The approach to Reducing Harm and Waste in Realistic Medicine is to focus on value. When resources are limited, interventions are offered to those who will benefit most and who are more willing to accept risk and in these conditions it is more likely that high value healthcare is delivered. However as resources increase, interventions are offered to those less likely to benefit while the likelihood and magnitude of harm stays the same and in these conditions it is more likely that low or negative value healthcare is delivered. A personalised approach to care can help communicate these concepts for patients and help understand what benefit and risk mean for a patient’s personal situation. Personalised care can also reduce the impact of adverse events. Being Open is a best practice framework used in Scotland which creates an environment where patients and families feel supported and healthcare professionals and managers have the confidence to act appropriately. “Psychological harm to families is reduced when they experience compassionate care, their perspective is valued and when they are central to the review of care.” Being Open has also been used to prevent future harm when staff participate with the learning and improvement generated from the adverse event review reports. [The Scottish Government. Personalising Realistic Medicine: Chief Medical Officer for Scotland’s Annual Report 2017-18. Published 2019. https://www.gov.scot/publications/personalising-realistic-medicine-chief-medical-officer-scotland-annual-report-2017-2018/pages/7/]
During the pandemic some healthcare services were scaled back in order to minimise harm. Also, people were reluctant to access services and it is of concern that they have chosen to stay away. Routine care has been delayed and is now becoming more urgent. The organisation and delivery of care will need to be reviewed as demand increases. Shared decision making and personalising care will help people make an informed choice about their care and allow effective and efficient use of services, reducing harm and waste. Modernising Patient Pathways Program (MPPP) is transforming outpatient services across Scotland by ensuring the optimal pathway is chosen at first point of contact. Active Clinical Referral Triage (ACRT) has the potential to reduce waiting times by eliminating unnecessary face to face appointments. Discharge Patient-Initiated Review (PIR) encourages patient independence and helps to avoid unwarranted use of our clinical resources, as well as our patients' valuable time, by avoiding routine "check-ups”. [The Scottish Government. The Chief Medical Officer for Scotland’s Annual Report 2020-21: Recover, Restore, Renew. Published 2021. https://www.gov.scot/publications/cmo-annual-report-2020-21/ ]
Value can be assessed in many different ways and can include cost-effectiveness analysis, economic analysis, disinvestment, and reducing overuse and overprescribing. Below is a selection of journal articles and reports which are about value in healthcare. If you are looking to answer a specific question please submit a literature search request at the link above. If you would like to be alerted when new content is available here then please sign in and select Follow. You are welcome to leave comments and suggestions below in the comments section.
Alderwich, H., Robertson, R., Appleby, J., et al. Better value in the NHS: the role of changes in clinical practice. The King’s Fund, 2015.
“The reasons why overuse happens are complex. They include failures to follow professional guidelines, lowering thresholds for treatment, lack of access to alternative treatment and supply-induced demand for services. Overuse can also be driven by ‘silent misdiagnosis’: the gap between what patients want and what doctors think they want. In fact, what patients often want when they are involved in decision making is less treatment….” (pg 49)
BADGERY-PARKER, T., et al, 2019. Exploring variation in low-value care: a multilevel modelling study. BMC Health Services Research, 19(1), pp. 345.
“Investigations into the causes of low-value care and initiatives to reduce low-value care might best be targeted at the hospital level, as the high variation at this level suggests the greatest potential to reduce low-value care.”
BADGERY-PARKER, T., et al, 2019. Low-value care in Australian public hospitals: prevalence and trends over time. BMJ Quality & Safety, 28(3), pp. 205-214.
“Low-value care in this Australian public hospital setting is not common for most of the measured procedures, but colonoscopy for constipation, endoscopy for dyspepsia and sentinel lymph node biopys for melanoma in situ require further investigation and action to reverse increasing trends. The variation between procedures and hospitals may imply different drivers and potential remedies.”
BOSCOLO, P.R., et al, 2019. Measuring Value in Health Care: A Comparative Analysis of Value-based Frameworks. Clinical therapeutics, 42(1), pp. 34-43."This paper presents a comparative analysis of value-based frameworks (VBFs) developed in the United States and Europe for both drugs and medical devices. The proliferation of frameworks used for measuring the value of different health care objects and processes seems certainly a worthy exercise, but a real paradigm shift toward value-based care could only happen if these tools will be systematically used in practice and if all of these levers are played together, with joint actions and shared awareness of the key stakeholders' groups." Copyright Â© 2019 Elsevier Inc. All rights reserved
CAB: Health Economics : Produced by Health Scotland this new bi-monthly current awareness bulletin rounds up the latest publications for you. You can sign up for alerts via the Knowledge Network to receive this bulletin, free of charge. Click on the link provided to find the latest issue, and contact form to sign up for updates.
DOWNEY, S., et al, 2020. Towards Value in an Integrated Care Environment: Early Lessons from an Ontario Health Team. Healthcarepapers, 19(1), pp. 11-18.
Integrated healthcare models are being experimented with in many jurisdictions as a way to improve patient care and lower system costs. This commentary presents early lessons from one Ontario Health Team as it works towards new models of care. The authors recount early discussions on developing an integrated health services network, how funding for "winter surge initiatives" became an opportunity to test ideas and how these experiences are informing current planning. Some of the early lessons learned include the value of trusted relationships, moving care upstream and framing problems as collective challenges. Copyright Â© 2020 Longwoods Publishing.
Healthcare Improvement Scotland , ihub, Value Management
“Value Management is a new collaborative that aims to test and spread an innovative model developed within NHS Highland that supports clinical, care and finance teams to apply quality improvement methods with combined cost and quality data at team level to deliver improved patient outcomes, experience and value.”
HORNE F. and MANION, R., 2019. A Made-in-Canada Approach to Value-Based Healthcare. HealthcarePapers, 18(4), pp. 10-19. "Healthcare reforms that do not address outcomes of importance to patients may not be poised to successfully deliver the ultimate objectives of improved outcomes and quality of life for patients. Value-based healthcare is a distinct approach to aligning diverse health-system stakeholders, including healthcare professionals, health system administrators and the pharmaceutical and medical devices industries, on delivering outcomes that matter to patients at the same or lower cost. This article examines existing pan-Canadian infrastructure, including quality improvement and data initiatives, to demonstrate a path forward for this international healthcare transformation movement in Canada."
KOFF E. and LYONS, N., 2020. Implementing value-based health care at scale: the NSW experience. The Medical journal of Australia, epub ahead of print
LEWANCZUK, R., et al, 2020. Value in Healthcare: Designing an Integrated Value-Based Healthcare System. Healthcarepapers, 19(1), pp. 59-64.
Value-based healthcare (VBHC) can be interpreted in many ways depending on one's jurisdiction. Often it is used synonymously with cost-effectiveness. In Alberta, VBHC might more appropriately be termed "values-based healthcare." This reflects our belief that a healthcare system should meet the needs and desires of its population and contribute to overall wellness. We therefore developed a framework based on the dimensions of quality, the Quadruple Aim and feasibility considerations, which enables us to assess and measure our system activities and initiatives to determine if they are in keeping with VBHC in the Alberta context. Copyright Â© 2020 Longwoods Publishing.
MARATT, J.K., et al, 2019. Measures Used to Assess the Impact of Interventions to Reduce Low-Value Care: a Systematic Review. Journal of General Internal Medicine, 34(9), pp. 1857-1864.
An evidence review was conducted to characterize measures used to assess interventions to reduce low-value care. A total of 1805 studies were identified, of which 101 published and 16 ongoing studies were included. Most published studies focused on reductions in utilization rather than on clinically meaningful measures (e.g., improvements in appropriateness, patient-reported outcomes) or unintended consequences. Investigators should systematically incorporate more clinically meaningful measures into their study designs, and sponsors should develop standardized guidance for the evaluation of interventions to reduce low-value care.
MCCAUGHEY D., et al, 2019. The Quest for Value in Canadian Healthcare: The Applied Value in Healthcare Framework. HealthcarePapers, 18(4), pp. 48-57. "Translating value-based healthcare (VBHC) into a framework that can be effectively utilized in the Canadian system remains a challenge. To address this challenge, we propose that VBHC can be adapted to fit the Canadian healthcare system through (1) visionary leadership for and conceptualization of VBHC at the federal government level and (2) thoughtful application of VBHC at the provincial government level. Our applied value in healthcare framework serves as a platform from which VBHC initiatives, programs and outcome measures can be systematically organized and executed within provincial healthcare systems. This methodical approach could support both provincial ministries and their health systems in pursuit of VBHC and provide the basis for explicit measurement of VBHC success, thereby helping to address the pressing issue of sustainability of the Canadian healthcare system while optimizing patient-centred outcomes of care."
NHS Improvement, Transforming patient-level costing in the NHS
The costing transformation programme aims to improve the quality of costing information in the NHS, with patient-level costing (PLICS) and a single annual cost collection. This will support providers to deliver better, more efficient outcomes.
To support the sustainable delivery of high quality patient care as outlined in the Five Year Forward View providers need to fully understand their current models of care and what the impact would be of moving to a new way of delivering services.
Cost is an important factor in evaluating how effectively and efficiently you're delivering care to patients. Having accurate, consistent, patient-level cost information will help you to:
- make the best possible use of resources
- evaluate clinical practice
- compare different ways of working
Link available to sign up to the programme newsletter.
NHS England - In this update of the NHS Five year plan the section on funding and efficiency provides a 10 point efficiency plan:
- Free up 2000 to 3000 hospital beds (reduction of delayed transfers)
- Further clamp down on temporary staffing costs and improve productivity
- Use the NHS' procurement clout
- Get best value out of medicines and pharmacy
- Reduce avoidable demand and meet demand more appropriately
- Reduce unwanted variation in clinical quality and efficiency (Getting it Right First Time)
- Estates, infrastructure, capital, and clinical support services
- Cut the costs of corporate services and administration
- Collect income the NHS owed
- Financial accountability and discipline for all trusts and CCGs.
To read more click here
NICE Cost Saving and Resource Planning
A guide to cost saving, and how to establish the costs of guidance. This replaces the previously known NICE "Do not Do" database.
OECD: Tackling wasteful spending on Health, 2017
PARKER, G., et al, 2019. Active change interventions to de-implement low-value healthcare practices: a scoping review protocol. BMJ Open, 9(3), pp. e027370.
“The purpose of this scoping review is to identify and characterise studies of active change interventions designed to reduce or eliminate low-value healthcare practices. The results can provide guidance and direction for future research in de-implementation.”
SEIXAS, B.V., et al, 2019. Assessing value in health care: using an interpretive classification system to understand existing practices based on a systematic review. BMC Health Services Research, 19(1), pp. 560.
Implementing adequate strategies to assess the value of health services plays a central role in the effort to deal with the financial pressures faced by health care systems worldwide. This study aimed to understand which approaches to value assessment have been used in developed countries. A rapid review and a gray literature search identified value assessment frameworks. One thousand one hundred seventy-six references were identified and 38 papers were selected for full-review. Among these 38 articles, 22 distinct approaches to assess value of health care interventions were identified and classified according to four points: 1) use of single or multiple considerations to base value estimates; 2) use of disease-specific or generic criteria; 3) reliance on process-based or outcomes-based consideration; and 4) type of input and evidence considered. The contextual nature of value assessment in health care becomes evident with the diversity of existing approaches. Despite most cases relying on the Incremental cost-effectiveness ratio as the measure of value, this approach has not met the needs of decision-makers. The use of multiple criteria has become more important, as well as patient-reported measures. Considerations of costs are not always explicit and consistent.
TEISBERG, E., et al, 2020. Defining and Implementing Value-Based Health Care: A Strategic Framework. Academic Medicine, 95(5), pp. 682-685.
The team measures the health outcomes and costs of its care for each patient and uses that information to drive ongoing improvements. Care provided in this way aligns delivery with how patients experience their health and reconnects clinicians to their purpose as healers. It also asks physicians to think differently about their role within the larger care team and about the services that team provides. The authors suggest medical schools should incorporate education on the principles and implementation of value-based health care throughout the undergraduate medical curriculum to prepare their graduates to lead the transformation to value-based health care as they enter the physician workforce.
OECD: Tackling wasteful spending on Health, 2017