Personalized Specialty Care: Value-Based Healthcare Frontrunners from the Netherlands

This book highlights the work of pioneers in this field, in order to inspire their peers, healthcare leaders and an interested audience. Prior to the respective care practices, the authors describe the core of personalized care and illustrate its connections to value-driven care and evidence-based medicine. The last part of the book addresses organizational and other conditions under which personalized care can thrive.

In the Netherlands, substantial work is being done on value-driven care and more is currently being discussed. This book focuses on the benefits of value-driven care for patients and healthcare providers alike. To do so, it explores a range of representative cases and scenarios, such as:

Scenario 1: You are able to surgically remove the most difficult tumors and find out one day that you don’t need to do so in all indicated patients. Later you can find out how to recognize when surgery isn’t the best treatment for certain patients. And now your team hasa fixed routine to find the optimal choice together with the patient.

Scenario 2: You consider yourself to be a patient-centered doctor who is really in touch with their patients – until you ask them to report for themselves on how they are doing. In the "patient-reported outcomes" you see that you have completely missed an important aspect. Later, you can structurally integrate this into your outpatient clinic. 

Scenario 3: In line with the planning principles of your hospital, you see chronic patients once a year – and of course also 'as needed' – until your data shows you that you see patients too early or too late, but rarely when it would be most helpful. Later you can discover how to offer your consultation exactly on time – based on early signals and often even before the patient calls the clinic. 

This is what value-driven care is all about: care is of more significance to the patient when it is tailored to his or her unique situation. Recognizingthe patient’s needs, preferences and values, and structurally adapting care accordingly – that is the noble profession of value-driven care, which takes us an important step closer to the ideal of personalized care. 

• Language: English
• Publisher: Springer
• Release date: May 19, 2021
• ISBN: 9783030637460

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© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021

N. van Weert, J. Hazelzet (eds.)Personalized Specialty Carehttps://doi.org/10.1007/978-3-030-63746-0_1

1. Introduction

Nico van Weert¹   and Jan Hazelzet²  

(1)

Society Personalized Health Care, Nijmegen, The Netherlands

(2)

Center for Value Based Health Care, Erasmus University Medical Center, Rotterdam, The Netherlands

Jan Hazelzet

Email: [e-mail]

Abstract

In the Netherlands, there is a lot going on with respect to value-based care [1, 2], and it is being discussed even more [3]. This book is about what it can yield in practice: for the patient and the health-care professional. It is our conviction that the interaction between those two parties is where its value should be demonstrated, and we have chosen practices where this is the case.

Keywords

Value-based Health CarePersonalized CareQuality of CareShared decision-makingOutcome measurementInterprofessional learningPatient participationQuality improvement

Our quality improvement work is primarily guided by outcome measures, especially measures of intended or desired outcomes. This is where our approach distinguishes itself from sheer guideline implementation and safety management, which tends to give primacy to the process of care [4] or the measurement of only the outcomes we try to avoid, i.e., surgical complications and failure to rescue [5]. Intended or desired outcomes can be clinically defined and clinician-reported or can be patient-reported using patient-reported outcome measures (PROMs). This approach is supported well by the Value-Based Health Care model and the internationally developed sets of outcome measures which recognize and operationalize outcome quality as a multidimensional phenomenon [6, 7]. However, we feel quality is not well represented by just the health status after treatment or the improvement compared with health status before treatment. On the contrary, it should start by setting out a treatment goal that is agreed upon in advance. Outcome quality should be defined as the degree to which the intended goal is achieved. This means that, for optimal quality, care must be precisely attuned to the patient as a person. This insight leads to reflections and learnings such as in the following examples.

You have been able to surgically remove the most difficult tumors, but one day you realized that maybe it was not the best course of action for all diagnosed patients. Later you found out how you could recognize the cases for which it is not. Now your team has a fixed routine to arrive at the best solution with the patient.

You used to feel like the people’s doctor, someone who had great communication with patients. But one day you started asking them to talk about how they were doing personally. In the patient-reported outcomes, you noticed that you had completely missed an important part of their everyday functioning. Later you include a structural focus on this aspect in your outpatient clinics.

In keeping with the traditional practice of your profession and the scheduling principles at your hospital, you were seeing your chronic patients once a year—and of course as needed in the meantime. Then you noticed that your data was telling you that you had been seeing your patients too early or too late, but rarely at the time that they would benefit from it the most. Later you discover how to offer the consultation at just the right moment: based on early signals and often before the patient contacts the outpatient clinic themselves.

That is what value-based care is about in practice: the care means more to the patient when it is tailored to their situation. Recognizing the important needs, preferences, and values of patients and structurally tailoring the care to them—that is the noble craft of personalized care. We agree with Gray’s operational definition of personalized care: The clinician’s job is (…) to relate (…) evidence to the unique clinical condition of the patient and to create a context in which the patient can be allowed to reflect on their values, the values they attach to different options that may occur, both good and bad, and the value they place on risk-taking or risk avoidance [8], and add the necessity of good timing of care. Furthermore, Gray et al. correctly see personalized health care as part and parcel of person-centered care [8]. It is a very essential part in our opinion, although until now it has not received the attention it deserves.

This book aims to share the inspiration of the pioneers in this field and the fruits of their labor with professional colleagues, leaders in care, and an interested audience. This is done in the Practices section (Part II) and includes many practical solutions and the use of tools to achieve them, such as a visual prioritization tool for patients to rate diverse treatment goals, which provides a powerful start for a dialog about treatment options. An individual dashboard on health outcomes enables sharing and discussing statuses as well as anticipating patient needs. Visualizing the patient journey and the care pathway allows us to stay organized as a multidisciplinary team. In particular, the model of the metro network, supported by the method Metro Mapping [9], provides clear options for putting an effective shared decision-making into place, designing a comprehensive division of tasks and roles, and creating a consistent information flow. Many other innovations, like e-health and bundled payment, make their contributions to help create personalized medical care, which itself takes center stage in this book.

Before health-care practices (in the Practices section (Part II)), we describe the essence of personalized care and establish a link with value-based care and evidence-based medicine (in the Ideas section (Part I)). The final section (Conditions (Part III)) discusses organizational and other types of conditions that are required for personalized care to flourish.

We are confident that our readers will be enthusiastic and feel supported in finding their own way in personalized care.

References

1.

NFU Kwaliteit | Waardegedreven Zorg. https://​nfukwaliteit.​nl/​programmas/​waardegedreven-zorg/​. Accessed 22 Nov 2020.

2.

VBHC Research Group - Santeon. https://​santeon.​nl/​onze-aanpak/​projecten/​vbhc-onderzoeksgroep/​. Accessed 22 Nov 2020.

3.

Steinmann G, van de Bovenkamp H, de Bont A, Delnoij D. Redefining value: a discourse analysis on value-based health care. BMC Health Serv Res. 2020;20(1):1–13. https://​doi.​org/​10.​1186/​s12913-020-05614-7.Crossref

4.

Wensing M, Grol R. Knowledge translation in health: how implementation science could contribute more. BMC Med. 2019;17(1):1–6. https://​doi.​org/​10.​1186/​s12916-019-1322-9.Crossref

5.

Pronovost PJ, Thompson DA, Holzmueller CG, Lubomski LH, Morlock LL. Defining and measuring patient safety. Crit Care Clin. 2005;21(1):1–19. https://​doi.​org/​10.​1016/​j.​ccc.​2004.​07.​006.CrossrefPubMed

6.

ICHOM | ICHOM Standard Sets | View Our Collection. https://​www.​ichom.​org/​standard-sets/​#methodology. Accessed 22 Nov 2020.

7.

What is QOL? | ISOQOL. https://​www.​isoqol.​org/​what-is-qol/​. Accessed 22 Nov 2020.

8.

Gray M, Gray J, Howick J. Personalised healthcare and population healthcare. J R Soc Med. 2018;111(2):51–6. https://​doi.​org/​10.​1177/​0141076817732523​.CrossrefPubMed

9.

Metro Mapping. www.​metromapping.​org. Accessed 22 Nov 2020.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2021

N. van Weert, J. Hazelzet (eds.)Personalized Specialty Carehttps://doi.org/10.1007/978-3-030-63746-0_2

2. Personalized Health Care as Value-Based Care

Jan Hazelzet¹   and Nico van Weert²

(1)

Center for Value Based Health Care, Erasmus University Medical Center, Rotterdam, The Netherlands

(2)

Society Personalized Health Care, Nijmegen, The Netherlands

Jan Hazelzet (Corresponding author)

Email: [e-mail]

The value of care is primarily related to the consultation room and not to a market of supply and demand.

The severity of symptoms was found to decrease by using PROMs, and physical function improved.

The inspiring effect that value-based health care has affects everyone, from politicians to insurers, and from healthcare administrators to medical or nursing professionals.

Abstract

I do not understand the way that you treat patients, said a resident to the medical specialist who had just seen two patients with pain in the hip joint. You prescribed heavy pain medication to one, but only some paracetamol to the other even though they have the same symptoms?

However, one played pool several times a week and the other sat at home on the couch. That non-medical difference was one of the factors that led to a different balance between the pros and cons of heavy pain medication in patients who presented with the same symptoms and disorders (Van Bruchem-Visser, personal communication, 28 November 2018).

This sensitivity is fundamental in value-based care: the treatment helps a patient best if it is tailored to their personal needs, preferences, and values. We have to use that as our compass if we want to improve patient experiences and outcomes in health care, as the Dutch university medical centers and others aim to do.

Keywords

Value-based Health CarePersonalized CareQuality of CareShared decision-makingOutcome measurementInterprofessional learningPatient participationQuality improvement

Personalized health care breaks with the idea that good health care is care according to the guidelines. That was the formal policy of the Dutch government just 5 years ago [2]. But there is no such thing as an average patient, and the progression of a disease can vary. Responding to these differences not only justifies variation in care, it also necessitates it. Long live variation, as long as it offers an answer to the personal needs, preferences, and values of the patient.

In other words, the value to the patient is linked to the extent that the health care provided is attuned to their situation. Two years ago, together with opinion leaders from university medical centers using this principle as our foundation, we formulated what the important characteristics of value-based care are. The Board of the Netherlands Federation of University Medical Centers has endorsed this course of action [3]. This approach currently consists of four elements:

1.

The right conversation with the patient.

2.

Collaboration between health-care professionals with different backgrounds and specializations.

3.

An overview of outcomes and costs.

4.

Shared learning to improve health care.

An important difference here with the Value-Based Health Care concept of Porter and Teisberg [4] is that to our opinion the value of care is primarily related to the consultation room and not to a market of supply and demand. To emphasize the importance of individual customization for value creation, we discuss personalized care.

2.1 The Genuine Conversation

The genuine conversation is a metaphor for the continuous adjustment of care to the needs, preferences, and values of the patient [5]. Essentially, it requires that all care is tailored to the person and personal situation of the patient. Carla Bastemeijer et al. have done an extensive content analysis of what patients find important. As far as the health-care provider is concerned, this is professionalism, responsiveness, and compassion, while the patient looks for autonomy and uniqueness; with respect to interactions partnership and empowerment are held in high regard [6]. This clearly shows the tasks in the health-care process.

We see the patient as a partner in health care, with whom the health-care team decides on treatment options.

In 2015, Anne Stiggelbout and her colleagues described the four steps that joint decision-making should consist of [7]. Step 1 is that the health-care provider informs the patient that a decision is to be made and that the patient’s engagement in this process is important. In practice, it is necessary to make a decision more than once. In step 2, the health-care provider explains the options and their pros and cons. Expected clinical and patient-reported outcomes are part of this explanation. In order to make an informed decision, it is important to specifically tailor these prospects to the patient’s situation. Step 3 was then distinguished in a new way: the health-care provider and the patient discuss the patient’s preferences, and the health-care provider supports the patient in the deliberations. Glyn Elwyn and others added the same element to the revised Three-Talk Model based on the terms team talk, option talk, and decision talk. It depicts how the patient’s values play a role in the decision-making regarding treatment [8]. They provide the frame of reference for the assessment of treatment options (see Chap. 4) [9]. Step 4, finally, works toward the actual decision.

Apart from the moment of fundamental treatment decisions, up-to-date information about the patient’s specific situation is also needed during the further care process and decision making. This brings us to the importance of measuring outcomes, patient-reported outcomes in particular.

2.2 Measuring and Discussing Outcomes

The American Institute of Medicine recommends routine outcome measurements in health care based on experiences at Intermountain Healthcare, Kaiser, and other organizations [10]. Porter distinguishes three levels of outcomes [11]. Tier 1 concerns the health status achieved or retained. Tier 2 deals with the process of recovery, in particular the time to recovery and time to return to normal activities, and also the arising complications and inconveniences. The sustainability of health is the subject of tier 3: recurrences and long-term consequences of treatment. He proposes the systematic measurement of outcomes at each of these levels. ICHOM has already published outcome sets for 39 conditions [12]. Dutch specialists contributed extensively to this, and ICHOM ensured the involvement of patients. The sets include both clinical outcome measures (such as blood sugar levels (HbA1c) and the survival of a transplanted kidney) and patient-reported outcomes (PROMs, such as pain, fatigue, physical function, and quality of life). This has led to a development in which we increasingly find it self-evident to routinely follow desired health-care outcomes. The results are then used both in the consultation room and to improve health care. This changes not only what is discussed (outcomes that matter to the patient) but also how it is discussed: the use of PROMs contributes to the creation of the health-care provider–patient relationship [13].

A review by Van Egdom et al. on the use of PROMs shows that participating patients experience benefits themselves. For example, the severity of symptoms was found to decrease compared to groups in which no PROMs were used, and physical function improved [14]. The authors cite a randomized controlled trial with 776 patients in oncology that even found a substantial effect of PROM application on quality of life and survival.

Even if results are not always discussed in the consultation room, they conclude, collecting PROMs has a positive effect. We know, however, that the response will increase further if this does happen: if filling in the PROM contributes to personalization of the treatment, the motivation increases accordingly [15]. Targeted use is further facilitated by reference values that allow the patient to be informed in advance about expected outcomes and during treatment about positive or negative anomalies. Lagendijk et al. already collected reference values for breast cancer in a study among former patients [16]. Moreover, among other items, it turned out that sexual functioning left much to be desired during and after the treatment, which led to adjustments in the health-care pathway.

The latter is an example of the use of outcome data for learning and improvement in health care. If outcome data is now collected by default from all patients with a particular condition, then learning and improving can also be a continuous activity. Cost and process data must be added more often than at present so that continuous learning and improvement can also be about the optimal ratio of results achieved and efforts made (see Chap. 15) [17].

In short, outcome measurements can play a major role in improving health care, both for the patient in the consultation room and for the clinical case. This while the assumed burden for the patient to fill in these questions seems to be not so significant in practice [18].

2.3 Collaboration and Shared Learning

We distinguish two other pillars of value-based health care in the NFU position paper: Interprofessional collaboration and shared learning for better health care. The essence of interprofessional collaboration is that the strengths of multiple care disciplines and professions for the patient are combined into one coherent treatment, including diagnostics, follow-up, and aftercare, by a closely collaborating team and network. Shared learning refers to the joint reflection on outcomes achieved for patients and the improvement thereof by adjusting the process, then measuring and evaluating the outcomes again. Both subjects are discussed in detail in Chap. 19 [19].

2.4 Actively Working on Improvement

In this way, value-based care develops into a tool for optimizing health-care practice based on locally experienced and prioritized problems. The constant ingredients lead to solutions found by the interprofessional team. This seems to contribute to the motivation of health-care professionals to work on value-based care because Our ambition as a physician has always been to improve care for and together with patients, says Fenna van Breda and her colleagues (see Chap. 7) [20]. We see that a growing circle of professionals becomes convinced after going through the first steps and that teams that have mastered learning and improvement based on outcomes are eager to continue (see Chap. 5) [21]. The chapters in the Practices section (Part II) of this book show a variety of achieved solutions for personalized health care. Below we provide an outline of this diversity and refer to the relevant chapters.

When patients experience or find other outcomes more important than previously assumed, a structural adjustment of outpatient care follows (see Chap. 17) [22]. However, what we see more often is that the