Case studies

The core of the project was the development of case studies in four priority areas (screening, coordination of care, rationale use of medicine, and healthcare associated infections). These case studies were intended to highlight best practice by contrasting more successful and less successful examples of efficient healthcare delivery. Cases were selected by an external Steering Group. These case studies are briefly summarised in Table 2 below and in more detail in the following sections.

These case studies are briefly summarised in Table 2 below…

3.1 Priority area 1: Colorectal cancer screening

^{Early diagnosis and prompt initiation of appropriate treatments have been shown to reduce the number of preventable deaths in many diseases, including cancer (World Health Organization, 2017).}

Conversely, delays in diagnosis are associated with a greater number of preventable deaths and, by definition, greater inefficiency.

In general, there are two approaches to population screening (Miles et al., 2004):

Organised systems: invitations to screening are issued using registered and centralised data.
Opportunistic systems: invitations are conditional on an individual’s decision or on visits to healthcare providers.

Compared with opportunistic systems, organised screening for early detection of colorectal cancer shows better results in improving screening participation (Eisinger et al., 2008; Senore et al., 2015), reducing disparities in screening uptake (Eisinger et al., 2008) and minimising harms such as over-screening, low quality screening, and screening-related complications (Levin et al., 2011).

The screening cases relate to organised screening programmes for colorectal cancer (CRC). CRC is the second most frequent cause of cancer mortality in Europe, associated with 16% of total cancer deaths (Ferlay et al., 2013). Many of these deaths, though, are preventable with early detection. The case studies contrast organised screening programmes in the Basque Country of Spain and Paris, France. The Basque experience has been effective in screening high-risk populations and has resulted in overall cost-savings and system efficiencies, whilst the Parisian experience has been less successful in terms of coverage and cost-savings.

CASE STUDY LESSONS.

Key lessons from contrasting the Basque and Parisian examples include:

1. Make participation as simple as possible

The Basque programme, like programmes in The Netherlands and Flanders (Belgium), included the Faecal Immunochemical Test kit with the invitations and made it as easy as possible for recipients to return a sample. The Parisian programme, in contrast, required individuals to collect the kit from their GP. This extra step is likely to have discouraged participation. Paris has already decided to include the kit with the invitation, but only for those individuals considered at greater risk of not participating. This includes: 1) individuals who did not participate in the first invitation; and 2) individuals who have previously participated in CRC screening.

2. Build on networks that are already in place

Build on networks that are already in place, such as regular neighbourhood meetings, or working with existing associations. From interviews conducted as part of the case study, we know that efforts are already being made in Paris to involve more primary care professionals, allowing them to provide as much information as possible to individuals in the target demographics who may be visiting primary care facilities for other reasons. Expert interviews highlighted the importance of educating and involving stakeholders such as patients’ organisations, primary care professionals, journalists, politicians and other community leaders. Information campaigns could be of greater impact if using celebrities or other well-known individuals. The use of social media to promote screening was also suggested.

3. Other suggestions

Other suggestions generated from expert interviews referred to ways to maximise avenues of communication, or to the importance of the use of past information regarding specific aspects that have generated a delay to diagnosis. For example, ensuring appropriate targeting strategies could reduce demand for tests that are less likely to be beneficial. If those services are expensive services, that might also substantially reduce healthcare utilisation costs. Another suggestion was qualitative research with non-participants to understand their reasons for not participating, which could be used to improve information campaigns.

3.2 Priority area 2A & 2B: Disease management and standardised patients’ pathways

^{The direct and indirect costs of chronic diseases are substantial. The direct healthcare costs associated with chronic conditions account for 70-80% of total EU26+UK healthcare expenditure, or more than €1 trillion in 2017, and indirect costs of lost productivity associated with chronic conditions can represent up to 7% of GDP for some countries.}

Much of these costs stem from inadequate management of diseases such as cardiovascular diseases, chronic obstructive pulmonary disease (COPD), cancer and diabetes, which require long-term monitoring and ongoing adherence to treatment. Failures in monitoring and adherence impose avoidable costs on healthcare systems in the form of unplanned outpatient visits and hospital admissions. Effective disease management and treatment coordination can avoid these events, reducing costs and improving patient outcomes.

Disease management programmes (DMPs) are a means to help patients with chronic diseases maintain treatment adherence and thus avoid costly outpatient visits and hospital admissions, increasing overall healthcare efficiency. Standardised patient pathways (SPPs) are a means to improve the structure and consistency of the patient pathway by clearly defining all necessary steps to be taken in diagnosis and treatment.

2A. Disease management programmes for chronic obstructive pulmonary disease

_{Chronic Obstructive Pulmonary Disease (COPD) is a chronic disease with an estimated prevalence rate of around 12 percent

in people aged 40 years and older across Europe (Blanco et al., 2017). Poor treatment adherence is a common cause of

hospitalisation and a leading cause of death, and as such, it is associated with a substantial economic burden.}

_{Two case studies of DMPs for COPD are considered: Bourbeau et al. (2019) evaluate the outcomes of a trial of a

home-based COPD disease management intervention in France, Germany, Italy, and Spain for severe COPD patients led by

nurses, and Achelrod et al. (2016) evaluate the outcomes of a disease management programme for COPD run by primary

care physicians that has been running in Germany since 2005.}

CASE STUDY LESSONS.

The COMET trial of a home-based DMP for COPD indicated gains in overall efficiency in France and Spain, with improved patient outcomes including gains in Quality Adjusted Life Years (QALYs) and reduced mortality, with no increase in total costs. Both German examples are less clear regarding efficiency. In both the trial and real-world experience, German DMPs were associated with improved outcomes but also an increase in overall costs among DMP participants. This likely reflects better case management and treatment adherence, but it is not an unambiguous improvement in efficiency.

In general, it is difficult to conclude best practice from a comparison of the two cases. Germany was included in both cases and saw a similar result in each: an increase in costs as well as outcomes, leading to an ambiguous effect on efficiency. However, comparison of the features and outcomes of the COPD management programmes described in the case studies suggests some general conclusions about the features of an efficient DMP:

1. Patients need to be equipped with the right knowledge on self-management of their disease.

Patient education is important for adopting healthier lifestyles (most importantly smoking cessation) and increasing medication adherence. Patient education in the COMET-trial was based on the “Living Well with COPD” programme, whereas the DMPs in Germany are supposed to adhere to up-to-date evidence-based clinical guidelines.

2. Regular reminders and encouragement for patients are key for successful condition management.

A single initial training session is not likely to be enough to change behaviour. The DMPs in Germany try to achieve change through agreement on personal therapy goals. In the COMET-trial, patients were motivated through regular phone calls with their case manager, and they self-monitored their condition through symptom reporting.

3. The design of a DMP must take cultural factors into consideration.

In countries where primary healthcare is centred around the primary care physician (as in Germany), a greater role for nurses in patient management might be initially met with scepticism by patients and result in lower adherence to advice from nurses.

2B. Patients’ pathways in cancer care

_{Cancer represents a substantial share of the total disease burden in Europe: more than one in four deaths are due to cancer, making it the second most common cause of death after cardiovascular diseases (Jönsson et al., 2016a). The economic burden of cancer is also significant with direct healthcare costs of €83.2 billion in the EU27+UK in 2014, and the indirect costs of lost productivity due to premature mortality and morbidity, together with informal care costs thought to be a similar amount (Jönsson et al., 2016b).

Standardised patient pathways (SPPs) in cancer care lay out the essential steps from suspicion of cancer to recommended diagnostic procedures and treatments. They are intended to enhance the coordination of care to enable timely access to diagnostics and treatment, with the primary aim of increasing patient survival.

Two case studies for programmes intended to improve coordination of cancer care are considered. Probst, Hussain

and Andersen (2012) and (Jensen et al., 2015; Jensen, Tørring and Vedsted, 2017) provide an evaluation of a Danish SPP

whilst the National Board of Health and Welfare (2019c) evaluates a Swedish SPP modelled on the Danish programme.}

CASE STUDY LESSONS.

In both cases, the implementation of the SPPs reduced waiting times and regional variability, but had no statistically significant effect on survival rates compared to patients treated outside of the SPP. If the process of care is an important outcome for a health system, then improvements in this process represent gains to the health system – although the additional costs of achieving these through SPPs mean that the impact on efficiency is ambiguous. However, the introduction of SPPs may also have had negative impacts on the care received by non-cancer patients, which should be better understood before conclusions about the effects of SPPs can be reached.

Despite these ambiguous results, a comparison of the features of the SPPs in Denmark and Sweden provide some insights for the implementation of efficient care pathways:

1. Careful consideration must be given to the ultimate aim of SPPs.

In Denmark the aim of the SPPs was to reduce waiting times, improve health outcomes of patients with cancer, and increase patients’ satisfaction by ensuring treatment as fast as possible. In Sweden, the aim of the SPPs was to reduce wait times and regional variability in cancer care. Both SPPs achieved some of the objectives, but there is little evidence that the SPPs improved survival outcomes or overall system efficiency. This highlights the importance of understanding the objective of such initiatives: ensuring a positive patient experience or maximising health outcomes.

2. Attention should be paid to not ‘crowd out’ patients in other disease areas.

In both Denmark and Sweden, the increased focus on cancer patients appears to have led to longer waiting times for patients with other diseases. This suggests that the resources allocated to implement the SPPs were insufficient to avoid ‘crowding out’ patients in other disease areas.

3. There should be clear referral tracks from primary care to hospital care.

Denmark has developed a clear strategy on how to refer patients from the GP to hospital care based on the severity of patient symptoms. No such strategy was implemented in Sweden. It was not possible to assess the impact of this difference, but it is likely to lead to inconsistent referral and possibly differences in outcomes.

3.3 Priority area 3: Rational use of medicines

^{The rational use of medicines covers many problems including over-prescription, inappropriate use of medicines (e.g. antibiotics), and poor adherence to prescribed treatment, all of which can lead to suboptimal outcomes and adverse events.}

Polypharmacy is a more complex example which lacks a standard definition, but is commonly described as the concurrent use of 5 or more medicines (Masnoon et al., 2017; World Health Organisation, 2019). Polypharmacy is common in the elderly due to the prevalence of multimorbidity (i.e. two or more chronic conditions) in this population which has been increasing in recent decades (Wastesson et al., 2018).

Polypharmacy in the elderly population can be associated with poor outcomes as the possibilities of adverse drug-drug and drug-disease interactions increase (Maher, Hanlon and Hajjar, 2014; Wastesson et al., 2018). If these interactions are not recognised and are incorrectly diagnosed as new illnesses, additional medicines may be prescribed, potentially leading to further unintended interactions in what has been called a “prescription cascade”. Adverse effects associated with polypharmacy can lead directly or indirectly to an increased number of outpatient visits and hospitalisations whilst physical and cognitive functioning, as well as quality of life, deteriorate and the risk of mortality increases. Medication non-adherence also increases with the number of medicines taken (Zelko, KlemencKetis and TusekBunc, 2016), contributing to the risk of suboptimal health outcomes.

The cost of mismanaged polypharmacy has been estimated to be 0.3 percent of all global health expenditure – US$18 billion worldwide – much of which could be avoided through improved polypharmacy management (Aitken and Gorokhovich, 2012).

Two programmes aimed at improving the management of polypharmacy in elderly people are considered: an evaluation of medication reviews in Scotland (UK) by the Scottish Government Polypharmacy Model of Care Group (2018), and a medication review programme in Lower Saxony, Germany, evaluated by McIntosh, Alonso and Codina (2016) as part of the SIMPATHY Project and by Seidling et al. (2017).

CASE STUDY LESSONS.

The Scottish experience indicates potential improvements in health system efficiency. Reviews were associated with estimated cost savings ranging from €9 to €232 per patient per year and a reduced proportion of patients on potentially harmful combinations of medicines. Long-term patient outcomes such as mortality, morbidity, and quality of life were not assessed, but are likely to be positive. The German experience was less successful and identified challenges in the design and implementation of medication reviews, particularly around the incentivisation of pharmacists and information sharing with physicians.

Contrasting the Scottish and German experience highlights some key lessons:

1. A successful medication review programme requires involvement of all relevant stakeholders – especially pharmacists and primary care physicians.

The Scottish polypharmacy guidelines were a joint effort by geriatricians, pharmacists, and General Practitioners (GPs). Medication reviews are performed by both pharmacists and GPs. In contrast, the ATHINA programme in Lower Saxony was independently developed by the Chamber of Pharmacists, with no involvement of GPs. A situation in which GPs perceive pharmacists as trying to challenge their competence in prescribing medications needs to be avoided.

2. Widespread participation of healthcare providers and low patient fees are critical for patient access.

The Scottish government was successful in having all local NHS Boards follow the polypharmacy guidelines on conducting medication reviews. In Lower Saxony, participation of pharmacists in the ATHINA programme was voluntary and led to low participation. Furthermore, patients in Lower Saxony had to pay out-of-pocket for voluntary medication reviews, whereas in Scotland medication reviews were embedded in standard working practices and free for patients.

3. Appropriate financial incentives are necessary.

In Scotland, pharmacists and physicians perform the medication reviews as part of their general service and are paid for the reviews. In Lower Saxony, pharmacists received initially no remuneration for the time spent on medication reviews from the sickness funds, forcing some of them to conduct the reviews in their spare time.

4. The recommendations from medication reviews need to be implemented.

In Scotland, physician participation in the reviews facilitates changes in medications. This is not necessarily the case in Lower Saxony, where patients may choose not to share the pharmacist’s recommendations with their prescribing physician.

3.4 Priority area 4: Healthcare-associated infections

_{^{Healthcare-associated infections (HCAIs) have a substantial impact on health system efficiency as they are associated with significant costs from the hospital perspective (Roberts et al., 2003; Perencevich et al., 2003), and are detrimental to patients’ quality-of-life and survival.}}

The World Health Organisation estimates that each year there are 4 million HCAIs in acute care hospitals in Europe, resulting in 37,000 deaths and €13–24 billion in avoidable costs (World Health Organization, 2009). Of these costs, €7 billion are direct costs to the healthcare system (World Health Organisation, 2013). In Europe, it is estimated that HCAIs occur in 7.1% of all hospital admissions (Danasekaran et al., 2014) and represent 16 million avoidable hospitalisation days (Manoukian et al., 2018).

The risk of HCAIs is associated with a lack of standardisation of procedures, and the absence of local and national guidelines and policies, as well as a lack of training and information with respect to the prevention and management of HCAI. Staff education and accountability are essential for making healthcare providers and patients aware of risks and consequences of HCAIs and for promoting prevention strategies.

One approach to prevent HCAIs is through the use of clinical surveillance, but the implementation of such surveillance is challenging as there is a lack of consensus on the best approaches and best indicators of care quality. Two case studies are presented with different approaches to surveillance: a Lean Six Sigma (LSS) clinical surveillance programme in Italy (Improta et al., 2018), and a surveillance programme of health professionals in the hospital setting in Germany (Hagel et al., 2019).

CASE STUDY LESSONS.

The implementation of the LSS in Italy was associated with substantial improvements in clinical outcomes, almost halving the number of HCAIs across the Federico II University Hospital. Moreover, given that this reduction in infections translated to a decrease in the mean number of hospital days associated with HCAIs from 45 to 36 per patient, it is likely that the programme also generated cost savings – and therefore unambiguous efficiency improvements. The clinical surveillance programme implemented in the Jena Hospital in Germany, however, did not decrease HCAIs nor generate substantial improvements in compliance with best hygiene practices. There are several differences between the approaches to clinical surveillance used in Italy and Germany which are likely to have contributed to these contrasting effects, and which can be extrapolated to broader lessons:

1. Data should be used to tailor interventions to context.

In the German case, interventions were implemented to deal with the most common sources of HCAIs, based on external evidence and international best practice, but it is unclear that these were sufficient to address the causes of HCAIs in the Jena Hospital. Moreover, the interventions implemented may not have been appropriate within the operational structures of the hospital. Indeed, although Arefian et al. (2019) speculate that lack of time and high workload may have contributed to low compliance observed over the course of the study, these factors do not appear to have been recognised or corrected at the time. In contrast, in Italy data were used to identify the specific deviations from good practices which were contributing to HCAIs in the Federico II University Hospital.

2. Engagement of staff is critical, during design and implementation.

The interventions designed in the Italian case were not only hospital-specific, but also validated by staff in order to ensure their appropriateness – thereby avoiding some of the challenges which have been speculated to have occurred in the German case. The poor compliance with interventions identified in the German case additionally indicates that, if staff are not engaged in interventions through measures such as training or consultation, the possibility of reducing HCAIs is likely to be severely constrained.

3. Improvement should be a continuous process.

In the Italian case, ongoing monitoring allowed insight into the success of the interventions, and how they may be refined. Had a similar approach been utilised in the German case, this could have alerted the hospital to the lack of progress and provided an opportunity to improve.