Determining value in contemporary healthcare has always been a matrix of competing and synergistic forces primarily driven by clinical parameters, costs and patients…until recently.
Earlier this year The American Society of Clinical Oncology attempted to unpack and quantify the matrix through the identification of five categories:
- Clinical benefit (as determined by survival),
- Palliation (a significant benefit in patient reported symptoms),
- Treatment-free interval,
and then assign a composite score.
Things are changing. Clinical signposts are becoming more complex and less differentiable and the economic modeling, which accompanies the findings of the clinical signposts, is descending into technical impenetrability enabling the emergence of other more patient-centred mechanisms for determining value.
So, as the oncologists were determining what was right for their cancer patients, the diabetologists were looking to patients to assist in the determination of value.
Patient centredness may amount to no more than a euphemism for clinician led care that incorporates some patient input.
In their recent guidelines The American Diabetes Association and the European Association for the Study of Diabetes acknowledged: clinical benefit might no longer be the primary driver of value; that the scientific evidence could only go so far; that the small variance between glucose-lowering agents, even within well-conducted trials, would be unlikely to result in any differential effect in individual patients. It concluded that a patient-centred focus was as important as clinical outcomes.
This is not new. Engaging patients in the determination of health value has been the core of the patient-centred health movement since its beginnings in 1940.
But it has taken some time to see it enacted in legislation – it wasn’t until 2013 the FDA implemented its plan for incorporating patient centredness in the Prescription Drug User Fee Act.
Nevertheless, there is much evidence that patient preference may still be overridden not just by clinician led decisions. In one study, the percentage of patients who received their preferred colon cancer screening test varied from 81% for colonoscopy (more expensive, more comprehensive and more inconvenient) to 19% for flexible sigmoidoscopy (cheaper, less comprehensive and less inconvenient).
In the UK, NICE guidance in this area is evolving. Recently it has shifted from a focus on the elderly to nursing management in hospitals.
However patient centredness may still amount to no more than a euphemism for clinician led care that incorporates some patient input.
Patients are a heterogeneous group of communities. For patient centredness to take control of its most valuable commodity – itself – it will need to broaden its scope from the individual to focus on a more population based model that includes channels of care (telemedicine, electronic visits), group medicine, medication management (polypharmacy, adherence) and transitions of care (hospital to community, residential to palliative care).
In this way the work of the past 70 years can help shift the value of healthcare from the goods and the providers to the patients and their communities.