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Samen Waarde CreërenJan A Hazelzet, MD PhD
CMIO and Professor Health Care Quality & Outcome
@janhazelzet
Van: ”What’s the matter”, naar: “What matters to you”.
Jan A Hazelzet, MD PhDCMIO and Professor Health Care Quality & Outcome
@janhazelzet
These are our aims! More information:http://koers18.online-magazine.nl
Ambition 1: Continually adding Value
Our guiding principle for research, education, and health care is creating added value for patients
Understanding the health, diseases, and wishes of patients
Personalized medicine (individualized treatment)
Prevention
Translating knowledge into useful, innovative products and health care concepts
Healthcare: Rapidly Increasing Complexity Diagnostic and treatment options are expanding and changing
Chronic diseases and comorbid conditions are increasing
Overtreatment / under treatment / unwarranted variation in outcome
Care delivery has become increasingly fragmented
Health care quality, and outcomes fall short of their potential
Growth rate of health care expenditures is unsustainable
Not patient centered
Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. IOM 2012 http://bit.ly/NS4Nln
KPMG rapport: Inzicht in uitgevraagde variabelen voor kwaliteitsmetingen. Juni 2016
Performance
JAMA Internal Medicine Published online October 17, 2016
VBHC: value based healthcare
Health Care Quality: Effective
Patient centered
Safe
Efficient
Timely
Equitable
==
Outcomes that matterto patients
Cost of achievingthe outcomes
VALUE
Fee for volume → performance
Focus on Disease / Individual
Team based approach
Care Path / Integrated Care
Measurement of outcome & costs in every patient
Culture / Organizational change
VBHC Value Based Health Care
Less is More
Why PRO (patient reported outcome)
Biomarkers fail to correspond with how patients actually feel
Patients value biomarkers differently
PROM’s provide a key component to understand burden of disease
Especially important in diseases with morbidity (and low mortality)
Starting point for improvement of therapy
Better communication and shared decision making
Detecting adverse effects of therapy
PRO → PROM → PRO-PM
oDepression – HADS - % pts wit initial HADS > 8, and < 8 at 6m
http://www.healthmeasures.nethttp://www.nihpromis.com
Breast Cancer
EORTC QLQ-BR23
BREAST-Q
CTCAE v4.0
EORTC QLQ-C30
BREAST-Q
EORTC QLQ-C30
EORTC QLQ-LMC21
FACT-ES
EORTC QLQ-BR23
EORTC QLQ-C30
Patient Reported Outcome Measures (PROMs) en Provider Reported Measures
• Results are discussed in the consultation room
Diagnoses VBHC in Erasmus MC
Set Outcome Measures defined Set Outcome Measures in development
Planned to start
Brain Tumors Frail Elderly NeMo (neurom. & mitoch. afw)
Bladder Cancer Familiar hypercholesterolemia Multiple sclerosis
Stroke Cervix Cancer Palliative Care
Breast Cancer Pediatric Brain Tumor Hemophilia
Turner Syndrome Obstruction icterus Auto-immune Diseases
Sickle cell Pregnancy & Child Birth Hemifacial Microsomia
Larynx Cancer Head and Neck Tumors Congenital Cardiac Anomalies
Cleft Lip Palate Liver Insufficiency IBD
Prostate Cancer Peripheral Vascular Disease Hip & Knee Replacement
Lung Cancer Pediatric Cardio Thoracic Surgery
Macula Degeneration Kidney Transplantation
Obesity Liver Cancer
Colorectal Cancer
Alzheimer’s Disease
Cataract
2nd Half 2016 1st Half 20171st Half 2016
Outcome Instruments
http://www.ichom.org/medical-conditions
Work in Progress:• Overall Health Adult• Overall Health Pediatric• ……• ……
Patiënt Gerichtheid
Bastemeijer et al. PEC 2016
NRC 4-10-2016
Hoffmann. JAMA 2014; 312: 1295
Kon. JAMA, 2010; 304:903
• Definition• Certify decision aids and use them• Educate communication skills• Develop measures of SDM• Integrate in the workflow
Spatz et al. JAMA 2017
Gainer et al. Med Decis Making. 2016 Nov 1
Gainer et al. Med Decis Making. 2016 Nov 1
JAMA Cardiology 2016: 1: 9
JAMA Cardiology 2016: 1: 9
Patient health outcome goals (care preferences)
Team-Based Care
JAMA August 23/30, 2016 Volume 316, Number 8 826-34
PreventableComplications
PROM’s
PREM’s
Key Process Measures
Team Culture
Finance
Towards Continuous Team-basedImprovement
Performance Data Set
Patient Support
Change Support
Disease TeamUnited, responsible, accountable
Data Support
..clinical leadership, team collaboration, personal commitment…
Care Proposition
Clinical Outcome
OrganizationalSupport
Shared Decision Making• Disease Burden• Outcome Expectations• Possible Harm & Risks• Alternatives
J Healthc Man 2016; 61: 402-19
J Healthc Man 2016; 61: 402-19
Research Designs in VB Purchasing
Qualitative Case Control
Grounded Theory
Ethnography
Quantitative Cross Sectional
Case Control
Pre- Post Test
Longitudinal
Time Series
J Healthc Man 2016; 61: 402-19
Integrated Care:Erasmus – Rehab – Nursing Home – Physio - GP etc.
VBHC Collaboration Erasmus MC – Zilveren Kruis
2 year claims data (total costs)
2 year follow-up for outcomes
Long-term project for shared savings/risk contracting &VB bundled payment
http://www.ichom.org/medical-conditions/stroke/
http://erasmussummerprogramme.nl/summer-programme-courses/?ct=ESP76&pg=Courses