Health Benefit Analyses for equity of care: an interesting experience in Finland

IISC_EqualityEquity
Source: Interaction Institute for Social Change – Artist: Angus Maguire

Equality for everyone in medical care, which is the basis of the National Health System, does not mean equity in the use of available resources. Starting from this reasoning a group of international researchers and Finnish doctors are experimenting with a system of analysis of health benefits.

The experience is taking place in the Saarijärvi-Viitasaari region, in the centre of Finland, where a group of primary care workers works to assist over 17,000 citizens. Doctors use an electronic medical record that is integrated with EBMeDS, a clinical decision support system (CDSS) developed by Duodecim, the scientific society of Finnish doctors.

Depending on the clinical context of each patient, EBMeDS provides more than 44,000 different messages, 7,000 of which through complex rules, 37,000 concerning interactions, contraindications and information on the dosage of drugs. Among other things, EBMeDS has a series of computers to assess clinical risks.

In addition to the daily use of the CDSS while using the electronic patient record, all patient data is then processed using EBMeDS which applies a set of rules to assess whether patients receive all the care required by the guidelines and medical evidence contained in the CDSS.

Health Benefit

A matrix is thus created which highlights the treatments carried out (green dots) and those to be carried out (red dots) [1]. The latter ones determine the gap of the treatments (Care Gap) [4]. The relationship between the patients who should receive care and those who have really received it determines instead an indicator of quality of care [2] and [3].

The list of patients who should receive the recommended treatment is then extracted [5]. The cost is calculated and the net benefit assessed [8]. The methodology for calculating the net benefit of a treatment has been developed by some researchers and can be consulted here.].

The methodology considers the effects that a given cure produces, the importance of the outcomes it determines, any risks or damages it implies, as well as the cost to be incurred. By dividing the net benefit with the cost, a cost effectiveness index is obtained, i.e. the value for the patient (and for the NHS). This can be further recalculated considering its acceptability and feasibility for the patient, whose values can be subjective (i.e. depending on the sensitivity, opinions and needs of each person).

bmjopen-2019-June-9-6--F1.large
Source: BMJ Open – Defining certainty of net benefit: a GRADE concept paper

With a shared decision-making process [6], the result of the net benefit analysis is used to elaborate a care plan. The patient determines the importance of each result and chooses the interventions to achieve the results most in accordance with his wishes.

Based on the care plans, service bookings can be automated [7].

The impact of each intervention on the health of the whole population is calculated by multiplying the number of patients who need the intervention (number of red points) with the average of the net benefits estimated individually for each intervention [8].

The cost-effectiveness ratio of each intervention at population level is calculated as the ratio between the net benefit and the unit cost of each intervention [9].

In conclusion, we can say that the model is particularly interesting because it does not limit itself to suggesting, in an uncritical way, the necessary interventions and treatments on a population, but correlates these indications with the net benefit that can be obtained and the relative cost. An excellent example of how, concretely, the theory of Value Based Healthcare can be applied to primary care.

I also found it interesting to involve the patient in the process of planning treatment. When there are, for example, side effects to a therapy (risk of bleeding to prevent the risk of stroke), it may be important to show the patient how these risks are related and consider his or her point of view and preferences.

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