Diana Brixner - She Leads Science

How do we know we're making the right treatment decision for the right patient at the right time? In this episode of She Leads Science, Dr. Liz Joy sits down with pioneering pharmacotherapy researcher Diana Brixner, RPh, PhD, to explore the science behind medication effectiveness, value, and real-world impact. Dr. Brixner reflects on a remarkable career spanning industry, academia, health systems, and policy, sharing how pharmacotherapy outcomes research has transformed the way clinicians, payers, and policymakers evaluate medications. Together, they discuss the promise and challenges of GLP-1 receptor agonists, the evolution of precision medicine, the future of pharmacogenomics, and whether science is approaching meaningful breakthroughs in Alzheimer's disease. Beyond her research, Dr. Brixner shares lessons learned from building the Pharmacotherapy Outcomes Research Center, mentoring generations of scientists, and leading national organizations. This thoughtful conversation highlights how rigorous science, interdisciplinary collaboration, and visionary leadership can improve healthcare decisions - and ultimately improve patients' lives.

Transcript

SPEAKER_01 0:15

Welcome back to She Lead Science. I'm your host, Dr. Liz Joy. Today I'm honored to welcome Dr. Diana Brixner. Dr. Brixner is one of the pioneers in pharmacotherapy outcomes research, pharmacoeconomics, and precision medicine. She is professor and former chair of the Department of Pharmacotherapy at the University of Utah and the founder of the Pharmacotherapy Outcomes Research Center, or PORC, as we call it, a center that has trained generations of scientists and helped shape how healthcare evaluates the effectiveness, safety, and value of medications. She has authored more than 150 peer-reviewed publications and has served as president of both the International Society for Pharmaco Economics and Outcomes Research ISPOR, which I know has another name now, but we'll get to that, and the Academy of Managed Care Pharmacy. Throughout her career, she has worked at the intersection of science, clinical care, health policy, and economics, helping answer one of healthcare's most important questions. How do we know we're making the right treatment decisions for the right patient at the right time? Today we'll explore Diana's remarkable career, the evolution of pharmacotherapy research, where therapeutics are headed, from GLP1 receptor agonist to pharmacogenetics, and what she believes the future holds for some of medicine's greatest challenges. Diana, welcome to She Lead Science.

SPEAKER_00 1:37

It is wonderful to have you. Thank you so much, Liz, and I really appreciate that very kind introduction.

SPEAKER_01 1:44

Well, there's so much more I could have said, but it would have taken all of our time. So we'll just have to learn more about you as we have our conversation today. And I'd like to start with a question so that our listeners get to know you a little bit better. And I know we're going to get around to actually defining what pharmacoeconomics and pharmacotherapy is all about. But when someone outside of healthcare asks what you do, how do you explain it?

SPEAKER_00 2:12

Great question. I feel like I'm answering that a lot as well, especially in today's environment around healthcare and all of the issues we have and making sure, again, that the right patients get the right drug at the right time. So the easy answer that I usually say is I start anchoring in clinical trials because most everyone is familiar that in order for a drug to be approved, it has clinical trials and then is approved by the FDA. So what I try to explain is that what I do is research how drugs work in populations after the FDA has approved the drug. And it's actually now available on the market and being utilized by thousands, sometimes millions of more patients than were ever evaluated during that clinical trial. We call that real world evidence. And that real world evidence is really what the many different entities that actually pay for pharmaceuticals want to know and understand along with the clinical trial data.

SPEAKER_01 3:14

You know, that is so important. And I think most people don't really appreciate, you know, the um the need for something like this. They just expect that if they can buy medication at the pharmacy or it's been prescribed by their provider, that it's going to be safe and effective for them. Because it was found to be safe and effective for a very well-defined patient or population. And that's not always true once, like as you said, thousands, if not millions, even tens of millions of people are taking that. And we're learning that even with the GLP ones, you know, in terms of both benefits as well as risks. I know we're going to come back to that.

SPEAKER_00 3:53

Absolutely. I just wanted to make one more comment to that because to your point, I mean, the first issue is that, you know, a very small population have been exposed to the drug in clinical trials. In the real world, the majority of the patients that actually take these drugs do not have the exact same characteristics as those patients that were in the clinical trial. And then the other huge component we will definitely get back to is adherence. Is the patient actually taking the drug as prescribed? And we know in clinical trials, they absolutely are because every aspect of them taking that drug is monitored in a clinical trial. In the real world, as we all know, any of us that have had a prescription, we don't always take it exactly as we were told to. And when that happens, it changes the outcomes. They can be very different than what you saw in that clinical trial.

SPEAKER_01 4:44

Yeah, you know, usually when we get a new prescription, it doesn't come in a blister pack that's labeled, you know, Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday. Right. Exactly. Well, you've really spent your career helping answer what sounds like a pretty simple question. You know, is this medication worth it? Um, do you think most people appreciate how much goes into answering that question? It's usually not, right?

SPEAKER_00 5:10

You know, if I could flesh out that question just a little bit more, I think, you know, the real more detailed question is does this treatment improve people's lives enough for the right patients to justify all the resources and trade-offs involved? And and our science is really doing all the work behind each of those components to help answer that final question. Is that medication worth it? And of course, even with all that evidence, different stakeholders in the healthcare system will answer that question differently.

SPEAKER_01 5:45

Yeah, that makes a lot of sense. Um you know, kind of switching from pharmacotherapy outcomes to pharmacoeconomics. Uh, I think, you know, if somebody broke that term down, they think it was probably about, you know, saving money and maybe uh even withholding medication, right? Some medications deemed to be too expensive to disperse or to dispense. But that's never really been my impression of your work at all. So can you define what pharmacoeconomics actually is?

SPEAKER_00 6:20

Sure. I mean, what we're looking at in pharmacoeconomics is very simply, what are the economics, what are the cost components around using a medicine? And it is so much more than just the actual cost of the drug. And that's what makes our science so interesting, but also sometimes so challenging. So when you take a particular medication, if you have adverse events, there are additional office visits, there are additional medications. There may be an emergency room visit, or even at the worst case, a hospitalization due to that adverse event. All the costs of that is part of the overall pharmacoeconomics of making a decision around one drug versus another.

SPEAKER_01 7:08

You know, my um, I have a family member who was um diagnosed with a condition, um, and the medication that was being considered was $300,000 a year. Exactly. And I I get it that you know, there's so much that goes behind that, you know, particularly around drug discovery, right? In the investment it takes to create some of these novel, you know, therapeutics, particularly in that immunotherapy category. Um, but wow, it it really kind of comes home when all of a sudden, you know, the prescriber says, this is $300,000 a year. I hope your insurance will pay for it.

SPEAKER_00 7:49

Exactly. And that's the challenge of the insurance companies, right? The ones that are expected to pay for these medications so that their health plan members can access them. Some may just pay a fixed co-payment that could be as low as $100 or $200. The health plan takes on the rest of that burden. Or in some cases, it's a co-insurance. And that's where things get really challenging, Liz. So if it's a 10% coinsurance on a $300,000 drug in a year, they still need to come up with $30,000 in order to be able to access that medication. So these are some significant affordability challenges. Well.

SPEAKER_01 8:30

And I really think that, you know, given your the breadth of your experiences professionally, um, you know, kind of has uniquely positioned you to actually study this, right? You've been a pharmacist, a researcher, you've worked in industry, academia, um, you know, you've advised health systems and payers. Um, you know, most people spend their entire career in just one of those worlds, but you've worked across all of them. Um and, you know, as we talk about the $300,000 um a year medication, you know, uh how has seen a medication like that through those different lenses changed the way you think about healthcare?

SPEAKER_00 9:14

Yeah, very much so. Um, as you mentioned mentioned, I started my career first in biotech, where I was actually making these drugs. And, you know, my PhD was medicinal chemistry. I was on the bench making them. And thinking to myself, you know, yes, it is a lot of work to make and test and get these drugs to market. Therefore, they're very expensive. But the question is then, who's gonna pay for it? And how do we decide if it's worth it or not? That became far more interesting to me than actually making the drugs themselves. So I got involved in actually pharmaceutical industry first, uh, working with health plans, trying to help them understand costs and value to support their decision-making process. Uh, so that was the industry perspective. And really, from a broader industry perspective, I believe industry is a little bit better at as they are developing, innovating, researching new potential drug therapies, thinking further down the line to what is the actual patient outcome? What is the likelihood that we can get health plans to accept this drug at this price based on the benefit it can bring to individuals and society? Whereas, again, you know, that is not always true, but certainly at least the goal is to have a better appreciation of not just the uniqueness of an innovation that, oh, this is an exciting molecule, isn't it cool how it fits this enzyme? But they really look at does it have a place in the current landscape of how this disease is being treated? Does is there an unmet need that this drug actually addresses such that it will be accepted and paid for once it's available on the market?

SPEAKER_01 11:01

You know, it reminds me of um, and we'll come back to implementation science, but you know, one of my jobs at Intermountain Health during my tenure there as the medical director of outcomes research was really to kind of help the process from discovery to delivery work better, right? And we are really good at discovery. We're smart people are good at discovery. Uh, with dissemination, you know, we get a little bit of a fall-off, right? And then there's this adoption piece, which is right, getting getting, you know, um providers uh to actually prescribe a new medication that may be more um efficacious, you know, perhaps than one that they're um used to prescribing. Um and after adoption, it's that implementation, you know, and and implementing with fidelity. And it's, you know, that fidelity has to happen at the practice level, you know, as well as with the patient, and then maintenance or the sustainability, right? Um, and then learning from all of that entire waterfall and starting all over again. And I guess that's part of the reason why we call it research, right? Since we're researching all the time. Absolutely. Um, I'm guessing that this is this question is going to be pretty obvious, but you know, did moving between all of these different environments kind of fundamentally change your definition of what constitutes good evidence?

SPEAKER_00 12:30

Yeah, it absolutely did, because again, every each one of these groups that I was part of or worked with, they look at the evidence differently. They look at it from a different lens, they use it in a different way to make very different decisions. But yet in the end, a lot of time it's still that same core evidence that they're all looking at, right? But everybody has their own perspective. So, you know, when I was in industry, you know, evidence tended to mean a well-conducted, randomized, controlled trial, right? You know, and today value trials are really important. So not only just the clinical trial, but also the real world evidence. And again, the real world evidence component is new. There's a lot of methodological issues, as you well know from your past experience in doing real-world evidence studies. It's not randomized, they're not controlled. You have to monitor and you know, look at confounding and control for all of that. So that is really a new science. And therefore, we do everything we can to strive that the level and rigor of that science is the same as what we were familiar with with randomized controlled trials, the best that we can. So, yes, that definition certainly changes from industry from academia. I mean, academics look at the research differently. You know, academics, a lot of times, they're producing the molecules that are ultimately licensed and purchased by pharmaceutical companies. They don't necessarily look at particular specific therapeutic area opportunities. They're looking more at the innovation, making something that's different than what's been out there already. But you have to know that it also has a matched, unmet need for the product. Then you get to the payers. So they're the ones that, okay, that's great. You know, you did this and you did that. But am I willing to pay for this versus what the current standard of care is? And when this new innovation that's on the market and available is really not a lot different than something they're already paying for, then that decision gets ever more challenging. So, yes, lots of different perspectives. I could talk about the pharmacist, what their thoughts are, the patient. You know, there's so many players, even men, you know, look at wholesalers, the distribution, the, and then the whole process of payment, public, private. There are so many pieces and components that go into looking at this evidence and deciding what its rigor is.

SPEAKER_01 15:01

You know, when you were answering that question, you know, you use the term value a number of times. And I, you know, I think of value simply as, you know, the benefit relative to the cost. Um, you know, is that too simplistic for this conversation or is that still about right?

SPEAKER_00 15:18

Well, I say it's still about right. It's just that all the work that goes behind how do you establish the benefit to whom? How do you assess the true all aspect cost and again to whom? Because you know, the patient is going to look at this very differently. What is the benefit to me? I may value something that the drug company never even looked at. I may be able to pay for one medication that you're offering me. I may not be able to afford this other medication you're offering. Therefore, for me, the best choice is the less expense, less expensive product, even if it has less benefit. So, you know, again, every prospective stakeholder is going to answer that question differently and they're going to analyze the benefit versus the cost differently. But the principle is still spot on, right? What is the benefit versus the cost? And is it worth it?

SPEAKER_01 16:16

Right. Right. So most scientists spend their careers trying to discover something new, but your work is really focused on helping healthcare decide what to do with what we already know. I mean, that's just kind of what you were talking about, right? Um, and you know, you made this transition from, you know, industry into academia. Um, so and you talk a little bit about recognizing that it's one thing to make a great product, but then it's how does that product get utilized and for whom does it benefit? Um, and I think that's really the discovery to delivery piece that we've been been talking about, and you know, is at the root of you know implementation science. Um and you know, you're doing implementation science in kind of a unique area. Um, do you think in pharmacotherapy it kind of receives the respect it really deserves?

SPEAKER_00 17:21

I think we're working on that. Um, a lot of my work with the Academy of Advantaged Care Pharmacy is really looking at the delivery of drugs to members through health plans. And I think what we're learning is it is a lot more than just getting a patient to take a drug. There are so many other components and really understanding what the issues are for an individual patient to actually take that drug. Is it transportation to get to the infusion center? Is it, you know, the timing of the day that they're able to leave work? Uh, you know, there's so many other factors that go into actually being able to take a medicine. We're gonna talk a little bit, I know, about pharmacogenomic testing. Uh, you know, there are some startling, you know, articles and results about how if you look at 100% of patients being tested, once you go down, the actually getting tested, getting the data back from the lab, getting the lab to the provider, have the provider pick the right drug, get that drug to the patient, have the patient get the right test, 32% of that hundred actually get the right drug at the right time due to the test that they took. That is a great example of what some of these challenges are.

SPEAKER_01 18:37

Um Yeah, I um remember uh when I was at the university working with um, and you'll remember Joyce Mitchell when she was leading biomedical informatics, and we were submitting an uh NIH challenge grant um about how to better integrate genomics into primary care practices to guide the um prescribing of um anticoagulant medication.

SPEAKER_00 19:04

Yeah, and it's such a challenge.

SPEAKER_01 19:07

It's so challenging.

SPEAKER_00 19:09

And it's and why? Why?

SPEAKER_01 19:12

Yeah, yeah, and we and we haven't solved for it.

SPEAKER_00 19:15

And I've been gone from the you for a long time. And if you want to talk about strong evidence, I mean, that is one of the cases where it is so clear that if you have certain genetics, you should or should not be on a certain blood thinner. So it's it's so basic, and yet it's very challenging to get the right pieces in place to make sure that everyone is tested up front, to make sure they're not being put on a drug that absolutely is predicted to not work and even worse, maybe cause significant adverse events without any benefit. Yeah. Right.

SPEAKER_01 19:49

And you know, and in some of this research, you know, it gets published in a um a genetic genomic journal. Right. Exactly. So we're not, you know, this is where there's discovery, but we don't have the right dissemination, you know, to use that waterfall. And so um, the people who need the information the most, you know, don't get it. And that's the what the 17-year blue highway, you know, from discovery to delivery, and still struggling with that to this day. Um, and I mentioned in your introduction that, you know, you've authored, you know, more than 150 papers. You know, if someone sat down and read every one of your papers, oh God helped them. But, you know, is there is there a thread, you know, a question that they would discover, you know, what you've been trying to answer all along?

SPEAKER_00 20:45

Great question. Um, yeah, I mean, I do believe that in in all the work, no matter how disparate each one of those publications may be, they're they're all somewhere along a repetitive question. It's it's recurring. You know, how do we design, how do we evaluate and implement therapies in a way that delivers real measurable benefit to patients and to systems, not just a theoretical benefit, you know, on a slide or in a publication, or oh great, we invented this. How are you making real impact to delivering true better patient outcomes? And maybe not at lower overall costs, but at reasonable overall costs that individuals and society can afford.

SPEAKER_01 21:34

Um, you know, looking back, would you say there are just two or three studies that you think genuinely changed healthcare? Not necessarily because they were highly cited, but because they changed how clinicians practice or how payers made decisions or ultimately, you know, to your point, improved patients' lives. Right.

SPEAKER_00 21:53

You know, and I look back at at the publications, and I certainly they're very scientific, some are very scientific. Know budget impact models, cost effectiveness models, you know, the true research and output. Others are directionally trying to create standards and provide ways for different stakeholders to gather and evaluate evidence and decision making. And I would say that group of papers to me hopefully would make the biggest impact in healthcare. Um, you know, one paper I recall probably over a decade ago, I worked with several individuals through the ISPOR Pharmacoeconomic and Outcomes Research Organization around quality of life. How do you evaluate quality of life and how do you monetize it in making an evidence decision? And, you know, hopefully some of those standards will help as payers look at how to value an increase in quality of life to a patient. More recently, we just published, really in the last year, a set of real-world evidence standards for evaluation by payers. And the reason that was interesting, Liz, is there are, because this is part of the research that I did, there are literally hundreds of published articles about real-world evidence standards. They're for the perspective of publishing, they're from the perspective of what data sources should I be using, they're from the perspective of what methodologies should we be using to control for confounding. None of them were actually looking at how do I evaluate the evidence from a payer perspective? Because as we've been discussing all along here today, the payer looks at evidence very differently than those other stakeholders. So the Journal of Managed Care Pharmacy just published this standards for payers. And hopefully that will help payers and you know, all payers, public, commercial, et cetera, build more confidence in how they evaluate the evidence for their decision making.

SPEAKER_01 23:58

Now we just have to hope they read it.

SPEAKER_00 24:01

Well, we're also doing training sessions, which is exactly addressing that point. Trying to hit some of their regional affiliates in the AMCP, um, inviting actual payers to come to be trained on, know how to use this to address exactly what you're saying. Sometimes we also need implementation science because we need to know how do we actually get trained to evaluate this evidence.

SPEAKER_01 24:24

Yeah, yeah, for sure. I think, you know, getting outside our silo, you know, and really working across disciplines and, you know, thinking about, you know, what is what is that journey uh in order to um really impact uh meaningful change. Yeah. Um, speaking of which, you know, uh an incredibly meaningful component of your career certainly has been um founding uh and leading the pharmacotherapy outcomes research center, which is you know where you and I met, you know, when I was at the University of Utah. Um and uh just a couple of questions, you know, around that. Um, you know, I and I think you've answered this to some extent, but but let me ask it directly. You know, what gap did you see that made you realize this center needed to exist?

SPEAKER_00 25:11

Oh, well, thank you for asking. And, you know, truly the pride and joy of my career has been the Outcomes Research Center for many reasons. I know we'll touch on a few. Uh, but as far as the gap, you know, it it we are a college of pharmacy at the University of Utah. There are four departments, you know, medicinal chemistry, discovery, pharmaceutics looking at delivery, pharma toxicology looking at you know, potential adverse events. And then our department, which is pharmacotherapy. How do these drugs work in populations? Well, we had a department of wonderful clinical pharmacists that deal with one-on-one patients every day to improve and optimize their outcomes. What the college did not have, or and specifically the department of pharmacotherapy did not have, was a group that was looking at how do drugs behave in populations. So that was a significant gap. And at the time I came, 2002, long, long time ago, um, you know, there were two goals for the dean of the college that he wanted out of this position. A, well, he wanted a chair to run the department, but he wanted somebody to lead an outcomes research center so they could be studying drugs and populations. And he also wanted someone that would develop a PhD program in pharmacotherapy outcomes research so that we would continue to grow scientists into the future that could carry this discipline forward. And, you know, I have to say, I'm very happy to say that we we did both. We created a very successful center that is known to this day and is now being led by Carl Ashe, who I'm sure you remember. And we have graduated many, many PhD students and pharmacoeconomic fellows that are in wonderful positions all around the world in all these different disciplines.

SPEAKER_01 26:57

So when you when you look at the faculty, you know, the trainees, the collaborations that have grown from pork, you know, what feels like your greatest legacy?

SPEAKER_00 27:07

You know, I think the greatest legacy to me are really all of these graduates that have learned from our center and now are out in various different positions, really impacting healthcare, outcomes for patients, and how drugs work across populations. We have, you know, I look at some of our early fellows now, they're directors, executive directors of outcomes or real-world evidence and cardiology at huge pharmaceutical companies. Um, others are academics, they're professors, you know, University of Florida, University of Oregon, Toro, St. John's in New York, all over. And they are now creating their own research centers and doing this themselves. And then we also have a group we're so proud of. They're active in health plans, and they're the ones now sitting at those PT committees, making those formulary decisions and bringing outcomes and real-world evidence to the decision-making process. I love that.

SPEAKER_01 28:04

You know, because I I think as I appreciate, you know, my own career, you know, our certainly our greatest legacy is it's not the papers we publish, right? It's the people we invest in. Absolutely. They're the ones that are going to carry this forward. Yeah, absolutely. And I mean, and you've definitely, you know, worked with people at at every stage, um, you know, from uh, you know, junior uh, you know, postdocs to junior faculty who are now kind of launching their own independent careers, as you mentioned. Um, I'm curious, you know, what qualities do you look for in someone who has the potential to become that exceptional scientist? Is it their intellect, their curiosity, perseverance, humility, probably all of the above. But, you know, over time, you know, do you think your answer to that question would has changed?

SPEAKER_00 28:56

Yeah, that's a good question. I and I mean curiosity strikes me. You know, curiosity to be willing, not afraid to ask the hard questions and to be willing to continue to ask if the first answer isn't satisfying or or doesn't make sense. I think that I see a lot of students coming in that have challenges with that, right? So I think it's a really important skill. Um, I also think, you know, perseverance, right? So perseverance, one that strikes me is in publications. You know, it's very difficult getting rejected. We we all have been so many times. Perseverance, right? Write the editor, address the questions, address why it was rejected, ask if there's still a way that you could be reconsidered. If not, look at the next journal. Look at the next journal. Uh, you and I have probably gone through five or six journals to finally get something published, right? It happens, but you have to realize that that's okay. You learn from every one of those rejections. The paper gets better every time. So I think these are some of the characteristics that are really important. Collaboration is another one to me, to not be siloed, whatever your position is in whatever stakeholder environment, that you reach out and learn what others are doing. Understand other stakeholders within the healthcare system that if you partner with them, this is how you and I got to know each other, right? If you partner with them, the end product is going to be much better than if you just produce something from your singular individual perspective.

SPEAKER_01 30:36

Well, that's a great pivot point because you know your work has been, you know, remarkably interdisciplinary. Um, and I'm again curious, you know, what have you learned about building those multidisciplinary teams that produce better science than any one discipline could do alone? Because I think that is the model, right? It's very unusual to have a single PI in a single discipline, you know, who is going to carry forth big, impactful, meaningful science.

SPEAKER_00 31:05

I couldn't agree more. And you know, I can answer that question really, both from industry and academia. You know, in industry, what are the silos? It's it's clinical development, they run the clinical trial. Their goal, FDA approval. Then there's health economics and outcomes research. Their goal is to look at cost versus benefit. And now there's market access, used to be account management or marketing, whatever you want to call it. They're worried about the payer and making sure that the payer is actually going to pay for the drug. If those three groups continue to work in silos, they're never going to get the output that, for example, if clinical development would ask the account managers, what is it that the market actually wants before they develop trials? If clinical development would talk to HEOR and say, okay, what costs should we be collecting along with the clinical outcomes in the trial? Those are the communications that need to happen that everyone then wins at a much higher level than each of those groups on their own.

SPEAKER_01 32:11

Well, maybe shifting back for a minute to, you know, again, the the trainees that you have worked with over the years. And I'm I'm sure there have been many. And, you know, they get a lot from us, right? I think of all the fellows that, you know, um I had the opportunity to work with at leading a sports medicine fellowship program, um, so many grad students in public health. Um, and but I think I got as much out of it as they got from me. Uh so can you talk a little bit about your experience working with trainees from different disciplines at different levels of uh you know experience?

SPEAKER_00 32:47

Well, I really enjoyed that about our program. Um, we had a very open program as far as what background you came into. It all goes right back to your point. You can come from very many different disciplines and learn other disciplines along the way to truly make you an excellent scientist as you leave with a PhD from the University of Utah. Um, we have had economists come in. Okay, they don't have clinical experience. They're not pharmacists, they're not necessarily MDs, they're really strong economists. And I would be amazed at times how quickly they would come up to speed on a clinical area. Um, let's say we were doing a real world study in Alzheimer's. Well, I didn't know anything about Alzheimer's, and sure enough, you know, within four to six months, they will have learned all the drugs available, what the different classes are, how this particular drug impacts that, how will that impact the economic analysis of you know different products, et cetera. So, and I could give many other examples, you know, a clinical pharmacist coming in and not having the analysis experience. We would always try to take two fellows at a time, Liz. And my ideal uh set was a clinical pharm D as one fellow, and then I always wanted an economist data analysis PhD as the other fellow, because then in that environment for two years, they'd be side by side and they could share and learn from each other. And of course, as mentors, it was just so fun to watch that evolve. Yeah.

SPEAKER_01 34:17

Yeah, that's a that's a great model. And I I think about you know, some of the work that I've done, you know, over the years and you know, looking at again that value equation, you know, answering the value question, you know, for the system, for the payer. And I gotta tell you, getting your hands on a really good health economist, you know, they were like gold, not even gold, platinum, right? Absolutely. It's just so, it's so important. Um, because, you know, chronic disease is increasingly common. Um, you know, the medications are getting better, but oftentimes that means they're getting more expensive. And so how do we kind of balance all the things we've been talking about for the last 30 minutes? Speaking of which, we're coming to the end of our time, but there's just a few things I wanna I want to touch on before I let you go. And, you know, if we're talking about medications, if we don't talk about GLP1 receptor agonists, then you know, that would be kind of a mess. Um, obviously, you know, obesity affects, you know, such a huge percentage of the population in the United States and and globally. Um, and we're learning, you know, so much about this particular class, literally, sometimes on a daily basis may sound a little dramatic, but it feels like that, right? With the papers that are coming out looking at their benefit for, you know, certainly for cardiometabolic disease, but for mental health, um, you know, and and gynecologic issues and cancer. It just goes on and on. Um, you know, as as you know, someone who has really you know spent her career, you know, evaluating therapeutic innovation, you know, is this is this the kind of breakthrough medication, you know, that you know stands alone compared to others?

SPEAKER_00 36:08

Oh, it's a great question. I I believe that there are a lot of areas that need to be explored further, a lot of dynamics to the GLP1s. First of all, let's let's put the you know the elephant in the room, the cost. And and look how much we've done from a health policy perspective to try to address the cost with so many negotiations between individual drug companies and our government and Medicare. And of course, starting July 1st, there's been this commitment to actually make the GLP ones affordable to Medicare patients. However, it's temporary, it's gonna end at the start of 2028. Now, from a pharmacoeconomic perspective, there are so many questions to answer. So if an individual benefits they're adherent, another big issue, how adherent will they continue to be? And then along comes 2028, and all of a sudden now it's not covered anymore. And so either the patient will stop taking it. And the issue, uh Liz, with the GLP1s is the economic benefit comes from the long-term cardiometabolic benefit, less heart attacks, less, you know, cholesterol issues, um, all diabetes, sleep apnea, all cancer, et cetera, all these other things that they say they the benefit can come from these GLP1s, the cost benefit of that is long-term, but yet we're paying today for all of that benefit. So it is so dependent on the adherence factor, because so many of the papers, I'm sure, as you've read as well, that if the patient stopped taking it, the weight comes back on. And then you really wonder what was the benefit of that expenditure because you stop taking the drug. We're never going to be able to see all of those benefits where some of those costs would be returned.

SPEAKER_01 38:08

Yeah, I I um had a paper published um not that long ago in the American Journal of Lifestyle Medicine that I wrote with a colleague. Um, it was titled Lifestyle First, Lifestyle Always, but not Lifestyle Only, Cardiometabolic Care in the Era of GLP1 receptor agonists. You know, and just recognizing that we have to, you know, we have to, you know, merge, you know, these these new novel therapeutics with what we know already works, at least to some degree. Um, and of course, there are you know lots of of benefits of lifestyle. But the point being is that you know, we can't be just dependent on the medication alone in the case of obesity and obesity-related conditions.

SPEAKER_00 38:52

Publication came out this morning, I believe it was GAMA, and what they were referring to in the GLP1s, so interesting that only a third of the vendors that distribute GLP1s through internet services or whatever have any kind of a consultation with an MD or a pharmacist. So talk about system breakdown, right? Because a clinical pharmacist, MD, some provide healthcare provider should be coaching individuals starting this expensive therapy to recognize how important it is to stay on the therapy. And then also combining this with lifestyle changes, you know, it reminds me a little bit of the statins and, you know, the impact on cholesterol. That's great. You have to keep taking them. And it doesn't mean you can keep eating McDonald's and ice cream cones and milkshakes every day, taking a statin any more than the same with the GLP ones. Yes, it suppresses your hunger, but if you stop taking the drug taking the drug, that hunger is going to come right back. And you're not gonna get the benefits that you really could from these products. So a lot of implementation, a lot of delivery, a lot of collaboration with the healthcare systems that could really improve the outcomes of these drugs.

SPEAKER_01 40:06

Yeah, we could talk about this one for a long time. Yeah. I I do want to talk about uh precision medicine and pharmacogenomics. I know this is an area that you are very active in. Um, and I think we're we're watching medicine evolve from that one drug fits all toward a much more precise approach to prescribing based on individual characteristics, specifically someone's someone's genetics. Um, again, another topic we could spend a long time on. Maybe we'll do this another time. Another podcast.

SPEAKER_00 40:41

Yeah.

SPEAKER_01 40:42

But uh, you know, just in a single question, you know, what's the next big discovery, you know, in pharmacogenomics that will impact the greatest number of people?

SPEAKER_00 40:52

You know what? I don't think it's the next big discovery. I I think it's taking the phenomenal tests that we already have today, next generation sequencing. We already have the ability in one test to understand the whole profile of genetic testing and impact on cancer treatments. So I really think that we need to get better in having the NGS test covered for every patient the first time they come in with an initial cancer, so that any cancer or any metastasis that comes forward, then you already know what the right drug is to give the patient at the right time to maximize the outcome. I have one funny, well, it's not funny, it's in a story I've said so many times is that in our healthcare system, it happens where a health plan will have a genetic test covered in the medical benefit, but then the drug that the genetic should take is not covered on the drug side, or vice versa. You'll have the drug covered on the formulary benefit, but the test to tell you that it's covered won't be. So you're using it in a lot of patients that won't even benefit. I mean, again, the irony of that, those are the simple problems that we need to be able to fix going forward. Wow, that is a such a phenomenal disconnect. Yes, it's a phenomenal disconnect. Yeah.

unknown 42:22

Yeah. Yeah.

SPEAKER_01 42:23

Well, I think I think the other, you know, condition, um, one of the other conditions that I think you know we're we're really having our eyes opened wide open to is um dementia, you know, because of the aging baby boomers, right? You've got 12,000 people who are turned 65 each day, you know, and age is the greatest risk factor, you know, for for Alzheimer's disease. Um you know, as a as a uh professional in in pharmacy, you know, how optimistic are you that we can fundamentally change the course of Alzheimer's disease in the next 10 years with pharmacal therapy? We already know that lifestyle, you know, what's good for the heart is good for the brain, right? We know that certainly we can in part prevent, you know, the progression, you know, of dementia or maybe even dementia and entirely through lifestyle. But there's got to be like some discovery in that space that's gonna work better than the current medications we have available, which have been really disappointing.

SPEAKER_00 43:27

I agree. I agree. Um, you know, in a way, also it's very similar to the GLP ones when we thought we would have a successful product. Again, the issue, like you mentioned, it is a huge population of the aged that would be eligible, right? Just like there are for the GLP ones. So it's going to be another major cost issue that Medicare health plans will have to bear. So that's one side of it. But I would say we can figure out a way to make it work. If the innovation shows true difference versus what we've seen to date. And so I remain optimistic. You know, disease modifying therapies are critical. I know they're still in development by many companies out there. And the other is the early detection. You know, the sooner we can understand that this patient is down a path towards dementia, which could go to Alzheimer's, and we have an effective treatment to stop that progression, we would really be making process. So progress. So my hope is in 10 years, we'll have clearer pathways for early diagnosis, more tools to slow that progression, at least for a majority of patients, and then coverage models, benefit design that recognize both the clinical and societal impact of dementia.

SPEAKER_01 44:51

Yeah, that's great. I I read an article just today about early detection using, you know, uh circular RNA, you know, and um, you know, 34 kind of proteins, you know, that were highly predictive of um developing or incident um Alzheimer's disease. So I think there's a lot of discovery happening in basic science that can serve as a foundation for you know innovation and discovery in pharmacotherapy. And then, of course, there's that other long tail, you know, of getting it from discovery to actually using it with um patients. So well, um, we are truly at time. Um, this has been wonderful. I have just a couple really quick, rapid fire questions for you. Um and then, and then we'll have to say goodbye. Um, or so later.

unknown 45:43

Yeah.

SPEAKER_01 45:44

Um so let me just ask you what's the best career advice you ever received?

SPEAKER_00 45:51

The best career advice I ever received was always remember along your career path to focus on people. Um, so I really think that's important. We touched on it a lot today. Um, that all of the science, the methods, the publications are important, but mentoring and training the people that are going to carry your discipline forward, I really believe that that is the most important aspect.

SPEAKER_01 46:18

And who is a woman scientist, past or present, you'd love to have coffee with?

SPEAKER_00 46:23

You know, that's a great question. And what I would love to get one of the past presidents of the Pharmacoeconomics and outcomes research society and one of the past presidents of the Academy of Managed Care Pharmacy together and have coffee with both of them and discuss how we can better integrate the science of evidence generation with the application of the evidence to better patient outcomes and health plans. I love that.

SPEAKER_01 46:50

I love that. Diana, this has been such a thoughtful conversation. Certainly, one of the themes I've heard, you know, throughout your career is that good science doesn't end with discovery. We've said that over and over again. It continues until it improves decisions and ultimately improves lives. And your work has really fundamentally changed how healthcare thinks about effectiveness and value and implementation of medications. You've trained generations of scientists who continue that work. You know, thank you for your extraordinary contributions. And to our listeners today, you know, thank you for joining us for another episode of She Lead Science. If you enjoyed today's conversation, please subscribe, leave us a review, share this episode with a colleague, trainee, or friend. Until next time, keep asking great questions, keep following the evidence, and keep leading science. Thank you so much, Diana. Thank you.