The Value-Based Hospital May Not Be

The report by the Boston Consulting Group (BCG), “The Value-Base Hospital” is interesting but disappointing. “Value” is one of the three current catchwords that is used throughout the health care industry (“Quality” and “Patient-Centered” being the other two) . We know that the BCG is off to a bad start when they state, “By definition, health outcomes are specific to a given disease, medical condition, or procedure.” I don’t know where they get that definition but my 50 years of medical practice has always been informed by the understanding that health care and outcomes are specific to patients (and no 2 patients are the same). Medical conditions don’t walk into the hospital. Patients come to the hospital. They almost always have accumulated a list of diagnoses and conditions, some of which are accurate, some wrong, and a lot of “sorts of”s and “atypical”s and “suspected”s.  And they come with a variety of needs, goals, expectations, strengths and attitudes. If there is any value it has to be for each individual patient, not each condition. And only the patient knows what is of value.

The authors’ lack of awareness of the difference leads them to a narrowed appraisal of the STEMI trial. They summarize their perspective by saying, “The study found that routine thrombus aspiration before PCI did not significantly reduce mortality and, therefore, did not contribute to health care value.” What the study really found was no difference in mortality at 30 days, not 90 days, not 1 year (as in the TAPAS trial), but 30 days. And there was no other end point such as post hospital angina, shortness of breath or return to normal activity. The study wasn’t designed to detect any “health care value”. Whether or not thrombus aspiration has any value needs much more sophisticated investigation. As an aside it should be noted that Value is Quality divided by Cost. As, such, the term Value is often misused in place of Quality. Health outcomes are a measure of Quality, not Value. When stakeholders talk of value they usually mean decreased cost to them.

The International Consortium of Health Outcomes Measurement defines health outcome by saying “Outcomes are the results people care about most when seeking treatment, including functional improvement and the ability to live normal productive lives”.  For instance, for low back pain they consider the following parameters: major surgical complications, need for reoperation, need for pain medications, work status, health-related quality of life. The last three of these are important but very subjective and can be measured or scored only by creating arbitrarily weighted number scales. The BCG admits that the usual quality metrics are rejected by physicians as not relevant to patient care. However, the attempt to replace Quality” with “Outcome” is equally naïve and, by necessity, has to focus on events and procedures, not medical care. And it ignores the larger issues such as whether or not the procedures were indicated or avoidable in the first place.

Attempts to measure outcomes for medical conditions introduce a subjective quicksand of forms, questionnaires, and multiple inputs for every hospitalization or patient care episode. And, with all of that, they represent only one moment in time. As an example see the Movement Disorder Society’s 31 page Unified Parkinson’s Disease Rating Scale .

We have a long way to go before we can measure “Quality” of medical care and, as disappointing as it may be, we may never be able to measure it anymore than we can measure the quality of a poem, a symphony or a sunset or, for that matter, a kiss, the touch of a hand, or the healing power of caring. But that doesn’t mean we can’t strive for personal and compassionate excellence of medical care.

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