Implementation of value-based healthcare in ophthalmology: a scoping review

Search strategy

In this scoping review, a literature search was conducted starting January 2006 (the year Porter and Teisberg introduced VBHC)1 up to 31 December 2023 by two reviewers (ZA and MAGM) from multiple electronic databases, including PubMed, Science Direct, ProQuest and Scopus. All databases were searched for the same timeframe. The search terminology was set up as follows: (‘Value-Based Health Care’ OR ‘Value-based healthcare’ OR ‘value based health care’ OR ‘value based healthcare’ AND ‘Ophthalmology’). In addition, some valid studies outside of the database will be included if eligible to meet the criteria.

Eligibility criteria

The main eligibility criteria of the included articles needed to be VBHC in line with Porter and Teisberg definition.1 Full-text articles in English that described the implementation of VBHC in a hospital setting or healthcare system in the field of ophthalmology were included. In order to create a complete comprehensive overview of VBHC that has been implemented and proposed to be implemented in the VBHC literature, we included empirical and non-empirical articles. No restrictions were made with regard to the type of study design or the outcomes measured. Literature reviews were excluded, but their references were evaluated for eligible articles. To align with the concepts of Porter and Teisberg, we narrowed down article selection to studies explicitly using the terms VBHC or value-based care with a clear reference to Porter and Teisberg. Articles not using these terms were excluded.

Study selection

All search results were exported to Rayyan.10 Duplicates were removed before screening. After duplicates were removed, eligibility screening was initiated. Initially, titles and abstracts were independently reviewed by two reviewers (ZA and MAGM), who subsequently resolved conflicts through discussion on completing the title and abstract screening process. Afterwards, full-text literature studies that meet the eligibility criteria will be included, while those that do not meet the criteria will be excluded and reasons for exclusion will be provided. The results of the full screening will be reported using the updated PRISMA guidelines.11

Data extraction and synthesis

Data collection will be carried out in all included studies. Data extraction and evaluation were performed together by two reviewers (ZA and MAGM). We used the following extraction data to organise and summarise study findings: (1) author, (2) year, (3) country, (4) settings, (5) study design, (6) VBHC agenda, (7) VBHC implementation/proposed VBHC implementation and (8) reported impacts (for empirical studies). Implication of VBHC was classified based on value agenda implementation and its reported impact to improving the quality of care and value for patient in the field of ophthalmology. Data synthesis collection will be presented in table form.

Search and screening results

The initial database search identified 1.077 records; outside of the database, we found 4 studies that are also related to the topic, so we found a total of 1.081 studies. After duplicate removal, 984 potentially relevant records remained for title/abstract screening. The title and abstract screening resulted in 23 full-text articles. Four articles were excluded because full text was not available. Eleven articles were excluded after full text inspection for the following reasons: was not implementing VBHC in the field of of ophthalmology in four articles or did not mention VBHC in the introduction or methods section in seven articles. After screening these, we selected 12 original articles for inclusion (eight empirical and four non-empirical). An overview of the article selection is shown in figure 1.

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Included articles’ characteristics

The 12 included articles were published between 2006 and 2023. Three articles were conducted in the UK,12–14 two articles in the Netherlands15 16 and the remaining in Sweden,17 Portugal,18 Bulgaria,19 Singapore,20 Canada,21 the USA22 and Wales.23 Among the included publications, eight studies described empirical research, as illustrated in figure 2. These studies were predominantly distributed in Europe,15–19 with one study each conducted in the USA,22 Canada21 and Singapore.20 Of these empirical studies, three were categorised as descriptive study,17 19 21 three as case control study15 18 22 and two as cohort study.16 20 All of the included empirical studies (100%) reported that the implementation was a success improved value. Implementation initiatives were considered successful if the authors indicated in the discussion and/or conclusion section that the implementation had led to value improvement and/or decreased healthcare cost. The main characteristics of the included publications are described in tables 1 and 2.

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Items and implementation of the VBHC agenda

All of the included empirical studies implemented VBHC agenda ‘measure outcomes and costs for every patient’.15–22 From these studies, only four studies15 18–20 simultaneously measured outcomes and costs, two studies21 22 exclusively focused only on cost measurement using time-driven activity-based costing (TDABC), while another two studies16 17 concentrated only on leveraging outcome data for value improvement. In the non-empirical study, the most frequently mentioned VBHC agenda was ‘measuring costs and outcomes for every patient’.12 13 23 Each article described the agenda ‘organising care into IPUs’,14 ‘integration of care delivery across separate facilities’12 and ‘building an enabling information technology platform’.23

Organise into IPUs around the patient’s medical condition

At the core of the value transformation, a shift towards a value-driven organisation involves restructuring the way clinicians deliver care. This restructuring entails organising healthcare around patient needs rather than specialty departments and discrete services, a model referred to as IPU.5 An IPU is a dedicated team comprising both clinical and non-clinical personnel collaborating to deliver the full care cycle for a group of patients with the same medical or behavioural condition, or a set of closely related conditions. This approach differs from organising around specialties or specific interventions.26 IPU consolidates patient volume for a specific medical condition, enabling its multidisciplinary team to develop profound expertise and capabilities for proactive patient care across the entire care cycle or within a targeted patient segment. This method engages an experienced multidisciplinary team in patient education, fostering adherence to treatment protocols and reducing the occurrence of adverse events.27

In this review, we found only one article that discussed an IPU in the field of ophthalmology.14 This non-empirical article discussed a concept of IPUs through redesign of comprehensive care pathway for cataract services post-COVID-19 using the principles of VBHC through the development of a cataract IPUs. This article suggests a division of cataract services into two IPUs: routine cataract IPU and complex cataract IPU. This categorisation is based on both patient characteristics (comorbid factors, American Society of Anesthesiologists (ASA) grade, mobility issues and overall operating room time) and surgery-related factors (surgeon competency, Polymerase Chain Reaction (PCR) risk score and required surgical time). The proposed approach aims to enhance the effectiveness and patient-centredness of cataract care within the National Health Service (NHS), ultimately increasing value for patients.

Despite not finding any studies related to the implementation of IPU in ophthalmology, it is noteworthy that several eye hospitals, such as JEC Eye Hospital and Singapore National Eye Centre, have established centres for various eye conditions, including Myopia Centre, Glaucoma Centre, Dry Eye Centre and Age-related Macular Degeneration Centre. The absence of relevant studies in the search results may be attributed to the keywords not explicitly using the terms ‘Integrated Practice Units’ or ‘IPU.’ Consequently, reports related to the implementation of the IPU concept in ophthalmology might exist without explicit references to the VBHC concept, potentially leading to their exclusion from this review. Therefore, further studies are needed to assess the effectiveness of IPUs in ophthalmology in enhancing value for patients.

Measure outcomes and costs for every patient

Despite being the most widely implemented agenda, only four studies15 18–20 concurrently measured outcomes and costs. de Korne et al’s study stands out as one of the earliest VBHC implementation adoption in the field of ophthalmology, predating the use of TDABC in healthcare. This 5-year case study in Rotterdam Hospital showcased the use of quality cost model (QCM) and care delivery value chain (CDVC) as tools for hospital management to oversee both quality and cost in glaucoma care as data driven to improve patient value (cost reduction per service with increasing in patient satisfaction and number of outpatients visit and surgery).15 It also highlighted that the VBHC agenda concept is interpreted using different tools. Another study in Bulgaria demonstrated the use of health outcomes data (clinical and patient-reported outcomes) and TDABC in optimising the care process for patients with AMD and macular oedema.19 This approach focuses on improving patients’ quality of life based on the care provided. Aligning with Kaplan and Wolberg, healthcare outcomes encompass clinical and functional aspects of the condition, along with patient-reported outcomes reflecting improvements in their quality of life and ability to perform normal activities.28

A study in IPO-Porto Hospital conducted a comprehensive measurement of cataract service outcomes using the International Consortium for Health Outcomes Measurement (ICHOM) standard, aiming to enhance value in cataract services.18 However, cost measurement did not use TDABC, as recommended by Kaplan and Porter.29 The ICHOM standard, incorporating Porter’s The Outcomes Hierarchy,30 makes it suitable for a comprehensive measurement of cataract care outcomes by considering patient risk factors. In a separate study, Hoong et al illustrated how this VBHC agenda implementation through the value-driven outcome (VDO) programme for cataract surgery at the National University Hospital (NUH) in Singapore, achieved cost reduction without compromising the quality of cataract surgery outcomes. The VDO programme, with its straightforward data reporting tool, identifies underlying factors of cost variability, serving as a crucial starting point for targeted process improvements or standardisation.20 Systematic outcome assessment, measuring outcomes relevant to the patient for a specific medical condition, can incentivise providers to innovate and offer more effective treatments.28

In addition to the four aforementioned studies, two studies21 22 exclusively focused only on cost measurement using TDABC, while another two studies16 17 concentrated only on leveraging outcome data for value improvement. These studies demonstrated that TDABC, besides accurately calculating the actual cost of cataract surgery,21 can also be used to compare efficiency between two eye services in different settings.22 However, both studies did not exhibit the use of TDABC for cost measurement in full care cycle, as recommended by Kaplan and Porter.29 This aspect is essential in preparing providers for the value-based bundle payment model,3 31 akin to a study illustrated in another field such as Total Hip and Knee Arthroplasty Service.32

Larsson et al underscored the significance of using a country’s disease registry, specifically data from the Swedish cataract registry, in developing clinical guidelines to prevent endophthalmitis after cataract surgery. This approach resulted in a substantial reduction in endophthalmitis rates in Sweden over 10 years.17 On the hospital level, van der Reiss et al demonstrated success in using clinical data from medical records linked to patient satisfaction to improve the value of patient care with neovascular age-related macular degeneration (nAMD) in hospitals in the Netherlands.16

In the review of non-empirical studies regarding this agenda, the proposed VBHC implementation primarily revolved around integrating the VBHC concept into the healthcare system within the NHS settings. These efforts included redesigning eye care pathways to focus on achieving outcomes and changing the financing model to programme budgeting,12 making cataract surgery decisions based more on patient needs rather than visual acuity threshold,13 and integrating patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs)-based outcome data with patient administrative and clinical data.23

Collectively, these studies emphasise that the ‘measure outcomes and costs for every patient’ agenda serves as a foundational framework applicable not only at the hospital level but also across the broader healthcare system. The utilisation of outcome data and cost of patient care enables efforts directed at enhancing patient value.

Integrate care delivery across separate facilities

This agenda requires healthcare systems to integrate care delivery in their region so that patients are treated at the appropriate care site. Primary care and care for simple conditions should be delivered in low-cost, convenient clinics and community hospitals, while complex care is delivered only by IPUs located in one or two of the region’s tertiary hospitals.28 This concept was found in articles by Malik et al. The idea involves embracing a population-based, value-oriented approach to delivering eye care by enhancing primary care structures and their connections to hospital services. This aims to establish an integrated system or service with a shared set of objectives and quality standards. By doing so, the services encompass the entire spectrum of enhancing clinical outcomes, spanning from prevention to treatment. The cornerstone of this approach is the improved integration of services. Achieving stronger networks of care between individuals within communities and hospitals is vital to realising this vision.12

Enhancing eye care services in primary care facilities is essential for preventive measures, early detection and prompt treatment of visual impairment and blindness within the community. This approach not only contributes to improved community health but also reduces overall healthcare costs. Patients who can be effectively treated in primary care settings may not require referrals to higher cost hospital treatments. Strengthening the structural components of primary care facilities involves enhancing the competency of providers and ensuring the availability of necessary diagnostic tools. Equally important is the establishment of a referral system from primary care facilities to secondary care facilities, emphasising quality principles such as effectiveness, safety, patient-centredness, timeliness, efficiency, equity and integration.

Build an enabling information technology platform

Withers et al serves as an exemplary illustration of the implementation of this VBHC agenda. Conducted in Wales, this study developed an integrated electronic platform to gather PROMs and PREMs from patients with cataract by unifying the collection and linking of patient outcome data with clinical and administrative information, which aims to actively involve patients in decisions about their care.23 This model aligns with the characteristics of a value-enhancing IT platform as outlined by Porter and Lee, such as patient-centred, encompasses all types of patient data and accessible to all parties involved in care.5

The platform development model proposed above can be an impactful initial step for adoption by both providers and within a health system. This simplifies the process for providers and policymakers to assess the achievements of health outcomes derived from patient care. The emphasis on being data-driven aligns with efforts directed at enhancing value and implementing VBHC.

In general, the results of this study are in line with the previous review of VBHC implementation in the broader field,6 8 which found that the most widely implemented VBHC agenda was measuring outcomes and costs. This suggests that this agenda is the easiest VBHC agenda to conceptualise and implement.

To successfully implement VBHC, healthcare providers may follow a strategic framework (figure 3) which begins by understanding patients’ health needs and expectations regarding their conditions. This involves defining the medical conditions and health outcomes important to patients and outlining the entire care cycle necessary for achieving these outcomes in an integrated manner, involving various related multidiscipline and/or providers. Care should be based on best practices to optimise outcomes, considering patients’ risk factors and comorbidities. Comprehensive measurement of health outcomes, including clinical outcomes, PROMs and PREMs, is essential. Accurate calculation of the actual costs incurred for the entire care cycle using TDABC is necessary. These data should be evaluated to identify opportunities for value improvement and benchmarked against both national and global standards. Improvement initiatives should be supported by policies aimed at enhancing patient value, including strengthening clinical governance (eg, clinical guidelines, integrated care pathways, standard operating procedures), investing in resources needed to improve patient outcomes (eg, medical equipment, IT systems), implementing value-based bundled payment and expand partnership as needed.33 34

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Strengths and limitations

Some limitations need to be considered when interpreting the results of this study. First, the search strategy did not specifically include search terms for each VBHC agenda item, which could have resulted in missing some of articles that fits the topic. Second, all of our empirical studies only discuss the VBHC agenda item ‘measure outcomes and costs for every patient.’ As a result, there is no evidence regarding the effects of implementing VBHC on other agendas in the field of ophthalmology that can be explained. Additionally, we failed to find existing literature that discussed two of Porter’s VBHC agendas in the field of ophthalmology: ‘moving to bundled payments for care cycles’ and ‘expanding excellent services across geography’. Third, the eligibility criteria in this study specifically focused on including related studies that explicitly referred to and used VBHC terminology. Consequently, if there were relevant studies with concepts aligned with one of the VBHC agendas but did not explicitly cite VBHC as the theoretical basis, they were not included in the review. The strength of this review lies in its pioneering exploration of the implementation and impact of VBHC within the field of ophthalmology. Being the first review into this specific area, it contributes significantly to the existing literature and offers a fresh perspective on the application of VBHC principles and their impact on ophthalmological practices.