Beyond empathy training for practitioners: Cultivating empathic healthcare systems and leadership.

Empathic care benefits patients and practitioners, and empathy training for practitioners can enhance empathy. However, practitioners do not operate in a vacuum. For empathy to thrive, healthcare consultations must be situated in a nurturing milieu, guided by empathic, compassionate leaders. Empathy will be suppressed, or even reversed if practitioners are burned out and working in an unpleasant, under-resourced environment with increasingly poorly served and dissatisfied patients. Efforts to enhance empathy must therefore go beyond training practitioners to address system-level factors that foster empathy. These include patient education, cultivating empathic leadership, customer service training for reception staff, valuing cleaning and all ancillary staff, creating healing spaces, and using appropriate, efficiency saving technology to reduce the administrative burden on healthcare practitioners. We divide these elements into environmental factors, organisational factors, job factors, and individual characteristics.

The use of PROMs and shared decision-making in medical encounters with patients: An opportunity to deliver value-based health care to patients.

BACKGROUND: The recent emphasis on value-based health care (VBHC) is thought to provide new opportunities for shared decision-making (SDM) in the Netherlands, especially when using patient-reported outcome measures (PROMs) in routine medical encounters. It is still largely unclear about how PROMs could be linked to SDM and what we expect from clinicians in this respect. AIM: To describe approaches and lessons learned in the fields of SDM and VBHC implementation that converge in using PROMs in medical encounters. APPROACH: Based on input from three Dutch forerunner case examples and available evidence about SDM and VBHC, we describe barriers and facilitators regarding the use of PROMs and SDM in the medical encounter. Barriers and facilitators were structured according to a conversational model that included monitoring and managing, team talk, option talk, choice talk, and decision talk. Key lessons learned and recommendations were synthesized. RESULTS: The use of individual, N = 1 PROMs scores in the medical encounter has been largely achieved in the forerunner projects. Conversation on monitoring and managing is relatively well implemented, and option talk to some extent, unlike team talk, and decision talk. Aggregated PROMs information describing outcomes of treatment options seemed to be scarcely used. Experienced barriers largely corresponded to what is known from the literature, eg, perceived lack of time and lack of tools summarizing the options. Some concerns were identified about increasing health care consumption as a result of using PROMs and SDM in the medical encounter. CONCLUSION: Successful implementation of SDM within VBHC initiatives may not be self-evident, even though individual, N = 1 PROMs scores are being used in the medical encounter. Education and staff resources on meso and macro levels may facilitate the more time-consuming SDM aspects. It seems fruitful to especially target team talk and choice talk in redesigning clinical pathways.

How to Integrate Personalized Medicine into Prevention? Recommendations from the Personalized Prevention of Chronic Diseases (PRECeDI) Consortium.

Medical practitioners are increasingly adopting a personalized medicine (PM) approach involving individually tailored patient care. The Personalized Prevention of Chronic Diseases (PRECeDI) consortium project, funded within the Marie Sklodowska Curie Action (MSCA) Research and Innovation Staff Exchange (RISE) scheme, had fostered collaboration on PM research and training with special emphasis on the prevention of chronic diseases. From 2014 to 2018, the PRECeDI consortium trained 50 staff members on personalized prevention of chronic diseases through training and research. The acquisition of skills from researchers came from dedicated secondments from academic and nonacademic institutions aimed at training on several research topics related to personalized prevention of cancer and cardiovascular and neurodegenerative diseases. In detail, 5 research domains were addressed: (1) identification and validation of biomarkers for the primary prevention of cardiovascular diseases, secondary prevention of Alzheimer disease, and tertiary prevention of head and neck cancer; (2) economic evaluation of genomic applications; (3) ethical-legal and policy issues surrounding PM; (4) sociotechnical analysis of the pros and cons of informing healthy individuals on their genome; and (5) identification of organizational models for the provision of predictive genetic testing. Based on the results of the research carried out by the PRECeDI consortium, in November 2018, a set of recommendations for policy makers, scientists, and industry has been issued, with the main goal to foster the integration of PM approaches in the field of chronic disease prevention.

Value based maternal and newborn care requires alignment of adequate resources with high value activities.

BACKGROUND: Evidence based practice has been associated with better quality of care in many situations, but it has not been able to address increasing need and demand in healthcare globally and stagnant or decreasing healthcare resources. Implementation of value-based healthcare could address many important challenges in health care systems worldwide. Scaling up exemplary high value care practices offers the potential to ensure values-driven maternal and newborn care for all women and babies. DISCUSSION: Increased use of healthcare interventions over the last century have been associated with reductions in maternal and newborn mortality and morbidity. However, over an optimum threshold, these are associated with increases in adverse effects and inappropriate use of scarce resources. The Quality Maternal and Newborn Care framework provides an example of what value based maternity care might look like. To deliver value based maternal and newborn care, a system-level shift is needed, 'from fragmented care focused on identification and treatment of pathology for the minority to skilled care for all'. Ideally, resources would be allocated at population and individual level to ensure care is woman-centred instead of institution/ profession centred but oftentimes, the drivers for spending resources are 'the demands and beliefs of the acute sector'. We argue that decisions to allocate resources to high value activities, such as continuity of carer, need to be made at the macro level in the knowledge that these investments will relieve pressure on acute services while also ensuring the delivery of appropriate and high value care in the long run. To ensure that high value preventive and supportive care can be delivered, it is important that separate staff and money are allocated to, for example, models of continuity of carer to prevent shortages of resources due to rising demands of the acute services. To achieve value based maternal and newborn care, mechanisms are needed to ensure adequate resource allocation to high value maternity care activities that should be separate from the resource demands of acute maternity services. Funding arrangements should support, where wanted and needed, seamless movement of women and neonates between systems of care.

Shifting to triple value healthcare: Reflections from England.

Increasing need and demand because of growing and aging populations combined with stagnant or decreasing resources being invested into healthcare globally mean that a radical shift is needed to ensure that healthcare systems can meet current and future challenges. Quality-, safety- and efficiency-improvement approaches have been used as means to address many problems in healthcare and while they are essential and necessary, they are not sufficient to meet our current challenges. To build resilient and sustainable healthcare systems, we need a shift to focus on triple value healthcare, which will help healthcare professionals improve outcomes at the process, patient and population levels while also optimising resource utilisation. Here we present a brief history of the Quality and Evidence-based Healthcare model and then describe how value emerged as a predominant theme in England. We then highlight the four solutions that we, as part of the RightCare programme, designed and refined in the English NHS to turn theory into practice: We end with a description of how triple value is being introduced into Germany and steps that can be taken to facilitate its adoption.

Visualizing value for money in public health interventions.

Background: The Socio-Technical Allocation of Resources (STAR) has been developed for value for money analysis of health services through stakeholder workshops. This article reports on its application for prioritization of interventions within public health programmes. Methods: The STAR tool was used by identifying costs and service activity for interventions within commissioned public health programmes, with benefits estimated from the literature on economic evaluations in terms of costs per Quality-Adjusted Life Years (QALYs); consensus on how these QALY values applied to local services was obtained with local commissioners. Results: Local cost-effectiveness estimates could be made for some interventions. Methodological issues arose from gaps in the evidence base for other interventions, inability to closely match some performance monitoring data with interventions, and disparate time horizons of published QALY data. Practical adjustment for these issues included using population prevalences and utility states where intervention specific evidence was lacking, and subdivision of large contracts into specific intervention costs using staffing ratios. The STAR approach proved useful in informing commissioning decisions and understanding the relative value of local public health interventions. Conclusions: Further work is needed to improve robustness of the process and develop a visualization tool for use by public health departments.

Equity and Value in 'Precision Medicine'.

Precision medicine carries huge potential in the treatment of many diseases, particularly those with high-penetrance monogenic underpinnings. However, precision medicine through genomic technologies also has ethical implications. We will define allocative, personal, and technical value ('triple value') in healthcare and how this relates to equity. Equity is here taken to be implicit in the concept of triple value in countries that have publicly funded healthcare systems. It will be argued that precision medicine risks concentrating resources to those that already experience greater access to healthcare and power in society, nationally as well as globally. Healthcare payers, clinicians, and patients must all be involved in optimising the potential of precision medicine, without reducing equity. Throughout, the discussion will refer to the NHS RightCare Programme, which is a national initiative aiming to improve value and equity in the context of NHS England.