Toward Patient-Centered Healthcare Value

See Article by Dodson et al

Who could argue with promoting high-value healthcare? The answer may depend on whose perspective is being addressed. Healthcare value is generally defined by the formula of outcomes over costs and has been proposed as a unifying approach to measure improvements in the quality and affordability of healthcare. However, value assessments can vary widely depending on (1) the outcome chosen, (2) the cost perspective (ie, who is paying), and (3) whether the assessment reflects the priorities of the patient, clinician, health system, or payer. For example, a clinician may offer a left ventricular assist device to a patient with advanced heart failure because clinical trials have demonstrated improvements in mortality. The patient may be reluctant to pursue a left ventricular assist device because of the potential for complications. The health system may wish to perform more left ventricular assist device implants due to financial incentives (the average Medicare reimbursement for left ventricular assist device implantation exceeds $150 000). Finally, the patient’s insurance provider may be reluctant to pay for the procedure if it is not cost-effective. Thus, the value equation cannot be easily distilled into a single summary measure because several separate and potentially conflicting perspectives need to be considered.

With such widely differing perspectives, where should our clinical and research priorities lie? We favor using the definition of value proposed by Porter, where outcomes reflect the health circumstances most relevant to patients.¹ Using this definition, patient-centered outcomes and health status measures (eg, symptom burden, functional status, and health-related quality of life) take on new importance alongside traditional outcome measures, such as mortality and readmission. In this issue of Circulation: Cardiovascular Quality and Outcomes, Dodson et al² assessed several health status measures (including cognitive and sensory impairment, activities of daily life disability, and functional mobility) among elderly patients hospitalized with acute myocardial infarction.² The authors found that adding functional impairment (as defined by Timed Up and Go test >15 seconds) to traditional clinical variables in a readmission risk model improved the model’s performance. The model had modest discrimination, and the authors point out that much of the variability in patient readmission remains unexplained by patient-level factors. Their study not only reinforces the importance of incorporating patient-centered measures into the assessment of healthcare outcomes but also highlights the opportunities to identify other patient-centered factors (eg, social determinants of health) that impact healthcare value.

Standardized measures of patient-centered outcomes such as health status offer a valid, sensitive, and reproducible approach to measure healthcare value from the patient’s perspective. This is consistent with the approach of the International Consortium for Health Outcomes Measurement, which has developed patient-centered standardized outcome measurement sets for a variety of conditions, including 5 in cardiovascular disease.³ The standardized sets include traditional measures such as mortality, but also include the patient’s burden of care (eg, treatment side effects and complications) and functioning (eg, symptom control, independence, and psychosocial health). Although these patient-centered outcomes are infrequently assessed in routine clinical care, an increasing number of patient-reported measures are being refined to allow collection outside of the clinical workflow (via web portals or automated telephone calls) and display summary scores that can be incorporated into assessments of healthcare value. Examples include the University of Rochester’s Patient-Reported Outcomes Measurement Information System for patient undergoing orthopedic surgery and the Veterans Health Administration’s Patient-Reported Outcomes and Symptom Tracker for patients undergoing percutaneous coronary intervention for stable angina. These methods should allow for collection of patient-centered outcomes more broadly.

As clinicians and researchers, it is important for us to prioritize the outcomes that are most important to our patients. More studies should incorporate patient-centered outcomes and health status measures into healthcare value assessments.

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