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Samen Waarde CreërenJan A Hazelzet, MD PhD

CMIO and Professor Health Care Quality & Outcome

j.a.hazelzet@erasmusmc.nl

@janhazelzet

Van: ”What’s the matter”, naar: “What matters to you”.

Jan A Hazelzet, MD PhDCMIO and Professor Health Care Quality & Outcome

j.a.hazelzet@erasmusmc.nl

@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