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References

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  2. Collins FS, Varmus H. A new initiative on precision medicine. N Engl J Med. 2015;372:793-795.
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  8. Doll R, Hill AB. Smoking and carcinoma of the lung. Br Med J. 1950;2:739-748. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2038856/ Accessed April 20, 2015.
  9. Centers for Disease Control and Prevention (CDC). Ten great public health achievements--United States, 1900-1999. MMWR Morb Mortal Wkly Rep. 1999;48:241-243. http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm Accessed April 9, 2015.
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  12. Brooks M. FDA OKs omalizumab (Xolair) for chronic hives. Medscape Medical News. March 21, 2014. http://www.medscape.com/viewarticle/822440 Accessed April 20, 2015.
  13. Sabroe RA. Commentary: Omalizumab for the treatment of chronic idiopathic or spontaneous urticaria. Br J Dermatol. 2014;17:13-15. http://www.medscape.com/viewarticle/829590 Accessed April 20, 2015.
  14. Jaroff L. Time Magazine's Medical Invention of the Year 2000. TIME. November 30, 2000. http://www.petscaninfo.com/zportal/portals/pat/news/awardsfol/time Accessed April 8, 2015.
  15. Smith KC. Botulinum toxin type A: new information about an old medicine. Skin Therapy Lett. 2011;16:3-6. http://www.medscape.com/viewarticle/752110 Accessed April 17, 2015.
  16. US Food and Drug Administration. FDA approves Botox Cosmetic to improve the appearance of crow's feet lines. September 11, 2013. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm367662.htm Accessed April 17, 2015.
  17. Lew MF. Review of the FDA-approved uses of botulinum toxins, including data suggesting efficacy in pain reduction. Clin J Pain. 2002;18:S142-S146.
  18. US Food and Drug Administration. FDA approves Botox to treat chronic migraine. October 15, 2010. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2010/ucm229782.htm Accessed April 17, 2015.
  19. US Food and Drug Administration. FDA approves Botox to treat overactive bladder. January 18, 2013. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm336101.htm Accessed April 17, 2015.
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  26. Saslow D, Solomon D, Lawson HW, et al; ACS-ASCCP-ASCP Cervical Cancer Guideline Committee. American Cancer Society, American Society for Colposcopy and Cervical Pathology, and American Society for Clinical Pathology screening guidelines for the prevention and early detection of cervical cancer. CA Cancer J Clin. 2012;62:147-172. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3801360/ Accessed April 17, 2015.
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Laurie Scudder, DNP, NP
Executive Editor
Medscape

Lauri R. Graham
Editorial Director
Medscape

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20 Years of Healthcare Advances

Laurie Scudder, DNP, NP; Lauri R. Graham  |  May 28, 2015

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Slide 1

Has It Really Been 20 Years?

To celebrate Medscape's 20th anniversary, we asked our wide range of experts and advisors to look back over that time and tell us what they thought were the biggest advances in their field. An impossible task? Perhaps. But the recommendations, which ranged from clinical advances to practice-altering changes in technology, were intriguing and sometimes surprising. Depending on your age, you might be saying, "Has it really been 20 years already?" Alternatively, you might not remember life before these things! Do you agree with their choices?

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Slide 2

Cardiology: Statins for Secondary Prevention

Seth Bilazarian, MD, a clinical and interventional cardiologist at Pentucket Medical Associates in Haverhill, Massachusetts, nominated the use of statins for secondary prevention. "Although statin therapy for primary prevention is controversial (because of difficulty in choosing high-risk patients), there is no doubt about the phenomenal impact that statins have had on secondary prevention. Since their increased use, we have seen declining rates in coronary intervention, coronary bypass surgery, myocardial infarction, and sudden cardiac death. We've also seen marked improvement in the durability and longevity of the coronary bypass grafts. Twenty years ago, at the end of my fellowship, we would discharge patients after bypass surgery without statin therapy, so the effects of statin therapy on the population at large is only being realized in the past decade or so."

In addition to the significant public health and clinical benefits of statins, the other major advance they have spurred are the robust data provided by the huge clinical trials investigating their use in a variety of settings. This approach has now become standard for new therapies.

Images from Dreamstime

Slide 3

Neurology: Genomics

Neil A. Busis, MD, director of community neurology and clinical professor of neurology at the University of Pittsburgh School of Medicine, nominated the field of genomics. Exome and genome sequencing has allowed the identification of the genetic causes of neurologic disease and potentially the ability to prevent or mitigate these disorders. In making his nomination, Dr Busis noted, "It's increasingly apparent that the old model of one gene mutation, one phenotype is overly simplistic. Many gene mutations manifest as different phenotypes even in the same family. Many phenotypes can be due to more than one gene mutation. As we aim to advance our knowledge of the etiology of neurologic disease, understand how genes and the environment interact to cause neurologic diseases, and develop treatments for currently untreatable conditions, we need to sequence the genomes of many patients with neurologic diseases, compare them to individuals without those diseases, and perform in depth clinical-genomic correlations."

There's no question that genomics has had an impact on the entire field of medicine and how that medicine is delivered to patients.

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Slide 4

Oncology: The Cancer Genome Atlas

Nearly every aspect of cancer research has benefited from The Cancer Genome Atlas (TCGA),[1] according to Bert Vogelstein, MD, Clayton Professor of Oncology and Pathology at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University. Begun in 2006 and completed in 2015, the Atlas is a compilation of the genomic changes in all cancers and is a "source book" informing the practice of individualized medicine. Individualized medicine—interpreted more broadly as "prevention and treatment strategies that take individual variability into account"[2]—has become an overarching goal of US healthcare.

Image courtesy of National Cancer Institute

Slide 5

Rheumatology: Targeted Biopharmaceuticals

Jonathan Kay, MD, director of clinical research in rheumatology and professor of medicine at the University of Massachusetts Medical School, was clear: "The biggest advance in rheumatology was the introduction of tumor necrosis factor (TNF) inhibitors as targeted biological therapies for rheumatoid arthritis (RA) in 1998. These agents were then followed by the introduction of targeted biopharmaceuticals for other inflammatory diseases." Although valid concerns have been raised about their cost, anti-TNF agents represent a major advance in the treatment of RA. Recent data suggest that the ones most commonly used (adalimumab, etanercept, and infliximab) are also cost-effective.[3]

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Slide 6

Psychiatry: Old Drugs, New Data

While there are a myriad of new pharmacologic agents, Nassir Ghaemi, MD, MPH, a professor of psychiatry at Tufts University School of Medicine and director of the Mood Disorders Program at Tufts Medical Center, suggests that new data supporting the use of older agents is the real story of the past 20 years. He cites strong clinical research evidence that lithium prevents suicide[4] and continues to be the best therapy for preventing bipolar relapse, as well as recognition of the agent's neuroplastic benefits, suggesting long-term neuroprotection.[5] Clozapine has been re-introduced for treatment-resistant schizophrenia.[6] And lamotrigine, an anticonvulsant, is now recognized to be the first new effective prophylactic treatment for bipolar disorder since the 1980s.[7] Studies of newer agents are less definitive than claimed; Dr Ghaemi describes many of these agents as "me-too drugs, though sometimes with fewer side effects."

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Slide 7

Infectious Disease: HAART for HIV

For Paul Auwaerter, MD, clinical director of the Division of Infectious Diseases at Johns Hopkins University, the hands-down winner is the development of highly active antiretroviral therapy (HAART) for treatment of HIV. "Until 1995, I mainly managed mostly young patients' sometimes slow, other times rapid, path to death. It was agonizing for all involved. My first patient started on HAART in 1996. Without the drugs, he would have succumbed, but he improved with near Lazarus-like vitality. Now I see him 20 years later, happy with family and friends, productive and enjoying life. Nothing has come to be more satisfying to me personally or professionally in medicine."

Images from Associated Press, Alamy

Slide 8

Gastroenterology: Treatment of Hepatitis C Virus

This one is a two-fer, nominated by our experts in gastroenterology and infectious disease. In the past few years, the landscape of direct-acting antiviral therapy has evolved at a breathtaking pace, with interferon-free, all-oral regimens now becoming the standard of care. Treatment has become shorter, safer, and even more effective. In a previous commentary on Medscape, John Bartlett, MD, professor emeritus in the Department of Medicine at Johns Hopkins Hospital, enthused that hepatitis C "has undergone a revolutionary change from no treatment to very poorly tolerated treatment to miraculous treatment for cure. This will be the first chronic viral infection that is cured." Both Paul Martin, MD, professor of medicine and chief of the Division of Hepatology at University of Miami School of Medicine and Hospital, and David Johnson, MD, professor of medicine and chief of gastroenterology at Eastern Virginia Medical School, echoed these sentiments, commenting that one of the biggest developments in the field over the past 20 years is the advent of oral antiviral agents for hepatitis C that are capable of cure.

Image from Science Photo Library

Slide 9

Pulmonary Medicine: The Move to Smoke-Free

Edwin Marshall, OD, MPH, professor emeritus in the Department of Public Health in the School of Medicine at Indiana University, cites the decreasing use of tobacco as the biggest game changer in healthcare in the past 20 years. Nicolas Gross, MD, PhD, emeritus professor at the Stritch-Loyola School of Medicine in Chicago, agrees, noting that the risks of smoking were identified much earlier; the first well-conducted studies documenting tobacco's associated risk for cancer were performed by Richard Doll, MD, and colleagues in 1950.[8] In fact, recognition of tobacco use as a health hazard was cited by the CDC as one of the great public health advances of the 20th century.[9] In the past 20 years, more bite has been added to public health warnings by restricting the ability to light up. As more municipalities have adopted smoke-free laws since the turn of this century, exposure to secondhand smoke has declined by half, from 52% of the population in 1999 to 25% by 2012.[10]

Image from Dreamstime

Slide 10

Public Health: Advancement of Palliative Care

Lionel Lim, MBBS, MPH, clinical assistant professor in the department of internal medicine at Yale School of Medicine, considers "the advancement of palliative care one of the biggest achievements in the past decade. With modern technology, healthcare has come a long way in helping people live longer... With this also comes the recognition that end-of-life matters deserve appropriate attention and discussion from practicing clinicians. It is less about doing more (life-sustaining treatments) and more about doing less harm and ensuring that our patients enjoy the quality of life that they desire when time becomes limited."

Image from Dreamstime

Slide 11

Ophthalmology: Anti-VEGF Therapy for Macular Degeneration

While many developments in the past 20 years have revolutionized the practice of ophthalmology, from improved diagnostic imaging (think optical coherence tomography) to premium intraocular lenses to endothelial keratoplasty and microinvasive glaucoma surgery, one of the most important for ophthalmologists and patients alike is anti-vascular endothelial growth factor (VEGF) therapy for age-related macular degeneration. David Brown, MD, director of clinical research at the Greater Houston Retina Research & Retina Consultants in Houston, Texas, says anti-VEGF therapy has been a major advancement in the fight against blindness from age-related macular degeneration. This therapy is now also being used for diabetic retinopathy and other retinal vascular diseases.

Image from Dreamstime

Slide 12

Orthopedics: Patient-Reported Outcome Measures

Ira H. Kirschenbaum, MD, chairman of the Department of Orthopaedics at Bronx-Lebanon Hospital Center in New York, speculates that "probably the greatest advance in orthopedics in the past two decades has been the way we look at the success or failure of treatment interventions. There has been a shift in focus on what the surgeon views as a success versus what the patient views as a success. In 1995, we thought we knew that when a patient reached certain postsurgical parameters, it was called a success. We have since realized that the patient's view of satisfaction is more important. In 2015, we talk about patient-reported outcomes (PROs) rather than specific surgical scoring systems. That has been a radical shift." The shift to PROs as a measure of efficacy extends beyond orthopedics. PROs, which can include overall health status; quality of life; specific symptoms and/or signs; physical, psychological, and social functioning; patient satisfaction/preference; and treatment adherence, are now widely used as an objective measure in palliative care, chronic disease management, and even pharmaceutical development trials. The importance of this outcome is increasingly apparent because improvements in clinical measures may not necessarily correspond to improvements in patient functioning or well-being.

Image from iStock

Slide 13

Diabetes: Medications and Monitoring

Diabetes care has undergone a sea change with a newly flowing pipeline of better drugs, new delivery systems (like the insulin pump), and continuous glucose monitoring (CGM). The latter technology "has given patients and clinicians information about blood sugars in a very different way than traditional point-of-care finger-stick checking and has provided a tool that is facilitating the development of the 'artificial pancreas,' linking insulin delivery to glucose levels," said diabetologist Dace Trence, MD, director of the Diabetes Care Center at the University of Washington Medical Center. The result of these many improvements? John Buse, MD, PhD, a professor of medicine at the University of North Carolina School of Medicine, recalls, "Twenty years ago, every day there were patients in my lobby with below-the-knee amputations, seeing eye dogs, or white canes. Today it is so rare; I am convinced that we are only beginning to understand what the natural history of diabetes will be in the 21st century. The prognosis for a normal life span free of disabling complications, I think, is excellent for people living with diabetes today."

Image from iStock

Slide 14

Nephrology: Noninvasive Diagnostics

The kidney biopsy has been the mainstay of diagnosis and management of kidney disease for decades, but in recent years, new diagnostic tests and genetic studies have provided less invasive methods of detecting earlier-stage kidney disease, including antineutrophil cytoplasmic antibodies (ANCA) in vasculitis, anti-phospholipase A2 receptor (anti-PLA2R) antibodies for membranous nephropathy, and the APOL1 gene's role in black patients. As a result, "Treatments can be guided by an understanding of the pathophysiology, potentially avoiding treatments that are less targeted," says Jeffrey Berns, MD, professor of medicine at the Perelman School of Medicine at the University of Pennsylvania. Similarly, kidney stones are now seen as something more than just a passing inconvenience, according to David Goldfarb, MD, professor of medicine at NYU School of Medicine. "We now recognize that they are often early manifestations of metabolic syndrome and may presage diabetes, coronary artery disease, hypertension, and chronic kidney disease," he said. Fortunately, the hazards associated with larger stones have been diminished with "amazing advances in endourology," he said, particularly the flexible ureteroscope.

Image from iStock

Slide 15

Allergy and Immunology: Biologics

Biologics have revolutionized care in a range of conditions, including allergic disease. Gary Stadtmauer, MD, assistant professor of medicine and clinical immunology at Mount Sinai School of Medicine in New York, asserts that the approval of the first biologic for use in asthma was the game changer in his field. Omalizumab (Xolair®), a humanized monoclonal IgG anti-IgE, was approved in 2003 to treat moderate to severe steroid-dependent persistent asthma,[11] and indications were expanded in 2014 to include chronic idiopathic urticaria.[12] In an article on Medscape, Dr Stadtmauer asserted that additional clinical applications for the agent would be found, but he noted that sufficient trial data to allow for FDA approval will be difficult to obtain for less common conditions. Cost, as well as the lack of trial data comparing this agent with other classes of drugs, may—at least currently—limit its use.[13]

Image courtesy of WebMD

Slide 16

Radiology: PET (Positron Emission Tomography)

Hossein Jadvar, MD, PhD, MPH, MBA, associate professor of radiology at the University of Southern California and attending radiologist at the University of California Keck Medical Center, noted that the impact of PET technology on oncology, and to some extent neurology and cardiology, has been tremendous. "PET is essentially now performed in hybrid form as PET/CT and PET/MRI." In 2000, PET was TIME magazine's Medical Invention of the Year.[14]

Image from iStock

Slide 17

Plastic Surgery/Dermatology: Fillers and Relaxers

The advent of fillers and relaxers has revolutionized the practice of plastic surgery, according to Darrick Antell, MD, assistant clinical professor of surgery at the Icahn School of Medicine at Mount Sinai in New York. The first of these products, onabotulinumtoxinA (Botox®), was approved in 1989 to treat blepharospasm and strabismus.[15] The product's use in cosmetic procedures was approved by the FDA in 2002, specifically for treatment of moderate to severe glabellar lines[16]; indications have since been expanded to cover other cosmetic changes. Dr Antell notes that these "injectables are minimally invasive and offer improvement to many patients at a relatively low price point. While they have not replaced surgery, they do offer tools that were simply not available in the past." Varying formulations of botulinum have also been approved by the FDA to treat cervical dystonia,[17] chronic migraine,[18] overactive bladder,[19] and a range of other conditions. In fact, these versatile biological products have been reported to be effective for over 100 medical, surgical, and aesthetic indications.[15]

Image from iStock

Slide 18

Emergency Medicine: Ultrasound

Real-time ultrasonography as an important diagnostic tool emerged in the 1980s as improved circuitry allowed for less expensive equipment with smaller probes and clearer imaging.[20] The tool was further improved in the 1990s with the advent of 3D and 4D images. Its widespread use in emergency medicine is the single biggest advance in emergency care, according to Robert Glatter, MD, attending physician at New York City's Lenox Hill Hospital. "The introduction of ultrasound into the practice of emergency medicine has improved and revolutionized the way we evaluate, treat, and make dispositions for patients, thus allowing a shift in the practice of the specialty over the past 20 years. It has allowed for rapid and accurate diagnosis of life-threatening conditions‎, and provision of expedited treatment to reduce the risk for complications and death. It has also improved our ability to provide ongoing care for patients who have rapidly changing vital signs and need immediate treatment. Most important, the use of ultrasound has improved safety by allowing invasive central lines to be placed more accurately, and has allowed better peripheral placement, where standard approaches may not succeed." Point-of-care, handheld devices have largely replaced auscultation in cardiology, obstetrics, and gastroenterology.[21] Many experts speculate that the technology will make the stethoscope obsolete in the foreseeable future.

Image from iStock

Slide 19

Pediatrics: Vaccines as Cancer Prevention

Vaccines as cancer prevention is a radical advance. Kathy Miller, MD, co-director of the Simon Cancer Center Breast Cancer Program at Indiana University School of Medicine, nominates the human papillomavirus (HPV) vaccine as among the most significant developments in medicine over the past two decades. Twenty years ago, Harald zur Hausen discovered the role of HPV in cervical cancer,[22] for which he won a Nobel Prize. It is estimated that the resultant vaccines, first approved in 2006, may prevent up to 90% of cervical cancers.[23] Paul Offit, MD, director of the Vaccine Education Center and an attending physician in the Division of Infectious Diseases at The Children's Hospital of Philadelphia, also named the HPV vaccine, stating that the "recently licensed 9-valent product has a chance to eliminate as many as 29,000 cases of cancer each year and as many as 5000 deaths."[24] In addition to being the leading cause of cervical cancer, HPV's role in oral and anal cancer is also now well established. Sandra Fryhofer, MD, a member of the Advisory Committee on Immunization Practices at the CDC, adds, "A vaccine that prevents cancer, rather than treating it once diagnosed, is major. Now we just have to increase vaccination rates."

Image from iStock

Slide 20

Women's Health: Advances in Cervical Cancer Screening

Dr Fryhofer notes that the HPV vaccine has also led to changes in screening recommendations for cervical cancer. Previously all sexually active women were screened using the Pap test to detect precancerous and cancerous processes in the endocervical canal. But according to Andrew Kaunitz, MD, professor and associate chairman of the Department of Obstetrics and Gynecology at the University of Florida, the 2012 cervical cancer screening guidelines "represent a major change in adolescent care. Because we no longer screen women younger than age 21 years with Pap testing, and can accomplish sexually transmitted infection screening using urine testing, many teens are able to avoid pelvic examinations. Furthermore, under the new guidance,[25,26] no woman younger than 21 years should have to face colposcopy, which was particularly anxiety-provoking in our younger patients."

Image from Science Source

Slide 21

Primary Care: The Rise of Corporate Healthcare

The past 20 years has seen a rapid consolidation of healthcare systems and payers,[27] a trend that Robert Morrow, MD, associate clinical professor in the Department of Family and Social Medicine at Albert Einstein College of Medicine in the Bronx and a family physician in independent practice, describes as relying on venture capital and creating "entities too big to fail." Mark Williams, MD, a clinical professor of medicine at the University of North Carolina School of Medicine, warns that "unquestionably the biggest challenge over the past 20 years has been the ascendency of the profit motive in healthcare."

Parallel to this trend has been an increase in the percentage of physicians who are employed, often by these large healthcare corporations. While estimates of the percentage of employed physicians have varied, it is clear that the numbers are rising, most notably among the youngest physicians. The passage of the Affordable Care Act in 2010 accelerated the trend by providing incentives for hospitals and physicians, particularly those in primary care, to team up to create accountable care organizations and earn bonuses for more efficient, higher-quality care. In a 2014 survey on Medscape, more than half (53%) of employed physicians who were previously self-employed felt that patient care was superior now that they were employed, although more than a third (37%) felt that it was about the same. So what's not to like? Employed physicians have complained about excessive rules, limited role in decision-making, less control over schedules, and a loss of autonomy.

Image from iStock

Slide 22

Business of Medicine: The Information Revolution Meets Healthcare

Matthew E. Falagas, MD, adjunct associate professor at Tufts University School of Medicine in Boston and director of the departments of internal medicine and infectious diseases at Iaso General Hospital in Athens, Greece, nominates the Internet as the biggest change agent in the past 20 years, noting that the expanded use of Web-based information and resources has fundamentally changed patient care, medical practice, and education. Adam Possner, MD, assistant professor in general internal medicine at George Washington University in Washington, DC, said, "I've often wondered how people used to practice medicine before the Internet age, when either you knew something or had to track it down physically in a book. In terms of doctors' ability to diagnose and treat, as well as patients' ability to educate (or mislead) themselves, I can't think of a development more impactful for medicine than the Internet."

Information, good and bad, is everywhere, including in direct-to-consumer advertising, another new trend of the past 20 years. According to JoAnn Manson, MD, professor of medicine at Harvard, patient-accessed information has led to a dramatic increase in shared decision-making between clinicians and patients, a trend she describes as favorable. "Patients are more engaged in their own healthcare, due primarily to greater access to health-related information via the Internet, health-monitoring devices and biosensors, and networking opportunities with other patients. These developments have converged to lead to greater empowerment, self-efficacy, and advocacy of patients in relation to their own health and healthcare."

That same information glut is also seen in the expanded use of electronic health records (EHRs). EHRs have many virtues, including the ability to improve documentation, cross-reference medication interactions, calculate weights, alert to contraindications based on medical history, capture at-risk family history details, and prompt appropriate screening. But in their present iteration, they also have detractors. Dr Williams contends that the EHR is "not really a medical record but a billing justification document and provides a command-and-control mechanism for senior administrators to maximize profits." Sanford Brown, MD, a family physician in solo practice in Mendocino, California, doesn't have an EHR. "By not having one, my practice has grown by leaps and bounds. Patients transfer to me every week because they are tired of relating to their doctor over a computer screen or with their back turned toward them while they do data entry... Being a solo practitioner and not having to share my records with other healthcare providers, I find EHRs needlessly burdensome in all respects. They will have to pry my pen out of my cold, dead hands."

Image from iStock

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