The need to focus on the value of the individual patient is increasingly receiving attention. Maureen Bisognano, the charismatic Director of the Institute of Healthcare Improvement, advocates that we move from ‘what’s the matter? medicine’ to ‘what matters to you? medicine’.The below illustrates the transformational shift necessary.
What matters to you? medicine’: A patient with mitral valve disease
Mrs X is 86 years old and has mitral valve disease. She receives care from a compassionate and high-quality cardiology and cardiac surgery team who have advised her that a mitral valve operation (open-heart surgery) is the only treatment that will effectively deal with the mitral valve narrowing that has been diagnosed – an example of ‘what’s the matter? medicine’.
When Mrs X was asked what her problem was, however, she expressed concern that she felt tired after two hours of gardening. The key issue in ‘what matters to you? medicine’ is not whether Mrs X has mitral valve disease, but whether cardiac surgery will significantly reduce the level of tiredness she feels after two hours’ gardening, taking into account not only the quality of the intervention, known to be high for this particular service, but also the implications of a considerable period of time in hospital and intensive care for a person 86 years of age.
Professor Al Mulley of Dartmouth University and his colleagues coined the term ‘the silent misdiagnosis’to describe the common situation in which clinicians have accurately diagnosed a disease but failed to identify the patient’s preferences. They argue that not only do decisions need to be based on the best current evidence but also that decision-making needs to be sensitive to the preferences of individual patients. When seeking to explain the causes of unwarranted variation, Wennberg highlighted that patients’ preferences were often either not elicited or, if they were, their preferences would be ignored.
“. . .elective, or ‘preference-sensitive’ care, interventions for which there is more than one option and where the outcomes will differ according to the option used because patients delegate decision making to doctors, physician opinion, rather than patient preference, often determines which treatment patients receive. I argue that this can result in a serious but commonly overlooked medical error: operating on the wrong patients – on those who, were they fully informed, would not have wanted the operation they received”
From the perspective of the patient, the value of the care received is measured not only by the outcome of the care but also by the way it is delivered. The value that patients are prepared to place on the care received will be influenced not only by the outcome but also by what has been termed the burden of treatment, and this requires services to measure outcomes from the perspective of patients as well as clinicians.
When considering costs, economists recognise the importance of capturing costs to patients as well as to providers of care. This has been recognised in the concept of the burden of treatment. Even patients who are appreciative often complain about the number of clinic visits they and their carers have had to make and the demands on their time.
Treatment burden includes the work of developing an understanding of treatments, interacting with others to organize care, attending appointments, taking medications, enacting lifestyle measures, and appraising treatments. Factors that patients reported as increasing treatment burden included:
- too many medications and appointments,
- barriers to accessing services,
- fragmented and poorly organized care,
- lack of continuity, and
- inadequate communication between health professionals.
Again, we see how different perspectives on value are interrelated. As more interventions are carried out in a population, people who are less severely affected are treated. They will get a smaller benefit than those who are severely affected but run the same risk of side effects of the same magnitude. Unfortunately, the probability and size of harm that may occur is the same for people who are severely affected and for people who are less affected and this changing balance can also be illustrated diagrammatically (see below). The diagram below also includes the language that clinicians use to describe this changing balance of good and harm with interventions ranging from Necessary, through Appropriate, then Inappropriate and then Futile.
These are different perspectives, emphasising again that healthcare is the most complex business on earth and the relationship between the population value perspective and the personal value perspective is shown below:
Population healthcare and personal value are not two separate concepts; they are two sides of the same coin.
The OVSP Learning Programme:
This is the fourth of the five modules in our online learning opportunity to help you develop the understanding and skill to:
- Ensure the survival of universal healthcare by increasing value and reducing waste (Module 1)
- Shift the focus from bureaucracies to populations (Module 2)
- Design population based systems and deliver care through networks (Module 3)
- Create a culture of stewardship (Module 4)
- Optimise personal value (Module 5)
As a result of learning from the first module, and from other people learning with you, you will be able:
- To differentiate between ‘personalised’ and ‘precision’ medicine
- To outline the relevance and importance of ‘patient-centred care’, ‘preference-sensitive decision-making’, the ‘silent misdiagnosis’ and ‘shared decision-making’ to the personalisation of care
- To identify the key points of differentiation between the traditional approach to decision-making and the personalised approach to decision-making
- To explain the implications of the recent legal ruling in the UK for professional practice during shared decision-making
- To describe the principles of evidence-based personalised decision-making
- To identify the obstacles to increasing the personalisation of care and how they can be overcome