Outcomes; the key to a Healthier FutureAlong with many stakeholders in healthcare, EFPIA and its member companies believe that an outcomes- or value-focused approach to healthcare holds the key to a more sustainable, healthier future for Europe.
As the population continues to age and grow, so does the prevalence of chronic diseases such as diabetes, cardio-vascular disease and cancer. Between the ages of 45 and 65, the incidence of heart disease more than doubles, and over a quarter of people aged 85 years and over lives with dementia.
The result of these significant demographic changes is that Healthcare systems across Europe are facing unprecedented challenges.
Despite the challenges, there are many reasons to be optimistic about a healthier future for Europe. With over 7,000 medicines in development, an exciting, new wave of innovation will play a key role in addressing the challenges faced by patients, healthcare systems, and society. This pharmaceutical innovation is mirrored by developments in medical devices, diagnostics, imaging and data science.
But patients can only benefit from this innovation if it is affordable now and sustainable in the future. In the context of ageing populations and chronic disease, the adoption of innovation places additional pressure on resources. How we manage the rising healthcare demand and capitalise on the new medical innovation in a sustainable way, is the foremost question for many stakeholders in European healthcare.
Analysing our current approach to managing healthcareEurope provides some of the best healthcare in the world. It has long been a centre of excellence for medical research, education and clinical practice. But despite the progress in public health measures across countries in Europe, significant health inequalities persist. This is not simply a question of economics; the evidence suggests significant variation in treatment outcomes for patients between countries but also within countries, which cannot be explained by different levels of investment in health and healthcare.
So what lies behind the variance in patient outcomes across Europe and across national healthcare systems within Europe?
Variations in clinical practice
The fragmented nature of healthcare systems across Europe means we often see significantly different care pathways for patients and large variations in clinical practice. Healthcare providers may have received different training, use different treatment guidelines, adopt innovation or new clinical developments at varying rates, provide care in multiple settings and have a wide range of political, social and healthcare priorities. Some variation is natural since medical science is constantly in development, and some is desired because certain patients may require a different treatment, for example due to different tolerability. However, too often care practices that deliver a less than optimal outcome continue to be used, despite better methods being available.
Complex care pathways
Healthcare systems are often large and complex. A patient with multiple chronic diseases often has to deal with a whole range of providers, from primary care physicians to specialists in hospitals and physiotherapists in rehabilitation centres. Many times these different providers don’t coordinate well with each other, leaving the patient alone to navigate a complicated system. Uncoordinated care can also lead to unnecessary duplication, when the patient has to undergo the same test several times. Similarly, it can result in under-treatment, when patients “fall into the gaps” between providers, and important interventions are not undertaken.
The fragmentation in care is also mirrored in the data systems intended to capture a patient’s health data. While many systems record data on procedures and interventions, models for measuring and collecting data on health outcomes are under-developed. As such, the data available to scrutinise the effectiveness of different health interventions and identify best practice is limited. Systems that systematically do not track interventions and health outcomes of patients, lack the basis for a root-cause analysis that would tell them why one patient is achieving a better outcome than another. With many systems lacking such a comprehensive evidence base, they struggle to make effective decisions.
In any field of activity, targets and incentives drive behaviours. Healthcare systems have tended to focus on targets, measures and incentives based on inputs and procedures rather than the outcomes they deliver. Success is often defined by transactional measures such as the number of tests completed, patient visits to a Doctor or waiting times rather than by the patient’s outcomes that result from these interventions. An inevitable consequence of this approach is that priorities and resources are focused on meeting these input targets with little reference to the impact they have on patients.
The cumulative effect of variations in clinical practice, complex care pathways, data fragmentation and transaction-based incentives is variation in outcomes for patients, waste and inefficiency in the system. A recent OECD report estimates that around one fifth of health expenditure make no or minimal contribution
to health outcomes. In the context of ageing populations, increasing prevalence of chronic disease, and constrained resources, this puts the long-term sustainability of healthcare in Europe at risk. It also provides a clue to how we can re-orientate the management of healthcare to improve outcomes for patients and make them more sustainable.
What are outcomes?
Outcomes are the results of treatment that patients care about most.
Outcomes are not “outputs”; they are not lab results; they are not technical details. They’re real-world results, like physical functioning or level of pain. Unfortunately, today, in healthcare systems around the world, evaluation efforts take into account a number of clinical indicators, structural metrics, and even reputation – but they tend to ignore outcomes.
International Consortium for Outcomes Measurement (2016)
Outcomes-focused, sustainable healthcare
By re-orienting healthcare systems towards outcomes, many stakeholders, including EFPIA, believe that we can put healthcare systems in Europe on a more sustainable path.
The principle behind outcomes-focused healthcare is that healthcare systems should focus on delivering health-outcomes, rather than on delivering interventions. Focusing on outcomes addresses the central problem that healthcare systems today do not incentivise what actually matters: better health for patients.
Instead of paying for hospital beds, visits to the doctor, pills, screenings and surgical interventions, our focus should be paying for better health and longer lives. By determining exactly what type of intervention brings the best health outcome for each patient, and directing our resources to those specific measures, facilitates better health outcomes and quality of life for patients. A focus on delivering outcomes also results in more value for money and can contribute significantly to healthcare system sustainability by identifying and discontinuing interventions that do not deliver superior or that fail to deliver patient outcomes. By eliminating spending on ineffective interventions, a focus on outcomes can free up the resources required to address the healthcare needs of an ageing population and fund those innovations that deliver positive results for patients and value for systems. The potential for waste reduction is significant. It is estimated that around 20% of healthcare spending currently is wasted on ineffective interventions.
True, value-based healthcare, in which systems guide their decision based on the ratio of outcomes to cost, is still in its infancy. Healthcare systems across Europe are still grappling with how to make the concept a reality and what kinds of tools are needed to make it work. Like other potentially paradigm-shifting concepts, such as big data or mobile health, the initial excitement is followed by the realisation that system-wide change is immensely challenging. Nevertheless, at EFPIA we believe that the goal, a healthier, more sustainable future, can be realised step by step, in partnership with stakeholders across the system.
This transition will take both time and investment, and most of all political will. Member States need to invest in integrated health information systems for tracking health outcomes – with disease registries and Electronic Health Records as key components – and standardise outcomes metrics that will make it possible to compare health outcomes across providers, regions and even countries. Patient involvement is key when agreeing on these outcomes metrics, but equally so is the involvement of healthcare professionals, since a continuous evolution of evidence-based clinical practice is at the core of an outcomes-focused approach to healthcare.
The good news is that we don’t have to wait for the perfect system to be in place: change can be implemented step-by-step. Even though reduced waste and better value for money will be one of the rewards, the main driver for change must be better health outcomes and putting the patient at the centre of healthcare management. The key is to learn from each other and spread the use of models that have been proven to work.
What are the barriers to moving towards an outcomes-focused healthcare system?
Better outcomes for patients and more sustainable healthcare systems are common goals for all stakeholders in the European healthcare landscape. Outcomes-focused approaches have been around for over a decade, but system-wide change is problematic and notoriously difficult. This section explores some of the barriers to a system-wide transition to a more value- and outcomes-focused approach and can be grouped into technical, structural, financial and political aspects.
Healthcare Data: The key to outcomes-focused healthcare
As healthcare begins to embrace the digital revolution, the potential of data to change the way we deliver healthcare, improve patient outcomes and shape future research is an important new frontier. The availability of healthcare data is increasing exponentially, providing an opportunity to explore new ways to capture and analyse healthcare data and to accelerate the transition to an outcomes-focused approach.
From a pharmaceutical perspective, for several decades, the clinical trial has been the gold standard of measuring safety and efficacy. In the future, clinical trials will continue to play an important role in generating data and evidence to shape healthcare. Yet with the advent of the digital revolution, encompassing electronic health records, disease registries, patient reported outcome measures, mobile health apps and advances in data analytics, our healthcare eco-systems are generating unprecedented amounts of “real world data” (RWD) that can complement clinical trial data in important ways.
Real world data is all health data that is generated and collected in real clinical practice right across our healthcare systems. Combining pre-clinical and clinical data generated by industry with real world data collected in clinical settings and beyond, we can drive medical innovation and improve patient care. With more and better data, clinicians can better target interventions to the patients where they will have the most impact, improving patient outcomes but also increasing efficiency. Data collection and analysis can help us better understand the side effects of medicines and improve patient safety. Genomic science is facilitating a revolution in personalised medicines and, crucially, all of this data can inform and shape tomorrow’s breakthrough innovations.
Maximising the potential of all this data for patients, though, requires a new level of collaboration to address a number of challenges.
In reality, much of our RWD is scattered across the healthcare system without any easy way of bringing this data together. They are noted down in individual patient’s records, recorded in registries kept by small groups of specialists for tracking a specific disease in a selected number of patients, or collected for reimbursement purposes for a specific product, and then discarded. Often, data privacy regulations limit the ability to re-use existing data, despite its potential to deliver important insight into clinical practice and patient outcomes.
Data should be generated according to the same standards in order to be comparable. E-health systems should be made compatible between hospitals or countries, with a single, electronic health record for individual patients, with all health data collected in one place. There should be a means of linking all data collected for a variety of purposes. Regulation needs to facilitate data being transferred between systems and used for research or quality improvement.
The situation, though, is changing rapidly. Considerable efforts are now being made both by public and private stakeholders to capture, consolidate and most importantly utilise this real-world data to benefit patients, science and our healthcare systems. Trust is critical in ensuring a new health data ecosystem can thrive. It is vital to be cognisant of the sensitive nature of healthcare data. Patients need clarity on how and why their data will be used. Systems need high standards of technical data protection, recognising that, as we move into a world of many different data sources and opportunities, these standards will need to evolve.
With more information about how different interventions actually compare in terms of health outcomes for patients, healthcare managers and policymakers will be able to take much more informed decisions on implementing clinical practice and resource allocation, creating not only better health outcomes for patients but also getting more value from every euro spent on healthcare. Progress will require dialogue, collaboration and investment, but as the key to an outcomes-focused, more sustainable future driving the healthcare data agenda, it is a critical success factor.
Moving along the outcomes-focused spectrum
No two healthcare systems in Europe are at the same point on the journey to a more outcomes-focused approach. Some have advanced examples of good practice, others are beginning to look at outcomes-based reimbursement models, others simply do not have the infrastructure in place to base clinical decision-making and service design on outcome measures. However, at whatever point a healthcare system is on the journey towards an outcomes-focused approach, there are a number of actions that can be undertaken to support change.
Develop integrated health information systems
Tools such as electronic health records, disease registries and user-friendly data capture systems all contribute to developing an outcomes-focused system
To spark, develop and deliver change, data needs to be of high quality and shared across the healthcare system for quality improvement and research
Data analytics provides the key to identifying variances in care and their impact on outcomes, to detect sources of waste and inefficiencies in the system
Identify best practice
Standardised outcomes measures, quality and transparent outcomes data, coupled with the use of data analytics will facilitate the identification of best practice for replication across health systems
Promote proof of concepts
Successful pilots of improving outcomes in a specific patient population build trust in the merits of an outcomes-focused approach and provide important clues into the practicalities of implementing outcomes-focused healthcare
Feedback and learn
As clinical practice and service delivery changes, real world evidence and data analytics provide a mechanism for real-time learning and continuous development
Remove budget siloes and reward quality of care
Establishing flexible and holistic finance systems that promote care integration, and payment models that reward good health outcomes for patients can help facilitate change
Standardising definitions of outcomes, agreeing measures and putting in place the infrastructure to capture, measure and analyse healthcare data to support outcomes-focused decision making is a long and complex process. To facilitate change requires dialogue, partnership and collaboration from across the healthcare spectrum. Often it will require attitudinal change at an individual and institutional level. System-wide transformation of healthcare is a bold and ambitious goal, but central to a more sustainable and Healthier Future.