Value-based healthcare in ischemic stroke care: case-mix adjustment models for clinical and patient-reported outcomes.

BACKGROUND: Patient-Reported Outcome Measures (PROMs) have been proposed for benchmarking health care quality across hospitals, which requires extensive case-mix adjustment. The current study's aim was to develop and compare case-mix models for mortality, a functional outcome, and a patient-reported outcome measure (PROM) in ischemic stroke care. METHODS: Data from ischemic stroke patients, admitted to four stroke centers in the Netherlands between 2014 and 2016 with available outcome information (N = 1022), was analyzed. Case-mix adjustment models were developed for mortality, modified Rankin Scale (mRS) scores and EQ-5D index scores with respectively binary logistic, proportional odds and linear regression models with stepwise backward selection. Predictive ability of these models was determined with R-squared (R2) and area-under-the-receiver-operating-characteristic-curve (AUC) statistics. RESULTS: Age, NIHSS score on admission, and heart failure were the only common predictors across all three case-mix adjustment models. Specific predictors for the EQ-5D index score were sex (ß = 0.041), socio-economic status (ß = - 0.019) and nationality (ß = - 0.074). R2-values for the regression models for mortality (5 predictors), mRS score (9 predictors) and EQ-5D utility score (12 predictors), were respectively R2 = 0.44, R2 = 0.42 and R2 = 0.37. CONCLUSIONS: The set of case-mix adjustment variables for the EQ-5D at three months differed considerably from the set for clinical outcomes in stroke care. The case-mix adjustment variables that were specific to this PROM were sex, socio-economic status and nationality. These variables should be considered in future attempts to risk-adjust for PROMs during benchmarking of hospitals.

[Doctors focus on the needs of the elderly]. / Artsen stellen behoeften van ouderen centraal.

The Dutch National Care for the Elderly Programme started in 2008. Eight regional networks were formed, in which more than 75 projects were carried out to improve care and wellbeing for frail elderly persons. The programme will come to an end in 2017. The results and lessons learned are being spread via the knowledge platform 'BeterOud'. In this article we describe some lessons from the programme for clinicians. The programme shows the value and the difficulties of clinicians taking the needs and wishes of frail elderly persons as the guiding principle of their care. Most frail elderly persons cannot be treated through generic interventions but need multidisciplinary and personalised care and support. In addition, standard research methods and outcome measures often do not coincide with the perceptions of elderly persons. This might explain the limited results of many projects in terms of cost-effectiveness. Benefits from the perspective of both professionals and elderly persons should be established in advance.