Operationalizing value in Chronic Care: The case of Swedish Rheumatology

A research project involving Karolinska Institutet/Medical Management Center, Stockholm University School of Business, Karolinska University Hospital, Stockholm County Council and

Harvard Business School.

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The cycle of disease: Rheumatoid Arthritis

REHAB- SERVICES

Lifestyle & self-medication

- SPECIALIST CARELAB TESTS

X-RAY

HOSPITALIZATIONS

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DAS28 (Disease Activity)

Time

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Disease cycle captured in the SRQ registry

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REHAB- SERVICES

Disease cycle captured in the SRQ registry

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Capturing the entire disease cycle

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Prioritizing measures based on the stage of the disease: defining two phases

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First phase of disease: reaching low or no disease activity

Early & aggressive treatment

Aims, phase 1

• Response by DAS28CRP or patients global

• Treatment to reach low or no disease activity

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Maintain low DAS28

•Aims, phase 2

•Low level of disease activity (Area under the curve, AUC), •Patient satisfaction with outcomes: trust in care, quality of life (EQ5D/QALY)

Second phase: long-term management and prevention

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Detect and curb flares

Second phase: long-term management and prevention

•Number, intensity and duration of recurrences (flares).

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RA outcome measures in the three tiers

Survival – Mortality Health / recovery – Patients global, EQ-5D, Work ability, Daily

function,DAS28, AUC Doctors global

Time to recovery – Time to remission, time to work ability regained

Disutility of care / Rx – Trust in care, Drug adverse events Continuity, empathy, access etc?

Sustainability of health / flares – Health / recovery AUC Long-term consequences of therapy – Patients global, EQ-5D,

Work ability, Daily function,DAS28, AUC Doctors global, adverse events, co-morbidities

Control for case-mix variables (gender, age, biomarkers, socio-economic status etc)

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Cost per patient - RA 2009Karolinska data

Costs – not charges

Number of out-patient visits 45 404

Total cost 157 692 215 SEK Medical service 9 481 442 SEK Operation 1 917 123 SEK ICU 13 311 SEK Drugs 93 835 356 SEK Visits 52 444 983 SEK

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Costs – micro level

Stockholm County Council data sources: In-patient and out-patient data and cost per patient (CPP). Figures will be added.

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Questions to discuss

Delimiting the medical condition and care cycle Using the available data to operationalize value

Prioritizing outcomes and cost measures Ensuring that measures are useful and acted upon

Flexibility: adjusting to new treatment goals “Patient´s choice” – reimboursement chronic care

Incentives for telephone follow ups Self care

Research question(s) Publication possibilities

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Thank You!

Sofia Ernestam, sofia.ernestam@karolinska.se Anna Essén, aes@fek.su.se Martin Neovius, martin.neovius@ki.se