Monday, 9 January 2017

Measuring results in health is still very complicated

In order to evaluate health institutions based on the value they provide, health outcomes must be measured. However the efforts to achieve this are bearing dismal results. Pay-for-performance initiatives are drifting in an ocean of indicators that don’t translate into anything too operational. To give some examples, in the US, CMS (Medicare and Medicaid) handles nearly a thousand indicators to promote new funding models (see Health Affairs Blog "The Quality Tower of Babel") and, not so far away, in the Results Central of Catalonia (AQuAS), more than 300 indicators are recorded. Everything suggests that the excess of information will not bring light if we are not able to clarify what it means to add value to people's health, and to make this statement comprehensible, we must distinguish between two different approaches:

Health value for citizens

A long life free of disability is a goal that most mortals share but this indicator is not very useful for service providers because the impact of the health system on life expectancy barely reaches 20%.

Health value for patients

When citizens become ill, the health system takes on a leading role and initiates diagnostic and therapeutic processes and health goals that now begin to materialize. Unfortunately there is still a far-reaching scientific agreement on how to assess the quality of health services. Both US News magazine (The Honor Roll) and Iasist (Top20) use management and process quality indicators to select the best hospitals in their respective countries, while John Wennberg proposes instead to value hospitals according to how they treat chronic patients in the last two years of life. These are two examples of two very different ways of addressing the issue of value.

At this point, I want to recall Michael Porter's commitment to the definition of outcomes for each specific clinical process (see post: How the health value can be measured?), and to illustrate this Porterian idea, I will present a case: when they value the chain of care for a poor prognosis pathology, health promoters must determine whether they opt for “the longer the life, the better” or for “the better quality of life, the better value”; It’s clear that depending on whether one option or another is chosen, two different ways of acting and two different ways of measuring results will be obtained.

In a world where clinical information circulates like we could never have imagined, we now realize that we have not debated sufficiently, either professionally or socially, the contribution to society value that certain clinical actions have and therefore, despite the fact that we live immersed in a cloud of indicators, measuring health outcomes is still a very complicated issue.

Jordi Varela

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