Multi-level analysis and evaluation of organizational improvements in thoracic surgery according to a Value-Based HealthCare approach

Abstract

Background: Value-Based HealthCare (VBHC), designed by Harvard University, is an evolving model of healthcare delivery that achieves better patient outcomes and greater financial sustainability for the healthcare professionals. According to this innovative approach, the value is determined by a panel of indicators and the ratio between results and costs. Our goal was to develop a panel of thoracic-fashioned key-performance indicators (KPIs) creating a model that could be applied in thoracic surgery for the first time, reporting our early experience.

Methods: Fifty-five indicators were developed based on literature review: 37 for outcomes and 18 for costs. Outcomes were measured by a 7 level Likert scale, while overall costs were defined through the sum of the individual economic performance on each resource indicator. An observational retrospective cross-sectional study was designed to make a cost-effective evaluation of the indicators. Therefore, the Patient Value in Thoracic Surgery (PVTS) score calculated value gained for every lung cancer patient undergoing lung resection at our surgical department.

Results: A total of 552 patients were enrolled. From 2017 to 2019 mean outcome indicators per patient were 109, 113 and 110 while mean costs per patient were 7.370, 7.536 and 7.313 euros respectively. Hospital stay and waiting time from consultation to surgery for lung cancer patients decreased from 7.3 to 5 and from 25.2 to 21.9 days, respectively. On the contrary, number of patients increased but overall costs decreased, despite cost of consumables has gone from 2.314 to 3.438 euros, since cost of hospitalization and occupancy of the operating room (OR) improved (from 4.288 to 3.158 euros). Variables analyzed showed that overall value delivered grew from 14.8 to 15.

Conclusions: Introducing a new concept of value, the VBHC theory applied to thoracic surgery may revolutionize traditional organizational management in lung cancer patients, showing how value delivered can increase in accordance with outcomes, despite the growth of part of the costs. Our panel of indicators has been created to provide an innovative score to successfully identify improvements needed and quantify their effectiveness in Thoracic Surgery and our early experience reports encouraging results.

Keywords: Thoracic surgery; Value-Based HealthCare (VBHC); enhanced recovery after surgery (ERAS); key performance indicators (KPIs); patient-centered care.

Figure 1

The overall value was obtained by dividing total outcomes per total resources, multiplying the ratio per 1,000 in order to make easier reading the results. VBHC, Value-Based HealthCare.

Figure 2

KPIs of PVTS score. List of the key performance indicators developed at our Thoracic Surgery Department. 37 indicators concerning outcomes, divided in 3 categories, were found: 16 related to clinical efficacy, 16 to patient experience and 5 to safety. 18 indicators regarding resources, also divided in 3 categories, were found: 10 about revenue costs, 6 capital costs and 2 non-financial costs. Green boxes represent indicators available at our hospital database and used by the VBHC tool. Red boxes represent the indicators not available at our hospital database. KPIs, key performance indicators; VBHC, Value-Based HealthCare; PVTS, Patient Value in Thoracic Surgery.

Figure 3

Average outcome and cost per patient. (A) Average outcome per patient on each year; the upper line represents the maximum achievable (n=126) whereas the lower line represents the minimum (n=18). The outcome performance of our clinical center, in a 3-year analysis, was constantly high: 109 in 2017, 113 in 2018, 110 in 2019. (B) Average cost per patient were 7.370 euros in 2017, 7.536 in 2018, 7.313 in 2019. (C) Annual trend of outcomes and costs indicators is reflected on the PVTS score (VBHC indicators). PVTS, Patient Value in Thoracic Surgery; VBHC, Value-Based HealthCare.

Figure 4

Outcomes in details. (A) Patient experience for each year analyzed and clinical efficacy gained per year. Based on variables evaluated at the ASST, patient experience is practically constant over the years, approaching the maximum achievable value (n=84). (B) There is an improvement in clinical efficacy value, from n=32 in 2017 to n=35 in 2019, getting closer to the maximum value (n=42). (C) Average hospital stay and waiting time for surgery went from n=25.2 in 2017 to n=21.9 in 201 and from 7.3 in 2017 to 5 in 2019 respectively, with a significant reduction.

Figure 5

Resources in details. (A) Amount of money spent per year divided in management costs and cost of capital. A decrease in the cost of capital compared to 2017 emerges, from 4.288 to 3.158 euros, and, on the contrary, management costs increased from 3.082 to 4.154 euros. (B) Operating costs were divided in consumables and medical staff for each year. The increase in operating costs in 2018 and 2019 was due to an increase in cost of materials for the OR, which reached the peak in 2018 with 3.970 euros spent for OR consumables, whilst the hourly cost of medical staff has evolved steadily. (C) Costs of hospitalization per year have considerably decreased from 3.006 euros in 2017 to 2.050 euros in 2019. OR, operating room.