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Official Journal of the Society to Improve Diagnosis in Medicine (SIDM)

Editor-in-Chief: Graber, Mark L. / Plebani, Mario

Ed. by Argy, Nicolas / Epner, Paul L. / Lippi, Giuseppe / Singhal, Geeta / McDonald, Kathryn / Singh, Hardeep / Newman-Toker, David

Editorial Board: Basso , Daniela / Crock, Carmel / Croskerry, Pat / Dhaliwal, Gurpreet / Ely, John / Giannitsis, Evangelos / Katus, Hugo A. / Laposata, Michael / Lyratzopoulos, Yoryos / Maude, Jason / Sittig, Dean F. / Sonntag, Oswald / Zwaan, Laura

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Weighting healthcare efficiency against available resources: value is the goal

Giuseppe LippiORCID iD: http://orcid.org/0000-0001-9523-9054
Published Online: 2018-06-02 | DOI: https://doi.org/10.1515/dx-2018-0031

According to the Cambridge dictionary, “healthcare” is conventionally defined as “set of services provided by a country or an organization for the treatment of the physically and the mentally ill” [1]. Very interestingly, this definition is accompanied by a short sentence underneath, stating that “healthcare workers are some of the lowest paid people in the country”.

In most countries, healthcare expenditure contributes between 10 and 30% of the total public expenditures, preceded only by costs attributable to social protection. The overall healthcare expenditure varies largely around the world, with countries like the US spending approximately 9900 US $/capita and others like South Africa spending less than 1150 US $/capita. Many countries lie between these expenditures, such as Germany (~5600 US $/capita), Australia (~4700 US $/capita), UK (~4200 US $/capita), Italy (~3400 US $/capita) and Greece (~2200 US $/capita) [2]. The figures of public healthcare expenditure do not overlap with those of the overall healthcare expenditures, wherein public healthcare coverage accounts for approximately 49% in the US, whilst it varies largely in the other countries such as Germany (~85%), UK (~79%), Italy (~75%), Australia (~68%), Greece (~58%) and South Africa (48%) [2].

The indicator “potential years of life lost” is a summary measure of premature mortality, thus providing a straightforward means for weighting preventable deaths in the single country. This value is 17,963/100,000 preventable death per inhabitants in South Africa, 4611/100,000 in the US, 2988/100,000 in Greece, 2880/100,000 in Germany, 2674/100,000 in Australia, 2490/100,000 in Italy and 2296/100,000 in the UK [2]. Using a multivariate linear regression analysis for establishing the potential correlation between preventable deaths and private or public healthcare expenditures, the correlation does not reach statistical significance, for either (i.e. r=0.41 and p=0.56 for total expenditure and r=0.59 and p=0.27 for public expenditure, respectively) (Figure 1). Results are virtually unchanged including data from other countries (data not shown).

Relationship between preventable mortality and total or public healthcare expenditures.
Figure 1:

Relationship between preventable mortality and total or public healthcare expenditures.

The results of this very simple analysis are not really unexpected, as data published in earlier studies showed, more or less, similar trends [3, 4]. Hence, it would seem reasonable to conclude that the health and wellbeing of the population is not substantially dependent on the amount of healthcare funding (either total or public), but it is probably more influenced by quality of care. This clear-cut concept should lead the way to rethinking the actual means of care delivery, which should henceforth be more focused on quality (and value) rather than on volume. It is now undeniable that the sustainability of all national healthcare services is seriously challenged by an unprecedented worldwide economic crisis, which has brought many countries to their knees, and which does not seem to have been completely overcome. Social, economic and political strains around the world do not allow envisioning a bright future for economy and national treasuries, thus challenging further both the sustainability and equity of healthcare delivery, with the serious threat of approximating a “double breakpoint” characterized by the unavailability of public resources to withstand the demands of care, compounded by such a contraction of private and personal finance that access to private care will no longer be feasible for more and more patients, especially in countries with the worst or the slowest-growing economies.

There is only one way out of this struggle, that is, to focus on value rather than on volume of healthcare performance. Albeit it may seem even paradoxical, this strategy will trigger a vicious and virtuous cycle, which starts from increasing value in healthcare, which in turn improves outcomes and this, very understandably, will lead to a lower need of economic resources for treating a healthier population (Figure 2).

The relationship between resources, enhanced value and outcome in healthcare.
Figure 2:

The relationship between resources, enhanced value and outcome in healthcare.

A paradigmatic representation of this policy is clearly summarized in the article of Mario Plebani, published in this issue of Diagnosis [5], who eagerly concludes that the mainstay for securing the survival of clinical laboratories in a world with increasingly limited resources encompasses a paradigm shift, necessitating a change in the current view of laboratory medicine, and thus focusing more on efficiency (and value) rather than on volumes. It is also undeniable that the burden of inappropriateness in laboratory medicine is extraordinarily high [6], more so than that of other diagnostic disciplines such as medical imaging [7]. The reasons are many and multifaceted, including a widespread perception of laboratory services as inexpensive commodities, the small amount of knowledge that some clinicians have about the “clinical” significance of laboratory tests, as well as the lack of clinical information which explains the objective difficulty for the laboratory to define whether the tests requested are really appropriate or not. Beside the shortage of public funding and private finance, inappropriateness will further impact laboratory budgets, by eroding precious economic and human resources, wasted on performing unnecessary and avoidable tests.

Indeed, the strategy proposed by Mario Plebani, i.e. focusing on an outcome-based evaluation of laboratory performance [5], perfectly matches a broader value- and patient-centered vision of future health care (Figure 2). Yet, like in the legendary “Trojan horse”, many problems also come from inside. Policymakers and hospital administrators indeed have their own responsibilities in driving a virtuous path towards the future, but laboratory professionals should be active in promoting an enlightened, far-reaching and pervasive culture of value [8]. This will unavoidably entail refraining from benchmarking their own laboratories (and activities) according to volume of tests because, as affirmed by Mario Plebani, we shall all be persuaded that “bigger is not always better” [5] and, sometimes, “less is even more” [9].


About the article

Corresponding author: Prof. Giuseppe Lippi, Section of Clinical Biochemistry, University Hospital of Verona, Piazzale LA Scuro, 37100 Verona, Italy

Published Online: 2018-06-02

Published in Print: 2018-06-27

Author contributions: The author has accepted responsibility for the entire content of this submitted manuscript and approved submission.

Research funding: None declared.

Employment or leadership: None declared.

Honorarium: None declared.

Citation Information: Diagnosis, Volume 5, Issue 2, Pages 39–40, ISSN (Online) 2194-802X, ISSN (Print) 2194-8011, DOI: https://doi.org/10.1515/dx-2018-0031.

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