As the decade comes to a close in gastroenterology, the specialty has never been at a point of more promise. Colorectal cancer incidence and mortality rates are decreasing as screening rates increase; the introduction of machine learning into the specialty is happening at a rapid pace; and the public has never been more aware of the importance of gut health.
Here, nine leaders from across the industry share their thoughts on how GI will look in 2030.
Note: Responses were edited for style and content.
Question: What will gastroenterology look like in 2030?
Purna Kashyap, MBBS, AGA Center for Gut Microbiome Research and Education Scientific Advisory Board; Mayo Clinic (Rochester, Minn.): GI is evolving rapidly, making it a really exciting time for clinicians managing patients with digestive disorders. [These] four developments have promise to transform [GI] over the next decade:
Advances in sequencing technologies. The declining cost of DNA sequencing and smaller size of sequencers has brought next-generation sequencing closer to clinical applications. Pharmacogenomic panels have already been introduced to the clinic, and I expect to see epigenetic and microbiome-based applications in the near future. The next decade will see a sharper focus on the mechanistic role of gut bacteria, and we can expect both diagnostics as well as data-driven therapeutics targeting the gut microbiome.
Artificial intelligence. The rapid accumulation of clinical, imaging and multiomics data has lured AI into GI, laying the path for precision medicine. [AI has already used] deep learning [to detect] polyps and GI bleeding [in real-world settings]. As we integrate clinical, imaging and -omics data, we will begin to see widespread application of AI-based models aimed at improving diagnosis and outcomes of complex GI diseases, such as cirrhosis and inflammatory bowel disease, as well as early detection of GI cancers.
Endo-robotics. Interventional endoscopy is already seeing a transformation with the emergence of endo-bariatrics. The current innovative pipeline will pave the way for endo-robotics for complex organ-sparing endoscopic surgery, nonthermal ablation and regenerative [biologics] therapies for chronic GI diseases, endoscopic therapies for diabetes and nonalcoholic fatty liver disease, and expansion of third-space endoscopy procedures over the next decade.
Home testing. Finally, the breakthrough in DNA-based testing allowing for in-home screening of CRC has opened a new avenue, making care accessible to larger populations. We can expect a continued push for point-of-care testing using miniaturized devices and digital technology for detection and monitoring of chronic GI conditions and cancers over the next decade.
While the list above is by no means comprehensive, it gives a snapshot of where our field is moving. I am excited to see what the next decade brings for GIs and our patients.
Vivek Kaul, MD, University of Rochester (N.Y.) Medical Center: Change is the only constant. In the last two decades, GI has undergone rapid and significant evolution. This fast-paced transformation is expected to continue over the next decade.
EHRs will continue to evolve and communicate better across healthcare systems regionally and nationally. Data acquisition and sharing, outcome and quality-based reimbursement and value-based purchasing will be cornerstones of future clinical practices.
Health systems will continue to consolidate, enabling efficiencies of scale. Service-line based multidisciplinary care delivery will be more widely established. The concept of GI hospitalists will take root more widely; advanced practice providers will assume greater responsibilities in most practice settings; and new technology — like voice recognition and phone-based apps — will penetrate daily practices more routinely. Technological sophistication will also enable meaningful telemedicine and remote consultation initiatives.
Whereas disruptive technologies, particularly genetic and molecular-based testing, may make a dent in routine endoscopic procedures, newer procedures and technologies, like motorized enteroscopy, nonendoscopic diagnostic tests, will become available to fill the gap for the general GIs.
For the therapeutic endoscopist, advanced resection platforms and robotic endoscopy would have come of age and be firmly established by 2030, thereby transforming third-space endoscopy and the entire endo-surgery field.
Endoscopic ultrasound interventions will continue to expand and bridge the gap between surgery and endoscopy. Defect closure and bleeding control devices will evolve to help conquer more complex endoscopic challenges and will be simpler to use in emergency situations. Disposable endoscopes will have found several niche applications, especially in high-risk procedures and clinical scenarios. AI platforms would have matured by 2030 with specific applications aimed to improve yield of endoscopy and diagnostic testing.
Bariatric endoscopic practice will have evolved into more of a metabolic endoscopy approach, from mechanical to increasingly physiologically oriented interventions. Personalized cancer medicine and immunotherapy will be the norm for GI-cancer management. Similarly, immune-modulators and biologics will continue to transform IBD care, particularly for severe patients. Increased global connectivity and networking will result in greater opportunities for teaching, training and research collaboration worldwide.
Ten years from now, the world and the GI space will be quite different. Those of us who can adapt and evolve accordingly will be most successful. Despite all the changes and advancements, our ultimate goal will and always should be to provide the highest quality patient care possible.
Michael Kochman, MD, AGA Governing Board Councilor for Development and Growth; University of Pennsylvania Perelman School of Medicine (Philadelphia): GI will change due to both iterative and disruptive innovation; some changes will be predictable and some completely unanticipated. We will see an increasing move toward molecular diagnostics and patient selection for therapies based upon predicted responses and outcomes.
Endoscopic procedures will expand into areas currently managed by both purely pharmacotherapy and surgical approaches. Current and near-term examples include the development of [peroral endoscopic myotomy], transoral gastroplasty and endoscopic antireflux procedures.
It may come to be that the major outgrowth of bariatrics may prove to be in the management of metabolic diseases such as diabetes, steatosis and hypertension, and as an adjunct to orthopedic procedures.
[Innovative thinking] will come solutions to the problems that plague humankind.
David Lieberman, MD, AGA Governing Board Past President; Oregon Health and Science University (Portland): There is substantial evidence that CRC screening of average-risk individuals reduces both incidence and mortality of CRC.
The current commonly used screening tests, such as fecal immunochemical test and colonoscopy, have limitations. A future serum test may incorporate genomics, proteomics or other risk markers that will enable accurate risk stratification: Higher-risk patients will be referred to colonoscopy and low-risk patients for repeat future testing.
The future may also bring advances in CRC prevention, either with lifestyle and behavioral change, chemoprevention or alteration of the microbiome.
Kevin Liebovich, MD, Illinois Gastroenterology Group (Chicago): Consumerism will be more influential as patients become more informed about their care options. Patients will be less reliant on their primary care physician as a referral source and rely more on digital informatics and social media. Cost and insurance benefit transparency will be a strong driver of where patients choose to receive care. Patients will be more adept at online scheduling and want their experience to become more efficient through the utilization of enhanced software applications.
Consolidation will continue among payers and providers, which will continue to impact every aspect of healthcare. However, as healthcare services transition to more risk-based compensation models, larger entities will pursue broader strategic partnerships in an effort to manage risk. This represents an opportunity for large independent physician practices who will be [better] equipped to aggregate data and provide services to a broader market, with lower cost and greater efficiency.
Endoscopic procedures will remain the cornerstone of the GI practice. Despite alternative CRC screening options, population demographics and a fixed number of physician trainees will result in continued high demand for endoscopic procedures. GI procedure volumes will continue to migrate away from the hospital outpatient departments to fully integrated and lower-cost ASCs. High demand for GI services may lead to challenges in physician recruitment.
Digital health applications and nanotechnologies are progressing at a rapid speed and could enhance the way we treat and manage many GI diseases. The combination of sensor-based technology, via ingestion of nanoparticles for chemotherapeutic drug delivery and monitoring of levels, to genomic evaluation of the individual patient's gut microbiome, will transform GI care as we know it. We will become more efficient in diagnosing and treating gastrointestinal and liver disease.
Paul Limburg, MD, CMO for screening at Exact Sciences; Mayo Clinic: In the coming decade, healthcare will undergo tremendous change as personalized medicine expands. As a practicing Mayo Clinic gastroenterologist and chief medical officer of Exact Sciences' screening division, I anticipate unparalleled improvements in our ability to address some of the deadliest — yet most preventable — conditions in GI. Advances in our molecular-level understanding of individual patients' symptoms will allow us to define tailored treatment plans, and personalized early cancer detection will become the norm for reducing GI cancer incidence and mortality. Across prevention, diagnostics, and treatment, patients and providers will have enhanced ability to pursue a less invasive, more effective option as their first choice.
Like other industries, medicine will continue evolving to meet patients where they are through innovations in at-home testing and noninvasive diagnostics. Combined application of data analytics, AI and augmented reality will play a pivotal role in our ability to identify and address emerging health trends. We will move beyond the outdated "one-size-fits-all" cancer screening paradigm toward individualized risk stratification. For example, based on recently recognized trends in CRC incidence and mortality in younger populations, the American Cancer Society now recommends that average-risk individuals start screening at age 45.1 Harnessing the vast potential of innovative digital platforms and molecularly-based laboratory technologies will permit rapid, deeper understanding of these disease patterns, leading to effective preventive and therapeutic interventions.
Unique collaborations are critical to accelerating future healthcare breakthroughs. For example, Mayo Clinic and Exact Sciences researchers collaborated to develop a multitarget stool DNA test. Collaborations like this, rooted in rigorous scientific discovery, will lead to revolutionary developments in precision oncology and GI over the next decade. As medical practice and technology evolve, I am confident our mission in GI and at Exact Sciences will remain the same: serving the needs of our patients.
Note: Dr. Limburg serves as chief medical officer for screening at Exact Sciences through a contracted services agreement with Mayo Clinic. Dr. Limburg and Mayo Clinic have contractual rights to receive royalties through this agreement.
Simon Mathews, MD, AGA Government Affairs Committee Member; Johns Hopkins Medicine (Baltimore): Over the next 10 years, GI will evolve into a field that is increasingly specialized and patient-centered, driven by advances in technology.
With respect to increased specialization, the frontier of advanced endoscopy is already pushing the boundaries of what was previously only possible with surgery. This trend will continue with advanced endoscopy providing a more frequent and less invasive alternative to surgical management of disease. This trend is aided by advancements in endoscopic capabilities and other related tools.
Ironically, technology will also replace some of our basic diagnostic GI procedures with noninvasive options. Further development of the intelligent capabilities of capsule endoscopy and similar ingestible diagnostics, and the development of novel biomarkers will likely supplant the need to use endoscopy as a primary form of diagnostic assessment. This will have broad implications for CRC screening as well as practice patterns in procedure-heavy practices.
Patients will also be able to more easily collect meaningful health data outside the clinical setting — such as in the home through stool-based diagnostics including a more nuanced understanding of the microbiome. As a result, patients and physicians will have a more convenient and comprehensive understanding of GI function in both disease and good health.
Finally, as vast amounts of data are collected on patients, researchers will be able to aggregate and analyze this information to derive population-based insights in a more timely and efficient way.
Luke Mitchell, partner and managing director of Edgemont Partners: When it comes to [predicting what GI will look like in 2030], there is only one certainty: It will look very different than it does today. Major changes in reimbursement models, evolving approaches to care delivery, variations in ownership structures and increasing consolidation among GI groups ensure that the only certain change will be change itself. Some changes will be positive for practitioners, some will be negative, but most will be both challenges and opportunities for those physicians and groups that are forward-thinking and willing to make the investments and adaptations necessary to remain leaders in their fields. Delivery of care, and how physicians get paid for that care, is not going to get any easier or less complex over the next 10 years.
The demographic trends driving the growth in GI, namely the aging U.S. population and increasing incidence of GI disease, will remain strong for many years to come, providing a stable foundation for the entire specialty. Also, the endoscopy center model does not seem to be at risk given the lower relative cost compared to inpatient alternatives.
While GIs have taken some lumps over the past several years in terms of reimbursement cuts, that doesn't necessarily mean that the pain is over. Most investors believe the future reimbursement landscape will be heavily focused on bundled payments and outcomes-based reimbursement, beyond [the Merit-based Incentive Payment System]. It is rare that a GI group can report outcomes data that would allow it to meaningfully differentiate their quality of care for payers, and bundled payments have the potential to significantly disrupt the current ownership models that rely heavily on distinct but separate entities providing ancillary services such as pathology, anesthesia, infusion and facility services. Finally, as investors continue to pour capital and expertise into the specialty, the chasm between the haves and have nots will become even more meaningful.
With their increased ability to fund growth, infrastructure and sophisticated systems, the large consolidators will make it harder for solo practitioners and small groups to thrive in many geographies.
Louis Wilson, MD, Wichita Falls (Texas) Gastroenterology Associates: My opinions about the future of the practice of GI are shaped by my work as the chairman of the American College of Gastroenterology practice management committee, as president-elect of the Texas Society of Gastrointestinal Endoscopy, and most importantly as the managing partner of a decidedly independent private practice GI group in a small- to medium-size market. A mixture of forces is coming together right now, shaping the state of affairs in our practice, as well as the future for the next decade.
Colonoscopy and endoscopy will continue to thrive as a screening and diagnostic tool, aided by new technologies such as AI. New technologies will improve our endoscopy capabilities rather than replace them. On a day-to-day basis, however, by 2030 or sooner, GIs will see their workflow and revenue sources evolve from traditional fee-for-service and endoscopy-focused work to more of a fee-for-value and chronic disease management type of practice. Some of the disease states that will consume our workflow include fatty liver disease, cryptogenic cirrhosis, autoimmune diseases, inflammatory bowel disease, Barrett's esophagus and eosinophilic esophagitis.
Ancillary service lines will be critical to both the business of GI and care delivery. ASCs will remain central, as well as the ancillary service lines ASCs support easily. Ancillary service lines, however, will need to prove themselves as clearly cost-effective for patients and improve the value patients receive to survive. Therefore, the service line I think is most at risk is anesthesia assistance for routine endoscopy. I don't see [it being] as relevant 10 years from now. Instead, pathology services, infusion services and pharmaceutical research will be better opportunities over the next decade. Each of these provides value to patients and complements clinical practices.
The business processes of hospital consolidation and private equity capitalization of private practices will certainly impact the practice settings and opportunities for GIs, but these forces will not be distributed geographically. I also don't think these processes will have the effect others predict. Independent medical practice will probably remain the best setting for physicians, while the availability and viability of that setting will vary from one market to another. As the current PE-backed management service organizations sell to larger entities, the advantages of independent private practice will increase in some areas.
Hospital-based systems will continue to be under significant stress over the next 10 years, and many of them will perform poorly as delivery systems for cost-effective care. They will need to take advantage of joint ventures with independent practices and provide excellent professional service agreements to physicians to remain profitable. Physician employment will peak but not deliver the type of stability and profits hospitals are hoping for. The demand for GIs will remain high. Markets where hospitals fail to effectively develop joint ventures and professional services agreements will have a difficult time attracting and keeping high-quality GIs.
References
1 Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin 2018;68:250-281.