How to Use Costs in Value-Based Healthcare: Learning from Real-life Examples.

BACKGROUND: Healthcare organizations measure costs for business operations but do not routinely incorporate costs in decision-making on the value of care. AIM: Provide guidance on how to use costs in value-based healthcare (VBHC) delivery at different levels of the healthcare system. SETTING AND PARTICIPANTS: Integrated practice units (IPUs) for diabetes mellitus (DM) and for acute myocardial infarction (AMI) at the Leiden University Medical Center and a collaboration of seven breast cancer IPUs of the Santeon group, all in the Netherlands. PROGRAM DESCRIPTION AND EVALUATION: VBHC aims to optimize care delivery to the patient by understanding how costs relate to outcomes. At the level of shared decision-making between patient and clinician, yearly check-up consultations for DM type I were analyzed for patient-relevant costs. In benchmarking among providers, quantities of cost drivers for breast cancer care were assessed in scorecards. In continuous learning, cost-effectiveness analysis was compared with radar chart analysis to assess the value of telemonitoring in outpatient follow-up. DISCUSSION: Costs vary among providers in healthcare, but also between provider and patient. The joint analysis of outcomes and costs using appropriate methods helps identify and optimize the aspects of care that drive desired outcomes and value.

Standardising personalised diabetes care across European health settings: A person-centred outcome set agreed in a multinational Delphi study.

OBJECTIVE: Standardised person-reported outcomes (PRO) data can contextualise clinical outcomes enabling precision diabetes monitoring and care. Comprehensive outcome sets can guide this process, but their implementation in routine diabetes care has remained challenging and unsuccessful at international level. We aimed to address this by developing a person-centred outcome set for Type 1 and Type 2 diabetes, using a methodology with prospects for increased implementability and sustainability in international health settings. METHODS: We used a three-round questionnaire-based Delphi study to reach consensus on the outcome set. We invited key stakeholders from 19 countries via purposive snowball sampling, namely people with diabetes (N = 94), healthcare professionals (N = 65), industry (N = 22) and health authorities (N = 3), to vote on the relevance and measurement frequency of 64 previously identified clinical and person-reported outcomes. Subsequent consensus meetings concluded the study. RESULTS: The list of preliminary outcomes was shortlisted via the consensus process to 46 outcomes (27 clinical outcomes and 19 PROs). Two main collection times were recommended: (1) linked to a medical visit (e.g. diabetes-specific well-being, symptoms and psychological health) and (2) annually (e.g. clinical data, general well-being and diabetes self management-related outcomes). CONCLUSIONS: PROs are often considered in a non-standardised way in routine diabetes care. We propose a person-centred outcome set for diabetes, specifically considering psychosocial and behavioural aspects, which was agreed by four international key stakeholder groups. It guides standardised collection of meaningful outcomes at scale, supporting individual and population level healthcare decision making. It will be implemented and tested in Europe as part of the H2O project.

Impact and effect of imaging referral guidelines on patients and radiology services: a systematic review.

OBJECTIVES: The objective of this systematic review was to offer a comprehensive overview and explore the associated outcomes from imaging referral guidelines on various key stakeholders, such as patients and radiologists. MATERIALS AND METHODS: An electronic database search was conducted in Medline, Embase and Web of Science to retrieve citations published between 2013 and 2023. The search was constructed using medical subject headings and keywords. Only full-text articles and reviews written in English were included. The quality of the included papers was assessed using the mixed methods appraisal tool. A narrative synthesis was undertaken for the selected articles. RESULTS: The search yielded 4384 records. Following the abstract, full-text screening, and removal of duplication, 31 studies of varying levels of quality were included in the final analysis. Imaging referral guidelines from the American College of Radiology were most commonly used. Clinical decision support systems were the most evaluated mode of intervention, either integrated or standalone. Interventions showed reduced patient radiation doses and waiting times for imaging. There was a general reduction in radiology workload and utilisation of diagnostic imaging. Low-value imaging utilisation decreased with an increase in the appropriateness of imaging referrals and ratings and cost savings. Clinical effectiveness was maintained during the intervention period without notable adverse consequences. CONCLUSION: Using evidence-based imaging referral guidelines improves the quality of healthcare and outcomes while reducing healthcare costs. Imaging referral guidelines are one essential component of improving the value of radiology in the healthcare system. CLINICAL RELEVANCE STATEMENT: There is a need for broader dissemination of imaging referral guidelines to healthcare providers globally in tandem with the harmonisation of the application of these guidelines to improve the overall value of radiology within the healthcare system. KEY POINTS: The application of imaging referral guidelines has an impact and effect on patients, radiologists, and health policymakers. The adoption of imaging referral guidelines in clinical practice can impact healthcare costs and improve healthcare quality and outcomes. Implementing imaging referral guidelines contributes to the attainment of value-based radiology.

Facilitators and Barriers in the Implementation and Adoption of Patient-Reported Outcomes Measurements in Daily Practice.

OBJECTIVES: At the Erasmus Medical Center, patient-reported outcomes measures (PROMs) are implemented on a hospital-wide scale. However, less than half of the patients and healthcare professionals (HCPs) use these PROMs. Therefore, this study aimed to investigate facilitators and barriers for adoption of PROMs to develop guidance around implementation. METHODS: A mixed-methods study with a combination of interviews and focus groups and questionnaires was conducted, involving patients, both PROM nonresponders and PROM responders, HCPs, and medicine students and nurse specialists in training (hereafter "students"). Interview transcripts were subjected to thematic content analysis. Subsequently, questionnaires were developed and presented to all stakeholders to validate the findings. Finally, identified themes and implementation recommendations were presented in a final questionnaire to the Value-Based Healthcare Erasmus Medical Center expert group to prioritize findings. RESULTS: Interviews were conducted with 15 patients, 14 HCPs and 4 students, and 2 focus groups with 5 students. The questionnaire was completed by 370 of 999 responders (37.0%), 173 of 1395 nonresponders (12.5%), and 44 of 194 HCPs (22.7%), and 40 students were reached via an open link. The identified facilitators and barriers were grouped into 4 overarching themes: training on PROMs at different levels in the education of (future) HCPs, motivate and reduce the burden for the HCP, implement generic and disease-specific PROMs simultaneously, and motivate, activate, and reduce the patient burden. CONCLUSIONS: Providing end users with digital tools, implementation support, and a clear hospital-wide vision is important, yet this does not guarantee successful adoption of PROMs. Successful adoption necessitates ongoing efforts to engage, motivate, and train end users.

New reimbursement models to promote better patient outcomes and overall value in laboratory medicine and healthcare.

The most widespread healthcare reimbursement models, including diagnostic laboratory services, are Fee-for-Service, Reference Pricing and Diagnosis-Related Groups. Within these models healthcare providers are remunerated for each specific service or procedure they operate. Healthcare payers are increasingly exploring alternative models, such as bundled payments or value-based reimbursement to encourage value of patient care rather than the simple amount of delivered services. These alternative models are advised, as they are more efficient in promoting cost-effective, high-quality laboratory testing, thereby improving patient health outcomes. If outcomes-based evaluation is a pillar in a new vision of "Value-Based Healthcare", an active policy of Value-Based Reimbursement in laboratory medicine will assure both an efficiency-based sustainability and a high-quality effectiveness-based diagnostic activity. This review aims to evaluate current and alternative reimbursement models, to support a wider agenda in encouraging more Value-Based Healthcare and Value-Based Reimbursement in laboratory medicine.

Identifying critical quality metrics in Mohs Surgery: A national expert consensus process.

BACKGROUND: Amid a movement toward value-based healthcare, increasing emphasis has been placed on outcomes and cost of medical services. To define and demonstrate the quality of services provided by Mohs surgeons, it is important to identify and understand the key aspects of Mohs micrographic surgery (MMS) that contribute to excellence in patient care. OBJECTIVE: The purpose of this study is to develop and identify a comprehensive list of metrics in an initial effort to define excellence in MMS. METHODS: Mohs surgeons participated in a modified Delphi process to reach a consensus on a list of metrics. Patients were administered surveys to gather patient perspectives. RESULTS: Twenty-four of the original 66 metrics met final inclusion criteria. Broad support for the initiative was obtained through physician feedback. LIMITATIONS: Limitations of this study include attrition bias across survey rounds and participation at the consensus meeting. Furthermore, the list of metrics is based on expert consensus instead of quality evidence-based outcomes. CONCLUSION: With the goal of identifying metrics that demonstrate excellence in performance of MMS, this initial effort has shown that Mohs surgeons and patients have unique perspectives and can be engaged in a data-driven approach to help define excellence in the field of MMS.

Value-Based Healthcare: A Primer for the Dermatologist.

BACKGROUND: Value-based healthcare (VBHC) is an increasingly employed strategy to transform healthcare organizations into economically sustainable systems that deliver high-value care. In dermatology, the need for VBHC is evident as chronic skin diseases require long-term, often expensive treatments. This narrative review aims to introduce dermatologists to the principles and implementation of VBHC. SUMMARY: VBHC emphasizes maximizing outcomes that are directly relevant to patients. Key components of VBHC include a systematic assessment of standardized patient-relevant outcomes by using core outcome sets and measurement of healthcare cost for the individual patient. Systematic reporting and comparing of risk-adjusted outcomes across the full cycle of care for a specific condition provide benchmarked feedback and actionable insights to promote high-value care and reduce low-value care. VBHC aims to organize care around the patient in condition-specific and team-based integrated practice units with multidisciplinary collaboration, utilize information technology platforms to enable digital data monitoring, reduce cost, and eventually reform payment systems to support bundled payments for the overall care cycle. VBHC implementation in practice necessitates the establishment of a systematic framework for outcome-based quality improvement, the incorporation of value and outcomes in shared decision-making practices, and the cultivation of a value-centric culture among healthcare professionals through continuous training. KEY MESSAGES: Dermatologists can benefit from implementing VBHC principles in their practice. An essential step toward value-driven dermatological care is to start measuring outcomes relevant for patients for each patient, which is lacking partly due to the absence of core outcome sets developed for clinical practice. By reducing low-value care and emphasizing optimal patient-centered outcomes, VBHC has the potential to improve the quality of care and ensure cost containment. Efforts are needed to enhance the development and uptake of VBHC in dermatological clinical practice to realize these benefits.

What are the perspectives of patients with hand and wrist conditions, chronic pain, and patients recovering from stroke on the use of patient and outcome information in everyday care? A Mixed-Methods study.

PURPOSE: To evaluate the patients' perspectives on the use of patient- and outcome information tools in everyday care and to investigate which characteristics affect general understanding and perceived value of patient- and outcome information. METHODS: This mixed-methods study included surveys and interviews on understanding, experience, decision-support, and perceived value in patients with hand and wrist conditions and chronic pain. We synthesized our quantitative and qualitative findings using a triangulation protocol and identified factors independently associated with general understanding and perceived value of patient- and outcome information using hierarchical logistic regression. RESULTS: We included 3379 patients. The data triangulation indicated that patients understand the outcome information, they find it valuable, it supports decision-making, and it improves patient-clinician interaction. The following variables were independently associated with better general understanding: having more difficulty with questionnaires (standardized odds ratio 0.34 [95%-CI 031-0.38]), having a finger condition (0.72 [0.57-0.92]), longer follow-up (0.75 [0.61-0.91]), and undergoing surgical treatment (ref: non-surgical treatment, 1.33 [1.11-1.59]). For more general value, these were: having more difficulty with questionnaires (0.40 [0.36-0.44]), having a wrist condition (0.71 [0.54-0.92]), better hand function (1.12 [1.02-1.22]), and requiring help with questionnaires (1.65 [1.33-2.05]). CONCLUSION: Patients value the use of patient- and outcome information tools in daily care and find it easy to understand. The factors associated with understanding and value can be targeted to personalized and value-based healthcare. We recommend using outcome information to improve patient independence, empowerment, and involvement in decision-making.

Increasing the number of midwives is necessary but not sufficient: using global data to support the case for investment in both midwife availability and the enabling work environment in low- and middle-income countries.

BACKGROUND: Most countries are off-track to achieve global maternal and newborn health goals. Global stakeholders agree that investment in midwifery is an important element of the solution. During a global shortage of health workers, strategic decisions must be made about how to configure services to achieve the best possible outcomes with the available resources. This paper aims to assess the relationship between the strength of low- and middle-income countries' (LMICs') midwifery profession and key maternal and newborn health outcomes, and thus to prompt policy dialogue about service configuration. METHODS: Using the most recent available data from publicly available global databases for the period 2000-2020, we conducted an ecological study to examine the association between the number of midwives per 10,000 population and: (i) maternal mortality, (ii) neonatal mortality, and (iii) caesarean birth rate in LMICs. We developed a composite measure of the strength of the midwifery profession, and examined its relationship with maternal mortality. RESULTS: In LMICs (especially low-income countries), higher availability of midwives is associated with lower maternal and neonatal mortality. In upper-middle-income countries, higher availability of midwives is associated with caesarean birth rates close to 10-15%. However, some countries achieved good outcomes without increasing midwife availability, and some have increased midwife availability and not achieved good outcomes. Similarly, while stronger midwifery service structures are associated with greater reductions in maternal mortality, this is not true in every country. CONCLUSIONS: A complex web of health system factors and social determinants contribute to maternal and newborn health outcomes, but there is enough evidence from this and other studies to indicate that midwives can be a highly cost-effective element of national strategies to improve these outcomes.

Evaluating patient participation in value-based healthcare: Current state and lessons learned.

INTRODUCTION: Value-based healthcare (VBHC) focusses on increasing value for patients. Hospitals aim to implement VBHC via value improvement (VI) teams for medical conditions. To determine the patient's perspective on value, collective patient participation is important in these teams. We therefore evaluated the current state of patient participation in VI teams and share lessons learned. METHODS: This mixed-methods study was conducted at seven collaborating hospitals in the Netherlands. A questionnaire (the public and patient engagement evaluation tool) was tailored to the study's context, completed by VI team members (n = 147 from 76 different VI teams) and analysed with descriptive statistics. In addition, 30 semistructured interviews were held with VI team members and analysed through thematic analysis. Data were collected between February 2022 and January 2023 and were triangulated by mapping the quantitative results to the interview themes. RESULTS: Thirty-eight of the 76 included VI teams reported using a form of patient participation. Many respondents (71%) indicated a lack of a clear strategy and goal for patient participation. Multiple VI team members believed that specific knowledge and skills are required for patients to participate in a VI team, but this led to concerns regarding the representativeness of participating patients. Furthermore, while patients indicated that they experienced some level of hierarchy, they also stated that they did not feel restricted hereby. Lastly, patients were satisfied with their participation and felt like equal VI team members (100%), but they did mention a lack of feedback from the VI team on their input. CONCLUSION: The results imply the lack of full implementation of patient participation within VI teams. Guidelines should be developed that provide information on how to include a representative group of patients, which methods to use, how to evaluate the impact of patient participation, and how to give feedback to participating patients. PATIENT AND PUBLIC CONTRIBUTION: Two patient advisors were part of the research team and attended the research team meetings. They were involved as research partners in all phases of the study, including drafting the protocol (e.g., drafting interview guides and selecting the measurement instrument), interpreting the results and writing this article.

The value of using patient-reported outcomes for health screening during long-term follow-up after paediatric stem cell transplantation for nonmalignant diseases.

INTRODUCTION: The assessment of using patient-reported outcomes (PROs) within comprehensive care follow-up programmes, specifically focused on health screening, remains largely unexplored. PROs were implemented in our late effects and comprehensive care programme after paediatric hematopoietic stem cell transplantation (HSCT) for nonmalignant diseases. The programme focuses solely on screening of physical and mental health and on discussing PROs during the consultation. METHODS: The primary method of this study was semistructured interviews to explore the perspective of both patients and healthcare providers' (HCP) on the use of PROs, which were thematically analyzed. Additionally, an explorative quantitative approach with patient-reported experience measures (PREMS) was used, with a pretest-posttest design, to assess whether the use of PROs was accompanied by more patient-centred care. RESULTS: From the patient-interviews (N = 15) four themes were extracted: use of PROs (1) help to discuss topics; (2) make the patients feel understood; (3) create a moment of self-reflection; and (4) make consultations more efficient. Pre- and postimplementation analysis of PREMs (N = 40) did not show significant differences in terms of patient-centeredness. CONCLUSION: Our results demonstrate the added value of integrating PROs for health screening purposes within the long-term follow-up programme after paediatric HSCT, as perceived by both patient and HCP. With the active use of PROs, patients are stimulated to consciously assess their health status. PATIENT CONTRIBUTION: This study included patients as participants. Caregivers were approached if patients were below a certain age. Additionally, preliminary results were shared with all patients (including nonparticipants) during a patient conference day.

Value-based healthcare implementation in the Netherlands: a quantitative analysis of multidisciplinary team performance.

BACKGROUND: Many hospitals worldwide have set up multidisciplinary Value Improvement (VI) teams that use the Value-Based Health Care (VBHC) theory to improve patient value. However, it remains unclear what the level of VBHC implementation is within these teams. We therefore studied the current level of VBHC implementation in VI teams. METHODS: A questionnaire was developed based on the strategic agenda for value transformation and real-world experiences with VBHC implementation. The questionnaire consisted of 21 questions, mapped to seven domains, and was sent out to 25 multidisciplinary VI teams. Median scores for individual questions (scale = 1-5) and average scores per domain were calculated. RESULTS: One hundred forty VI team members completed the questionnaire. The overall average score is 3.49. The 'culture and responsibility' domain obtained the highest average score (µ = 4.11). The domain 'measure and improve outcomes' and the domain 'multidisciplinary team' obtained average scores that are slightly higher than the overall average (µ = 3.78 and µ = 3.76 respectively), and the domains 'strategy and organizational policy,' 'collaboration and sharing,' and 'IT and data' scored a little below the overall average (µ = 3.41, µ = 3.32, and µ = 3.29 respectively). The domain 'costs and reimbursement' obtained the lowest average score (µ = 2.42) of all domains, indicating that the implementation of this particular aspect of VBHC remains lagging behind. CONCLUSIONS: Our results indicate activity in each of the questionnaire domains. To bring VBHC implementation to the next level, more attention should be given to the financial aspects. Our questionnaire can be used in future studies to identify improvements or differences within VI teams.

Expanded perspectives: integrating clinicians' insights for comprehensive patient-reported outcomes in value-based healthcare.

The manuscript explores value-based healthcare (VBHC) and its role in assessing healthcare quality beyond clinical metrics. It identifies four value types: personal, technical, allocative, and societal. Emphasizing the integration of diverse stakeholder perspectives, including patients, families, and clinicians, the study highlights the importance of patient- and family-reported measures (PROMs and PREMs) and clinician input. Clinicians' insights on treatment feasibility and effectiveness are crucial for a holistic understanding of healthcare quality. The manuscript advocates for combining machine learning with participatory approaches to enhance data analysis and continuous quality improvement in VBHC, driving better outcomes for patients and communities.

How to facilitate the introduction of value-based payment models?

Value-based payment (VBP) models are designed and implemented to improve outcomes at the same or lower costs. Their adoption requires significant changes in the way healthcare organisations and insurance companies operate. Usually, before VBP models are widely implemented, pilot projects are conducted. Payers need to have a comprehensive set of requirements to enter into agreements with healthcare organisations on these pilots. In this short communication, we outline key elements reported in the literature, inside and outside healthcare organisations, as well as within the contract, that need to be considered in a pilot VBP model. Discussions regarding the introduction of VBP models may be strongly affected by external contextual factors, including regulations, which are outside the control of healthcare organisations. It requires collaboration between organisations, including primary care organisations and hospitals, while within organisations, it frequently requires creating multidisciplinary teams. The focus is on ensuring transparency, collaboration, and shared decision-making, realised by standardising communication processes and regular meetings. Additionally, effective leadership is needed, in which leaders set goals and priorities, as well as manage change. In the contractual agreements between payers and healthcare organisations, outcome measures need to be adequately defined and measured, including individual patient outcomes and composite scores, as well as absolute and relative performance measures. These measures should be tested periodically and catered to the organisations adopting the model. Also, incentives should have adequate size and frequency and be intrinsic and extrinsic. The consideration of these sets of key elements by the payers is essential when implementing VBP model pilot projects.

A prospective observational study of pH testing to confirm ongoing nasogastric tube position.

AIMS AND OBJECTIVES: To measure the reliability of pH testing to confirm ongoing nasogastric tube (NGT) position and to document associated complications. BACKGROUND: Confirming NGT position is essential, as use of an incorrectly positioned tube can cause harm. Substantial evidence examines initial confirmation of NGT position, yet limited evidence exists considers NGT displacement which is identified via ongoing NGT position tests. In the NHS, pH testing is recommended to confirm ongoing NGT position; however, there may be an association with excess X-rays and missed enteral nutrition and/or medications. DESIGN: Prospective observational study using STROBE checklist. METHODS: Data collected from medical records of 136 patients with NGTs in a London NHS Trust included pH tests, test results and complications related to ongoing pH tests which failed to confirm the tube was positioned in the stomach, that is, X-rays, and disruptions to enteral nutrition and medication. Cohen's Kappa determined pH test reliability. RESULTS: Of 1381 pH tests conducted to confirm NGT position, five (0.3%) correctly identified an NGT displacement, and one (0.07%) failed to identify displacement before use. The reliability of ongoing pH tests using Cohen's Kappa was minimal (0.29). Ongoing pH tests that failed to confirm a correctly positioned NGT led to 31 (22.8%) patients having X-rays, 24 (17.6%) missing >10% of prescribed enteral nutrition and 25 (18.4%) missing a critical medication. CONCLUSION: Ongoing NGT position testing using pH tests did not prevent the use of a displaced tube, and more than one-fifth of patients required X-rays to confirm a correctly position NGT, contributing to missed medications and enteral nutrition. RELEVANCE TO CLINICAL PRACTICE: Caution should be used when confirming ongoing NGT position with a pH test. Future guidelines should balance the risk of using a displaced tube with potential delays to nutrition and/or medication. More research is needed to explore alternative methods of ongoing NGT position testing.

[Health-economic aspects of radiotherapy]. / Aspects économiques de la radiothérapie.

Cancer care poses a significant economic burden, challenging healthcare budgets to balance patient benefits with affordability. Radiotherapy takes up only a limited part of oncology budgets, but the cost is rarely clear-cut due to influential factors such as complexity of treatments, highly-trained personnel and technologies. Health-economic appraisal is complex and can be performed in several ways, balancing costs and outcomes, but not all approaches are equally suitable for assessment of radiotherapy interventions. The concept of «value-based healthcare¼ offers a broader perspective to health-economic appraisal, considering various outcomes and the cost of the total cycle of care, thus addressing some of the challenges in radiotherapy: the diversity of interventions, a broad range of outcomes (including organ preservation or local control) and challenges in evidence generation. However, as the existing value-based frameworks in oncology are aimed at systemic therapies, a tailored approach for radiotherapy interventions is necessary to enhance access to innovative care and optimize resource allocation. This article explores the economic aspects of radiotherapy, providing an overview of radiotherapy cost determinants and calculations, discussing different health-economic strategies and value-based healthcare, and how these can address the specific challenges in radiotherapy.

Le coût économique du cancer représente un fardeau significatif, nécessitant un équilibre entre les bénéfices et la viabilité financière des budgets de santé. La radiothérapie ne représente qu'une part limitée des budgets d'oncologie, mais le coût est rarement clairement défini en raison, entre autres, de la complexité des traitements et du recours à un personnel hautement qualifié. L'évaluation est complexe et peut être réalisée de plusieurs manières, en équilibrant les coûts et les résultats, mais toutes les approches médico-économiques ne sont pas également adaptées à l'évaluation de la radiothérapie. Le concept de «value-based healthcare¼, qui prend en compte différents résultats et le coût du cycle total des soins, peut résoudre certains des défis de la radiothérapie : la diversité des interventions, un large éventail de résultats (comme le contrôle local) et les défis liés à la production de données probantes. Cependant, comme les cadres existants basés sur «value¼ en oncologie visent les thérapies systémiques, une approche adaptée à la radiothérapie est nécessaire pour améliorer l'accès aux soins innovants et optimiser l'allocation des ressources. Cet article explore les aspects économiques de la radiothérapie, en présentant les déterminants des coûts, ainsi qu'une discussion sur diverses stratégies et sur la manière dont elles peuvent répondre aux défis spécifiques de la radiothérapie.

Quality of hospital care and clinical outcomes: a comparison between the Lombardy Region and the Italian national data.

Background: Improving the quality and effectiveness of healthcare is a key priority in health policy. The emergence of the COVID-19 pandemic has exerted considerable pressure on hospital networks, requiring unprecedented reorganization and restructuring actions. This study analyzed data from the Italian National Outcomes Program to compare some volumes and outcomes of public and private accredited hospitals in the Lombardy Region with national data. Study design: Observational study. Methods: A thorough examination of hospital outcomes between 2019 and 2021 was conducted, considering 45 volume indicators and 48 process and outcome indicators, comparing Lombardy with other Italian regions and public versus private accredited hospitals. Results: In 2020, Italy and Lombardy experienced a considerable reduction in overall hospital admissions, with Lombardy showing a deeper decline (21.3% compared with 16.0% in Italy). In 2021, both experienced a partial recovery, especially marked in the Lombardy region (+7.3%, compared with national data). Focusing specifically on the private sector in Lombardy, a recovery of +9.3% in hospitalization was observed. In the analysis of clinical outcomes, Lombardy outperformed the national average for 63% of the indicators in 2020 and 83.3% in 2021. Conclusions: The study shows the continuing decline in volumes compared to 2019 (pre-COVID), the excellent performance of hospitals in Lombardy and a relevant contribution for the volumes and the quality of outcomes of private accredited hospitals.

Defining the Values and Quality of Life of Cancer Survivors Following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: An International Survey Study.

BACKGROUND: Advances in treatment of peritoneal surface malignancies including cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS±HIPEC) have led to long-term survivorship, yet the subsequent quality of life (QOL) and values of these patients are unknown. PATIENTS AND METHODS: Survivors were offered surveys via online support groups. Novel items assessed how patients prioritized experience, costs, longevity, and wellbeing. RESULTS: Of the 453 gastrointestinal/hepatobiliary (GI/HPB) surgical patients that responded, 74 underwent CRS±HIPEC and were 54±12 years old, 87% female, and 93% white. Respondents averaged 29 months from diagnosis, with a maximum survival of 20 years. With a moderate level of agreement (W = 39%), rankings of value metrics among respondents were predictable (p < 0.001). Longevity and functional independence were ranked highest; treatment experience and cost of treatment were ranked lowest (p < 0.001). Those who underwent CRS±HIPEC or other GI/HPB surgeries reported the same rank order. QOL in CRS±HIPEC survivors, both mental (M-QOL) (44±13) and physical (P-QOL) (41±11) were lower than in the general population (50±10); p < 0.001. Impairments persisted throughout survivorship, but M-QOL improved over time (p < 0.05). When comparing CRS±HIPEC with other GI/HPB cancer surgery survivors, M-QOL (43±13 versus 43±14, p = 0.85) and P-QOL (40±11 versus 42±12, p = 0.41) were similar. CONCLUSIONS: Although CRS±HIPEC survivors experience long-term mental and physical health impairments, they were similar to those experienced by survivors of other GI/HPB cancer surgeries, and their QOL improved significantly throughout survivorship. As CRS±HIPEC survivors prioritize longevity above all other metrics, survival benefit may outweigh a temporary reduction in QOL.

Healthcare utilization and costs among intracranial meningioma patients during long-term follow-up.

PURPOSE: Few studies have reported on healthcare utilization and costs for intracranial meningioma patients, while the tumor and its treatment profoundly affect patients' functioning and well-being. Here we evaluated healthcare utilization and costs, including their determinants. METHODS: A multicenter cross-sectional study of adult meningioma patients ≥ 5 years after intervention. Patients completed three validated patient-reported outcome measures (PROMs) assessing patients 'functioning and wellbeing (SF-36, EORTC QLQ-BN20, and HADS) and a study-specific questionnaire assessing healthcare utilization over the previous twelve months. Healthcare costs of the twelve months prior were calculated using reported healthcare utilization ≥ 5 years after intervention by the Dutch Manual for Economic Evaluation in Healthcare. Determinants for healthcare utilization and costs were determined with regression analyses. RESULTS: We included 190 patients with WHO grade I or II meningioma after a mean follow-up since intervention of 9.2 years (SD 4.0). The general practitioner (80.5%), physiotherapist (37.9%), and neurologist (25.4%) were visited most often by patients. Median annual healthcare costs were €871 (IQR €262-€1933). Main contributors to these costs were medication (45.8% of total costs, of which anti-seizure medication was utilized most [21.6%]), specialist care (17.7%), and physiotherapy (15.5%). Lower HRQoL was a significant determinant for higher healthcare utilization and costs. CONCLUSION: In patients with meningioma, medication costs constituted the largest expenditure of total healthcare costs, in particular anti-seizure medication. Particularly a lower HRQoL was a determinant for healthcare utilization and costs. A patient-specific approach aimed at improving patients' HRQoL and needs could be beneficial in reducing disease burden and functional recovery.

Diagnostic radiology and its future: what do clinicians need and think?

OBJECTIVE: To investigate the view of clinicians on diagnostic radiology and its future. METHODS: Corresponding authors who published in the New England Journal of Medicine and the Lancet between 2010 and 2022 were asked to participate in a survey about diagnostic radiology and its future. RESULTS: The 331 participating clinicians gave a median score of 9 on a 0-10 point scale to the value of medical imaging in improving patient-relevant outcomes. 40.6%, 15.1%, 18.9%, and 9.5% of clinicians indicated to interpret more than half of radiography, ultrasonography, CT, and MRI examinations completely by themselves, without consulting a radiologist or reading the radiology report. Two hundred eighty-nine clinicians (87.3%) expected an increase in medical imaging utilization in the coming 10 years, whereas 9 clinicians (2.7%) expected a decrease. The need for diagnostic radiologists in the coming 10 years was expected to increase by 162 clinicians (48.9%), to remain stable by 85 clinicians (25.7%), and to decrease by 47 clinicians (14.2%). Two hundred clinicians (60.4%) expected that artificial intelligence (AI) will not make diagnostic radiologists redundant in the coming 10 years, whereas 54 clinicians (16.3%) thought the opposite. CONCLUSION: Clinicians who published in the New England Journal of Medicine or the Lancet attribute high value to medical imaging. They generally need radiologists for cross-sectional imaging interpretation, but for a considerable proportion of radiographs, their service is not required. Most expect medical imaging utilization and the need for diagnostic radiologists to increase in the foreseeable future, and do not expect AI to make radiologists redundant. CLINICAL RELEVANCE STATEMENT: The views of clinicians on radiology and its future may be used to determine how radiology should be practiced and be further developed. KEY POINTS: • Clinicians generally regard medical imaging as high-value care and expect to use more medical imaging in the future. • Clinicians mainly need radiologists for cross-sectional imaging interpretation while they interpret a substantial proportion of radiographs completely by themselves. • The majority of clinicians expects that the need for diagnostic radiologists will not decrease (half of them even expect that we need more) and does not believe that AI will replace radiologists.