Joaquin* was a 79-year-old man, capable of independently carrying out his daily activities while living together with his wife. A year ago, he had a stroke that caused moderate weakness of his left side (hemiparesis) and difficulty in understanding language (aphasia). Directly after the stroke, he received initial care in the intensive care unit for stroke victims, where he stayed for six days, after which he spent 40 days in the geriatric ward specialising in stroke rehabilitation. After this, a primary care centre organised a physiotherapist and occupational therapist to visit Joaquin at home for his rehabilitation sessions. At the start, his usual activities were still met with many limitations as well as his trouble in communicating. However, as these symptoms improved, the rehabilitation team visited less frequently, from almost daily at the start of the treatment to every couple of weeks. The focus of care shifted from physiotherapy and occupational therapy to language and speech therapy. To supplement this help from the rehabilitation team, Joaquin’s wife and home-help service encouraged him to regain independence and resume previously valued activities.
A brief case-study of a stroke victim: adapted from Hussey, P. S., Wertheimer, S., & Mehrotra, A. (2013).
Over the last decade, a pattern is emerging wherein increasing health care costs have a paradoxically low association to health care quality. This discerns the need for change. Perhaps in elements of, or even wholly reforming our current healthcare system (Hussey, Wetheimer & Mehrotra, 2013). While this statement is very bold, more and more countries are shifting their focus from applying a broad standard method of care, to patients under the same umbrella of disability, to instead focusing the care on the patients individual perspectives, their goals and relevant input on shared decision making (Elf et al., 2017). This trend is attempting to move health care service towards a value-based organisation, aiming to improve the patients' outcome without escalating the costs or else delivering equality good outcomes more efficiently.
However, what exactly is a value-based approach? In essence, it is the association between an organisation, performance, and payment of a health service and its achieved outcome. This relates to the patients' implications, whose complex disabilities (as seen in the case study above) or long-term conditions require a multi-disciplinary support approach of various health care professions in various health care services.
The overarching aim, therefore, is to improve the quality of healthcare services while simultaneously improving the patients' safety and cost efficiency. The question follows about how we can improve this quality? How can we integrate multiple healthcare disciplines to collaborate, provide feedback, and standardise outcomes? Ultimately lowering the costs.
"Every hospital should follow every patient it treats long enough to determine whether the treatment has been successful, and then to inquire ‘if not, why not’ with a view to preventing similar failures in the future".
Dr. Ernest Codman, 1914
Michael Porter, Erika Pabo and Thomas Lee, some of the initiators of a value-based healthcare system, believed that “the absence of a robust overall strategy is a fundamental cause of these [healthcare] struggles” (2013). They, therefore, developed a five step-framework focused on sustaining and improving the primary care practice. Firstly, the organisation of primary care should revolve around subgroups of patients with similar needs. Secondly, a team-based approach should cover a full care cycle for each patient subgroup. Thirdly, Patients outcomes and actual costs are measured as a routine part of the care for each subgroup. Fourth, the costs should be modified to include reimbursements for each subgroup and reward “outcome to cost” improvements. Lastly; the patient subgroups primary care teams should be integrated with relevant specialty providers. (Porter, Pabo & Lee, 2013)
This proposed strategy is no longer theoretical, the Karolinska University Hospital in Stockholm in transforming their healthcare to this value-based system. It is focussing on the patients' experience of his or her cycle of care while making sure to adhere to well-defined standard outcome measurements. This standardisation is central to a cogent analysis of the care provided (Porter, 2008). You cannot improve on something if you do not know the results of it.
The value or quality of care should be defined as “the patients' outcome achieved relative to the amount of money spent” (Porter, Pabo & Lee, 2013) and needs to be measurable. Either as an individual measurement or a composition of several that are taken throughout the cycle of care for each patient. These can be based on the health status achieved, the outcomes related to the service itself (experience-based measure) or the sustainability of the care (how long does the patient maintain the health improvements). Previous research done by Tistad et al. in 2012 have however shown a disparity between the outcomes measures defined by health care professionals and those most relevant or desired by the patients themselves. Perspectives and goals differ between the two. Therefore, to “ensure universal, consistent and fair measurement” the outcomes need to transcend the entire cycle of care, including complex conditions and the multidimensional care that is needed.
The reality of this, however, is questionable. The potential complexity of such a cycle requires incredible amounts of data on patients' healthcare contacts and their healthcare activities. So how can this be achieved?
The value of mobile applications in healthcare, such as Teamscope, is a development towards improving the quality of care, increasing the patients' satisfaction, safety and convenience while ultimately reducing the time and costs. Mobile data collection is now a growing and necessary part of a value-based healthcare system (Ventola, 2014). These technologies reduce the simple yet consuming aspect of treatment and allow the specialist to have more time with a high-value treatments (Williams, 2012). Teamscope, a mobile data collection app enables not only the doctor to collect and analyze clinical data but also the patient to report their symptoms and treatment outcomes. Teamscope can act as a central hub of information, with patient recorded data such as blood pressure, blood glucose, heart rate, and many others, that can be transmitted directly to their appropriate primary healthcare team instantly. This mobile apps provides real-time statistical analysis to see the development, improvement or deterioration of certain conditions. It can further monitor potential side effects leading to a fast patient-specific treatment. All the while being completely mobile.
This gathering, compiling and analysing of patient-specific data is essential in guiding individual value-based decision making. The flexibility and adaptability of such apps for both the patient and the primary care team will guide, and I believe ultimately lead this transition from a “one-size-fits-all” treatment to individual value-based outcomes.
*name has been changed
As long as I can remember medicine, and in particular neurology has been my fascination. I am currently a pre-med student at the Erasmus University in Rotterdam. I have been exploring countries and medical fields my whole life and it has ultimately lead me to the Netherlands where next to uni, I work as an assistant researcher at the Erasmus Medical Center and write blogs here and there. And this is just the beginning...