Measuring the effectiveness and value of clinical practice

In the "XIV Conference of the Sign Foundation", Jens Deerberg-Wittram, Director of the Boston Consulting Group, gave the inaugural lecture entitled "From volume to value". It was a very timely speech, at a time when the obsessive control of budgets and waiting lists prevents clinicians and managers from reflecting on what contributes so much care activity to society. The concept of value expressed by the German speaker is very new for healthcare managers, who tend to understand clinical effectiveness as a rhetorical concept more typical of epidemiological studies.

To talk of value, I must first talk about so prized clinical effectiveness, which traditionally is measured with ultimate indicators that analyze quantity of life (mortality) and quality of life (morbidity). However, the difficulty lies in interpreting the indicators of effectiveness this it’s not easy, since by their nature; they are contrived by the social determinants of health. On the other hand, the current focus on the patient emphasizes the importance of the perception that people have of the clinical actions and, from this perspective, the health value could be defined as the perceived clinical effectiveness, an indicator of immeasurable entry, because individualism is in its essence.

Tenaciously eight years ago, Michael Porter got down to work with the problem and developed a scale of value indicators in three stages: 1) quantity and quality of life, 2) effects of the clinical process, both positive and negative, and 3) long-term effects caused by recurrences and adverse effects. The Porter scale is a great help to build indicators of outcomes from the specific perceptions, maybe not from each person, but from groups of patients who, due to their pathology, are forced to be candidates for a specific clinical process.

Jens Deerberg-Wittram was one of the founders of the "International Consortium for Health Outcomes Measurement" (ICHOM), an organization that aims to put into practice the Porterian principles of the development of health outcomes. The lecturer spoke about the essence of ICHOM and, for this reason, I thought it would be interesting to present a couple of examples.

Tracking the ICHOM indicators

If we look at the indicators proposed by ICHOM for the pregnancy and delivery process, in addition to the expected mortality and morbidity, those in the right upper third, we observe that, along the circle, other indicators appear that reflect the human face of the process, such as the experience of childbirth, maternal confidence or success in breastfeeding, in addition to others of involvement such as shared decisions, and some significant morbidity, such as postpartum depression, so little present in the thinking. ICHOM indicates to the specialized units that it’s better to hurry to deploy models of indicators of results according to the proposed parameters, if they want to value their clinical actions.

A second example that I have chosen is the results of the breast cancer process, where the women who have participated have proposed, in addition to survival, complications and recurrences, many aspects of treatment experiences, such as pain, fatigue and depression; or of long-term complications such as the appearance of the feared arm lymph oedema, breast appearance, neuropathies, arthralgias or sexual dysfunction. If now, thanks to the greater effectiveness of the treatments, the prognosis has improved, many women wonder what price, in terms of limitations and chronic conditions, they must pay.

Health systems, managers, clinical leaders and quality experts continue to focus on measuring tons of parameters of structure, process and "subrogated" outcomes, but they must realize that it’s now imperative, as Jens Deerberg-Wittram proposed, that the indicators of effectiveness and value be measured and also explained.

Jordi Varela
Editor