As payers become more active, they are linking rewards to positive results, with outcomes reflecting all the interventions in the continuum. Health professionals cannot be content with simply completing their treatment; there must be an improvement in the longer-term outcome, which becomes the responsibility of all providers. This notion of a continuum of care is particularly relevant to the increasingly complex management of care for chronic conditions.
There is a wide range of desired outcomes, from absence of complications after interventions, to longer-term rehabilitation of functions and total recovery of patients. As patients exert more influence on what is measured, goals relating to quality of life, general wellness and emotional wellbeing have been introduced. These form a continuum of outcomes, which starts with the basic resolution of a condition and ends with longer-term goals such as resuming a normal life or living without pain. For a patient with a stroke, the continuum might follow this path:
Short-term outcome: immediate stroke care, followed by a return home within 6 months, with minimum loss of functionality.
Long-term outcome: prevention of further strokes within 2 years, with the patient gaining full independence and returning to work.
In an outcome-driven system, health professionals make better decisions that are more likely to improve the patient’s overall quality of life. Surgery and subsequent recovery may be an appropriate path for Mr. Johnson, the healthy 40-year-old with knee cartilage damage. For Mrs. Murphy, the 80-year-old with multiple health conditions, however, the same surgery could supersede any benefits and may be approached more effectively with physiotherapy (see Rethinking value in healthcare).
For an Oxford Knee Score, the outcome indicator may be the percentage of patients that improve by more than two to-ten points. The acceptable ‘norm’ could mean 90 percent or more of patients reaching this indicator, with targets to beat this average.1
The quality of an outcome indicator is determined by its relevance to the patient group, the quality of the measuring instrument and the reliability of the data measured.
When outcome measurements are plotted over time, a pattern of patient value starts to emerge. Many current outcome measurements only cover the short-term effects of care, whereas ParkinsonNet measures both short- and long-term outcomes of care delivery, which is more representative of the total value for patients. The four key measures are:
The more standardized the measurement, the easier it is to compare outcomes between patients, clinicians, institutions and entire health systems. The Oxford Knee Score2 is a 12-item, patient-reported questionnaire to assess function and pain after total knee replacement surgery. It is short and easily replicated worldwide, and because it is completed by the patient, it minimizes any possibility of bias in the assessment. Questions cover physical capabilities such as: Could you kneel down and get up again afterwards? Have you been limping when walking, because of your knee? Could you walk down a flight of stairs?
Broad, global benchmarks challenge an organization to improve the quality of its care. By setting tough targets, and making results freely available, providers can encourage a culture of excellence, knowing that patients will choose doctors, clinics and hospitals with the best track records, leading to a survival of those people and organizations best able to adapt. Such ‘health Darwinism’ may appear brutal, but can play an essential part in raising standards in the health system.
Sweden has a long history of quality registries, collecting comprehensive, reliable data and following outcomes of patients with similar conditions and/or medical procedures. In recent years, these measurements have been enhanced with patient input, with reports published, to ensure transparency for taxpayers and patients, promote quality improvement and to share best practice. Despite spending less than half per capita on healthcare than the US, health outcomes are far better in Sweden along virtually every dimension, with an infant mortality rate of less than half that of the US.3 Professor Jörgen Nordenström shares lessons from Sweden on organizing value-based healthcare (see Governance: Maintaining a focus on value).
Within a continuum of care, communicating the final outcomes to the various providers will improve the understanding of how each set of interventions affects the quality of care. For example, midwives and gynecologists could review the measures associated with complications in pregnancy or childbirth. Physiotherapists and orthopedic surgeons can collaborate similarly to help improve mobility after hip replacements.
As this type of thinking becomes more commonplace, organizations start to look beyond single or even multiple interventions toward measuring the longer-term effects of care. This could include outcomes such as a patient’s independence, ability to undertake specific activities or return to work. For patients with co-morbidity, care coordinators are needed, with the capability to steer patients across different providers or systems, to achieve the best possible outcomes.
Over time, wider health trends can be tracked by making all outcomes public, to compare providers and chart the effectiveness of preventive care programs that prevent obesity, heart disease, smoking and diabetes.
An example of single disease integration is the Sun Yat-sen Cancer Center, which formed multidisciplinary cancer teams, mostly focused on a particular type of cancer. The teams included nurses and clinical support staff, and evolved to include care managers, with appropriate technicians included when needed. Teams meet at least twice per month to review new cases and discuss existing patients’ care, and every team member knows patients’ names and medical circumstances.
Reimbursement was seen as the catalyst for reform, along with quality measurement. The Center introduced pay-for-performance, in collaboration with Taiwan’s Bureau of National Health Insurance. Providers received retrospective quarterly capitated payments for each patient, supplemented by performance bonuses based on patient survival rates.
The Taiwanese system had previously lacked comprehensive clinical information (such as health outcomes) and did not report results at the individual provider or physician level. The Sun Yat-sen Cancer Center established patient electronic medical records that included physician order entry, copies of x-rays and other images, lab reports, surgical records, outpatient physician notes, and scheduling.
Data related to quality measures was entered every day by care managers into patients’ medical records, and patient safety measures were also tracked, along with patient satisfaction, which was used to inform areas for improvement.
The center’s 1-to-5-year breast cancer survival rates exceeded all hospitals in Taiwan, and adherence to all 10 quality indicators was significantly associated with better overall survival and progression-free survival among patients. Patient safety rates, such as hospital-based infections were also the lowest in Taiwan.
2Dawson J, Fitzpatrick R, Murray D, Carr A. Questionnaire on the perceptions of patients about total knee replacement. J Bone Joint Surg Br. 1998 Jan;80(1):63-9
3What Sweden Can Tell Us About Obamacare, New York Times, 15 June 2013