How outcomes should be measured

Outcomes should be measured by medical condition or primary care patient segment and not by procedure or intervention, Prof. Bob Kaplan told the HSE Mastertclass. Maureen Browne reports.

Prof. Bob Kaplan
Prof. Bob Kaplan

Outcomes should be measured by medical condition or primary care patient segment and not by procedure or intervention, Prof. Bob Kaplan, Marvin Bower Professor of Leadership Development, Emeritus at the Harvard Business School told the Masterclass. referencing work carried out by Prof. Michael E Porter of the Harvard Business School.

Prof. Kaplan said outcomes should reflect the full cycle of care for the condition. Outcomes are always multi-dimensional and should include the health results most relevant to patients.

Measurements must include initial conditions/risk factors to allow for risk adjustment and outcome measures should be standardised to enable comparison and learning across time and across institutions.

There should be long term outcomes. In hip replacements, for example, measurement often stopped at 30 days or 90 days or one year post-intervention, but many critical outcomes that mattered to patients were revealed over longer time periods.

Outcomes should reflect the full cycle of care for the condition. Outcomes are always multi-dimensional and should include the health results most relevant to patients.

Prof. Porter said that care should be organised into Integrated Practice Units (IPUs) around patient medical conditions. Primary and preventive care should serve distinct patient segments.

Outcomes and costs should be measured for every patient. There were three tiers in the outcome measures hierarchy:

  • Tier 1 – Health status achieved which included survival and degree of health/recovery.
  • Tier 2 – The process of recovery, which included the time to recovery and return to normal activities, disutility of the care or treatment process e.g. diagnostic errors and ineffective care, treatment-related discomfort, complications or adverse effects, treatment errors and their consequences in terms of additional treatment.
  • Tier 3 – Sustainability of health and this included sustainability of health/recovery and nature of recurrences and long term consequence of therapy e.g. care-induced illnesses.

Taking as an example the outcome measures hierarchy in localised prostate cancer, Prof. Kaplan said you could make six outcome measurements.

  1. Survival – which covered disease-specific survival.
  2. Degree of recovery/health – Level of anxiety and depression.
  3. Time to recovery or return to normal activities – This involved time to diagnosis, time to treatment, length of inpatient stay and time to return to work
  4. Disutility of care or treatment process (e.g. treatment related discomfort, complications, adverse effects, diagnostic errors, treatment errors) – This would cover bleeding, thrombosis, incontinence, erectile dysfunction.
  5. Sustainability of recovery or healthy over time – Was there biochemical recurrence, metastatic progression.
  6. Long term consequences of therapy (e.g. care-induced illnesses) – Did patients have radiation-induced complications of intestine, bladder, bones, skin?

Prof. Kaplan said that an Integrated Practice Unit (IPU) should be:

  • Organised around a medical condition or set of closely related conditions.
  • Care should be delivered by a dedicated, multidisciplinary team which devoted a significant portion of their time to the medical condition
  • Providers on the team should see themselves as part of a common organizational unit
  • The team should take responsibility for the full cycle of care for the condition, encompassing outpatient, inpatient, and rehabilitative care, as well as supporting services (such as nutrition, social work, and behavioural health)
  • Patient education, engagement, and follow-up should be integrated into careIt should have a single administrative and scheduling structure
  • Much of care should be co-located in one or more dedicated sites
  • A physician team captain or a clinical care manager (or both) should oversee each patient’s care process
  • The team should measure outcomes, costs, and processes for each patient, using a common measurement platform
  • The providers on the team should meet formally and informally on a regular basis to discuss patients, processes, and results
  • There should be joint accountability accepted for outcomes and costs.

Prof. Kaplan said the following were the principles of measuring the Cost of Care Delivery:

  • Cost is the actual expense of patient care, not the tariff billed or collected
  • Cost should be measured around the patient, not just the department or provider organization
  • Cost should be aggregated over the full cycle of care for the patient’s medical condition
  • Cost depends on the actual use of resources involved in a patient’s care process (personnel, facilities, supplies)