The Roadmap for Implementing Value-Based Healthcare in European University Hospitals-Consensus Report and Recommendations

OBJECTIVES

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 article, we present a blueprint for the implementation of VBHC in hospitals, based on our experience as members of the European University Hospital Alliance.

METHODS

The European University Hospital Alliance is a consortium of 9 large hospitals in Europe and aims at increasing the quality and efficiency of care to ultimately drive better outcomes for patients.

RESULTS

The blueprint describes how to prepare hospitals for VBHC implementation; analyzes gaps, barriers, and facilitators; and explores the most effective ways to turn patient pathways into a process that results in high-value care. Using a patient-centric approach, we identified 4 core minimum components that must be established as cornerstones and 7 organizational enablers to waive the barriers to implementation and ensure sustainability.

CONCLUSION

The blueprint guides through pathway implementation and establishment of key performance indicators in 6 phases, which hospitals can tailor to their current status on their way to implement VBHC.

Managing transition to ValueēBased hospital care pathways

Issue

San Raffaele Hospital (OSR) is part of a European alliance of 9 University Hospitals (EUHA) which promotes comparison and excellence in the clinical, research and training strategies.

Description of the Problem

The development of Value-Based (VB) strategies has been active in OSR since March 2019, with multidisciplinary healthcare pathways and with the promotion of patient engagement.

Results

The prostate cancer pathway was identified as a pilot and replicable model to promote the VB culture in different areas, in particular in the field of digitalization, human resources, research, redesigning of paths and outcomes collection. The other clinical pathways progressively launched during 2019 were: breast cancer, stroke, heart failure and pancreatic cancer.

The project was realized by: • setting up a Multidisciplinary disease teams; developing a training course on VB, involving all the healthcare professionals (clinicians and managers);involving patient associations in the development of the pathway;adopting sets of clinical outcomes, Patient-Related Outcome Measures (PROMs) and Patient-Related Experience Measures (PREMs) with a specific collection platform, currently under implementation;identifying new IT support tools, activated from March to December 2019 in 11 Disease Units: HealthMeeting, a platform supporting document and data sharing, connecting different Specialists and performing advanced digital multidisciplinary meetings; DNM-Digital Narrative Medicine, a platform connecting patients with their clinical team, supporting web-based storytelling and personalized therapeutic approach.

Lessons

The introduction of a new shared and patient-centred work model, with the reorganization of spaces, resources and dedicated IT tools, has improved the diagnostic-therapeutic process.

Key messages

The main challenge of hospital transition to VB pathways is organizational and cultural. For VB implementation is needed sustainable use of available resources and IT, to achieve better outcomes.

Narrative medicine in the cancer care: implementation and impact

Issue

National and international health authorities have described Narrative-based medicine (NBM) in clinical practice as a fundamental tool for acquiring, understanding and integrating the different points of view of those involved in the disease and its treatment, promoting more effective and appropriate care.

Description of the problem

The use of NBM is part of the strategic project to improve patient-engagement in San Raffaele Hospital in Milan. Its implementation started, using the 'DNM-Digital Narrative Medicine' web-based platform, with the pilot prostate cancer path in March 2019.

Results

A 10-item questionnaire was sent to all 47 patients and 45 doctors involved, to evaluate: benefits perceived by the care team in terms of communication support, personalization of therapy, observation of cognitive elements not otherwise evident; benefits perceived by the patient (support, communication, self-management, identification of emotional, relational, social elements of daily life); patient and medical staff opinions in terms of compliance, accessibility, ease of use. The overall rating was 4.3/5 for doctors and 4.2/5 for patients. Patients valued the most the platform supporting them in the decision on what treatment to undergo (4.8/5), for the doctor the platform has been important in considering unknown aspects of the patient and understanding the patient's point of view (4.4/5). Patients, more than doctors, perceived platform usability positively. 43% of the patients who decided not to participate reported to prefer a direct approach with the doctor.

Lessons

The oncologic field represents an optimal setting for the implementation of methods aimed at strengthening communication and relationship of care. NBM offers the possibility of exploring elements as adherence to treatment, perception of illness, socio-psychological impact, sometimes missed during the visit, enhancing the conversation between patient and care team and stimulating the co-construction of care.

Key messages

NBM has proven to be a useful tool and a good communication channel in the oncologic setting. The NBM platform demonstrated good acceptability and ease of use by doctors and patients.

Audit methodology for the quality assessment of medical records in the emergency department

Issue

Filling out medical records properly in Emergency Departments (ED) can be challenging, due to the high number of daily admissions and the variety of involved health care professionals (HCP).

Description of the Problem

The ED of IRCCS San Raffaele Hospital (OSR), with a mean of 198 admissions per day in 2019, suffers of frequent overcrowding; patients are managed by multiple HCPs, based on specific care needs; coordination and handover between them are crucial to guarantee quality care. The OSR Healthcare Directorate, the ED's Staff and the School of Public Health of Vita-Salute San Raffaele University developed and validated a model of internal audit to identify ED medical records' quality issues and to implement corrective actions. The workflow included: developing a structured checklist, mapping critical processes and highlighting each figure's tasks. A group of auditors, made up by medical residents in Public Health, tested n = 300 medical charts, filled out during the first semester of 2019, picked up in order to provide a representative sample of the triage priority codes assigned to patients in this period.

Results

To assess completeness and quality of ED's medical records, a new checklist was developed, comprising 4 major sections, furtherly divided in 14 items, scored from 1 (poor adherence/completeness) to 5 (excellent), providing a total score for each record, ranging from 14 to 70. Specific comments to items could be added and an ultimate judgement was written by each auditor. This approach made medical records measurable and comparable.

Lessons

The new checklist and the audit process are useful instruments for the evaluation of medical records and the identification of corrective measures in the ED of our hospital. Next steps will be the extension of the sample, the implementation of corrective actions, and the institution of a stable working group for a regular evaluation.

Key messages

ED's medical records must be clear, understandable and complete. The developed checklist is a tool for preventing and correcting wrong behaviours in a continuous improvement perspective.

[Risk assessment for eating disorders in a high school: a study based on the Eating Attitudes Test 26]

AIM

Disordered eating behaviours can lead to clinically evident and serious eating disorders (ED). Aim of this paper is to determine their extent among adolescents and to evaluate the associated characteristics.

METHODS

All students of a high school (age 14-18) have been asked to fill up the Eating Attitudes Test (EAT-26) anonymously. EAT-26 is a self-reported questionnaire identifying subjects at risk for ED. This questionnaire included also an integrative section, aimed at investigating some ED-related variables (family composition, diet among relatives, social relationships, spare time activities, self-esteem). Collected data have been analyzed using EpiInfo6.

RESULTS

The study involved all the 902 students of the school; 833 questionnaires have been distributed and 701 were collected (89.4% from girls, 10.3% from boys). The percentage of EAT-26 positive boys (i.e. scoring = or > 20) is 3%, while for girls is 13.7%. A positive test significantly correlates with low self-esteem (OR = 46.67, CI = 13.16-182.04), contentious relationships with the mother (OR = 2.20, CI = 1.12-4.29) and the father (OR=2.45, CI=1.24-4.80). No significant correlation has been found for being an only child, living in a single-parent family having limited/not having social relationships, having unsatisfactory social relationships, spending spare time mostly alone, watching TV more than 2 h per day.

CONCLUSION

Our data suggest an increasing diffusion in the risk for ED among adolescents. Personal characteristics and behaviours related to this risk are good start points to program projects focusing on primary and secondary prevention of ED in high schools.

[Assessment of eating disorders-related risk in a cohort of adolescents living in Northern Italy. Results from a multicenter study]

BACKGROUND

Clinical evidence and epidemiological research show an increasing number of subjects trying to become lean and reaching consequently harmful weight conditions. Aim of this paper is to assess the risk for eating disorders during adolescence.

METHODS

In a multicentric study high school students of 5 different districts of Northern Italy have been asked to fill up anonymously the Italian version of the American YRBSS (Youth Risk Behaviour Surveillance System) questionnaire. For each school a section has been selected and between January and March 1999, students of every level have been involved. The data enrollected have been analysed using EpiInfo6.

RESULTS

The study involved 4135 adolescents (57% girls and 43% boys) coming from 260 classes and 47 different schools. The proportion of boys perceiving themselves as overweight and underweight was the same (22%), while the proportion of girls considering themselves overweight raised up to 42%. The majority of the girls (53%) is trying to slim making use of physical activity (48%), diets (32%), vomiting (8%) and drugs (5%).

CONCLUSIONS

Our data suggest that specific projects focusing on primary and secondary prevention of eating disorders should be considered for high schools. In addition, further studies are suggested to understand characteristics and behaviours related to eating disorders.