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Não se Aplica The management of Health Systems, whether public or private, faces challenges in different realities around the planet. The main challenges are related to sustainability, rising costs and accessibility. Porter et al. (2006) were pioneers in studies to understand why the competitiveness and technological development that accelerated the growth and accessibility of other markets did not present the same benefit in health markets and systems, especially in the private market such as the USA (United States of America), abundant in technology and financial resources. From this investigation, Porter et al. (2006) found that the current zero-sum competition relationships and cost pass-throughs between market actors are not focused on generating value for the user, but mainly on their profitability. Based on this criticism, they created a proposal for a health model based on competition for the generation of value to the end user, and that the generation of this value would be, in short, an equation that produces the best quality related to clinical outcomes and user experience with the rational use of the necessary resources. In other words, the most efficient actors in generating Value to the user would be more competitive and better remunerated in this new model. However, unlike the industry, which has production and logistics processes with less variability, health systems are affected by different cultures, political models, legislation, economic models, social and genetic characteristics of each population. This makes the creation of solutions for these internally and externally heterogeneous systems more complex. Despite the greater complexity of health systems and markets in relation to other markets and industries, the Lean Philosophy originated in the post-War reconstruction of the Japanese automobile industry was successfully adapted to optimize different work processes related to health services, this adaptation being described in the literature most often as Lean HealthCare. This systematic review investigated different Lean initiatives applied in health care and found evidence that the complex challenge of structuring Value-based health systems can through Lean HealthCare, a management philosophy that contains the necessary tools for continuous process optimization and cost reduction, efficiently operationalize these systems, despite their complexity and variability between different population groups and/or pathologies. The findings demonstrate, with statistical significance, that more than 50% of the studies related to Lean HealthCare resulted in the generation of value through one or more components of this equation. This study finds evidence to justify the investment in Lean initiatives in order to organize the different processes in complex health systems and optimize the results of the Value equation. New studies that prospectively evaluate the results of these Lean initiatives, as well as the inter-influence of the quality and cost components of the equation, can provide more robust data and new operational strategies to generate more sustainable and value-capable health systems. A gestão de Sistemas de Saúde, sejam estes públicos ou privados, enfrenta desafios em diferentes realidades ao redor do planeta. Os principais desafios estão relacionados à sustentabilidade, custos crescentes e acessibilidade. Porter e colaboradores (2006) foram pioneiros nos estudos para compreender por que a competitividade e desenvolvimento tecnológico, que acelerou crescimento e acessibilidade de outros mercados, não apresentou o mesmo benefício nos mercados e sistemas de saúde, principalmente no mercado privado, como dos Estado Unidos da América (EUA), abundante em tecnologia e recursos financeiros. A partir desta investigação, Porter e colaboradores (2006) descobriram que as relações vigentes de competição de soma zero e repasses de custos entre atores do mercado não estão focadas na geração de valor para o usuário, mas principalmente em suas rentabilidades. A partir desta crítica, criaram uma proposta de modelo de saúde baseada em competição pela geração de valor ao usuário final, e que a geração deste valor seria, em síntese, uma equação que produza a melhor qualidade relacionada aos desfechos clínicos e experiência do usuário, com uso racional dos recursos necessários. Ou seja, os atores mais eficientes na geração de valor ao usuário seriam mais competitivos e mais bem remunerados neste novo modelo. Entretanto, diferentemente da indústria que possui processos de produção e logística com menor variabilidade, os sistemas de saúde são afetados por diferentes culturas, modelos políticos, legislações, modelos econômicos, características sociais e genéticas de cada população. Isso torna mais complexa a criação de soluções para estes sistemas tão heterogêneos interna e externamente. Apesar da maior complexidade dos sistemas e mercados de saúde em relação aos demais mercados e indústrias, a filosofia Lean, originada na reconstrução da indústria automobilística japonesa pós-Guerra, foi adaptada com sucesso para otimizar diferentes processos de trabalho relacionados aos serviços de saúde, sendo esta adaptação descrita na literatura mais frequentemente como Lean HealthCare. Esta revisão sistemática investigou diferentes inciativas Lean aplicadas na assistência à saúde e encontrou evidências de que o complexo desafio de estruturação de sistemas de saúde baseados em Valor pode, através do Lean HealthCare, uma filosofia de gestão que contém as ferramentas necessárias para otimização contínua dos processos e redução de custos, operacionalizar de forma eficiente estes sistemas, apesar de sua complexidade e variabilidade entre diferentes grupos populacionais e/ou patologias. Os achados demonstram, com significância estatística, que mais de 50% dos estudos relacionados ao Lean HealthCare resultaram na geração de valor através de um ou mais componentes desta equação. Este estudo encontra evidências para justificar o investimento em iniciativas Lean com o intuito de organizar os diferentes processos nos complexos sistemas de saúde e otimizar os resultados da equação de Valor. Novos estudos que avaliem prospectivamente os resultados destas iniciativas Lean, bem como a interinfluência dos componentes de qualidade e custos da equação, podem fornecer dados mais robustos e novas estratégias operacionais para geração de sistemas de saúde mais sustentáveis e capazes de gerar valor.

Background: Maternal and neonatal mortality rates in many low- and middle-income countries (LMICs) are still far above the targets of Sustainable Development Goal (SDG) 3. Value-based healthcare (VBHC) could potentially surpass traditional input-oriented approaches to create a high-quality health system and to improve maternal, newborn and child health (MNCH) outcomes. This paper describes the implementation of VBHC in urban and rural Kenya with the aim to significantly improve MNCH outcomes.Methods: We developed a theory of change (ToC) and used an incremental cohort-based implementation approach to create short and long learning cycles along which different components of the VBHC framework were introduced and evaluated. We sought to leverage local resources and used a mobile phone-based platform to support pregnant women and MNCH providers throughout the patient journey, using the system for communication, payment and data collection. We created dashboards and used interviews and focus group discussions to gather feedback and to collect the data to describe the implementation process in this paper.Results: We implemented all elements of VBHC, starting small and expanding cohort by cohort. Short and long learning cycles between cohorts enabled implementation of the framework in a relatively short time frame. Data on outputs and outcomes show that the VBHC framework had impact on three levels: Mothers’ improved adherence to maternal healthcare, incentivizing providers to improve quality of care, and transparency of outcomes and costs. This paper describes the implementation process and while the evaluation of health outcomes is ongoing, first results show improved adherence to evidence-based care pathways at a low cost per enrolled person.Conclusion: This study has shown that implementation of the VBHC framework in an LMIC setting is possible with some adaptations to the local context. The incremental, cohort-based approach enabled an iterative learning process, which could support the restructuring of health systems in low resource settings going from a supply-driven model to a value-driven model.Trial registration: Not applicable

Value based Healthcare (VBHC) focuses on patient centered outcomes, by incorporating Patient Reported Outcome Measures (PROMS). Expectations on the benefits of VBHC are high, but few data are available that validate its routine use. We wanted to investigate if VBHC is feasible and beneficial for lung cancer patients in clinical practice. METHOD We developed a digital transmural care pathway for lung cancer patients. During systemic therapy, patients digitally reported side effects weekly. Every six weeks, quality of life was reported trough EORTC questionnaires. Case-mix variables, treatment approaches and outcome indicators were systematically collected. We evaluated the compliance of the patients with the digitally reporting system and the impact of the care pathway on patient centered outcomes such as emergency department (ED) visits, time spent on the oncology day clinic, survival and quality of death. RESULTS 221 lung cancer patients were included in the care pathway. 3091 weekly questionnaires were digitally collected. Compliance with the weekly digital follow-up was 92%: 2835 of 3091 questionnaires were completed. Patients in the care pathway had significantly less ED visits (3.5% vs 4.8%, p 0.04) and a shorter length of stay at the day clinic (2.5 h vs 4.1 h, p

SUMMARYValue-based healthcare holds great potential to transform healthcare globally. This commentary reviews the historical milestones in its evolution and raises critical questions regarding how it should proceed.

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.

Background. With rising healthcare costs, there is a need to transform healthcare financing to provide better care value and sustainability. Healthcare providers and consumers need to be educated about value-based care and financing. This can be done through games. Intervention & Methods. We describe the design of our board game Health$en$eTM which aims to let players simulate the role of funding patients’ care as the patients move across the care value chain. In the game, players will learn how certain care funding innovations help to optimize healthcare expenditure for better value. Discussion & Conclusion. We envisage that some game elements of Health$en$eTM may motivate players to transform healthcare financing systems in the real world. We formulate a matrix to predict the possible associations between game elements and psychological core drives relevant to Health$en$eTM. Further analysis of the game’s potential impact and validation of the matrix could be conducted in due course after the game is launched in a workshop.

PurposeNon-functioning pituitary adenomas (NFPA) have a substantial impact on patients’ healthstatus, yet research on the extent of healthcare utilization and costs among these patients isscarce. The objective was to determine healthcare usage, associated costs, and theirdeterminants among patients treated for an NFPA.MethodsIn a cross-sectional study, 167 patients treated for an NFPA completed four validatedquestionnaires. Annual healthcare utilization and associated costs were assessed through themedical consumption questionnaire (MTA iMCQ). In addition, the Leiden Bother and NeedsQuestionnaire for pituitary patients (LBNQ-Pituitary), Short Form-36 (SF-36), and EuroQol(EQ-5D) were administered. Furthermore, age, sex, endocrine status, treatment, and durationof follow-up were extracted from the medical records. Associations were analyzed usinglogistic/linear regression.ResultsAnnual healthcare utilization included: consultation of an endocrinologist (95% of patients),neurosurgeon (14%), and/or ophthalmologist (58%). Fourteen percent of patients had ≥1hospitalization(s) and 11% ≥1 emergency room visit(s). Mean overall annual healthcare costswere € 3040 (SD 6498), highest expenditures included medication (31%), inpatient care(28%), and specialist care (17%). Factors associated with higher healthcare utilization andcosts were greater self-perceived disease bother and need for support, worse mental andphysical health status, younger age, and living alone.ConclusionHealthcare usage and costs among patients treated for an NFPA are substantial and were associated with self-perceived health status, disease bother, and healthcare needs rather thanendocrine status, treatment, or duration of follow-up. These findings suggest that targetedinterventions addressing disease bother and unmet needs in the chronic phase are needed.

Purpose Structured application of patient-reported outcome measures (PROMs) is a key element in Value Based Healthcare. This study aimed to evaluate the feasibility of a broad set of PROMs reflecting similar patient reported health domains as proposed within the International Standard Set of Patient-Centered Outcome Measures After Stroke within the first year after stroke. Methods The study included consecutive stroke patients admitted to inpatient or outpatient specialized rehabilitation. PROMs were administered upon admission, discharge (inpatients only), and at 3, 6, and 12 months. PROMs included: EuroQol 5 Dimensions (EQ-5D), Stroke Impact Scale (SIS), Stroke and Aphasia Quality of Life Scale (SAQOL-39NL), Utrecht Scale for Evaluation of Rehabilitation-Participation (USER-P), Hospital Anxiety and Depression Scale (HADS), and Fatigue Severity Scale (FSS). Feasibility was defined as participation, retention, and response rates. Paired t tests were conducted to analyze their changes over time. Results Of 485 inpatients and 189 outpatients who were invited, 291 (60.0%) and 82 (43.3%) participated, of whom 45 (15.5%) and 7 (8.5%) dropped out before 12 months, respectively. Two hundred seven (71.1%) and 71 (86.6%) of the inpatients and outpatients returned the questionnaires on all or all but one time points, respectively. Between admission and 12 months statistically significant improvements of PROMs addressing general health and quality of life (EQ-5D), psychiatric functioning (HADS), motor functioning (SIS mobility), and social functioning (USER-P, SIS communication) were seen. The SIS memory scale, the SAQOL-39NL and the FSS did not show any changes. Conclusions Participation, retention, and response rates for a comprehensive set of PROMS for stroke in patients in rehabilitation were moderate to good, with clinical improvements seen until 1 year post stroke. The SAQOL-39NL and FSS did not demonstrate changes over time and cannot be recommended for repetitive measurements in this setting. By simplifying the set of questionnaires, participation and response rates may be further enhanced.

To construct a value-based healthcare system for rural Chinese hypertensive patients through an increasing outpatient care reimbursement ratio.This comparative study sampled two similar counties, Dangyang County and Zhijiang County, in Hubei Province of China, as the intervention group and the control group, respectively. The Social Health Insurance Fund of the intervention group budgeted 600 yuan per capita per year to insured patients with third stage hypertension to cover their outpatient expenditures, while the outpatient expenditures of the control group were not covered by its Social Health Insurance Fund. The inpatient expenditure reimbursement policies in both groups were not adjusted during the study. Value improvement in this study was defined as reduction in medical costs and improvement in health outcomes within the pilot healthcare system. A propensity score matching model combined with a difference-in-differences model was used to estimate the changes in medical costs and health outcomes.In total, 1,673 pairs of patients were enrolled into statistical analysis after the propensity score matching. The intervention increased per capita annual outpatient expenditure by 81.2 (+31.8%) yuan (p .05), but decreased the per capita annual inpatient expenditure and total medical expenditure by 475.4 (-40.7%) yuan and 394.2 (-27.7%) yuan, respectively (p .05). Accordingly, the per capita annual total medical expenditure reimbursement decreased by 192.3 (-28.5%) yuan (p .05), and the per capita annual total out-of-pocket expenditure by 201.9 (-29.9%) yuan (p .05). The diastolic blood pressure of the intervention group decreased significantly by 2.9 mmHg (p .05), but no significant change was found in systolic blood pressure and prevalence of hypertension complications (p .05).Increasing the outpatient expenditures, the reimbursement ratio was beneficial to the value of the healthcare system for hypertensive patients. Outpatient care for patients with chronic diseases should be prioritized for rural China and healthcare settings with inadequate health insurance funds.

Background: The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation. Methods, findings and interpretation: This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the health-care value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined.

Value based healthcare (VBHC) aims at improving patient outcomes while optimizing the use of hospitals’ resources among medical personnel, administrations and support services through an evidence-based, collaborative approach.In this paper, we present a blueprint for the implementation of VBHC in hospitals, based on our experience as members of the European University Hospital Alliance (EUHA). The EUHA is a consortium of nine large hospitals in Europe and aims at increasing quality and efficiency of care to ultimately drive better outcomes for patients. The blueprint describes how to prepare hospitals for VBHC implementation, analyses gaps, barriers and facilitators and explores the most effective ways to turn patient pathways to a process that results in high value care. Using a patient centric approach, we identified four core minimum components that must be established as cornerstones and seven organisational enablers to waive the barriers to implementation and ensure sustainability. The blueprint guides through pathway implementation and establishment of key performance indicators in six phases, which hospitals can tailor to their current status on their way to implement VBHC.

Value-based healthcare is a new health-care model in which what is important is value to the patient. Value is a broad term, but in essence, it is the best outcome for the patient per dollar spent. To provide value to the patient, the medical practice should be centered around conditions and care cycles and the results must be measured. We now know that the model we have right now, the fee-for-service model, is not linked to quality of the patient. All around the world, many hospitals and clinics are making the transition to this value-based model. To provide the best for the patient, we must have the best medical evidence to follow. In the following chapter, we will cover a few aspects of value-based healthcare, its reimbursement model, the integrated practice units, and the information technology necessary to implement it.

This review examines axial spondyloarthritis (axSpA) and the wider field of rheumatology through a value-based healthcare (VBHC) lens. VBHC is focused on ensuring patients receive high quality care to improve outcomes and reduce unnecessary costs. There are many opportunities to apply the principles of VBHC in axSpA. These include the appropriate utilization of diagnostic investigations, such as HLA-B27 and magnetic resonance imaging, assessing outcomes meaningful to patients, and optimizing care pathways. Multidisciplinary care may improve value, and reduced specialist review and medication tapering may be appropriate. Increasing the value of the care we provide to patients can occur across domains and directly and indirectly improves patient outcomes. Taking the time to integrate principles of VBHC into our practice will allow us to justifiably gain and maintain access to diagnostic and therapeutic advances for the benefit of all our patients.

ObjectivesWhile the uptake of value-based health care (VBHC) is remarkable, uncertainty prevails regarding the most important actions and practices in establishing a value-based healthcare system. In this paper, we generate expert consensus on the most important aspects of VBHC.DesignThe Delphi technique was used to reach consensus on the most important practices in moving towards a value-based healthcare system.Setting and participantsA Dutch expert panel consisting of nine members participated in a two-round survey.Primary and secondary outcome measuresWe developed 39 initial items based on the pioneering literature on VBHC and recent health policies in the Netherlands. Experts rated the importance of each item on a 4-point Likert scale. Experts could change items or add new ones as they saw fit. We retained items that were rated (very) important by ≥80% of the panel.ResultsAfter two survey rounds, 32 items (72%) were included through expert consensus. Experts unanimously agree on the importance of shared decision-making, with this item uniquely obtaining the maximum score. Experts also reached consensus on the importance of outcome measurements, a focus on medical conditions, and full cycles of care. No consensus was reached on the importance of benchmarking.ConclusionThis paper provides new insight into the most important actions and practices for establishing a value-based healthcare system in the Netherlands. Interestingly, several of our findings contrast with the pioneering literature on VBHC. This raises the question whether VBHC’s widespread international uptake indicates its actual implementation, or rather that the original concept primarily serves as an inspiring idea.

PurposeDecision-makers are looking for innovative approaches to improve patient experience and outcomes with the finite resources available in healthcare. The concept of value-based healthcare has been proposed as one such approach. Since unsafe care hinders patient experience and contributes to waste, the purpose of this paper is to investigate how the value-based approach can help broaden the existing concept of patient safety culture and thus, improve patient safety and healthcare value.Design/methodology/approachIn the arguments, the authors use the triple value model which consists of personal, technical and allocative value. These three aspects together promote healthcare in which the experience of care is improved through the involvement of patients, while also considering the optimal utilisation and allocation of finite healthcare resources.FindingsWhile the idea that patient involvement should be integrated into patient safety culture has already been suggested, there is a lack of emphasis that economic considerations can play an important role as well. Patient safety should be perceived as an investment, thus, relevant questions need to be addressed such as how much resources should be invested into patient safety, how the finite resources should be allocated to maximise health benefits at a population level and how resources should be utilised to get the best cost-benefit ratio.Originality/valueThus far, both the importance of patient safety culture and value-based healthcare have been advocated; this paper emphasizes the need to consider these two approaches together.

EXECUTIVE SUMMARY Value-based initiatives are growing in importance as strategic models of healthcare management, prompting the need for an in-depth exploration of their outcome measures. This systematic review aimed to identify measures that are being used in the application of the value agenda. Multiple electronic databases (PubMed/MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials) were searched. Eligible studies reported various implementations of value-based healthcare initiatives. A qualitative approach was used to analyze their outcome measurements. Outcomes were classified according to a tier-level hierarchy. In a radar chart, we compared literature to cases from Harvard Business Publishing. The value agenda effect reported was described in terms of its impact on each domain of the value equation. A total of 7,195 records were retrieved; 47 studies were included. Forty studies used electronic health record systems for data origin. Only 16 used patient-reported outcome surveys to cover outcome tiers that are important to patients, and 3 reported outcomes to all 6 levels of our outcome measures hierarchy. A considerable proportion of the studies (36%) reported results that contributed to value-based financial outcomes focused on cost savings. However, a gap remains in measuring outcomes that matter to patients. A more complete application of the value agenda by health organizations requires advances in technology and culture change management.

Background Value-Based Health Care (VBHC) is an evolving model of healthcare delivery aimed at achieving better patient outcomes at lower costs to the healthcare provider. The practise of VBHC requires efficient information systems with good reporting capability and subsequent outcome measuring. Information systems within the National Health Service (NHS) are often multiple and not necessarily integrated to one another. We therefore developed a systematic approach to collecting, validating and analysing data from multiple sources and information systems, with the aim of designing and endorsing an automatic system to capture health outcomes data in heart failure to support future VBHC models. Methods A retrospective cohort of heart failure patients with reduced ejection fraction undergoing Implantable Cardioverter Defibrillator (ICD) or Cardiac Resynchronization Therapy (CRT) procedures within a limited geographical area in South London were evaluated. A purpose built database was created to integrate, transform and validate health care data from multiple information systems. Results Validation analysis shows that our implemented methodology has produced a robust dataset. Our limited cohort of 134 patients does not allow for any complex statistical analysis however has identified some important themes related to outcomes and costs. Conclusion We have created a validated database specific to our Trust that can be upscaled locally with ease and transferred to other health diseases. Due to variations in local procedure from one Trust to another, this methodology now requires implementation across multiple sites to understand differences in transformation of data and outcome measuring.

Objective The aim of this work is to investigate the efficiency of the perioperative processing of pedicle screw systems (PSS) prior to and after fusion surgery for conventional systems compared to an innovative value-based system. Methods This literature and application-based evaluation of efficacy compares a single-use PSS to conventional systems which require re-sterilization. The literature review focuses on sterilization factors, perioperative factors and surgical site infection (SSI) with particular consideration of liability, logistics and costs. An economic benefit simulation considers operating room (OR) time savings and resulting costs regarding preoperative OR preparation, intraoperative OR handling and postoperative OR disposal, and sterilization costs. Results According to literature, re-sterilizable surgical instruments shows severe contamination after sterilization and reprocessed pedicle screws foreseen may demonstrate corrosion, contamination, deterioration and damage. In addition to the reprocessing costs, the re-sterilization of devices causes indirect expenses due to surgery delays, cancellations and infection treatments. Economic simulation shows average savings per case of 1.167€ for percutaneous and 983€ for open surgery, and of 21 min OR time for a terminally sterilized PSS. Considering also tray sterilization, the average cost savings amount 1.415€ per case. Conclusions To evaluate the benefits of disposable instruments compared to re-sterilizable systems, process-oriented comparative analyses are required. For the specific setting of spinal fusion surgery, single-use implants and instruments, streamlined instrumentation and optimized operative techniques have the potential to save costs due to significantly decreased expenses for processing, logistics, decreased rates of contaminated instruments, less OR delays, and potentially lower revision and SSI rates.

Background Surgical repair of full-thickness rotator cuff tears in symptomatic patients is known to offer significant benefits. Despite this there remains a lack of universal appreciation that such surgery offers high clinical value, with some commissioners even limiting access to it. The value-based healthcare agenda provides a means to design, deliver and measure the impact of healthcare to a defined segment of patients. The aim of this study was to measure the value of surgically repairing primary symptomatic full-thickness rotator cuff tears when outcomes and costs were assessed over an entire care pathway. Methods A prospective study of patients undergoing rotator cuff tears repair was undertaken. Patients were managed using a standardised integrated care pathway. Subsequent outcomes and costs were measured over the whole care pathway. Outcomes were assessed from both traditional and patient centric re-formatted prisms. Results Significant improvement in clinical outcomes where recognised when assessed from either the traditional or re-formatted prisms. Economic review of this approach revealed the pathway generated a sustainable and notable positive margin. Discussion This study evidences how a well-designed value-based healthcare shoulder approach can be delivered and measured. It demonstrates rotator cuff surgery to be a high value treatment for patients with symptomatic rotator cuff tears.

Introduction In this article, we present the Canadian Dermatology Association’s (CDA) Choosing Wisely Canada (CWC) list of top “Five Things Physicians and Patients Should Question in Dermatology” and the evidence in support of each recommendation. Methods Using a nominal technique, the CDA Working Group and Task Force generated an initial list based on literature review and expert consultation. After several rounds of list refinement via a modified Delphi process, a final list of recommendations was generated. These were approved by the CDA Board of Directors, presented at the CDA 93rd Annual Conference in 2018, and published by CWC in 2019. Results The top five recommendations are as follows: (1) Don’t routinely prescribe antibiotics for bilateral lower leg redness and swelling; (2) Don’t routinely prescribe topical combination corticosteroid/antifungal products; (3) Don’t routinely use topical antibiotics on a surgical wound; (4) Don’t prescribe systemic antifungals without mycological confirmation of dermatophyte infection; and (5) Don’t use oral antibiotics for acne vulgaris for more than 3 months without assessing efficacy. Discussion This list of recommendations aims to encourage both physicians and patients to reevaluate ineffective, yet common, practices in treating dermatologic conditions. These recommendations represent actionable changes in practice, and therefore have considerable potential to enhance value-based care in dermatology. Conclusions This list was developed to identify tangible changes in practice within dermatology that may reduce inefficiencies, prevent potential patient harm, and improve care. Future advocacy work may include updates, feedback obtainment, and patient care handouts, to continue to promote value-based healthcare and best practices.

BackgroundValue-based healthcare (VBHC) argues healthcare needs to be refocused to maximize value creation, defining value as the value quota (VQ) of outcomes important for the patient divided by the cost of the care. Value is central to the VBHC concept but could be an ambiguous term for professionals wanting to adopt the concept in an implementation process. We set out to explore the perception of value amongst different stakeholders who implement VBHC.Methods The perception of value, cost and VBHC was analysed using content analysis of semi-structured interviews from 19 clinicians and non-clinicians involved in implementation of VBHC. In addition, we exemplified the value quota (VQ) with data from a clinical trial to exemplify the possible association between patient reported outcome measurements (Kansas City Cardiomyopathy Questionnaire and the EQ5D ), their perception of care (n=248) and cost. ResultsClinicians described value as a dynamic concept dependent on the patient and the clinical setting, stating that improving outcomes was more important than containing costs. Value for non-clinicians appeared more driven by the interplay between the outcome and cost or resources. The quantitative data suggested a poor association between patients’ perception of value and VQ. ConclusionsOur findings indicate that there is great variation in how different stakeholders (clinicians, non-clinicians) perceive the key concept of value when implementing VBHC. The most dominant influence was the voice of clinicians, focusing on increasing treatment efficacy and improving medical outcomes but having a limited focus on cost and what matters to patients. Moreover, patients’ own perception of value provided during a care period was poorly connected to the calculated value quota. If the concept of value is defined primarly by clinicians’ own assumptions, there is a clear risk that history will simply be repeated and the need for innovation will not be met. A single-minded focus on value” could therefore result in missing the target. The patients’ and non-clinicians’ perception of value must also be integrated with the clinical perception, if VBHC is going to deliver on the promise to increase healthcare efficiency and effectiveness.

If the goal of "value-based healthcare" (VBHC) is to promote health, the shift towards health promotion as fostering resilience of individuals through supportive systems and environments is grounded in the importance of providing value or outcomes that matter to all patients. VBHC puts patients at the centre of healthcare, but critical questions include which patients and what services? Here we explore the importance of life-course considerations of a resilience-based definition of health and consider the role of a broader horizontal and vertical system and individual level integration to attain VBHC for children and families.

The 2015 merger of health authorities in Nova Scotia was aggressive in pursuit of greater value. The goal was to create an integrated, accountable care network across the entire province. Years of pent-up frustration, death by a thousand cuts, declining service and growing expectations merged into a slow, insidious bleeding of support for change. The lessons learned from Nova Scotia are vital to achieving a value-based health system. The article describes some of the barriers to progress and the steps needed to achieve the goal of a value-based healthcare system for Canadians.

Patients, caregivers, providers, provider organizations such as hospitals and provincial government funders each have their perspectives on how and when healthcare should be delivered and have expectations for its quality, convenience and efficiency. These competing viewpoints on the value from healthcare have led many to wonder: what is the path for improving value from healthcare in provinces?

Objectives To describe the implementation and 1-year results of a value-based bariatric surgery program in Brazil. Methods The study was conducted at a private hospital in Sao Paulo, Brazil (Hospital Alemao Oswaldo Cruz). A value-based healthcare program was implemented by designing an episode of care for eligible patients and developing a bundled payment model in which a single payment was made for the bariatric surgery covering the preoperative workup and ending 30 days after discharge. Assessment of outcomes included complication rate, hospital length of stay, intensive care admissions, reoperations, readmissions, and visits to the emergency department in the 30-day postoperative period. The results were compared with real-world evidence retrieved from a Brazilian private insurance database containing information on bariatric procedures performed in similar institutions (benchmark group). Results Eighty-three patients were enrolled in the value-based healthcare program (80.7% women; 18.0% with type 2 diabetes mellitus; 31.0% with high blood pressure). The mean age was 40.9 years, and body mass index was 42.1 kg/m2. The outcomes recorded in the benchmark group versus the value-based healthcare group involved complication rate, 2.6% versus 1.4% (P = 0.69); length of stay, 2.5 versus 2.0 days (P = 0.0001); intensive care admissions, 4.0% versus 1.2% (P = 0.31); emergency care visits, 15.0% versus 6.0% (P = 0.04); and readmissions, 2.3% versus 0 (P = 0.35), with an estimated cost reduction of 7.1%. Conclusions These initial results showed favorable surgical and 30-day outcomes, demonstrating the benefits of a value-based approach for the surgical management of obesity and its comorbidities.

Background Bariatric surgery is the most effective treatment for patients affected by morbid obesity. The Enhanced Recovery After Surgery (ERAS) protocol increases clinical outcomes, but the most recent literature shows incomplete patients’ adherence. This study aims to demonstrate the feasibility of applying a Value-Based Healthcare (VBHC) strategy associated with ERAS to increase patients’ engagement and outcomes. Method A multiprofessional team redesigned the process considering ERAS recommendations and patients’ feedbacks. Outcomes that matter to patients were defined with structured patients’ interviews and collected in the electronic clinical record. Adherence to the pathway and the cost of the cycle of care were measured to demonstrate sustainability. A model was developed to grant its replicability. Results A total of 2.122 patients were included. The lowest adherence to the protocol for a single item was 82%. 74% of excess weight loss; 90% better comorbidities control; 77.5% had no pain after surgery; 61% no postoperative nausea and vomiting. Zero mortality; 1.8% overall morbidity; 0.4% readmission and reoperation rate within 30 days. The average length of stay is 2.1 days. Patient-Reported Outcome Measures (PROMs) documented increased productivity and quality of life. Conclusion Building a caring relationship by a multidisciplinary team, adding patient wellness in a VBHC framework on top of ERAS as a patient-centered approach, increases patients’ engagement and adherence to the pathway of care, resulting in better health outcomes (clinical and PROMs). The Value-Based Model is sustainable and replicable; it represents the prototype for redesigning other pathways and may become a model for other organizations.

Healthcare represents a paramount issue in the current debate around sustainability. Developing sustainable practices within health systems is fundamental not only to guarantee the right of care, but also to enhance the growth of a country. The widespread dissemination of innovation, on the one hand, could represent a way for providing a better service, in terms of quality and access. On the other hand, it is severely undermining the sustainability of health organisations due to high costs and magnitude on existing organisational arrangements. Among the various research strands aimed to identify theoretical framework to face the various challenges, Value-Based Healthcare is largely considered as the blueprint for promoting sustainable management approaches in healthcare. This paradigm stresses the importance to deliver care towards enhanced value for the patient, which could be measured through the ratio between outcomes and costs.

Especially in the US, many are advocating for the incorporation of a value-based system for healthcare delivery including bundled payments for services in an attempt to address escalating healthcare costs. The following proffers the role for digital health solutions to support health and wellness management and the need to develop suitable sustainable business models. However, this approach brings a focus onto comorbidities and chronic conditions, which often need to be addressed or at least better managed before surgery can take place. This opens up the opportunity to examine the potential for digital health solutions such as mobile apps and serious games to provide an enabling or support role for individuals to better manage their chronic conditions. It also brings up the need for better, flexible models to assist health and wellness solution development.

Introducció. La millora de l’adequació de la pràctica clínica fa referència a l’elecció de proves diagnòstiques, tractaments i altres prestacions que, segons l’evidència científica, tenen més beneficis que riscos, un balanç cost-benefici raonable i s’ajusten a les preferències de les persones i de la societat. Aquest procés inclou identificar i eliminar pràctiques de poc valor i promoure aquelles de valor. Objectius 1. Documentar les iniciatives destinades a millorar l’adequació de la pràctica clínica en l’àmbit mundial; 2. Desenvolupar recursos metodològics que permetin avaluar i millorar l’adequació en l’entorn hospitalari i 3. Analitzar la percepció dels professionals sobre les pràctiques de poc valor i sobre les recomanacions per a eliminar aquestes pràctiques. Mètodes. Vam dur a terme cinc estudis. Per a documentar les iniciatives vam fer una revisió de la literatura. Com a nous recursos metodològics vam crear una pàgina web que permet consultar iniciatives per millorar l’adequació de la pràctica clínica i información d’interés. A més, vam desenvolupar una sèrie d’indicadors basats en revisions sistemàtiques per a avaluar l’adequació en dues àrees de l’entorn hospitalari. Finalment, per a aconseguir el tercer objectiu vam realitzar dues enquestes i dos grups focals amb professionals de medicina i infermeria. Resultats. Amb la cerca vam identificar 22 iniciatives de 10 països, incloent-hi Espanya. Fins a juliol de 2015, aquestes iniciatives havien generat 2.940 recomanacions i anàlisis d’adequació procedents principalment de guies de pràctica clínica i majoritàriament de societats científiques. Vam trobar una gran variabilitat en el rigor metodològic per a desenvolupar aquests recursos i garantir que estiguessin basats en la millor evidència científica disponible. A partir d’aquests resultats vam crear el lloc web Dianasalud.com, que inclou una base de dades amb aquestes iniciatives i les seves recomanacions i anàlisis d’adequació. Vam obtenir 18 indicadors aplicables en l’atenció del part a partir de 303 revisions sistemàtiques (6%) i sis indicadors procedents de 149 revisions (4%) en l’atenció de la malaltia arterial perifèrica. En les enquestes vam trobar un alt grau d’acord amb les recomanacions per a reduir pràctiques de poc valor entre professionals de medicina i infermeria (83% i 96%, respectivament). Aquests creuen que hi ha una bona adherència a aquestes recomanacions a l’hospital (90% i 80%) i les consideren útils (70% i 90%). En els grups focals vam identificar com a principals barreres per a reduir pràctiques de poc valor: medicina defensiva, mala gestió de la incertesa i evidència científica contradictòria. Com a facilitadors destaquen el lideratge positiu i el treball en equip. Conclusions. Les iniciatives més conegudes són aquelles que han produït recomanacions per a eliminar pràctiques de poc valor, provinents de societats científiques. Malgrat les seves importants contribucions, la falta d’una metodologia rigorosa i estandarditzada desperta inquietuds i limita la seva implementació. Respecte als dos recursos metodològics desenvolupats, el lloc web contínua actiu i és consultat sovint. Quant als indicadors, la quantitat que se’n podrien formular està limitada per la falta d’evidència sòlida sobre pràctiques de poc valor i que la seva implementació depèn del grau de detall i la qualitat de la informació clínica. A més de l’evidència científica, la millora de l’adequació implica altres aspectes relacionats amb les creences i actituds dels professionals sanitaris, l’entorn hospitalari i la dinàmica del sistema sanitari i de la societat en general. Aquests aspectes s’han de treballar simultàniament i amb la mateixa intensitat amb la qual es busca assegurar que les iniciatives es basen en la millor evidència disponible. Introducción. La mejora de la adecuación de la práctica clínica hace referencia a la elección de pruebas diagnósticas, tratamientos y demás prestaciones que, según la evidencia científica, tienen más beneficios que riesgos, un balance coste-beneficio razonable y se ajustan a las preferencias de las personas y la sociedad. Este proceso incluye identificar y eliminar prácticas de poco valor y promover aquellas de valor. Objetivos. 1. Documentar las iniciativas destinadas a mejorar la adecuación de la práctica clínica a nivel mundial; 2. Desarrollar recursos metodológicos que permitan evaluar y mejorar la adecuación a nivel hospitalario y 3. Analizar la percepción de los profesionales sobre las prácticas de poco valor y sobre recomendaciones para eliminar aquellas prácticas. Métodos. Llevamos a cabo cinco estudios. Para documentar las iniciativas hicimos una revisión de la literatura. Como nuevos recursos metodológicos creamos una página web que permite consultar iniciativas para la mejora de la adecuación de la práctica clínica e información de interés. Además, desarrollamos una serie de indicadores basados en revisiones sistemáticas para evaluar la adecuación en dos áreas del entorno hospitalario. Finalmente, para el tercer objetivo realizamos dos encuestas y dos grupos focales con profesionales de medicina y enfermería. Resultados. Con la búsqueda identificamos 22 iniciativas originarias de 10 países, incluyendo España. Hasta julio de 2015, dichas iniciativas habían generado 2940 recomendaciones y análisis de adecuación procedentes principalmente de guías de práctica clínica y mayoritariamente de sociedades científicas. Encontramos una gran variabilidad en el rigor metodológico para desarrollar estos recursos y garantizar sus bases en la mejor evidencia científica disponible. A partir de éstos resultados creamos la página DianaSalud.com que incluye una base de datos con dichas iniciativas y sus recomendaciones y análisis de adecuación. Obtuvimos 18 indicadores aplicables en la atención del parto a partir de 303 revisiones sistemáticas (6%) y seis indicadores a partir de 149 revisiones (4%) en la atención de la enfermedad arterial periférica. En las encuestas encontramos un alto grado de acuerdo con las recomendaciones para reducir prácticas de poco valor entre profesionales de medicina y enfermería (83% y 96% respectivamente), quienes creen que hay una buena adherencia a dichas recomendaciones en el hospital (90% y 80%) y las consideran útiles (70% y 90%). En los grupos focales identificamos como principales barreras para reducir prácticas de poco valor: medicina defensiva, mala gestión de la incertidumbre y evidencia científica contradictoria. Como facilitadores destacan el liderazgo positivo y el trabajo en equipo. Conclusiones. Las iniciativas más conocidas son aquellas que han producido recomendaciones para eliminar prácticas de poco valor, provenientes de sociedades científicas. Pese a sus importantes contribuciones, la falta de una metodología rigurosa y estandarizada para identificar prácticas de poco valor o generar recomendaciones despierta inquietudes y limita su implementación. Con respecto a los dos recursos metodológicos desarrollados, la página web continua activa y es frecuentemente consultada. En cuanto a los indicadores, observamos que la cantidad que podrían formularse está limitada por la falta de evidencia sólida sobre prácticas de poco valor y que su implementación depende del grado de detalle y la calidad de la información clínica. Además de la evidencia científica, la mejora de la adecuación implica otros aspectos relacionados con las creencias y actitudes de los profesionales sanitarios, el entorno hospitalario y la dinámica del sistema sanitario y de la sociedad en general. Estos aspectos deben trabajarse simultáneamente y con la misma intensidad con la que se busca asegurar que las iniciativas se basan en la mejor evidencia científica disponible. Introduction. Improving the appropriateness of clinical practice refers to the choice of tests, treatments and other interventions that, according to scientific evidence, possess more benefits than risks, a reasonable cost-benefit ratio, and are compatible with the preferences of people and the society. This process includes identifying and eliminating low-value practices and promoting those that are more appropriate. Objectives. 1. to describe the initiatives aimed at improving the appropriateness of clinical practice worldwide; 2. to develop methodological resources that assess and improve appropriateness in the hospital setting; and 3. to analyse the perceptions of health professionals about inappropriate or low-value practices and recommendations to reduce them. Methods. We carried out five studies. To document initiatives of interest, we conducted a literature review. As methodological resources, we developed an open online database for consulting initiatives to improve the appropriateness of clinical practice and other information of interest. We also developed a set of indicators based on systematic reviews to assess appropriateness in two areas of the hospital setting. Finally, to achieve our third objective, we carried out two surveys and two focus groups with doctors and nurses. Results. With the literature review we identified 22 initiatives from 10 countries, including Spain. As of July 2015, these initiatives produced 2,940 outputs in the form of recommendations and appropriateness analyses mainly from clinical practice guidelines and most commonly from scientific societies. We found great variability in the methodological rigor employed to develop these resources and to guarantee that they draw on the best evidence. Based on our search results we created the website DianaHealth.com, which includes a database of the initiatives and their associated recommendations and appropriateness analyses. We obtained 18 indicators applicable on delivery care from 303 systematic reviews (6%) and six indicators on peripheral arterial disease care from 149 reviews (4%). In the surveys, we found a high agreement among doctors and nurses (83% and 96% respectively) with the recommendations for reducing low-value practices. In both groups, professionals believe that there is good adherence to these guidelines in the hospital (90% and 80%) and consider them useful (70% and 90%). In the focus groups we identified defensive medicine, bad management of uncertainty and contradictory scientific evidence as the main barriers to reducing low-value practices. As facilitators, positive leadership and teamwork stand out. Conclusions. The best-known initiatives for improving the appropriateness are those producing recommendations to reduce low-value practices, developed by scientific societies. Despite their important contributions, the lack of a rigorous and standardised methodology for identifying low-value practices or producing recommendations arouses concerns and jeopardises the implementation of their contributions. Regarding the two methodological resources developed in this tehsis work, DianaHealth.com is still active and it is frequently consulted. As for the indicators based on systematic reviews, we found that the number of indicators that could be produced is limited by the lack of solid evidence on low-value practices and their implementation depends on the degree of detail, as well as the quality of clinical information. In addition to employing scientific evidence, improving the appropriateness of clinical practice involves other aspects related to the beliefs and attitudes of healthcare professionals, the hospital environment and the dynamics of the healthcare system and society in general. These aspects should be worked on simultaneously and with the same intensity that should be devoted to ensuring that the initiatives are supported by the best scientific evidence available. Universitat Autònoma de Barcelona. Programa de Doctorat en Metodologia de la Recerca Biomèdica i Salut Pública

Routine pathologic examination of specimens is a common practice with ill-defined value. The present study is the first to investigate the incidence and cost of incidental microscopic lesions in both haemorrhoidectomy and stapled haemorrhoidopexy specimens. Pathological reports of specimens obtained from haemorrhoidectomy and stapled haemorrhoidopexy procedures performed from January 2003 to May 2017 were analysed. Specimens resulting from patients treated for any disease other than haemorrhoids alone were excluded from the study. Unexpected diagnoses in the pathological report were defined as incidental diagnoses. A cost analysis was then performed. In the considered period we performed a total of 3017 procedures complying with our criteria. We found 65 (2.15%) unexpected lesions. Of the incidental diagnosis, 30 (0.99%) altered either the follow-up or the treatment. The incidences of both findings were extremely higher in haemorrhoidectomies specimens (p

Improving the value of care is one of the essential aspects of Value-Based Healthcare (VBHC) model today. VBHC is a new HC delivery model which is centered on patient health outcomes and improvements. There is anecdotal evidence that the use of decision aid tools like dashboards can play a significant role in the successful implementation of VBHC models. However, there has been little or no systematic studies and reviews to establish the extent to which analytics dashboards are used to support patient care in a VBHC delivery context. This paper bridges this knowledge gap through a systematic review of the existing literature on dashboards in the HC domain. Our study reveals dashboard capabilities as an enabling tool for value improvements and provides insight into the design of dashboards. This study concludes by highlighting a few gaps, question, and need for research in the future.