How the health value can be measured?

At first, talking of health value seemed as if it was initiating a debate in the area of epistemology. Instead, in the hands of Michael Porter, this issue becomes very practical: “What results in terms of health have been achieved and what were the costs?”. Put this way, it seems fairly clear, but then it’s logical to ask ourselves: What is an outcome in terms of health?

As the renowned Harvard professor sees us, the ones dedicated to this, as a bit stuck, he gives us a clue in the following table, proposing three levels of results (tiers) and two subgroups within each.

Now, with the previous table on the retina, let's get into the skin of a Integrated Practice Unit who needs to present their clinical results, beyond the usual indicators of suitability and efficiency. If, for example, we think of a functional unit responsible for an oncologic process, a very important fact should be the survival of patients treated in a given period, say five years. And while admitting that this would be very useful information, we have, however no knowledge at this point as to what are the survival factors attributable to the different oncologic units.

Better health per dollar spent

"Better health for dollar spent", Michael Porter’s celebrated phrase, summarizes, like no other quote, the spirit of the current focus of clinical management. Porter is a professor at the Harvard Business School renowned worldwide for his work on company strategy and competitiveness. This professor shocked the world of health services when in 2006 he published ”Redefining Health Care", a book in which the author put his finger on the pulse of the American health care system, when he said he did not understand the organization in specialties that had little to do with the needs of patients. Neither did he understand how there were no indicators to measure the value that the ”health industry” contributed to the people’s health, nor how the clinical activities are remunerated per volume of work done, regardless of achieved health outcomes.

In an article in JAMA in 2007, Porter said that competitiveness in values ​​is the basis of the economy and that in the health system only the doctors can achieve it, if they set themselves the goal that clinical activities have a final purpose and not a meaning in themselves. 

Fast-track surgery. A new revolution after laparoscopy?

In the 90s, two different groups of surgical professionals developed new strategies aimed at improving the postoperative outcome of colon or rectal surgery patients. On the one hand, a group led by Dr. Kehlet from Scotland proposed different measures pre and post operatory while in Cleveland, another group led by Dr. Delaney focused his studies on postoperative models of introduction of an oral diet and early mobilization. Note that these new guidelines were not based on innovative technologies, but what they wanted was to simply lessen the suffering of the sick taking care to accomplish a combination of essential elements: better informed patients on the overall process, stress reduction, decreased pain, exercise as soon as possible, etc (Kehlet 1997).

In 2001, the same Dr. Kehlet led the group ERAS (Enhanced Recovery After Surgery), which coordinated several units of colo-rectal surgery in the Nordic European countries. ERAS developed 17 strategies, all evidence based with the intent to promote activities ranging from the politics of patient’ preparation to the process’ evaluation and outcomes (Fearon 2005).

Subsequently several systematic reviews and a meta-analysis have demonstrated the success of the ERAS program, also known as fast-track multimodal rehabilitation or (multimodal rehabilitation), which managed to obtain a significant reduction in the average hospital stay without increasing readmissions (Varadhan 2010).

Waste, the oncologists say

"In first world countries, cancer treatment has adopted a culture of excess: excess in diagnosis, excess in treatment, excess in promises"

The chosen title belongs to the report that “The Lancet Oncology Commission" published and which was signed by a large group of oncologists. In the excerpt below you can see on the right, the heading of the list of authors that extends over two pages.

This is an important document critically reviewing all aspects of approaching cancer in Western countries: the cost effectiveness, the use of technology, the mad race of the new drugs, the adequacy of the research, the role of medical oncology, the surgery, the radiotherapy, the genomics, the palliative, but mostly the question that the authors pose is whether the path followed by oncology is the most appropriate, and if as a society we can afford it.

Mental Health, the strongest transformation

The provision of mental health services have taken a dramatic shift in the last 40 years, which is why I think a blog like this, specialized in "Advances in clinical management," is bound to echo.

The mass closure of asylums

The critique of institutionalizing psychiatric patients in mental hospitals began in the late ‘60s, although the closure of beds was observed during the ‘80s, and especially ‘90s, as seen in the following graph:

According to a report by the London School of Economics and Political Science (Medeiros 2008), where the above graph came from, psychiatric deinstitutionalization has three main components:

• The transfer of patients from psychiatric hospitals to the community
• The involvement of general hospitals
• The deployment of alternative community services

The cited document reflects the vicissitudes that European countries came across when trying to address these policies, starting especially with the famous Italian Law 180 of 1978 which ordered the dismantling of psychiatric institutions. The document admits however, that despite the success of this policy, the difficulties in the operation of each of the three components mentioned above have been large.

Four ways to make Sutton’s law a reality

It occurs to me that there are four possible approaches to address Sutton's law (remember that this law tells us that we have to go after the waste to raise funds for activities that really provide a health value to people, see post March 28th) and I think we need the four approaches at once:

1. Medical service based on patient preference (see post February 27th)

There is a report from a Cochrane review that says that when patients have contrasting information, other than from their doctor, they have a tendency to choose more conservative therapies within the range that is offered with their diagnosis. And, according to some researchers, up to a 20% reduction in some scheduled surgical procedures can be expected with this method.

2. The role of scientific associations in addressing evidence-based medicine

The difficulties in the practice of medicine begin in the gap that exists between the scientific evidence and the reality of clinical practice. In this area there is a missing link that causes a striking variability in clinical practice and the utilization of health care resources. For this reason, in recent times interesting professional initiatives are being observed (which we will discuss further in later posts), of which highlight "Do not do" from NICE in the UK and "Choosing Wisely” from ABIM Foundation in USA.

Waste due to clinical management according to Berwick and Halvorson

Donald Berwick’s reviews have a great impact in the US, as well as being for a short period of time the CMS Administrator, surely the public health agency that moves the biggest budget in the world, was very well known in his time as the President of the Institute for Healthcare Improvement. Berwick and his colleague Hackbarth in this JAMA article, put a value on the waste of resources in the US. They say the cross cuts do not promote structural change and that in exchange, they can damage services of proven quality. For this reason, the study's authors strive to show where the waste is, i.e. where there are performances that if left out, the quality would remain unaffected or may even improve.

The authors believe that the overall savings of the system could be in a range going from 21% to 47%, but if you read the article carefully and ignore the parts about the complexities specific to the American system, it turns out that the estimate obtained out of the waste due to clinical errors, poor coordination between levels of care and overtreatment, would be as indicated in the chart above, at an average value of 13% and a range that would go from 12 to 16%.