Patti et al. (1) have reported an analysis of the literature searching for an evaluation of robotic liver and pancreatic surgery according to a value-based health care (VBHC) approach. This model was developed by Porter (2) in order to consider the following two aspects:
- the outcomes that matter most to patients, which are defined as the sum of patients’ health objectives;
- the costs required to achieve these results.
Currently, there is much talk about patient care and its relevance to make our healthcare system more efficient and reduce health-related costs. But what is really meant by “relevance”? In France, according to the French National Authority for Health (HAS), relevance means the “appropriate public health intervention, at the right time, at the right place, for the right patient”. However, what does relevance mean to me, as a surgeon working in a hospital? Does it mean a low rate of postoperative complications? Fewer readmissions? Shorter hospital lengths of stay?
When are we going to acknowledge the importance of replacing the “right intervention” by the “right healthcare pathway”? It is high time we consider the patient as a whole, taking into account his expectations in terms of care and his personal and professional issues? Combining a whole host of “relevant” healthcare acts does not necessarily mean that the whole healthcare pathway is relevant.
Each actor who intervenes tends to use silo thinking in relation to a short-term endpoint without integrating the specificities and expectations of the patient when it comes to choosing any therapeutic modality. For several years, this relevance evaluation has called upon two methods:
- the measurement of variations in practice (which very often depends on non-medical parameters);
- the respect of medical recommendations.
There is a third route which offers the possibility of comparing the “results that matter most to patients” with the costs induced to achieve these results. Thus we have gone from a care-based system to a health-based system, and from a short-term to a long-term perspective in order to allow the patient to achieve his life plan.
Whether in manufacturing or services, quality assurance has long since become widely used in order to satisfactorily achieve the desired level of quality. The commitment of all is mandatory to respond to the challenge of quality over quantity. In their review of literature, Patti et al. (1) reported that not one study concerning robotic HPB surgery merged the interests of all involved stakeholders to construct a complete value proposition for HPB surgery. We must collectively take the lead and jointly build up a value-based healthcare system with every actor, and truly take into account the expectations of patients. The objective is to deploy and implement optimal and tailored management modalities and arrangements. This VBHC approach follows a rigorous methodology, that is:
- to define measurement indicators for each pathology and each healthcare pathway, integrating clinical, organizational data, along with the patient’s expectations;
- to ensure the collection of data;
- to compare data in full transparency in order to understand the factors which influence the outcomes;
- to adapt the financing model which promotes virtuous practices imparting every actor with a sense of responsibility. Since the fee for healthcare service is a potentially inflationary system, the trend must be towards a financing that is tailored to the healthcare pathway or to the specific healthcare episode.
The aim now is to prompt the conditions to create a virtuous circle for the improvement of quality, namely to measure and compare means to better know and understand, to appropriate one’s results and learn from others. This constraint-free audit approach is already working, and has met great success in Sweden and in the Netherlands where it helped to better treat an increasing number of patients at a lower cost in just a few years.
Additionally, medical innovations currently face a stringent regulatory environment, making access to the markets more difficult. Besides jeopardizing companies (very often young start-ups), when evaluation takes several years to go through (while the duration of a technology is fairly short), this deprives our healthcare system of a new source of efficiency and our patients from their benefits. It is fundamental to change the evaluation modalities applied to technological and organizational innovation. This value-based healthcare approach ensures an ongoing evaluation via the use of real-time data and the integration of what really matters to our patients. Consequently, it is easy to appreciate the variations/fluctuations on the different indicators related to the introduction of technological or organizational innovations.
These novel approaches deeply change our habits and require adapted tools for data monitoring and reporting. They involve new coordinating approaches which will impact the organization and remuneration of every actor. However, we feel that this is one of the solutions that will allow to reconcile the interests of our patients and collective effectiveness, to restore flexibility and impart greater effectiveness in order to have a sustainable healthcare system.
The authors are grateful to Guy Temporal, professional in medical English proofreading, for the assistance in revising the manuscript.
Conflicts of Interest: Patrick Pessaux is a board member of Merck and an Integra orator. The other author has no conflicts of interest to declare.
- Patti JC, Ore AS, Barrows C, et al. Value-based assessment of robotic pancreas and liver surgery. Hepatobiliary Surg Nutr 2017;6:246-57. [Crossref] [PubMed]
- Porter ME. What is value in health care? N Engl J Med 2010;363:2477-81. [Crossref] [PubMed]