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Dr. Barry Rubin, medical director at Peter Munk Cardiac Centre at Toronto General Hospital, poses for a photograph in a multi-purpose operating room on Monday, February 13, 2012. He is seen through a CT scan machine. (Matthew Sherwood)
Dr. Barry Rubin, medical director at Peter Munk Cardiac Centre at Toronto General Hospital, poses for a photograph in a multi-purpose operating room on Monday, February 13, 2012. He is seen through a CT scan machine. (Matthew Sherwood)

The Dragon's Den of health care: Who decides which innovations get funded? Add to ...

As doctors hashed it out – some over the telephone, others in the room – Jordan Dermer, managing partner for CD Capital, a Toronto-based real estate development firm, seemed unsettled by the discussion.

“For me, there was great discomfort to be in judgment of what patient is deserving of additional quality of life,” he said afterward. “It’s not something a businessman should be deciding.”

And yet, that’s the business of doctors every day.

Even Eric Horlick, director of the structural disease interventional program, who authored the proposal, described it as a “big ask.”

Another of his procedures, a transcatheter aortic-valve implant [TAVI]done on at least 170 patients who couldn’t tolerate open-heart surgery, has been bankrolled by the innovation fund for about three years. The Ontario Health Technology Advisory Committee has since recommended the province fund it for those patients ineligible for open-heart surgery. It is now under consideration by the Ontario Health Ministry.

That’s how innovation starts: at the hospital, funded by philanthropy.

One of the beneficiaries of this innovation is Toronto’s Paul Szasz, 83, who had the TAVI operation – which involves inserting a replacement valve made of bovine tissue, mounted on a stainless-steel stent, into the human heart – in February, after open-heart surgery was deemed too risky. He is back at work, running the plastics moulding factory he founded.

“I like pioneering,” said Mr. Szasz. “I’ve always believed in innovation.”

Committee judges rank proposals with an A, B or C. Factored in to their ratings are how leading edge the procedure is, the benefit to patients and added costs to the hospital.

DRUG-ELUTING BALLOONS

The Pitch: To reduce the number of amputations of those with peripheral artery disease by inserting drug-coated balloons into patients whose stents placed in leg vessels are clogged with tissue. An estimated 800,000 Canadians have peripheral artery disease, resulting from plaque in the arterial system, a condition that leads to nearly 10,000 amputations a year.

The Device: A drug-coated balloon is inserted into the femoral artery with a catheter, which delivers the medication paclitaxel at the site of the arterial disease, helping break down the tissue and prevent re-narrowing of the artery.

The Cost: $27,000 was funded for balloon therapy. Cost per patient is about $1,600.

The Grade: All As.

Approved.

RENAL ARTERY DENERVATION

The Pitch: Reduce the amount of medication required by thermally heating or ablating the renal artery nerve as a way to control a patient’s persistently high blood pressure and help prevent stroke, heart failure or kidney failure. The targets for the treatment are those 2 per cent of patients whose hypertension is not controlled despite various medications.

The device: A catheter-based renal denervation system. A radio-frequency generator sends a high-frequency signal through a catheter placed in a renal artery and alters nerve traffic, which reduces the stimulus for high blood pressure, with a foot switch and power cable, provided on consignment.

The cost: $366,000 cost approved. Medtronic, the current supplier of renal denervation catheters, was asked to find other funding for the co-ordinator and the stimulator device that delivers the ablation. Cost per patient: about $7,600, including follow up on blood-pressure monitoring.

The Grade: All As and one B.

Approved: Doctors have already begun performing the procedures.

MITRACLIP

The Pitch: To clip, with a catheter-mounted device, the middle of two central parts of the mitral valve, which regulates the flow of blood between the filling and pumping chamber of the left side of the heart. This is for the less than 5 per cent of patients at University Health Network whose heart failure is such that the risks of death during an open-valve operation are too high. It improves quality of life and in some cases, possibly lengthens life.

The Device: The MitraClip, a less-invasive therapy delivered by catheter to reduce mitral regurgitation, a condition where the valve does not close properly when the heart pumps out blood.

The Cost: $600,000 in the first year, plus $720,000 each of the two years afterward. Cost per patient: about $30,000.

The Grade: Three As, Seven Bs, one C

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