Nathan N. O’Hara MHA1, and Daniel Mwayafu MBChB MMed2 1 Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA 2Mbale Regional Referral Hospital, Mbale, Uganda Healthcare expenditures account for roughly 10–20% of the gross domestic product in most high‐income countries.1 Despite rising healthcare costs in many of these countries, most countries have observed limited improvement in basic health outcomes, such as life expectancy.2 Currently, models of healthcare are often volume based and compensate providers using a fee‐for‐service system. While the volume‐based reimbursement model rewards activity, it has limited influence in ensuring improved patient outcomes. To reduce the disconnect between health treatments and patient outcomes, Robert Kaplan and Michael Porter, professors at the Harvard Business School, have proposed a new model deemed value‐based healthcare.3 In value‐based healthcare, value is generally defined as the benefits (health outcomes, patient satisfaction, prevention of illness) over the costs, both direct and indirect.4 As in other fields, value should be from the consumer’s perspective, or in healthcare – the patient’s perspective. The delivery of healthcare services involves numerous organizational units, ranging from hospitals to a physician’s clinic and laboratories to imaging facilities. However, the proper unit for measuring value should encompass all of the services or activities that, in combination, will determine if a patient meets their desired outcomes for a given medical condition. Value for the patient is created through the combined efforts of healthcare providers over the full cycle of care for a given medical condition. The benefits of any one intervention may be contingent on the effectiveness of other interventions throughout the care cycle. For primary and preventative care, value should be measured for a defined patient population with similar healthcare needs, such as healthy children, healthy adults, or frail elderly people. For patients with multiple medical conditions, value should be measured for each condition, with the presence of the other conditions used for risk adjustment. This approach allows for relevant comparisons among the patient’s results, including comparisons of providers’ ability to care for patients with complex conditions. Determining the group of relevant outcomes to measure for any medical condition should follow several principles. Outcomes should include the health circumstances most relevant to patients and include both short‐term and long‐term health. Long‐term health should be a time period long enough to encompass the ultimate results of care. Risk factors or initial conditions should be incorporated into the outcome measurement to allow for accurate risk adjustment. For any medical condition or patient population, multiple outcomes measures will collectively define success. The complexity of medical care means that competing outcomes (e.g. short‐term safety versus long‐term function) must often be weighed against one another. The outcomes for any medical condition can be arrayed in a three‐tiered hierarchy. The top tier is generally the most critical, and the lower‐tier outcomes involve a progression of results contingent on higher‐tier outcomes. Each tier of the framework contains two levels, involving one or more distinct outcome dimensions. For each dimension, success is measured with one or more specific metrics. Tier 1 is the health status that is achieved or, for patients with some degenerative conditions, retained. The first level, survival, is of overriding importance to most patients and can be measured over various periods appropriate to a given medical condition. However, maximizing the duration of survival may not be the most important outcome to all patients. The second level in Tier 1 is the degree of health or recovery achieved or retained. Examples may include freedom from disease and relevant functional status. For some patients, the second level in Tier 1 may, in fact, be more important than survival. Tier 2 outcomes are related to the recovery process. The first level is the time required to achieve recovery and return to the patient’s normal or best attainable function. Recovery can be further divided into the time needed to complete various phases of the care cycle. Cycle time is a critical outcome for the patient – not a secondary process measure. Delays in diagnosis or formulation of treatment plans can cause unnecessary anxiety. Furthermore, reducing the cycle time can improve functionality and reduce complications. The second level in Tier 2 is the disutility of the care or treatment process in terms of discomfort, short‐term complications, adverse events. Tier 3 is the sustainability of health. The first level of Tier 3 outcomes is the recurrences of the original disease or longer‐term complications. The second level captures new health problems created as a consequence of treatment. When recurrence or new illnesses occur, all outcomes must be remeasured. Measurement efforts should begin with at least one outcome dimension at each tier, and ideally one at each level. Improving one outcome dimension can benefit others. Mapping these trade‐offs, and seeking ways to reduce them, is an essential part of value‐based healthcare. To identify the set of outcome dimensions, the cycle of care for the medical condition can be charted using a care delivery value chain (CDVC). A CDVC maps the full set of activities or processes involved in patient care and highlights the associated entities or units within the full care cycle. This chart allows a systematic identification of all relevant outcome dimensions as well as when and where measurement should occur. The CDVC also enables particular outcome dimensions to be linked to the specific processes of care from which they arise. Using the CDVC and outcomes in tandem can guide outcome improvement.
6 Value‐Based Orthopedics
Introduction
Top four questions
Question 1: What is value‐based healthcare?
Defining specific outcome dimensions and measures
Hierarchy of outcomes
Relating outcomes to processes
Selecting particular measures
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