Patient Reported Outcome Measures: Canada’s opportunity to be a leader

By Neil Fraser & Melicent Lavers-Sailly

Given our single payer healthcare system within each province and territory, Canada is uniquely positioned to be a leader in implementing value-based healthcare by addressing both elements of the value equation: measuring outcomes that matter to patients, and integrating funding for the costs associated with those outcomes.

Before we become the leader, however, first we have to be in the race.

Leading the charge on harmonizing outcomes measurement globally is the International Consortium for Health Outcomes Measurement (ICHOM), which has developed standard sets for almost 50 per cent of the global disease burden. These standard sets not only measure acute complications, survival, and disease control, but also patient reported outcomes.  For example, if a patient has prostate surgery, the data set would measure urinary incontinence, sexual dysfunction, and vitality, in addition to complication rates, recurrence, and survival.

One of the most striking examples of the impact of measuring patient reported outcomes is their use at the Martini Klinik in Hamburg, Germany, which has one of the largest prostate cancer treatment programs in the world.  By measuring, comparing, and acting upon the results of patient reported outcomes, the program has achieved significantly better results relative to the national average — 6.5 per cent rate of incontinence versus the national average of 43.3 per cent; and 34.7 per cent rate of severe erectile dysfunction versus the national average of 75.5 per cent.

The impact of measuring and comparing results is clear. In a fragmented system, with each hospital, regional health authority, and province having its own measurement criteria, it is challenging — but necessary — to make meaningful comparisons.

Santeon, a group of six independently run hospitals in the Netherlands, aimed to address this issue by collaborating on a project entitled Collaborating for Value: The Santeon Hospitals in The Netherlands. The report outlines how the six hospitals worked together to standardize reporting of: outcomes — including the addition of patient reported outcome measures — all costs associated with surgery (e.g. diagnostics, treatment days, and outpatient visits), and processes (e.g. cancellation rates).

Santeon discovered that by sharing best practices among clinicians, and adopting a centre of excellence approach (also known as an integrated practice unit), they could improve outcomes and reduce costs. For example, by merging the radical prostatectomy programs of two hospitals, post-operative complications for prostatectomies were cut in half; and the expense of buying a second robot was spared.

They also discovered that the simple act of making data transparent had a notable impact. For example, only two hospitals decided to make reducing overnight admission rates for breast cancer care a focus for their improvement teams; nonetheless, all six hospitals reduced the rate of overnight admissions — by an average of 65 per cent — once the data was made transparent.

Canada has some of the best hospitals and physicians in the world.  Imagine the opportunity for Canada to improve clinical outcomes if we were able to leverage standard sets and compare outcome measures among our own hospitals, across provinces, and with other countries?

In addition to the impact on patients, measuring outcomes would allow governments, healthcare administrators, and care providers to measure the results of adopting new procedures, new payment models, and new technologies — including those provided by companies like Medtronic.

At the 2017 ICHOM Conference, Ernst van Koesveld, Deputy Director-General, Ministry of Health, Welfare and Sport, in the Netherlands said the country’s goals are to measure 50 per cent of outcomes by 2021, and to give 100 per cent of patients digital access to their health records by 2020. They are also planning to broadly experiment with health funding models and innovative procurement.

If a country of 17 million people has the potential to accomplish this ambitious goal in such a short timeframe, imagine what each province in Canada could accomplish?

According to Harvard Professor Michael Porter, who also spoke at the ICHOM conference, having standardized outcome measurements by clinical condition and patient segment is the single most powerful driver of improvement in healthcare.

Not surprisingly then, at an OECD conference in January 2017, Ministers of Health from around the world – including Canada – agreed, “We need to invest in measures that will help us assess whether our health systems deliver what matters most to people.”

Now that we are in agreement, we have the opportunity to act. The federal government in Canada could play a leadership role in harmonizing outcomes measurement across the country by working with the provinces and aligning with ICHOM data sets. Doing so would address the first element of the value equation.

In order to address the second element of the value equation, and to be able to act on the information gleaned from the outcomes data, we need to be prepared to also address the way we fund healthcare.

As with measuring outcomes, there are plenty of international examples of integrated funding models we could leverage.  There are even a half dozen Canadian examples of bundled payment pilots in Ontario.  We can do better though — by measuring all costs over a complete cycle of care for a specific clinical condition, not just the elements that are reimbursed. Harvard’s Dr. Robert Kaplan has shown that this time-driven, activity based costing method does work in healthcare, not just in factories.

Now that we know measuring outcomes and costs works, let’s not only join the race on a national scale, but aim to be a leader in the field.

Neil Fraser is the President of Medtronic Canada, Chair of MEDEC, the industry association representing the medical device industry in Canada, and a Member of the federal Economic Strategic Table, Health & Biosciences.  Melicent Lavers-Sailly is Senior Manager, Communications & Corporate Marketing at Medtronic Canada and a Member of the TOHealth! Marketing Working Group.