Monday, 20 May 2019

Value-based healthcare: the patient's perspective

Gloria Gálvez

More and more organizations are adopting the new model of value-based healthcare (VBHC) where, according to the formula developed by Michael Porter:

                                                         Results that matter to the patient
                                        Value = ______________________________

In order for the results to be measured correctly and standardized, the International Consortium for Health Outcomes Measurement (ICHOM) -a non-profit organization recently joined by Vall d'Hebron Hospital- is defining sets of indicators standardized by clinical conditions. In this line, the Vall d'Hebron Hospital, which is implementing this new model of care, has set up working groups to define the indicators that they provide value to patients for the clinical conditions of stroke and localized prostate cancer.

In a patient-centred care model (aligned with value-based healthcare), it’s important to empower patients to be the ones who report the results that matter most to them, without interfering with the clinician's interpretation, nurse or social worker. At the same time it’s necessary to sensitize the professionals about how the patient feels and to share with them the methodology that will identify the aspects that add value to the patient.

With the methodology of design thinking and using tools such as the empathy map (image that illustrates the article) and the map of the patient's experience, the Vall d'Hebron Hospital have organized groups in which clinicians, patients, family members, social workers and patient representatives participate with the intention of jointly defining the indicators for the diseases mentioned above, and three types have been differentiated:

  1. The measures of the results reported by the patient (patient reported outcome measures, PROM), relating to problems that affect their quality of life and of which the patient reports directly. In localized prostate cancer some results have to do with the loss of social relationships, erectile dysfunction or urinary incontinence.
  2. The measures of the experiences reported by the patient (patient reported experience measures, PREM), related to their experience throughout the care cycle (primary, hospital and social) and related to aspects such as receiving clear and understandable information, if there have been shared decisions or if the waiting times have been adequate.
  3. Measurements of clinical results. These results are also important from the patient's perspective, but they are recorded by the professional and are related to survival, complications or readmissions.
These co-creation groups and the analysis of the results that are important for the patient will be the starting point of conversations and shared decisions among professionals, patients and family members. This will not only improve their relationships, but also the costs of care, since, by simplifying processes and reducing fragmented attention, more efficient results will be obtained and effectiveness and efficiency will be harmonized again.

Monday, 13 May 2019

Financing models do not promote value

The budgets of public health systems and those of private insurers are highly pressured by the constant emergence of new drugs, such as direct-action anti-virus to cure hepatitis C, or new technologies such as transcatheter aortic valve implants (TAVI) and logically the funders expend a lot of energy in limiting the use of these innovations. The battle, needless to say, has a predictable outcome because the conjunction of investors with the beneficiaries is usually lethal to the guardians of health expenses. An article based on American healthcare, emphasizes the waste induced by the "low cost" rates (if you are interested in the subject, I leave a second related link). The issue explained in Health Affairs  would take the opposite extreme as instead of "very little but expensive activity", this analysis focuses on "a lot of very cheap activity" and, it sounds untrue, but, at least in the US, at this point there could be more waste.  

Monday, 6 May 2019

The doctor gives me three weeks; can you send me to emergency department?

Pere Vivó

The train crash returns between the professionals and the managers, the perception of some users and their own reality... The best thing is to verify it: call and request a visit with your doctor at the users’ care centre and you will see that in the best of cases they will probably give you an appointment within a few days. Then try to call your doctor for a consultation over the phone; you most likely receive a call in a few minutes. Finally, go to your health centre and ask for an appointment and you will see that they will probably offer you an emergency visit within a very short time.

Monday, 29 April 2019

Mental health: involuntary treatment and its consequences

Andrés Fontalba

"If Mr. McMurphy doesn’t want to take his oral medication [...], I'm sure we can administer it in another way."

The character of nurse Mildred Ratched in One Flew Over the Cuckoo's Nest presents a serious, strict, orderly and authoritative figure, with a lot of self confidence and all her actions are carried out with the firm conviction that they are aimed at the welfare of the patients in her care. If we asked her if she takes into account the patients' point of view she would answer, without a doubt, affirmatively. The clear example appears in a discussion in which she is asked to watch a game of baseball on television where she goes the extra mile in persuading all that everyone's vote is necessary for any change in the usual programming, thus she finally manage to impose her point of view. She would not hesitate at any time to use persuasion, interpersonal influence, or even threat to guarantee the administration of a prescribed treatment.

Friday, 26 April 2019

"You expect the world to adapt to your distortion"

Salvador Casado

Deconstructing Harry, a film directed by Woody Allen
From time to time I like to reread the first chapters of the Martín Zurro Family Medicine Book. Review the excellent reviews of Borrell, Gené, Casajunana, de la Revilla and many others. I try to seek inspiration and encouragement, guidance and light when the confusion or complexity I face in my clinic overwhelms me. There are days or weeks when I sail the seas of uncertainty, as Juan Gérvas would say, with sufficient dignity but in others I shipwreck when the swell of my ignorance, the shortcomings of the system or the great pressure of an unbearable number of complex patients overflow me.

Monday, 22 April 2019

The health care footprint on the planet, one more reason for right care

Cristina Roure

According to the Health and Climate Change Commission of The Lancet, the greatest opportunity in 21st century health is an adequate response to climate change. I have to confess that, had I been asked, I would surely have answered that the next revolution in health would be technological, probably connected to personalized medicine, 3D printing or electronic health.

Monday, 15 April 2019

The hospital at home, one of the challenges of the upcoming integrated care systems

Marco Inzitari

The content of this week's article has been developed, over the past few years, with my colleague and friend Miquel Àngel Mas (@DrMqAgMas), a geriatrician, former PhD student in our research group and currently a member of the expert nucleus in chronicity of the Gerència Territorial Metropolitana Nord de l'Institut Català de la Salut. We’ll discuss the subject from two points of view in the hope of generating interest and debate among the blog followers.

Our health and social system experiences periods of rethinking, mainly due to the changing requirements in the need of attention of older adults. This fact suggests that the approach to problems solving from the big acute hospitals, as structures that works separately from the community, loses centrality. The logic that follows is the evolution towards increasingly integrated systems, adapted to the different territories, with primary care and attention to the community in the middle. As Professor Dennis L. Kodner said in his classic - Integrated care: meaning, logic, applications, and implications - without a discussion at different levels, all aspects of the provision of attention suffer: patients lose (and get lost), the services are not provided correctly (or arrive late), the quality and the satisfaction of the patients goes down and the potential for sustainability of the system diminishes.