Skip to 0 minutes and 18 seconds What is value in healthcare? Value in health care, I think we can look at it from three perspectives. As a professional obligation, from one perspective, as a general conceptual approach, and then these sort of specific measures that are used technically to define value, for example by agencies like NICE in the United Kingdom. So I really like the Institute for Health care Improvement approach to health improvement and then care improvement and value as the three aims of health care overall, with a real emphasis on the fact that value is part of our job. it’s not something that we can it’s not that we can blame the managers for the fact that there isn’t enough money.
Skip to 1 minute and 8 seconds It is a professional obligation for us to think about the relationship between cost and benefit for patients because there are scarce resources to go around. If we squander those resources on treatments that have a relatively low value in comparisons to other treatments, then we are effectively depriving some of our patients of those treatments. I think that’s an important overriding framework to think of this in terms of if you’re in for the standard textbook standard definition of value, it’s outcomes per pound or outcomes per door. So it’s what you can achieve for a patient for a given cost. And an important element of thinking about that is it is very, very difficult to define value in small silos of health care.
Skip to 1 minute and 53 seconds So if you think about anaesthesia and the theatre environment, it’s really difficult to work out the incremental benefit of any particular drug for a particular price. And so a lot of the thought of using this, Michael Porter, in particular emphasised looking at value across the whole pathway. So from a patient’s perspective, they have an illness that they want to get treated that has an outcome and then there’s a total cost to that whole pathway and that may involve primary care physicians, surgeons, anaesthetists, geriatricians and all sorts of different specialists.
Skip to 2 minutes and 25 seconds But the cost is what’s spread across the pathway and can only be essentially considered in that way because otherwise effectively you have different players in that space almost competing with each other. And often our health systems are not set up in that way. So that’s a challenge for us looking forward.
Skip to 2 minutes and 45 seconds How do you measure value? There are a variety of different measures but probably the gold standard in respect of health care in the United Kingdom is something known as the “incremental cost effectiveness ratio.” And that’s best conceptualised using a simple diagram where you have outcome on the horizontal axis, cost on the vertical axis. And you can see that in the bottom right hand corner outcome is improved and the cost is diminished. So that’s gotta to be a good thing. So that’s straightforward. That’s a win. And conversely in the top left hand corner costs are increased and outcomes are worse. So that’s a clear don’t go there don’t do it.
Skip to 3 minutes and 24 seconds And then the other two quadrants are areas in which there’s a degree of uncertainty. Either you’ve got an excess cost but also an excess benefit or a diminished cost with a diminished benefit. But maybe the relative relationship between those two means that in comparison with another intervention this thing is worth doing. So you can draw a line across those two quadrants, above or below which you will decide to do or not do, whatever your intervention is. And the grading to that line effectively depends on how much money you’ve got available. So, for example, NICE have a standard, not officially published, but a standard said to be around 30,000 pounds per quality-adjusted life year.
Skip to 4 minutes and 6 seconds So if your treatment, your intervention comes in under that cost, then it’s probably something we should do when compared with other interventions. And if it comes in over that, you’d need to have a pretty good reason to explain why you would need to do it because it doesn’t look as though it meets the value criteria.
Skip to 4 minutes and 25 seconds What are the problems with the current perioperative care pathway? So if we look at the current perioperative care pathway– this is characterising a little bit but I think it’s probably typical of many hospitals in the United Kingdom– a patient encounters a surgeon and they’ve been referred by a GP. They may have come up to a specialist clinic and had a cystoscopy or colonoscopy and something identified that looks like it might need surgery. They go and meet the surgeon and then they undergo a whole sequence of different tests. Maybe it’s a malignant process, the tumour needs to be staged or the joint needs to be evaluated.
Skip to 4 minutes and 59 seconds And at the end of that– and typically a very short time, maybe days or a week or so before surgery– they’ll meet an anaesthetist and their risk will be evaluated in various other processes will be gone through. And at that point, we’ve missed the opportunity to do many things. So we tell the patient that they’re at high risk of harm following surgery. There’s very little we can do. Probably the best we can do is delay surgery and that’s going to upset them, it’s going to upset the surgeon, it’s going to upset the institutional processes. And if there’s anything that we could have changed, it’s usually a bit late to change it.
Skip to 5 minutes and 37 seconds How would you redesign the perioperative care pathway? So one way of adding value to the perioperative pathway is to re-engineer or redesign it. So move that moment when the anaesthetist and the patient encounter each other much earlier in the pathway. And in order to do that, we need to somehow get some basic information from patients early on. And so many people are thinking about using electronic screening methods to get the core data for risk stratification. Dividing patients into different groups. So very clearly, low risk patients would go straight through the current normal process or maybe even bypass pre-assessment.
Skip to 6 minutes and 15 seconds Moderate risk patients that would go along a standard pathway and high-risk patients that would immediately be devoted to a specialist high-risk clinic and probably undergo specialist tests such as cardiopulmonary excise testing. But the advantage of having that information early is that we can both that we can evaluate the patient alongside evaluating the pathology. And so when a decision is made about whether to have surgery or not, both sets of information are available and we can weigh the harms and benefits together, rather than having a more typical current situation where basically the harms of not having the surgery are the only thing on the table so it seems like a good idea to operate so we go ahead.
Skip to 6 minutes and 51 seconds And then the die is set so the patient thinks they’re going to have an operation, it’s very distressing to then have that all unravelled and backtracked upon. So the first opportunity it presents is better opportunity for collaborative decision-making and for better decision-making. And therefore potentially avoiding some patients having surgery. And the value proposition in that is very clear in that it’s a better outcome for that patient but it’s also a better outcome for the health system because those patients are likely to be in the highest risk groups, therefore most likely to have complications, and be a resource burden on the system. So that’s a win-win for everyone.
Skip to 7 minutes and 29 seconds The additional advantages of being able to get in early in the pathway are that we have opportunities to modify the modifiable risk factors. So In particular lifestyle factors and comorbidities. So on the comorbity side, one might think about preoperative anaemia clinics. If you’ve got six, seven, eight weeks, there’s plenty of time to evaluate anaemia, think about haematinics, even think about a specialist referral. And there are several examples of services that have been set up that have been highly effective in that respect. And then the other opportunity is the potential to modify lifestyle. So, smoking, drinking, activity and exercise, nutrition, and weight loss. And all of those are potentially amenable to change over a time frame of a few weeks.
Skip to 8 minutes and 15 seconds And there are a number of studies now around the country further developing the smoking and alcohol cessation literature and some really intriguing so-called prehabilitation studies looking at exercise interventions prior to surgery. And I think all those opportunities are opened up by this redesign of the pathway whereby we meet the patients earlier so we can evaluate earlier, and then we can both make the right decision about surgery and intervene when necessary before surgery.
Skip to 8 minutes and 43 seconds How else can you add value in practice?So I think I’m going to build on the examples we’ve talked about. The anaemia committee is a really good one to think about because in common with most preoperative interventions the primary aim is to present the patient for surgery in a better physical state so they’re more resilient. But that can be quite a difficult business case to make. The numbers of people that you have to study to demonstrate that you can reduce medical stay can be quite challenging with all sorts of noise in the system. One of the beauties of the anaemia clinic is that there’s a clear cost reduction in terms of the avoided transfusions.
Skip to 9 minutes and 22 seconds Most places have found that irrespective of the benefit for the patient separate from that, the cost of what is typically a virtual anaemia clinics a pathway that’s set up, a set of testing, often done by the general practitioner. And then essentially an automatic set of processes unless something abnormal, very abnormal comes up. So that ought to pay for itself simply, more than pay for itself simply by the reduction in perioperative transfusions which themselves have a cost somewhere between 100 and 130, 140 pounds depending on the institution.
Skip to 9 minutes and 57 seconds I guess if we look beyond the preoperative pathway, there are opportunities probably less well-investigated but opportunities to improve value in the postoperative setting probably around the use of postoperative care teams and better implementation of postoperative care pathways. And even beyond that in the phase where patients are leaving hospital and going home in terms of optimising medications. Straightforward things like ensuring that they’re still on the medicines that they should be on. They’re not on medicines that now should be stopped because they re no longer relevant because of the surgery. And reinforcing the messages around quality– of lifestyle improvements. So exercise, activity, alcohol cessation, smoking cessation, for example because I think we have good reason to believe this teachable moment before surgery.
Skip to 10 minutes and 48 seconds So you can alter behaviour certainly in that interval. But I think also reason to speculate that that may be a participant in long-term changes in behaviour. If we can just reinforce that on the way out of hospital as people return to their normal life. We may be able to just give them the additional nudge that it needs for a long term change in behaviour and therefore potentially a longer term public health impact on life expectancy.
Skip to 11 minutes and 15 seconds How would you summarise Perioperative medicine: the value proposition So summarising perioperative medicine and the value proposition, the big question I think number one is that we currently have in terms of a business metaphor that we have this driver for change in terms of a burning platform of increasing burdens and ageing, population with multi-mobility, lots of innovation coming along with potentially increased cost but only yet we’re tightly cost-constrained so the annual health care budget is decreasing. And that’s going to be a problem for us. But it’s also potentially an opportunity and a catalyst for change.
Skip to 11 minutes and 54 seconds And I think if we look across the whole perioperative pathway, the obvious areas where people are already doing this in quite a number of centres are in the preoperative pathway. So a redesign of the pathway with really early identification of patients who are at risk, modification of comorbidities, modification of lifestyle factors, a whole host of things like anaemia and the like. I think it’s probably less culturally appealing to us as anaesthetists but improving the standardisation of intraoperative practise This is going to be really important. It’s important. And we either know how to do something well or we don’t. And if we know how to do it well, we probably should all be doing it in a roughly similar way.
Skip to 12 minutes and 40 seconds Most of those centres and groups that I visit and work with, the teams that are really good tend to have aligned around a single approach for that team. So the colorectal anaesthetists have all agreed that they will do it in one particular way. And I think that standardisation piece is very important. And it’s also important for quality improvement. You can’t– practise is chaotic. You can’t identify the good bits and the bad bits. So we’re at least trying to play into a recipe that we’ve all agreed then you can see where the outliers are, where we’re not meeting the goals that we’ve set ourselves. And then I think in the postoperative phase, careful use of postoperative critical care.
Skip to 13 minutes and 17 seconds So it’s a limited resource, making sure we send the right patients there and keep them there long enough but not too long. And we rapidly identify those patients that we don’t send, and avoid the failure to rescue scenario. That, in turn, probably means this idea of perioperative and postoperative care teams. And then following through on that into the discharging and the post-discharge phase in terms of management of pharmacology, reinforcement of the health care messages. And the whole thing that we need to wrap all of that up in is the data and quality improvement piece.
Skip to 13 minutes and 54 seconds So making sure we actually can reliably record what we’re doing and we’re in a position to go back and review it and reflect on where we might improve. We can compare it with other people’s practise and outcomes and see how they might be doing it better or maybe not as well. And then reassure ourselves. I think that data quality improvement piece is absolutely critical to all of this.
Resource management and perioperative medicine as the value proposition
In this extended video Professor Mike Grocott discusses value in healthcare and how a streamlined perioperative service could save money for institutions as well as improve care for patients.
From watching the video, take a moment to consider the following key points about maximising value in clinical practice:
Avoid “wrong for the patient” surgery
Ensure patients undergo surgery in the best possible condition through minimisation of surgical risk and shortening recovery time: early risk stratification of patients, dedicated “high risk surgery” clinics, normal (moderate risk) early preoperative assessment, by pass of pre-assessment clinic for those patients at lowest risk (with educational support from Fit 4 Surgery school)
Risk based interventions to minimise postoperative complications and reduce recovery time (length of stay)
Early specialist input to manage chronic health and acute illness (e.g. anaemia clinic)
Personalised intraoperative pathways
Optimise the use of critical care beds
Continue post critical care follow-up (in-hospital) by the perioperative medicine team to shorten recovery times
Minimise inappropriate re-admissions through post-discharge telephone (patients help-line) follow-up and care signposting
Continue data collection, service evaluation and audit to inform service development and improvement
In the following steps we will conclude the course by looking ahead to what the future holds for perioperative medicine.
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