A recent copy of The New England Journal of Medicine leads with an editorial from Michael E. Porter, PhD, of the Harvard Business School, entitled “What Is Value in Health Care?” It is a thoughtful perspective on how we physicians, ultimately responsible for improving our patients' health and well being, need to rethink the manner in which we take measurement of ourselves. The article is well worth reading, and I recommend it so that you may formulate your own thoughts, but here are some reflections I’d like to share.
Porter starts with the commonly used definition of value as outcomes/cost, but explores with greater precision what outcomes and costs really mean. For complex diseases, no single outcome by itself can measure value, and he divides outcomes into three tiers. The first tier for oncology encompasses survival, freedom from disease, and improved quality of life; metrics that we are all familiar with since these are standard ways of measuring outcomes in cancer clinical trials. The second tier of outcome measures evaluates efficiency and toxicities of care delivery, such as time to diagnosis and start of treatment, ineffective diagnostic steps or care and side effects of treatments such as emesis or febrile neutropenia. The third tier evaluates the sustainability of health and long-term consequences of treatment, what we think of as survivorship.
On the cost side, Porter emphasizes the need to consider both the total cost of an episode of care as well as the longitudinal costs over time. This requires capturing the costs across multiple medical specialties and care delivery settings. Integrated health care delivery systems or their less efficient surrogate, accountable care organizations, rise to the occasion here. It is hard for me to see how we will achieve value in health care without learning how to integrate both information systems and providers across the spectrum of patient care. Porter writes, “The current organizational structure and information systems of health care delivery make it challenging to measure (and deliver) value. Thus, most providers fail to do so. Providers tend to measure only what they directly control in a particular intervention and what is easily measured, rather than what matters for outcomes.”
Societies such as ASCO spend considerable time and effort writing evidence-based guidelines. Adherence rates to guidelines are an attractive way to measure quality, but because guideline adherence does not by itself guarantee improved outcomes, there is a danger in assuming that fidelity to guidelines is synonymous with quality care. Guidelines and QOPI measures typically address an aspect of process of care rather than an outcome measure. If a chain is only as strong as its weakest link, then we can only safely assume that process-of-care measurement evaluates quality improvement if we measure every step of a workflow process. Porter states, “There is no substitute for measuring actual outcomes, whose principal purpose is not comparing providers but enabling innovations in care. Without such a feedback loop, providers lack the requisite information for learning and improving.” A rapid learning healthcare system, where every patient’s experience is used to create knowledge, stimulate research, and inform health care is dependent on outcomes measurement.
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