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Value-based healthcare of state-of-the-art care pathways for adult spinal deformity in University Hospitals Leuven

Healthcare providers, working with limited healthcare budgets, attempt to achieve better clinical outcomes at lower costs of care and thus, to improve the so-called “value in healthcare”. Improving value certainly benefits diseases with a high financial and clinical burden on society, such as Adult Spinal Deformity (ASD), a chronic disease affecting the ageing population. Especially in these chronic diseases, with lifelong outcome (and cost) impact, value improvements are beneficial, both for society and patients.

ASD, affecting 2 to 32% of the adult population6, is a progressive and asymmetric degeneration of the vertebral column that leads to a structural deformity. This deformity causes pain, loss of functioning and impacts the health-related quality of life (HRQOL), equal to, or worse than arthritis, chronic lung disease, diabetes and congestive heart failure. To treat these symptoms, patients often need resource-intensive surgery as surgeons operate together, use implants and need extensive pre- and postoperative medical imaging. In addition, revision surgery is often needed.

To choose the treatment with the best value for ASD patients, physicians need data on both outcome and costs. Indeed, a new intervention may result in the better outcome compared to standard care but may lead to a decrease in value if costs increase even more. Few data are available about the actual cost of ASD and the few studies that are available document costs based on reimbursements and charges to the patient. Ideally, costs are measured in terms of the monetary value of the resources spent when providing care. Moreover, when comparing different treatment options, it often suffices to measure only the costs of those care components that differ between the treatment options that are being compared. Hence, overhead costs (i.e. costs of support services, such as administration, cleaning, …) can often be excluded in economic evaluation studies.

In the University Hospitals Leuven, an Activity Centre – Care Program (AC – CP) model was developed over the course of several years. This model does not only allow to compare the care delivered to different patient groups (“care programs”), but also to document and compare the (variations in) care trajectories between and within different patient groups. The costing components of this AC-CP-model are activity-based costing (ABC) inspired. The costing model distinguishes direct and indirect costs. Direct costs can be accurately linked to the patient with little effort (e.g. medication, implants). However, linking indirect costs to a patient is less trivial. These costs are assigned to the patient via a two-stage allocation principle. First, costs of a resource (e.g. staff, utilities, equipment) are allocated by a resource cost driver to activity centres (ACs). An AC is characterized by activities of a similar nature and forms a functional unit within the hospital, e.g. the operating room, the ward, etc. Next, the activity cost pool at the level of the AC is allocated to patient groups through activity cost drivers, for example, the number of X-rays or the duration of surgery. For each activity, a cost can be calculated, with the “cost of the hospital care pathway” being the sum of all care activity costs consumed by the patient (per type of activity and taking their frequency into account).

The AC‐CP model makes use of routinely available clinical and accounting data. It provides insights into the relative resource consumption of the different ACs for each care program. However, the AC‐CP model is a “push model” which means that the cost of the total capacity (of e.g. the operating time), including that of unused or idle capacity, is allocated to individual patients. Furthermore, for some ACs, the AC‐CP model has a low granularity: the routinely available cost drivers likely do not reflect variations in actual resource use between patients with sufficient accuracy. In this doctoral plan, we will pursue further refinements for such care activities by splitting activities into sub‐activities and/or by using time as a cost driver. Therefore, the first aim of our study is to analyse the care trajectories of (subgroups of) ASD patients and to compare the costs of these activities, thereby making use of the available AC-CP model and by refining the costing model for certain activities.

Next to costs, outcome data are required to evaluate ‘value in health care’. To express the outcome in the value equation, quality‐adjusted life years (QALYs) can be used. QALYs, comprising both quality and quantity of life, result from the multiplication of duration of time spent in a certain health state with the corresponding HRQOL utility score, measured with the EuroQol (EQ‐5D) questionnaire QALYs have the clear benefit that they allow outcome comparisons across different diseases. However, clinicians often have little ‘clinical feeling’ for QALYs and they prefer to evaluate outcomes in terms of functional parameters, that are directly relevant for the patient group they treat. The clinicians treating ASD patients in our institution are currently developing an ASD-specific clinical evaluation platform, including balance and movement analysis, to measure functional outcomes. Another aim of our study will be to evaluate whether this platform can be used as an alternative to QALYs in economic evaluation studies.

Besides providing a more clinically relevant outcome measurement, the balance and movement analysis is also expected to improve outcome. In different disease groups, functional outcome has proven to be better when surgery is preceded by balance and movement analysis due to improved clinical decision making. However, for ASD patients, no evidence is available yet on cost, nor on value of balance and movement analysis. Therefore, the third aim of our study is to provide the first cost analysis of a balance and movement analysis in ASD-patients, which will form the basis for future economic evaluations of such balance and movement analysis.

Additionally, the clinicians in our institution aim to develop and implement enhanced recovery pathways (ERP). This pathway entails different steps focused to improve and enhance the recovery after surgery of the patient. Some ERPs for different pathologies were already developed, and economic evaluations were performed. However, for the ASD population, such an ERP-protocol and economic evaluation, comparing ERP with standard care are still absent. Therefore, a final aim of our study is to perform an economic evaluation of the ERP protocol for ASD patients developed and implemented by our clinicians.
Date:1 Sep 2018 →  31 Aug 2022
Keywords:value based healthcare
Disciplines:Public health care
Project type:Service project