can we really “listen to patients’ voices” and “deliver
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Can we really “listen to patients’ voices” and “deliver cost-effective health care”?
Or do these system goals represent uncomfortable bedfellows?
Stirling Bryan, PhD
www.c2e2.ca
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Disclosures and Acknowledgements • I am not aware of any actual or potential conflicts of interest in relation to this
presentation.
• Some of my relevant current activities: – Chair, CADTH’s Health Technology Expert Review Panel – Member, BC’s Health Technology Assessment Committee – Director, VCH’s Centre for Clinical Epidemiology & Evaluation
• Collaborators on these topics – UBC/C2E2/CHEOS: Mohsen Sadatsafavi, Craig Mitton, Nick Bansback, Logan Trenaman, Nitya
Suryaprakash, Ellen Randall – SFU/C2E2: Laurie Goldsmith – TWU/CHEOS: Rick Sawatzky – FHA/VIHA: Valerie MacDonald, Patrick McAllister, Samar Hejazi, Susan Chunick – University of Aberdeen: Graham Scotland, Mandy Ryan – And many, many more…
• Funding – $s: CIHR, MSFHR, BC Rural & Remote Health Research Network, VCH – In-kind: Fraser Health, VCH
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Overview
• Triple Aim health system goals
• Patient-centred care • Efficiency
• Examples: – Shared decision making for joint replacement – Patients’ Experiences of Arthroplasty of the Knee
(PEAK)
Can they be comfortable bedfellows?
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The IHI Triple Aim
Population Health
Per Capita Cost Experience of Care
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The BC Triple Aim + 1
Population Health
Per Capita Cost
Experience of Care
???
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The BC Triple Aim + 1
Population Health
Per Capita Cost
Experience of Care
Experience of Providers
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The IHI Triple Aim
Population Health
Per Capita Cost Experience of Care
Efficiency and cost-
effectiveness
Patient-centred care
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Efficiency is about costs and health outcomes
And, in our continuing effort to minimize surgical costs, I’ll be hitting you over the head
and tearing you open with my bare hands.
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Efficiency is about costs and health outcomes
Sergio et al. Antiviral Therapy 2013; 18:623-633
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Patient-centred care • Most health care system in the developed world
strive to deliver ‘patient-centred care’
• BC Ministry of Health: patient-centred care should be ‘the foundational driver of all strategic actions’
• A core element of patient-centred care is listening to patients’ voices: – patients’ needs/preferences guiding care delivery – consideration of outcomes and experiences valued by
patients
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BC Ministry of Health Patient-Centred Care Framework
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Shared decision making
Listening to patients’ experiential voices
‘Improvements’ guided by
experiential voices
Patients’ Voices in Health Care
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Shared decision making
Listening to patients’ experiential voices
‘Improvements’ guided by
experiential voices
Patients’ Voices in Health Care
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Experiential voice example: Knee replacement surgery
• Total knee arthroplasty (TKA) – TKA is the most common joint replacement
surgery in Canada. – Demand is still increasing, in part due to an
aging population. – The goals of TKA: reduce knee pain and
restore the physical mobility.
• The patient experience – 20% of TKA patients indicate
dissatisfaction. – The underlying problems and solutions are
unclear and under-researched. – In an era of patient-centered care, patient
experience is of primary importance.
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Time Quantitative Measurement
Qualitative Measurement
Baseline (before surgery)
6 months after surgery
Baseline questionnaire
(n=515)
7 months after surgery
12 months after surgery
13-14 months after surgery
7 month in-depth interview
(n=50)
6 month questionnaire
(n=466; 91%)
12 month questionnaire
(n=455; 88%)
13 month in-depth 2nd interview
(n=20)
iterative analyses
iterative analyses
univariate &
bivariate analyses (n=100)
iterative analyses
univariate &
bivariate analyses (n=varies)
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Mean scores over time
Improvement across the board at 6 months
Very little further change, on average, at 12 months
Variable Baseline Mean (SD)
6-month Mean (SD)
12-month Mean (SD)
EQ-5D-Scale (0-100) 69 (18) 78.3 (15) 78.2 (14.5) WOMAC: Pain (0-20) 10 (4) 3.4 (3) 2.9 (3.2) WOMAC: Stiffness (0-8) 4.2 (1.7) 2.1 (1.6) 1.7 (1.5) WOMAC: Physical Function (0-68) 33.8 (12) 13.2 (11.2) 12.4 (11.5) SLANSS 7.0 (6.6) 6.4 (6.9) 5.7 (6.4) HADS: Anxiety (0-21) 5.6 (3.9) 4.0 (3.4) 4.1 (3.6) HADS: Depression (0-21) 4.8 (3.3) 3.1 (3.2) 3.3 (3.1) Social Support 4.1 (1.0)
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Key Qualitative Thematic Results • Patients’ descriptions of their TKA experience primarily
concerned with concept of ‘support’
• Support seen as insufficient when expectations of support not met
• Support expectations formed both: – In advance of their surgery and in response to emergent needs
• Three key domains of support: – Informational support – Clinical support – Personal support
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Example: Pain and Pain Management
• Suggestion of “go to” clinical person to provide support, answering patient questions about pain
• “There is nobody to talk to. You call the surgeon and unless there is a major problem they don’t want to hear from you because all they care about is what the x-ray shows and the x-ray shows perfect. The GPs, they didn’t do the surgery so it’s more pain control: ‘Do you want stronger pain pills?’ I said no. I don’t want to just cover up the symptoms. I need to know what is going on. So I get on the internet and check things but there is nobody to really talk to about the pain, the swelling.”
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PEAK policy/practice implications • Room for improvement in the health care system and
provider behaviour around TKA: – Better preparation, esp. around post-surgical pain – Pain needs to be managed better
• TKA process and the health care system can provide more patient-centred care: – Challenging the boundaries of where the system ends its
relationship with the patient – Patient navigator within health care system – Sharing patient trajectory stories
• Such changes might strengthen PCC but would they also be cost-effective?
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Conclusions … • Listening to patients’ voices and efficiency
considerations: Are they comfortable bedfellows? – In some instances, yes…
e.g., shared decision making and use of decision aids in joint replacement surgery
– But not a given… We need an economics lens on all proposed improvements
• Neither patient-centred care nor efficiency should be a Trump card!
