Value-Based Medicine

A Review, and a Preview of VBM to Come

By Melissa M. Brown, MD, MN, MBA

It seems hard to believe we are at the one year mark in this Value-Based Medicine column. While I understand the strengths of a monthly column to provide information over time, I am also aware of what I call the “monthly melt” that occurs between columns. With new topics, the details of the preceding column can get fuzzy, making cumulative learning a bit more difficult.

One quick and easy way to catch up is to review all of the previous VBM columns archived at this magazine's Web site: www.ophthalmologymanagement.com.

A Quick Review of VBM Concepts

Our initial columns showed how the concepts of Value-Based Medicine fall into three key areas: (1) evidence-based medicine, (2) the human value of care, and (3) economic analyses. We visited the concept that human value gain is only as good as the evidence upon which it is based.

Evaluation of the clinical evidence in our studies is imperative. Recall that Type I errors of measurement show a positive effect when one truly does not exist and must be kept to a minimally acceptable level, depending on the intervention of interest. Just as important is the power of a study that both demonstrates the strength of the numbers of patients studied and allows confidence in the results of a negative trial demonstrating no difference between study intervention and placebo. A study that fails to identify a potentially helpful therapy is a Type II error.

Later, we presented other key elements in the evidence that are to be considered noteworthy: (1) validity (how believable were the results?), (2) significance (is it clinically relevant?) and (3) clinical importance (look at the absolute risk reduction; beware of the relative risk reduction).

The definition of value as it relates to our concept of “Value-Based Medicine” was then reviewed. We noted that economists often refer to “value” using a monetary framework. However, in the clinical world, physicians (including those at the Center for Value-Based Medicine) define value in terms of care and benefit derived by the patient. Thus, value is defined within the medical care in terms of what enhances the length and, especially, the quality of life. This allows us to amalgamate the evidence of efficacy and safety with the value it brings to our patients. By looking at positive and adverse effects, we can compare value among various healthcare interventions to determine which provides the highest quality of care.

Quality-of-Life Assessments

We then looked at some details of quality-of-life measurement, highlighting utility analysis as a methodology often deemed most useful in this endeavor. This health-related quality-of-life method is significant in that it is all-encompassing regarding the different variables: it is sensitive to small changes in health, reliable, applicable across all medical specialties, understandable by our patients and able to be integrated with economic analyses.

The concept of utilities as a unit measure and use of the time trade-off method was discussed. The quality-adjusted life year (QALY) was also introduced. Recall that a utility for each level of a health state can be determined. The difference in utility seen following a medical intervention can document the improvement in quality-of-life. When the duration of time for which the patient experiences the benefit is factored into those results, total improvement in utility can be expressed in QALYs.

The degree of lessening of quality-of-life has been defined for many levels of vision and can be compared with that induced by other health-related states. Minimal visual loss in the presence of ocular disease seems to reduce the quality of life to the same degree as having a mild stroke. With severe visual loss to the level of legal blindness, the resultant utility may be similar to someone with severe angina or moderately severe stroke. Utilities were identified for various visual acuity levels and we then noted utilities of various health states in similar ranges for comparison.

More recently, I introduced decision analysis (DA), which incorporates elements of evidence-based medicine, but values them in terms that are relevant to patients — the desirability of different outcomes. Using the method, treatment alternatives can be compared to one another. We then applied a simple DA model to initial cataract surgery.

As we continue to move forward, I will examine how comparative effectiveness data can be assimilated with costs to maximize healthcare quality with great financial savings to our medical system.

Our ophthalmic interventions not only deliver considerable human value gain, they also deliver a great financial return on investment to society. OM

Value-Based Medicine is a registered trademark of the Center for Value-Based Medicine.

Melissa M. Brown, MD, MN, MBA, is president and CEO of the Center for Value-Based Medicine in Philadelphia, She can be reached via e-mail at mbrown@valuebasedmedicine.com