Assessing value-based health care delivery for haemodialysis.

RATIONALE, AIMS AND OBJECTIVES: Disparities in haemodialysis outcomes among centres have been well-documented. Besides, attempts to assess haemodialysis results have been based on non-comprehensive methodologies. This study aimed to develop a comprehensive methodology for assessing haemodialysis centres, based on the value of health care. The value of health care is defined as the patient benefit from a specific medical intervention per monetary unit invested (Value = Patient Benefit/Cost). This study assessed the value of health care and ranked different haemodialysis centres. METHOD: A nephrology quality management group identified the criteria for the assessment. An expert group composed of stakeholders (patients, clinicians and managers) agreed on the weighting of each variable, considering values and preferences. Multi-criteria methodology was used to analyse the data. Four criteria and their weights were identified: evidence-based clinical performance measures = 43 points; yearly mortality = 27 points; patient satisfaction = 13 points; and health-related quality of life = 17 points (100-point scale). Evidence-based clinical performance measures included five sub-criteria, with respective weights, including: dialysis adequacy; haemoglobin concentration; mineral and bone disorders; type of vascular access; and hospitalization rate. The patient benefit was determined from co-morbidity-adjusted results and corresponding weights. The cost of each centre was calculated as the average amount expended per patient per year. RESULTS: The study was conducted in five centres (1-5). After adjusting for co-morbidity, value of health care was calculated, and the centres were ranked. A multi-way sensitivity analysis that considered different weights (10-60% changes) and costs (changes of 10% in direct and 30% in allocated costs) showed that the methodology was robust. The rankings: 4-5-3-2-1 and 4-3-5-2-1 were observed in 62.21% and 21.55%, respectively, of simulations, when weights were varied by 60%. CONCLUSIONS: Value assessments may integrate divergent stakeholder perceptions, create a context for improvement and aid in policy-making decisions.

Outcomes weighting for comprehensive haemodialysis centre assessment.

BACKGROUND: At present, there is no adequate system available for evaluating dialysis centres. OBJECTIVES: To construct an overall haemodialysis results weighting system, acceptable to the different stakeholders involved which allows the comparison of centres using a compound marker. METHOD: The Quality Management Work Group of the Spanish Society of Nephrology (WG) established a set of preselected indicators. A Focus Group, independent of the WG, was established. It was made up of nine individuals: three patients, three clinicians and three clinical managers, who assessed these indicators using an approved methodology and established the selected indicators. Finally, the indicators were weighted through three weighting stages, each separated by two debate periods, which involved the distribution of 100 points between each variable, according to the personal assessment and the debate sustained. RESULTS: The clinical results included: haemodialysis doses, anaemia, plasma calcium and phosphorus, type of vascular access, and hospitalisation days. The weighting given to each variable following the third weighting process, expressed as an average of all the factors, was as follows: clinical results 38.9; annual mortality 25.0; satisfaction with the centre 12.2; health-related quality of life 15.6; and cost 8.3 (total 100). CONCLUSIONS: The weighting structure covers relevant and overall results and includes the opinion of all stakeholders involved; all of which will increase its acceptability and widespread use and contribute to the analysis of the value produced by the centres and the improvement of the results.