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.

Barriers and facilitators of meaningful patient participation at the collective level in healthcare organizations: A systematic review.

INTRODUCTION: Collective patient participation, such as patient participation in policy making, has become increasingly important to achieve high-quality care. However, there is little knowledge on how to let patients participate in a meaningful manner at this level. The aim of this systematic literature review was to provide an overview of barriers, facilitators, and associated impact of collective patient participation. METHODS: PubMed and EMBASE were searched until May 2023 for studies that evaluated collective patient participation. Study characteristics, methods for patient participation, barriers and facilitators, and impact (if measured) of patient participation were extracted from the articles. RESULTS: We included 59 articles. Identified barriers and facilitators of collective patient participation were grouped into five categories: (1) preconditions for patient participation, (2) strategy for patient participation, (3) preparation of patients and staff for patient participation, (4) support for patients and staff during patient participation, and (5) evaluation of patient participation. Impact of patient participation was reported in 34 included studies at three levels: quality of care and research, the team and organization, and the participants themselves. Only three studies reported quantitative outcomes. CONCLUSION: Interestingly, similar challenges were experienced during a period of twenty years, indicating that little progress has been made in structuring patient participation. Our overview of barriers and facilitators will therefore help to improve and structure collective patient participation.

How to Use Lean Thinking for the Optimization of Clinical Pathways: A Systematic Review and a Proposed Framework to Analyze Pathways on a System Level.

Lean Thinking and clinical pathways are commonly used concepts to improve healthcare. However, little is known on how to use Lean Thinking for the optimization of pathways or the quantification of both concepts. This study aims to create a framework to analyze pathways with Lean Thinking on a system level, by quantifying the seven wastes, flow and pull. A systematic literature review was performed. Inclusion criteria were the focus of the article on a well-defined group of patients and studied a pathway optimization with Lean Thinking. Data were extracted on measured outcomes, type of intervention and type of researched pathway. Thirty-six articles were included. No articles described the implementation of the Lean Thinking philosophy or studied the development of their people and partners ("4 P" model). Most articles used process optimization tools or problem-solving tools. The majority of the studies focused on process measures. The measures found in the review were used as input for our suggested framework to identify and quantify wastes, flow, and pull in a clinical pathway. The proposed framework can be used to create an overview of the improvement potential of a pathway or to analyze the level of improvement after an enhancement is introduced to a pathway. Further research is needed to study the use of the suggested quantifications.

Real-world outcomes of first-line chemotherapy for unresectable stage III and IV bladder cancer.

PURPOSE: For many malignancies, considerable divergence between the efficacy found in clinical trials and effectiveness in routine practice have been reported (efficacy-effectiveness gap). The purpose of this study was to evaluate the efficacy-effectiveness gap in palliative first-line (1L) chemotherapy treatment (CTx) for urothelial carcinoma of the bladder. METHODS: From seven Dutch teaching hospitals, all patients diagnosed with unresectable stage III (cT2-4aN1-3M0) and IV (cT4b and/or cM1) disease, who received 1L-CTx (for both primary as recurrent disease after radical cystectomy) between 2008 and 2016, were captured. Results were compared with data from seven randomised trials that investigated 1L gemcitabine + cisplatin (GemCis) and/or gemcitabine + carboplatin (GemCarbo). RESULTS: Of the 835 included patients, 191 received 1L-CTx. Median overall survival (mOS) of GemCis patients (N = 88) was 10.4 months [95% CI 7.9-13.0], which was shorter compared to clinical trial findings (range mOS: 12.7-14.3 months) despite comparable clinical characteristics. The mOS of GemCarbo patients (N = 92) was 9.3 months [95% CI 7.5-11.1]. Patients who received GemCarbo had worse prognostic characteristics (higher age, impaired renal function and worse performance status (all P-values < 0.001)) compared to GemCis patients, but were equal in occurrence of dose reductions (24.4% vs. 29.5%, P-value = 0.453), early termination (55.7% vs. 54.1%, P-value = 0.839), clinical best response (P-value = 0.733), and toxicity (68.1% vs. 63.3%, P-value = 0.743). In multivariable regression, GemCis was not superior to GemCarbo (HR 0.90 [95% CI 0.55-1.47], P-value = 0.674). CONCLUSION: There seems to be an efficacy-effectiveness gap in 1L GemCis treatment, despite patients having similar baseline characteristics. Early termination of treatment occurred more often and dose reduction less often compared to clinical trials, hinting towards abandonment of treatment in case of adverse events. Patients treated with 1L GemCis did not have superior survival compared to GemCarbo patients, even though GemCarbo patients had worse baseline characteristics.

Outcomes in pulmonary sarcoidosis: results of a newly implemented prednisone protocol.

Background and aim Prednisone is used as first-line therapy for patients with pulmonary sarcoidosis. There is however no clear association between prednisone dose and FVC change in patients with pulmonary sarcoidosis. In order to improve our standard of care we introduced a more conservative prednisone protocol. Methods This study is a single centre observational study, applying value-based healthcare (VBHC) and quality improvement (QI) principles. Prednisone intake was reduced from a starting dose of 40 mg to a starting dose of 20 mg. Primary outcomes evaluated were FVC, FEV1 and DLCO % predicted. The secondary outcome measure was BMI. Results 369 patients were included in the old-cohort and 215 in the new-cohort. In the old-cohort, 182 (49.0%) of the patients were treated with prednisone. In total, 114 patients (62.6%) were treated according to the old protocol with a mean initial prednisone dose of 32.1 ±14.2 mg. In the new-cohort, 93 patients (45.0%) were treated with prednisone of which 53 patients (57.0%) received prednisone according to the new protocol. The mean initial prednisone dose in the new-cohort was 21.4 ±9.8 mg. Changes in FVC and FEV1 % predicted did not vary. Change in % predicted DLCO was 2.4 ±9.3 for the old-cohort and -1.3 ±11.4 for the new-cohort (p = 0.01). No statistically significant changes in BMI were observed. Conclusions Our results indicate that in more than half of the patients the new protocol was followed. Data support the observation that a more conservative prednisone regimen might be equally effective, looking at changes in pulmonary function and BMI.

Five years' experience with value-based quality improvement teams: the key factors to a successful implementation in hospital care.

BACKGROUND: In recent years, value-based healthcare (VBHC) has become one of the most accepted concepts for fixing the 'broken' healthcare systems. Numerous hospitals have embraced VBHC and are trying to implement value-based quality improvement (VBQI) into their practice. However, there is a lack of knowledge on how to practically implement VBHC and organizations differ in their approach. The aim of this study was to explore the main factors that were experienced as hindering and/or supporting in the implementation of VBQI teams in hospital care. METHODS: A qualitative study was performed with semi-structured interviews with 43 members of eight VBQI teams in a large Dutch top-clinical teaching hospital. Participants included physicians, physician assistants, nurses, VBHC project leaders, managers, social workers, researchers and paramedics. Interview grids were structured according to the RE-AIM model (reach, effectiveness, adoption, implementation and maintenance). A thematic content analysis with open coding was used to identify emerging (sub)themes. RESULTS: We identified nine main factors divided over three domains (organization, culture and practice) that determined whether the implementation of VBQI teams was successful or not: 1). Practical organization of value-based quality improvement teams, 2). Organizational structure 3). Integration of VBHC with existing quality improvement approaches and research 4). Adoption and knowledge of the VBHC concept in the hospital 5). Multidisciplinary engagement 6). Medical leadership 7). Goal setting and selecting quality improvement initiatives 8). Long-cycle benchmarking and short-cycle feedback 9). Availability of outcome data. CONCLUSIONS: Overall, this study goes beyond the general VBHC theory and provides healthcare providers with more detailed knowledge on how to practically implement value-based quality improvement in a hospital care setting. Factors in the 'organization' and 'practice' domain were mentioned in the strategic value agenda of Porter and Lee. Though, this study provides more practical insight in these two domains. Factors in the 'culture' domain were not mentioned in the strategic value agenda and have not yet been thoroughly researched before.

Effectiveness and implementation of SHared decision-making supported by OUTcome information among patients with breast cancer, stroke and advanced kidney disease: SHOUT study protocol of multiple interrupted time series.

INTRODUCTION: Within the value-based healthcare framework, outcome data can be used to inform patients about (treatment) options, and empower them to make shared decisions with their health care professional. To facilitate shared decision-making (SDM) supported by outcome data, a multicomponent intervention has been designed, including patient decision aids on the organisation of post-treatment surveillance (breast cancer); discharge location (stroke) and treatment modality (advanced kidney disease), and training on SDM for health care professionals. The SHared decision-making supported by OUTcome information (SHOUT) study will examine the effectiveness of the intervention and its implementation in clinical practice. METHODS AND ANALYSIS: Multiple interrupted time series will be used to stepwise implement the intervention. Patients diagnosed with either breast cancer (N=630), stroke (N=630) or advanced kidney disease (N=473) will be included. Measurements will be performed at baseline, three (stroke), six and twelve (breast cancer and advanced kidney disease) months. Trends on outcomes will be measured over a period of 20 months. The primary outcome will be patients' perceived level of involvement in decision-making. Secondary outcomes regarding effectiveness will include patient-reported SDM, decisional conflict, role in decision-making, knowledge, quality of life, preferred and chosen care, satisfaction with the intervention, healthcare utilisation and health outcomes. Outcomes regarding implementation will include the implementation rate and a questionnaire on the health care professionals' perspective on the implementation process. ETHICS AND DISSEMINATION: The Medical research Ethics Committees United in Nieuwegein, the Netherlands, has confirmed that the Medical Research Involving Human Subjects Act does not apply to this study. Bureau Onderzoek & Innovatie of Santeon, the Netherlands, approved this study. The results will contribute to insight in and knowledge on the use of outcome data for SDM, and can stimulate sustainable implementation of SDM. TRIAL REGISTRATION NUMBER: NL8374, NL8375 and NL8376.

Development of an online patient decision aid for kidney failure treatment modality decisions.

BACKGROUND: Patient decision aids (PtDAs) support patients and clinicians in shared decision-making (SDM). Real-world outcome information may improve patients' risk perception, and help patients make decisions congruent with their expectations and values. Our aim was to develop an online PtDA to support kidney failure treatment modality decision-making, that: 1) provides patients with real-world outcome information, and 2) facilitates SDM in clinical practice. METHODS: The International Patient Decision Aids Standards (IPDAS) development process model was complemented with a user-centred and convergent mixed-methods approach. Rapid prototyping was used to develop the PtDA with a multidisciplinary steering group in an iterative process of co-creation. The results of an exploratory evidence review and a needs-assessment among patients, caregivers, and clinicians were used to develop the PtDA. Seven Dutch teaching hospitals and two national Dutch outcome registries provided real-world data on selected outcomes for all kidney failure treatment modalities. Alpha and beta testing were performed to assess the prototype and finalise development. An implementation strategy was developed to guide implementation of the PtDA in clinical practice. RESULTS: The 'Kidney Failure Decision Aid' consists of three components designed to help patients and clinicians engage in SDM: 1) a paper hand-out sheet, 2) an interactive website, and 3) a personal summary sheet. A 'patients-like-me' infographic was developed to visualise survival probabilities for each treatment modality on the website. Other treatment outcomes were incorporated as event rates (e.g. hospitalisation rates) or explained in text (e.g. the flexibility of each treatment modality). No major revisions were needed after alpha and beta testing. During beta testing, some patients ignored the survival probabilities because they considered these too confronting. Nonetheless, patients agreed that every patient has the right to choose whether they want to view this information. Patients and clinicians believed that the PtDA would help patients make informed decisions, and that it would support values- and preferences-based decision-making. Implementation of the PtDA has started in October 2020. CONCLUSIONS: The 'Kidney Failure Decision Aid' was designed to facilitate SDM in clinical practice and contains real-world outcome information on all kidney failure treatment modalities. It is currently being investigated for its effects on SDM in a clinical trial.

Health Outcomes Management Evaluation-A National Analysis of Dutch Heart Care.

AIMS: A group of heart centres in the Netherlands have been at the forefront internationally to implement the principles of value-based healthcare. This study aims to give an up-to-date assessment of outcome-based quality improvement in 2020 at a national level in Dutch heart care. METHODS AND RESULTS: Physicians and healthcare professionals for each participating hospital filled out a questionnaire with 26 detailed questions on quality improvement and organization of care. In total, 20 hospitals participated; 11 heart centres with thoracic surgery and 9 without thoracic surgery. Results show that outcome reports are actively used within the heart centres to support quality improvement initiatives. In 50% of the centres, apart from physicians, also nurses and hospital management are involved. For 60% of the heart centres, outcome measurement is embedded in strategy and annual plans. The stage of development of supporting IT infrastructure (outcome measurement in the Electronic Health Record and dashboards) is very diverse. A wide range of different learning strategies supports outcome-based quality improvement. CONCLUSION: Health outcomes have become a relevant element in quality improvement and organization of Dutch heart centres. Earlier research shows that in 2012-2016 heart centres focused mainly on measuring outcomes. Now in 2020, heart centres are more able to actually use the acquired insights based on these measurements to initiate improvement projects. The diversity in how this is done indicates that this field is still strongly developing and shows potential for heart centres to share best practices in the implementation of value-based healthcare.

The new strategic agenda for value transformation.

The model for value-based healthcare introduced in 2006 by Porter and Teisberg is still relevant, but it is incomplete. Porter and Teisberg put a strong focus on measuring outcomes, but how to use these measurements to actually improve quality of care has not been described. In addition, value-based healthcare as originally introduced neglects that a true shift from volume to patient value requires a change in culture and way of working of healthcare professionals. The original strategic agenda for value transformation (in short: 'value agenda') consists of six elements: organize into Integrated Practice Units (1), measure outcomes and costs for every patient (2), move to bundled payments for care cycles (3), integrate care delivery systems (4), expand geographic reach (5), and build an enabling information technology platform (6). For value-based healthcare to become a reality, the strategic agenda needs to be extended with four elements. First, healthcare providers need to set up a systematic approach for value-based quality improvement. Second, value needs to be integrated in patient communication. Third, we should invest in a culture of value delivery. And fourth, we should build learning platforms for healthcare professionals based on patient outcome data. Best practices on value-based healthcare implementation are working on these four elements in addition to the original value agenda. In conclusion, a new strategic agenda for value transformation is proposed that combines the vision of the founders of value-based healthcare with implementation experience in order to support healthcare providers in their shift to become value-based.

Development of the First Patient-centred Set of Outcomes for Muscle-invasive and Metastatic Bladder Cancer: A Multicentre Initiative.

BACKGROUND: To improve and compare outcomes in healthcare, it is necessary to standardise outcome measurements. There are no widely accepted standardised outcome measures reflecting quality of care for bladder cancer (BCa) patients. OBJECTIVE: The aim of this study was to create a standardised set of outcomes for patients with muscle-invasive or metastatic BCa, using the value-based healthcare principles. DESIGN SETTING AND PARTICIPANTS: A multidisciplinary working group of 25 healthcare professionals and patient representatives was assembled, to develop the set. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: We used an online RAND-modified Delphi process to prioritise, discuss, and reach consensus regarding the outcomes, case-mix variables, and treatment factors. RESULTS AND LIMITATIONS: Recognising the heterogeneity of patients with BCa, the working group defined the scope as patients with muscle-invasive and metastatic BCa. A total of 24 outcomes, including ten patient-reported outcomes, were included in the standard set of outcomes, covering survival, complication rates, recurrence of disease, readmissions after treatment, and quality of life (QoL). Fourteen case-mix variables were included. The EQ-5D and European Organisation for Research and Treatment of Cancer quality of life (EORTC-QLQ) questionnaires were recommended to measure QoL. CONCLUSIONS: We developed the first standardised set of patient-centred outcomes for muscle-invasive and metastatic BCa. The sue of this set enables institutions to monitor, compare, and improve the quality of BCa care, on an international level. PATIENT SUMMARY: Our group of healthcare professionals and patient representatives recommended a standardised set of patient-centred outcomes to be followed during the treatment of patients with muscle-invasive or metastatic bladder cancer, in order to monitor, compare, and improve the quality of care.

Increased long-term mortality after open colorectal cancer surgery: A multicentre population-based study.

AIM: Unlike meta-analyses of randomized controlled trials, population-based studies in colorectal cancer (CRC) patients have shown a significant association between open surgery and increased 30- and 90-day mortality compared with laparoscopic surgery. Long-term mortality, however, is scarcely reported. This retrospective population-based study aimed to compare long-term mortality after open and laparoscopic surgery for CRC. METHOD: The Dutch Colorectal Audit and the Dutch Cancer Centre registry were used to identify patients from three large nonacademic teaching hospitals who underwent curative resection for CRC between 2009 and 2018. Patients with relative contraindications for laparoscopic surgery (cT4 or pT4 tumours, distant metastasis requiring additional resection and emergency surgery) were excluded. Multivariable regression was used to assess the effect of laparoscopic surgery on long-term mortality with adjustment for gender, age, American Society of Anesthesiologists score, TNM stage, chemoradiation therapy and other confounders. RESULTS: We included 4531 patients, of whom 1298 (29%) underwent open surgery. The median follow-up was 43 months (interquartile range 23-71 months). Open surgery was associated with an increased risk of long-term mortality (adjusted hazard ratio 1.26, 95% confidence interval 1.10-1.45, p = 0.001). Mixed-effects Cox regression with year of surgery as a random effect also showed an increased risk after open surgery (adjusted hazard ratio 1.33, 95% confidence interval 1.11-1.52, p = 0.004). CONCLUSION: Open surgery seems to be associated with increased long-term mortality in the elective setting for CRC patients. A minimally invasive approach might improve long-term outcomes.

Patterns of healthcare resource utilization in patients with sarcoidosis: a cross-sectional study.

BACKGROUND: Limited data are available on healthcare resource use and costs in patients with sarcoidosis. OBJECTIVES: The primary aim of this study was to describe cost-drivers of the top 1% and top ≥1-5% high-cost patients with sarcoidosis. The secondary aim was to compare costs of patients with and without fatigue complaints and to compare comorbidities. METHODS: We conducted a retrospective observational cross-sectional study in 200 patients diagnosed with sarcoidosis. Hospital administrative databases were used to extract healthcare utilization on the individual patient level. Healthcare costs were categorized into nine groups. RESULTS: Average total health care costs for the top 1% (n=22), top ≥1%-5% (n=88) and bottom 95% beneficiaries (n=90) were € 108.296, €53.237 and €4.817, respectively. Mean treatment time in days for the top 1%, top ≥1-5% and the random sample of the bottom 95% was 1688 days (±225), 1412 days (±367) and 775 days (±659), respectively. Mean annual costs for the top 1%, top ≥1-5% and the random sample of the bottom 95% are €51.082, €27.840 and €8.692, respectively. We identified three cost-drivers in the top 5% high-cost patients: 1) expensive medication, 2) intensive care and 3) costs made at the respiratory unit. Patients with and without fatigue showed to have comparable mean costs. High-cost patients were more likely to have multiple organs involved due to sarcoidosis. CONCLUSIONS: We identified expensive medication as the main cost-driver in the top 5% high-cost patients with sarcoidosis. The study findings can help to tailor interventions for improving the quality of care and reducing overall costs. (Sarcoidosis Vasc Diffuse Lung Dis 2020; 37 (3): e2020002).

Treatment patterns and clinical outcomes of chemotherapy treatment in patients with muscle-invasive or metastatic bladder cancer in the Netherlands.

This retrospective study was performed to evaluate real-world oncological outcomes of patients treated with chemo-based therapy for muscle-invasive or metastatic bladder cancer (MIBC/mBC) and compare results to data from RCTs and other cohorts. Among 1578 patients diagnosed, 470 (30%) had MIBC/mBC. Median overall survival (mOS) for RC alone (47 months), first-line (13 months) and second-line (7 months) chemotherapy, and chemotherapy for recurrent disease (8 months) were similar to literature. Treatment with neoadjuvant and induction chemotherapy (NAIC) was only utilized in 9% of patients, and often in patients with poor disease status, resulting in a lower mOS compared to literature (35 and 20 months, respectively). Patients treated with chemotherapy had many adversities to treatment, with only 50%, 13%, 18% and 7% of patients in NAIC, first-line, salvage after RC, and second-line setting completing the full pre-planned chemotherapy treatment. Real-world data shows NAIC before RC is underutilized. Adversities during chemotherapy treatment are frequent, with many patients requiring dose reduction or early treatment termination, resulting in poor treatment response. Although treatment efficacy between RCTs and real-world patients is quite similar, there are large differences in baseline characteristics and treatment patterns. Possibly, results from retrospective studies on real-world data can deliver missing evidence on efficacy of chemotherapy treatment on older and 'unfit' patients.

Selecting interventions to improve patient-relevant outcomes in health care for aortic valve disease - the Intervention Selection Toolbox.

BACKGROUND: Measuring and improving outcomes is a central element of value-based health care. However, selecting improvement interventions based on outcome measures is complex and tools to support the selection process are lacking. The goal was to present strategies for the systematic identification and selection of improvement interventions applied to the case of aortic valve disease and to combine various methods of process and outcome assessment into one integrated approach for quality improvement. METHODS: For this case study a concept-driven mixed-method approach was applied for the identification of improvement intervention clusters including: (1) benchmarking outcomes, (2) data exploration, (3) care delivery process analysis, and (4) monitoring of ongoing improvements. The main outcome measures were long-term survival and 30-day mortality. For the selection of an improvement intervention, the causal relations between the potential improvement interventions and outcome measures were quantified followed by a team selection based on consensus from a multidisciplinary team of professionals. RESULTS: The study resulted in a toolbox: the Intervention Selection Toolbox (IST). The toolbox comprises two phases: (a) identifying potential for improvement, and (b) selecting an effective intervention from the four clusters expected to lead to the desired improvement in outcomes. The improvements identified for the case of aortic valve disease with impact on long-term survival in the context of the studied hospital in 2015 include: anticoagulation policy, increased attention to nutritional status of patients and determining frailty of patients before the treatment decision. CONCLUSIONS: Identifying potential for improvement and carefully selecting improvement interventions based on (clinical) outcome data demands a multifaceted approach. Our toolbox integrates both care delivery process analyses and outcome analyses. The toolbox is recommended for use in hospital care for the selection of high-impact improvement interventions.

Organization of outcome-based quality improvement in Dutch heart centres.

AIMS: Fourteen Dutch heart centres collected patient-relevant outcomes to support quality improvements in a value-based healthcare initiative that began in 2012. This study aimed to evaluate the current state of outcome-based quality improvement within six of these Dutch heart centres. METHODS AND RESULTS: Interviews and questionnaires among physicians and healthcare professionals in the heart centres were combined in a mixed-methods approach. The analysis indicates that the predominant focus of the heart centres is on the actual monitoring of outcomes. A systematic approach for the identification of improvement potential and the selection and implementation of improvement initiatives is lacking. The organizational context for outcome-based quality improvement is similar in the six heart centres. CONCLUSION: Although these heart centres in the Netherlands measure health outcomes for the majority of cardiac diseases, the actual use of these outcomes to improve quality of care remains limited. The main barriers are limitations regarding (i) data infrastructure, (ii) a systematic approach for the identification of improvement potential and the selection and implementation of improvement initiatives, (iii) governance in which roles and responsibilities of physicians regarding outcome improvement are formalized, and (iv) implementation of outcomes within hospital strategy, policy documents, and the planning and control cycle.

Developing process measures in value-based healthcare: the case of aortic valve disease.

Background: As process measures can be means to change practices, this article presents process measures that impact on outcome measures for surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) within value-based healthcare. Methods: Desk research and observations of patient trajectories were performed to map the processes involved in TAVR and SAVR. Semistructured interviews were conducted with healthcare professionals (n=8) and patients (n=2) to explore which processes were most important in relation to a standard set of outcome measures that was already monitored. Additionally, open interviews (n=2) were held to prioritise results. A focus group was performed for validation of the formulated process measures. Numerical data for these measures was not collected. Results: Process maps of the full cycle of care of TAVR and SAVR treatments in theory and in practice were developed. 28 processes were found important by interview participants due to their expected impact on patient-relevant outcomes. Seven processes were prioritised to be most important and were formulated into 12 process measures for both TAVR and SAVR: 'Number of times that deficient information provision to SAVR patients causes negative outcomes', 'Type of TAVR/SAVR prosthesis', 'Brand of TAVR prosthesis', 'Number of times the frailty score of a TAVR/SAVR patient >75 years is measured', 'Time between TAVR/SAVR surgery indication and surgery', 'Number of times that anticoagulants are stopped within 3 days before surgery', 'Time in hours between TAVR/SAVR surgery and permanent pacemaker implantation' and 'Percentage of standardised pain measurements'. Conclusion: This study proposes an addition of select process measures to standard sets of outcome measures to improve healthcare quality. It illustrates a clear method for identifying process measures with impact on health outcomes in the future.

Results of the standard set for pulmonary sarcoidosis: feasibility and multicentre outcomes.

Our study presents findings on a previously developed standard set of clinical outcome data for pulmonary sarcoidosis patients. We aimed to assess whether changes in outcome varied between the different centres and to evaluate the feasibility of collecting the standard set retrospectively. This retrospective observational comparative benchmark study included six interstitial lung disease expert centres based in the Netherlands, Belgium, the UK and the USA. The standard set of outcome measures included 1) mortality, 2) changes in pulmonary function (forced vital capacity (FVC), forced expiratory volume in 1 s, diffusing capacity of the lung for carbon monoxide), 3) soluble interleukin-2 receptor (sIL-2R) change, 4) weight changes, 5) quality-of-life (QoL) measures, 6) osteoporosis and 7) clinical outcome status (COS). Data collection was considered feasible if the data were collected in ≥80% of all patients. 509 patients were included in the retrospective cohort. In total six patients died, with a mean survival of 38±23.4 months after the diagnosis. Centres varied in mean baseline FVC, ranging from 110 (95% CI 92-124)% predicted to 99 (95% CI 97-123)% pred. Mean baseline body mass index (BMI) of patients in the different centres varied between 27 (95% CI 23.6-29.4) kg·m-2 and 31.8 (95% CI 28.1-35.6) kg·m-2. 310 (60.9%) patients were still on systemic therapy 2 years after the diagnosis. It was feasible to measure mortality, changes in pulmonary function, weight changes and COS. It is not (yet) feasible to retrospectively collect sIL-2R, osteoporosis and QoL data internationally. This study shows that data collection for the standard set of outcome measures for pulmonary sarcoidosis was feasible for four out of seven outcome measures. Trends in pulmonary function and BMI were similar for different hospitals when comparing different practices.

The implementation of change model adds value to value-based healthcare: a qualitative study.

BACKGROUND: Value-based healthcare (VBHC) is a concept that focuses on outcome measurement to contribute to quality improvement. However, VBHC does not offer a systematic approach for implementing improvement as implementation science does. The aim is to, firstly, investigate the implementation of improvement initiatives in the context of VBHC and secondly, to explore how implementation science could be of added value for VBHC and vice versa. METHODS: A case study with two cases in heart care was conducted; one without the explicit use of a systematic implementation method and the other one with the use of the Implementation of Change Model (ICM). Triangulation of data from document research, semi-structured interviews and a focus group was applied to evaluate the degree of method uptake. Interviews were held with experts involved in the implementation of Case 1 (N = 4) and Case 2 (N = 7). The focus group was held with experts also involved in the interviews (N = 4). A theory-driven qualitative analysis was conducted using the ICM as a framework. RESULTS: In both cases, outcome measures were seen as an important starting point for the implementation and for monitoring change. Several themes were identified as most important: support, personal importance, involvement, leadership, climate and continuous monitoring. Success factors included intrinsic motivation for the change, speed of implementation, complexity and continuous evaluation. CONCLUSION: Application of the ICM facilitates successful implementation of quality- improvement initiatives within VBHC. However, the practical use of the ICM shows an emphasis on processes. We recommend that monitoring of outcomes be added as an essential part of the ICM. In the discussion, we propose an implementation model that integrates ICM within VBHC.