What defines the "value" of robotic surgery for patients with gastrointestinal cancers? Perspectives from a U.S. Cancer Center.

The use of robotic surgery has experienced rapid growth across diverse medical conditions, with a notable emphasis on gastrointestinal cancers. The advanced technologies incorporated into robotic surgery platforms have played a pivotal role in enabling the safe performance of complex procedures, including gastrectomy and pancreatectomy, through a minimally invasive approach. However, there exists a noteworthy gap in high-level evidence demonstrating that robotic surgery for gastric and pancreatic cancers has substantial benefits compared to traditional open or laparoscopic methods. The primary impediment hindering the broader implementation of robotic surgery is its cost. The escalating healthcare expenses in the United States have prompted healthcare providers and payors to explore patient-centered, value-based healthcare models and reimbursement systems that embrace cost-effectiveness. Thus, it is important to determine what defines the value of robotic surgery. It must either maintain or enhance oncological quality and improve complication rates compared to open procedures. Moreover, its true value should be apparent in patients' expedited recovery and improved quality of life. Another essential aspect of robotic surgery's value lies in minimizing or even eliminating opioid use, even after major operations, offering considerable benefits to the broader public health landscape. A quicker return to oncological therapy has the potential to improve overall oncological outcomes, while a speedier return to work not only alleviates individual financial distress but also positively impacts societal productivity. In this article, we comprehensively review and summarize the current landscape of health economics and value-based care, with a focus on robotic surgery for gastrointestinal cancers.

A protocol for the formative evaluation of the implementation of patient-reported outcome measures in child and adolescent mental health services as part of a learning health system.

BACKGROUND: Mental health conditions affect one in seven young people and research suggests that current mental health services are not meeting the needs of most children and youth. Learning health systems are an approach to enhancing services through rapid, routinized cycles of continuous learning and improvement. Patient-reported outcome measures provide a key data source for learning health systems. They have also been shown to improve outcomes for patients when integrated into routine clinical care. However, implementing these measures into health systems is a challenging process. This paper describes a protocol for a formative evaluation of the implementation of patient-reported measures in a newly operational child and adolescent mental health centre in Calgary, Canada. The purpose is to optimize the collection and use of patient-reported outcome measures. Our specific objectives are to assess the implementation progress, identify barriers and facilitators to implementation, and explore patient, caregivers and clinician experiences of using these measures in routine clinical care. METHODS: This study is a mixed-methods, formative evaluation using the Consolidated Framework for Implementation Research. Participants include patients and caregivers who have used the centre's services, as well as leadership, clinical and support staff at the centre. Focus groups and semi-structured interviews will be conducted to assess barriers and facilitators to the implementation and sustainability of the use of patient-reported outcome measures, as well as individuals' experiences with using these measures within clinical care. The data generated by the patient-reported measures over the first five months of the centre's operation will be analyzed to understand implementation progress, as well as validity of the chosen measures for the centres' population. DISCUSSION: The findings of this evaluation will help to identify and address the factors that are affecting the successful implementation of patient-reported measures at the centre. They will inform the co-design of strategies to improve implementation with key stakeholders, which include patients, clinical staff, and leadership at the centre. To our knowledge, this is the first study of the implementation of patient-reported outcome measures in child and adolescent mental health services and our findings can be used to enhance future implementation efforts in similar settings.

A policy option towards improving efficiencies in Victorian public oral healthcare.

BACKGROUND: International oral health policy directions led by the World Health Organisation call for the inclusion of oral health within universal health coverage. The aim of this study is to perform a budget impact analysis of a policy option for a more cost-efficient oral health workforce skill-mix (dentists and oral health therapists) to provide public oral healthcare in Victoria, Australia. METHODS: Two hypothetical standard care pathways were developed. A dynamic population Markov model in TreeAge software, with a time horizon of 6 years. Two scenarios were modelled to determine: (1) base-case scenario: the threshold the dentist workforce could reduce per year, while achieving the same service delivery outputs, and (2) alternative scenario: the potential cost-savings for utilising an optimally cost-efficient oral health workforce skill-mix. RESULTS: The threshold analysis showed a minimum reduction of 13% of the dentist workforce being replaced with oral health therapists can occur without having any impact on the same service delivery outputs. Under the alternative scenario, the potential cost-savings would be AUD$1,425,037 (standard deviation 58,954). CONCLUSIONS: Governments and policy-decision makers should consider strategies in training, attracting, and retaining oral health therapists to achieve an optimally cost-efficient oral health workforce skill-mix when delivering public oral healthcare.

Business case for psychosocial interventions in clinics: potential for decrease in treatment discontinuation and costs.

RESEARCH QUESTION: From a value-based healthcare (VBHC) perspective, does an assessment of clinical outcomes and intervention costs indicate that providing cognitive behavioural therapy (CBT) or mindfulness to women seeking fertility treatment add value compared with no such intervention? DESIGN: Proof-of-concept business case based on a VBHC perspective that considers clinical outcomes and costs. Potential effects on psychological and fertility outcomes were based on existing research. Cost outcomes were estimated with a costing model for the Dutch fertility treatment setting. RESULTS: Thirty-two studies were identified; 13 were included. Women who received CBT had 12% lower anxiety, 40% lower depression and 6% higher fertility quality of life; difference in clinical pregnancy rates was six percentage points (CBT [30.2%]; control [24.2%]); difference in fertility discontinuation rates was 10 percentage points (CBT [5.5%]; control [15.2%]). Women who received training in mindfulness had 8% lower anxiety, 45% lower depression and 21% higher fertility quality of life; difference in mean clinical pregnancy rate was 19 percentage points (mindfulness [44.8%]; control [26.0%]). Potential total cost savings was about €1.2 million per year if CBT was provided and €11 million if mindfulness was provided. Corresponding return on investment for CBT was 30.7%, and for mindfulness 288%. Potential cost benefits are influenced by the assumed clinical pregnancy rates; such data related to mindfulness were limited to one study. CONCLUSIONS: The provision of CBT or mindfulness to women seeking fertility treatment could add value. Higher quality primary studies are needed on the effect of mindfulness on clinical pregnancy rates.

Does an allied health transdisciplinary stroke assessment save time, improve quality of care, and save costs? Results of a pre-/post- clinical study.

PURPOSE: Demand for stroke services is increasing. To save time and costs, stroke care could be reorganised using a transdisciplinary assessment model embracing overlapping allied health professional skills. The study compares transdisciplinary assessment to discipline-specific allied health assessment on an acute stroke unit, by evaluating assessment time, quality of care, and cost implications. METHOD: The pre-/post- clinical study used non-randomised groups and 3-month follow-up after hospital admission. Patients with confirmed/suspected stroke received usual discipline-specific allied health assessment (pre-implementation phase) or the novel transdisciplinary assessment (post-implementation phase). Staff/student assessment times (primary outcome) and medical record data (secondary outcomes) were collected. Time differences were estimated using multivariable linear regression controlling for confounding factors. Cost minimisation and sensitivity analyses estimated change in hospital resource use. FINDINGS: When the transdisciplinary assessment was used (N = 116), compared to usual assessment (N = 63), the average time saving was 37.6 min (95% CI -47.5, -27.7; p < 0.001) for staff and 62.2 min (95% CI -74.1, -50.3; p < 0.001) for students. The median number of allied health occasions of service reduced from 8 (interquartile range 4-23) to 5 (interquartile range 3-10; p = 0.011). There were no statistically significant or clinically important changes in patient safety, outcomes or stroke guideline adherence. Improved efficiency was associated with an estimated cost saving of $379.45 per patient (probabilistic 95% CI -487.15, -271.48). DISCUSSION AND CONCLUSION: Transdisciplinary stroke assessment has potential for reorganising allied health services to save assessment time and reduce healthcare costs. The transdisciplinary stroke assessment could be considered for implementation in other stroke services.

"An excellent servant but a terrible master": Understanding the value of wearables for self-management in people with cystic fibrosis and their healthcare providers - A qualitative study.

BACKGROUND: Wearables hold potential to improve chronic disease self-management in conditions like cystic fibrosis (CF) through remote monitoring, early detection of illness and motivation. Little is known about the acceptability and sustainability of integrating wearables into routine care from the perspectives of people with CF (pwCF) and their treating clinicians. METHODS: A cross-sectional qualitative study involving semi-structured interviews with adult pwCF and focus groups comprising members of a CF multidisciplinary team (MDT) were conducted at a specialist CF centre in Australia. A phenomenological orientation underpinned the study. Inductive thematic analysis was performed using the Framework method. The study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. RESULTS: Nine pwCF and eight members of a CF MDT, representing six clinical disciplines, participated in the study. Eight themes were inductively generated from the data, of which four were identified from each group. PwCF valued wearables for providing real-time data to motivate healthy behaviours and support shared goal-setting with healthcare providers. Wearables did not influence adherence to CF-specific self-management practices and had some hardware limitations. Members of the CF MDT recognised potential benefits of remote monitoring and shared goal-setting, but advised caution regarding data accuracy, generating patient anxiety in certain personality traits, and lack of evidence supporting use in CF self-management. CONCLUSIONS: Perspectives on integrating wearables into CF care were cautiously optimistic, with emerging risks related to patient anxiety and lack of evidence moderating acceptance.

Value-Based Health Care Implementation: The Case Study of mTBI Biomarkers.

Traumatic brain injury is a significant global health issue, affecting approximately 69 million people annually. Early diagnosis is crucial for effective management, and biomarkers provide a promising approach to identifying traumatic brain injury in various settings. This study investigates the perceived usefulness of biomarker testing in two distinct contexts: emergency departments and sports settings. Comprehensive interviews were conducted among healthcare professionals in emergency departments and sports-related medical staff. The interviews assessed their perceptions of the diagnostic accuracy, practicality, and overall value of traumatic brain injury biomarker testing. The findings indicate that the perceived usefulness of biomarker testing is high among professionals in both settings. However, significant differences emerged in the perceived barriers to implementation, with emergency department staff citing logistical issues and sports professionals expressing cost concerns. Addressing identified barriers could enhance the adoption and effectiveness of these tests, ultimately improving patient outcomes. Future research should focus on optimizing testing protocols and reducing implementation challenges. This study aims to evaluate the implementation of mild traumatic brain injury biomarkers within the framework of value-based health care, focusing on diagnostic accuracy and patient outcomes.

Selecting patient-reported outcome measures: "what" and "for whom".

Patient-reported outcomes (PROMs) are becoming more widely implemented across health care for important reasons. However, with thousands of PROMs available and the science of psychometrics becoming more widely applied in health measurement, choosing the right ones to implement can be puzzling. This article provides a framework of the different types of PROMs by organizing them into 4 categories based upon "what" is being measured and "from whom" the questions are asked: (1) condition-specific and domain-specific, (2) condition-specific and global, (3) universal and global, and (4) universal and domain-specific. We delve deeper into each category with clinical examples. This framework can empower health care leaders and policymakers to make more informed decisions when selecting the best PROMs to implement, ensuring PROMs deliver on their potential to promote high quality, patient-centered care.

MMpowerment: Empowering patients with multiple myeloma for shared decision-making by developing an intervention to integrate personal preferences into digital care pathways.

OBJECTIVE: As part of a quality improvement initiative in the context of value-based health care we aimed to optimize the shared decision-making (SDM) process in the care pathway for Multiple Myeloma as part of a digital care pathway (DCP). For this, more insight was needed in health care professionals' (HCPs') perspectives on SDM, and how SDM elements could be addressed in a DCP for MM to facilitate HCPs' performance of SDM. METHODS: HCPs were interviewed as per the theory of planned behaviour and the model of organizational context and SDM (phase 1). Multidisciplinary development sessions were organized to discuss concepts of the solution with HCPs (phase 2). The solution was evaluated with two patients from the quality improvement team. RESULTS: In phase 1, ten interviews were held. HCPs' attitudes and the subjective norm towards SDM were positive, and the intention to perform SDM was high. The clinical environment (physical context, disease characteristics, assumptions about patient characteristics, and workflows) for MM posed challenges on the actual SDM behavior. Education and use of the DCP to create awareness of SDM were seen as possible facilitators for SDM. A prepared and active patient would facilitate the SDM process. In phase 2, three concept solutions were developed before arriving at the final solution. The final solution consisted of three elements to incorporate SDM steps in the DCP: 1) creating patient awareness and activation with two questions about their preferences prior to a consultation, 2) visualisation of preferences centrally in the DCP to trigger HCP to discuss them, 3) monitoring and improving SDM with patient-questionnaires after decision-making. Patients and HCPs were willing to implement it. CONCLUSION: HCPs intention to engage in SDM was high, but their actual behaviour was challenged by the clinical environment. A 3-element DCP-based intervention was developed to increase SDM. PATIENT OR PUBLIC CONTRIBUTION: Input on the solution was obtained from end-users including two patients and ten healthcare professionals.

Development of an International Standard Set of Outcomes and Measurement Methods for Routine Practice for Adults with Epilepsy: The International Consortium for Health Outcomes Measurement Consensus Recommendations.

At present, there is no internationally accepted set of core outcomes or measurement methods for epilepsy clinical practice. Therefore, the International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group of experts in epilepsy, people with epilepsy and their representatives to develop minimum sets of standardized outcomes and outcomes measurement methods for clinical practice that support patient-clinician decision-making and quality improvement. Consensus methods identified 20 core outcomes. Measurement tools were recommended based on their evidence of strong clinical measurement properties, feasibility, and cross-cultural applicability. The essential outcomes included many non-seizure outcomes: anxiety, depression, suicidality, memory and attention, sleep quality, functional status, and the social impact of epilepsy. The proposed set will facilitate the implementation of the use of patient-centered outcomes in daily practice, ensuring holistic care. They also encourage harmonization of outcome measurement, and if widely implemented should reduce the heterogeneity of outcome measurement, accelerate comparative research, and facilitate quality improvement efforts.

Development of an International Standard Set of Outcomes and Measurement Methods for Routine Practice for Infants, Children, and Adolescents with Epilepsy: The International Consortium for Health Outcomes Measurement Consensus Recommendations.

At present, there is no internationally accepted set of core outcomes or measurement methods for epilepsy clinical practice. The International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group of experts in epilepsy, people with epilepsy, and their representatives to develop minimum sets of standardized outcomes and outcome measurement methods for clinical practice. Using modified Delphi consensus methods with consecutive rounds of online voting over 12 months, a core set of outcomes and corresponding measurement tool packages to capture the outcomes were identified for infants, children, and adolescents with epilepsy. Consensus methods identified 20 core outcomes. In addition to the outcomes identified for the ICHOM Epilepsy adult standard set, behavioral, motor, and cognitive/language development outcomes were voted as essential for all infants and children with epilepsy. The proposed set of outcomes and measurement methods will facilitate the implementation of the use of patient-centered outcomes in daily practice.

Adding value for clients during work disability assessments: A qualitative exploration from the perspective of medical examiners.

BACKGROUND: Value-based healthcare delivery focuses on optimizing care provided by measuring the healthcare outcomes which are most important to the clients relative to the total care costs. However, the understanding of what adds value for clients during work disability assessment is lacking. OBJECTIVE: To explore what medical examiners (MEs) perceive as valuable during the work disability assessment process, by exploring possible: 1) facilitators, 2) barriers and 3) opportunities to add value for the client during the work disability assessment. METHODS: For this explorative qualitative study, 7 semi-structured interviews were conducted with MEs in the Netherlands. Thematic coding was performed for all interviews. RESULTS: A large variety of facilitators (n = 22), barriers (n = 17) and opportunities (n = 11) were identified and inductively subdivided into four main themes: 1) coherent process, including all time related aspects, 2) interdisciplinary collaboration, including all aspects related to the collaboration between the ME and other professionals, 3) client-centred interaction, including all aspects related to the supportive interplay from the ME towards the client, and 4) information provision on all aspects during the work disability assessment process towards the client to ensure a valuable work disability assessment process. CONCLUSIONS: The overview of identified possible facilitators, barriers and opportunities to add value for clients from the perspective of the ME may stimulate improvement in the current work disability assessment practice and to better match the client needs.

Assessing the variation and drivers of cost in 1-level lumbar fusion: a time-driven activity-based costing analysis.

BACKGROUND CONTEXT: As value-based health care arrangements gain traction in spine care, understanding the true cost of care becomes critical. Historically, inaccurate cost proxies have been used, including negotiated reimbursement rates or list prices. However, time-driven activity-based costing (TDABC) allows for a more accurate cost assessment, including a better understanding of the primary drivers of cost in 1-level lumbar fusion. PURPOSE: To determine the variation of total hospital cost, differences in characteristics between high-cost and non-high-cost patients, and to identify the primary drivers of total hospital cost in a sample of patients undergoing 1-level lumbar fusion. STUDY DESIGN/SETTING: Retrospective, multicenter (one academic medical center, one community-based hospital), observational study. PATIENT SAMPLE: A total of 383 patients undergoing elective 1-level lumbar fusion for degenerative spine conditions between November 2, 2021 and December 2, 2022. OUTCOME MEASURES: Total hospital cost of care (normalized); preoperative, intraoperative, and postoperative cost of care (normalized); ratio of most to least expensive 1-level lumbar fusion. METHODS: Patients undergoing a 1-level lumbar fusion between November 2, 2021 and December 2, 2022 were identified at two hospitals (one quaternary referral academic medical center and one community-based hospital) within our health system. TDABC was used to calculate total hospital cost, which was also broken up into: pre-, intra-, and postoperative timeframes. Operating surgeon and patient characteristics were also collected and compared between high- and non-high-cost patients. The correlation of surgical time and cost was determined. Multivariable linear regression was used to determine factors associated with total hospital cost. RESULTS: The most expensive 1-level lumbar fusion was 6.8x more expensive than the least expensive 1-level lumbar fusion, with the intraoperative period accounting for 88% of total cost. On average. the implant cost accounted for 30% of the total, but across the patient sample, the implant cost accounted for a range of 6% to 44% of the total cost. High-cost patients were younger (55 years [SD: 13 years] vs.63 years [SD: 13 years], p=.0002), more likely to have commercial health insurance (24 out of 38 (63%) vs. 181 out of 345 (52%), p=.003). There was a poor correlation between time of surgery (i.e., incision to close) and total overall cost (ρ: .26, p<.0001). Increase age (RC: -0.003 [95% CI: -0.006 to -0.000007], p=.049) was associated with decreased cost. Surgery by certain surgeons was associated with decreased total cost when accounting for other factors (p<.05). CONCLUSIONS: A large variation exists in the total hospital cost for patients undergoing 1-level lumbar fusion, which is primarily driven by surgeon-level decisions and preferences (e.g., implant and technology use). Also, being a "fast" surgeon intraoperatively does not mean your total cost is meaningfully lower. As efforts continue to optimize patient value through ensuring appropriate clinical outcomes while also reducing cost, spine surgeons must use this knowledge to lead, or at least be active participants in, any discussions that could impact patient care.

Untangling the perception of value in value-based healthcare - an interview study.

PURPOSE: Value-based health care (VBHC) argues that health-care needs to re-focus to maximise value creation, defining value as the quota when dividing the outcomes important for the patient, by the cost for health care to deliver such outcomes. This study aims to explore the perception of value among different stakeholders involved in the process of implementing VBHC at a Swedish hospital to support leaders to be more efficient and effective when developing health care. DESIGN/METHODOLOGY/APPROACH: Participants comprised 19 clinicians and non-clinicians involved in the implementation of VBHC. Semi-structured interviews were conducted and content analysis was performed. FINDINGS: The clinicians described value as a dynamic concept, dependent on the patient and the clinical setting, stating that improving outcomes was more important than containing costs. The value for non-clinicians appeared more driven by the interplay between the outcome and the cost. Non-clinicians related VBHC to a strategic framework for governance or for monitoring different continuous improvement processes, while clinicians appreciated VBHC, as they perceived its introduction as an opportunity to focus more on outcomes for patients and less on cost containment. ORIGINALITY/VALUE: There is variation in how clinicians and non-clinicians perceive the key concept of value when implementing VBHC. Clinicians focus on increasing treatment efficacy and improving medical outcomes but have a limited focus on cost and what patients consider most valuable. If the concept of value is defined primarily by clinicians' own assumptions, there is a clear risk that the foundational premise of VBHC, to understand what outcomes patients value in their specific situation in relation to the cost to produce such outcome, will fail. Health-care leaders need to ensure that patients and the non-clinicians' perception of value, is integrated with the clinical perception, if VBHC is to deliver on its promise.

Preoperative Symptoms of Depression are Associated With Worse Capability 6-weeks and 6-months After Total Hip Arthroplasty for Osteoarthritis.

BACKGROUND: Symptoms of depression have been associated with greater incapability following total hip arthroplasty (THA). A brief, 2-question, measure of symptoms of depression - the Patient Health Questionnaire-2 (PHQ-2) - may be sufficient to measure associations with the magnitude of incapability during recovery from THA. This study investigated whether preoperative symptoms of depression (measured with the PHQ-2) correlated with levels of incapability 6 weeks and 6 months after THA, accounting for demographic and clinical factors. METHODS: We performed a prospective cohort study across 5 centers and recruited 101 patients undergoing THA, of whom 90 (89%) completed follow-up. Patients completed demographics, a preoperative 2-item (PHQ-2) measure of symptoms of depression, and the Hip Dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS JR) at 6-weeks and 6-months postoperatively. Negative binomial regression models determined factors associated with HOOS JR at 6 weeks and 6 months, accounting for potential confounders. RESULTS: Accounting for potential confounding factors, we found that higher preoperative PHQ-2 scores (reflecting greater symptoms of depression) were associated with lower HOOS JR scores (reflecting a greater level of hip disability) at both 6 weeks (regression coefficient = -0.67, P < .001) and 6 months (regression coefficient = -1.9, P < .001) after THA. CONCLUSIONS: Symptoms of depression on a 2-question preoperative questionnaire are common, and greater symptoms of depression are associated with reduced capability within the first year following THA. These findings support the prioritization of routine mental health assessments before THA. Measuring mindset using relatively brief instruments will be important considering the current shift toward implementing self-reported measures of health status in clinical practice and incorporating them within alternative payment models.

Impact of a Nationwide Medication History Sharing Program on the Care Process and End-User Experience in a Tertiary Teaching Hospital: Cohort Study and Cross-Sectional Study.

Background: Timely and comprehensive collection of a patient's medication history in the emergency department (ED) is crucial for optimizing health care delivery. The implementation of a medication history sharing program, titled "Patient's In-home Medications at a Glance," in a tertiary teaching hospital aimed to efficiently collect and display nationwide medication histories for patients' initial hospital visits. Objective: As an evaluation was necessary to provide a balanced picture of the program, we aimed to evaluate both care process outcomes and humanistic outcomes encompassing end-user experience of physicians and pharmacists. Methods: We conducted a cohort study and a cross-sectional study to evaluate both outcomes. To evaluate the care process, we measured the time from the first ED assessment to urgent percutaneous coronary intervention (PCI) initiation from electronic health records. To assess end-user experience, we developed a 22-item questionnaire using a 5-point Likert scale, including 5 domains: information quality, system quality, service quality, user satisfaction, and intention to reuse. This questionnaire was validated and distributed to physicians and pharmacists. The Mann-Whiteny U test was used to analyze the PCI initiation time, and structural equation modeling was used to assess factors affecting end-user experience. Results: The time from the first ED assessment to urgent PCI initiation at the ED was significantly decreased using the patient medication history program (mean rank 42.14 min vs 28.72 min; Mann-Whitney U=346; P=.03). A total of 112 physicians and pharmacists participated in the survey. Among the 5 domains, "intention to reuse" received the highest score (mean 4.77, SD 0.37), followed by "user satisfaction" (mean 4.56, SD 0.49), while "service quality" received the lowest score (mean 3.87, SD 0.79). "User satisfaction" was significantly associated with "information quality" and "intention to reuse." Conclusions: Timely and complete retrieval using a medication history-sharing program led to an improved care process by expediting critical decision-making in the ED, thereby contributing to value-based health care delivery in a real-world setting. The experiences of end users, including physicians and pharmacists, indicated satisfaction with the program regarding information quality and their intention to reuse.

Cost-effectiveness of shoulder arthroplasty for osteoarthritis and rotator cuff tear arthropathy. An economic analysis using real-world data.

INTRODUCTION: This study aimed to assess cost-effectiveness of shoulder arthroplasty for osteoarthritis (OA) and rotator cuff tear arthropathy (CTA) from the perspective of a publicly funded health care system using patient data, health utilities and costs from a real-world situation. HYPOTHESIS: Our hypothesis was that arthroplasty for OA is more cost-effective than for CTA. MATERIAL AND METHODS: We gathered a cohort of patients with 153 anatomic total shoulder arthroplasty (TSA) for OA and 107 reverse shoulder arthroplasty (RSA) for CTA between years 2016-2020 at a university hospital. Short-term (mean 2.8years) shoulder function, health utilities and costs were obtained from prospectively collected data, and a Markov cohort simulation was carried out to assess lifetime cost-utility. The primary outcome measures were change in 15D score to calculate gain in quality-adjusted life years (QALYs) and change in Western Ontario osteoarthritis score of the shoulder (WOOS). RESULTS: Both TSA and RSA restored shoulder function well, WOOS improvement was 59.7 (95% CI: 56.2-63.2) and 55.8 (95% CI: 50.4-61.2), respectively. The cost/QALY gained was 20,846.82 € for TSA and 38,711.90 € for RSA. The cost-utility was not remarkable sensitive to costs, discounting of future costs or estimated revision rates. However, the cost-effectiveness was very sensitive to change in 15D health utility scores and thus QALY gain, especially for RSA patients. DISCUSSION: Shoulder arthroplasty restores shoulder function well in both OA and CTA. In health economic terms, RSA is less cost-effective than TSA in an everyday setting, mainly due to inferior improvement of health-related quality-of-life and reduced life expectancy of CTA patients. LEVEL OF EVIDENCE: III; case series.

Action Opportunities to Pursue Responsible Digital Care for People With Intellectual Disabilities: Qualitative Study.

BACKGROUND: Responsible digital care refers to any intentional systematic effort designed to increase the likelihood of a digital care technology developed through ethical decision-making, being socially responsible and aligned with the values and well-being of those impacted by it. OBJECTIVE: We aimed to present examples of action opportunities for (1) designing "technology"; (2) shaping the "context" of use; and (3) adjusting the behavior of "users" to guide responsible digital care for people with intellectual disabilities. METHODS: Three cases were considered: (1) design of a web application to support the preparation of meals for groups of people with intellectual disabilities, (2) implementation of an app to help people with intellectual disabilities regulate their stress independently, and (3) implementation of a social robot to stimulate interaction and physical activity among people with intellectual disabilities. Overall, 26 stakeholders participated in 3 multistakeholder workshops (case 1: 10/26, 38%; case 2: 10/26, 38%; case 3: 6/26, 23%) based on the "guidance ethics approach." We identified stakeholders' values based on bottom-up exploration of experienced and expected effects of using the technology, and we formulated action opportunities for these values in the specific context of use. Qualitative data were analyzed thematically. RESULTS: Overall, 232 effects, 33 values, and 156 action opportunities were collected. General and case-specific themes were identified. Important stakeholder values included quality of care, autonomy, efficiency, health, enjoyment, reliability, and privacy. Both positive and negative effects could underlie stakeholders' values and influence the development of action opportunities. Action opportunities comprised the following: (1) technology: development of the technology (eg, user experience and customization), technology input (eg, recipes for meals, intervention options for reducing stress, and activities), and technology output (eg, storage and use of data); (2) context: guidelines, training and support, policy or agreements, and adjusting the physical environment in which the technology is used; and (3) users: integrating the technology into daily care practice, by diminishing (eg, "letting go" to increase the autonomy of people with intellectual disabilities), retaining (eg, face-to-face contact), and adding (eg, evaluation moments) certain behaviors of care professionals. CONCLUSIONS: This is the first study to provide insight into responsible digital care for people with intellectual disabilities by means of bottom-up exploration of action opportunities to take account of stakeholders' values in designing technology, shaping the context of use, and adjusting the behavior of users. Although part of the findings may be generalized, case-specific insights and a complementary top-down approach (eg, predefined ethical frameworks) are essential. The findings represent a part of an ethical discourse that requires follow-up to meet the dynamism of stakeholders' values and further develop and implement action opportunities to achieve socially desirable, ethically acceptable, and sustainable digital care that improves the lives of people with intellectual disabilities.

Building for Value: A Foundational Structure to Support Population Health.

The journey to value relies heavily on a strong foundation in population health and on supporting systems of care. However, as the Centers for Medicare & Medicaid Services and commercial insurers rethink reimbursements to achieve cost savings, both patients and payments to health care organizations are at risk. The case for value-based care is ever stronger yet health systems will have to mature their culture, population health infrastructure, technologies and analytics capabilities, and leadership and management systems. In this article, the authors describe the functional organizational structure of the clinical transformation team responsible for population health in the University Hospitals Accountable Care Organizations (ACO). Based on their experiences building and evolving population health for the University Hospitals ACO, the authors layout the 3 pillars supporting their structure, including operations, clinical design, and data and analytics, and key areas of focus for each pillar.