's an orthopedic resident at Lennox. Yeah. And
• 15:01
  - and going back a couple decades ago,
• 15:04
  - that might not have been the top residency
• 15:07
  - to match at, and it's become,
• 15:09
  - you know, the pride and joy of the
• 15:10
  - family that he's at Lennox, which which is
• 15:12
  - a Northwell institution. I mean, it's really amazing
• 15:14
  - the evolution of Northwell over the last twenty
• 15:17
  - five, twenty six years, the last few decades
• 15:19
  - from the Long Island Jewish merger to what
• 15:21
  - you've done to where it's come together. But
• 15:23
  - this research front
• 15:25
  - is such an important part of being a
• 15:27
  - great health system. So you see, like, in
• 15:29
  - Chicago, Endeavor, Russia coming together so they could
• 15:32
  - combine those things. And advocate in North Carolina
• 15:36
  - is pairing up with Wake Forest to to
• 15:38
  - make sure that they could be great on
• 15:40
  - research as well as being community system. And
• 15:42
  - it's really amazing what Northwell has done over
• 15:44
  - the last couple decades. And what's really exciting
• 15:46
  - is... And whether they're talking about cancer research,
• 15:48
  - all the clinical trials, everything else. We are
• 15:51
  - sitting in one of the most populated but
• 15:53
  - also the most diverse
• 15:55
  - areas in the world. You think about the
• 15:57
  - population of Queens and, you know, the New
• 15:59
  - York City boroughs,
• 16:00
  - that provides a tremendous
• 16:02
  - opportunity
• 16:03
  - to bring research to a whole new level
• 16:05
  - that fully represents, you know, again, a lot
• 16:08
  - of diverse populations,
• 16:10
  - which a lot of research studies are lacking
• 16:12
  - is that level of diversity to really understand
• 16:14
  - what works in what populations and what ethnicities
• 16:17
  - and so forth. So it really is... We
• 16:19
  - have almost like the perfect scenario of the
• 16:21
  - academic
• 16:22
  - know how and the expertise, and then the
• 16:24
  - expertise keeps getting recruiting, but you add it
• 16:26
  - to the environment we're in, and there's incredible
• 16:29
  - possibility.
• 16:30
  - Right. An incredible community that you serve. And
• 16:32
  - combine that world class research
• 16:34
  - with that size of community, that diverse community,
• 16:37
  - you have the ability to make a huge
• 16:38
  - difference. Doctor D'Angelo, it is fantastic to visit
• 16:41
  - with you. It's it's a it's a true
• 16:42
  - pleasure and an honor to visit with you
• 16:44
  - and the Northwell leadership.
• 16:46
  - Just remarkable what you are doing. I I
• 16:48
  - wanna thank you for joining us. And I
• 16:49
  - so appreciate you joining us on a specific
• 16:52
  - subject rather than the general leadership of Northwell,
• 16:54
  - but one of the things that Northwell is
• 16:56
  - really advancing,
• 16:57
  - it's really impressive, and I love you being
• 16:59
  - at the forefront of it with your team.
• 17:01
  - Thank you so much for joining us. Thank
• 17:03
  - you, Scott.