Aspects of quality of life in the patient journey in glaucoma

Open angle glaucoma is a chronic disease of the optic nerve, where damage to the visual field can result in loss of vision. There is currently no cure for the disease. The four studies presented within this thesis aimed to explore aspects of the impact of glaucoma on patients’ everyday living and quality of life. The studies were designed to capture aspects of the ‘journey’ in glaucoma which may be particularly challenging for the patient; the initial stage, where quality of life may be reduced and the accompanying burden of ongoing disease monitoring; and the end stage, where significant loss of vision will likely cause visual disability and the daunting prospect of undergoing high-stakes ocular surgery. In the first study, the relationship between visual field loss (measured using mean deviation [MD]) and vison-related quality of life was assessed. Evidence indicated that glaucoma has a negative impact on vision-related quality of life, even in the earliest stage of the disease. However, the relationship is likely to be non-linear, as certain phases of the disease are more likely to have a greater impact than others. Specifically, each 1 decibel reduction in MD was associated with a decline of 2.3 (out of 100) units on a quality of life metric in the early stage of glaucoma (p<0.001), and 4.6 units in advanced disease (p=0.009). In the second study, vision-related quality of life was assessed amongst a cohort of newly-diagnosed glaucoma patients taking part in a randomised glaucoma therapy clinical trial. Responses on patient-reported outcome measures (PROMs) were assessed for group differences between treatment arms of the trial. In addition, group differences in quality of life between the stable patients and those with glaucomatous progression was compared. There were no statistically significant differences on PROMs between the two trial arms. Differences between stable and progressing glaucoma patients were observed only on PROMs specific to glaucoma (Glaucoma Quality of Life-15, p = 0.02; Glaucoma Activity Limitation-9, p = 0.02). In the third study, the equivalence of visual field measurement outcomes were assessed between patients attending standard glaucoma care services and those attending a novel glaucoma service, a virtual clinic. Average MD measurements for 250 patients in the virtual clinic were compared with a ‘big data’ repository of patients in the standard glaucoma service, which was used to calculate expected MD values. The speed of visual field progression between the two groups was also assessed. In the first analysis, 12 (4.8%; 95% confidence interval 2.5% to 8.2%) virtual clinic patients scored outside the 90% expected values based on the big data repository. In the second analysis, 1.9% (95% confidence interval 0.4% to 5.4%) virtual clinic patients had visual field changes outside of the expected 90% limits. In the fourth study, patient and surgeon experiences of advanced glaucoma surgery were assessed in a qualitative analysis. Interview transcripts underwent thematic analysis where, for the patients, key emerging themes included the emotional impact surgery, developing coping mechanisms, and how to improve the patient’s surgical journey. For the surgeons, themes included strategies for risk reduction, views on training, and the emotional impact of performing surgery on advanced glaucoma patients. To conclude, these studies highlight aspects of the patient journey in glaucoma where the disease may be most burdensome and troubling for the patient. Some practical changes, such as performing monitoring measurements in a virtual clinic, or augmented surgical care services for patients with advanced disease may help to ease the burden of glaucoma. In addition, the findings from these studies can help to improve understanding of the glaucoma journey and serve as an effective resource for learning, support, and professional development for patients, relatives, and carers, as well as professionals specialising in eye care

The Role of Value Stream Mapping in Healthcare Services: A Scoping Review

[EN] Lean healthcare aims to manage and improve the processes in the healthcare sector by eliminating everything that adds no value by improving quality of services, ensuring patient safety and facilitating health professionals' work to achieve a flexible and reliable organization. Value Stream Mapping (VSM) is considered the starting point of any lean implementation. Some papers report applications of VSM in healthcare services, but there has been less attention paid to their contribution on sustainability indicators. The purpose of this work is to analyze the role of VSM in this context. To do so, a scoping review of works from recent years (2015 to 2019) was done. The results show that most applications of VSM reported are in the tertiary level of care, and the United States of America (USA) is the country which leads most of the applications published. In relation with the development of VSM, a heterogeneity in the maps and the sustainability indicators is remarkable. Moreover, only operational and social sustainability indicators are commonly included. We can conclude that more standardization is required in the development of the VSM in the healthcare sector, also including the environmental indicators.Marin-Garcia, JA.; Vidal-Carreras, PI.; García Sabater, JJ. (2021). The Role of Value Stream Mapping in Healthcare Services: A Scoping Review. International Journal of Environmental research and Public Health (Online). 18(3):1-25. https://doi.org/10.3390/ijerph18030951S12518

An Industrial Engineering-Based Approach to Designing and Evaluating Healthcare Systems to Improve Veteran Access to Care

Access to healthcare is a critical public health issue in the United States, especially for veterans. Veterans are older on average than the general U.S. population and are thus at higher risk for chronic disease. Further, veterans report more delays when seeking healthcare. The Veterans Affairs (VA) Healthcare System continuously works to develop policies and technologies that aim to improve veteran access to care. Industrial engineering methods can be effective in analyzing the impact of such policies, as well as designing or modifying systems to better align veteran patients’ needs with providers and resources. This dissertation demonstrates how industrial engineering tools can guide policy decisions to improve healthcare access by connecting veterans with the most appropriate healthcare resources, while highlighting the trade-offs inherent in such decisions. This work comprises four stages: (1) using optimization methods to design a healthcare network when introducing new provider options for chronic disease screening, (2) developing simulation tools to model how access to care is impacted when scheduling policies accommodate patient preferences, and (3) simulating triage strategies for non-emergency care during COVID-19, and (4) evaluating how treatment decisions impact patient access when guided by risk-based prediction models compared to current practice. In the first stage, we consider veteran access to chronic eye disease screening. Ophthalmologists in the VA have developed a platform in which ophthalmic technicians screen patients for major chronic eye diseases during primary care visits. We use mixed-integer programming-based facility location models to understand how the VA can determine which clinics should offer eye screenings, which provider type(s) should staff those clinics, and how to distribute patients among clinics. The results of this work show how the VA can achieve various objectives including minimizing the cost or maximizing the number of patients receiving care. In the second stage, we simulate patients seeking care for gastroesophageal reflux disease with primary care and gastrointestinal providers. This simulation incorporates policies about how to schedule patients for visits in various modalities, including face-to-face and telehealth, and also considers uncertainty in key factors like patient arrivals and demographics. Results of these models can help us understand how scheduling based on these preferences impacts access, including time to first appointment and number of patients seen. Such metrics can guide healthcare administrators as new technologies are introduced that offer options for how patients interact with their providers. In the third stage, we simulate patients seeking non-emergency outpatient care under reduced appointment capacity due to the COVID-19 pandemic. We demonstrate this using endoscopy visits as a central example. We use our simulation model to understand how various strategies for adjusting patient triage and/or clinic operations can mitigate patient backlog and reduce patient waiting times. In the fourth stage, we integrate multiple industrial engineering methods to examine how access is impacted among chronic liver disease patients when predictive modeling is introduced into treatment planning. We developed a simulation model to help clinical decision-makers better understand how using a predictive model may change the care pathway for a specific patient and also impact system decisions, such as required staffing levels and clinical data acquired at specific patient visits. The model also helps clinicians understand the value of specific clinical data (lab values, vitals, etc.) by demonstrating how better or worse inputs to the predictive models have larger system impacts to patient access.PHDIndustrial & Operations EngineeringUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/169942/1/ajvandeu_1.pd

Telemedicine

Telemedicine is a rapidly evolving field as new technologies are implemented for example for the development of wireless sensors, quality data transmission. Using the Internet applications such as counseling, clinical consultation support and home care monitoring and management are more and more realized, which improves access to high level medical care in underserved areas. The 23 chapters of this book present manifold examples of telemedicine treating both theoretical and practical foundations and application scenarios

Trends and health economic aspects of service delivery of glaucoma

Glaucoma describes a group of optic neuropathies characterised by progressive irreversible loss of visual function. Within this thesis, a health economic model was constructed to map service provision from diagnosis considering two competing strategies: the current practice of annual visual field (VF) monitoring against the proposed guidelines of performing 6 VFs in the first two years. The constructed model found the proposed practice to be cost effective at a willingness to pay ceiling ratio of £30,000 per quality adjusted life year (QALY), identifying an incremental cost effectiveness ratio (ICER) of £21,679. The findings of the model however were potentially sensitive to the modelled infrastructure improvement costs required to undertake the proposed guidelines and a costing study to more accurately ascertain these costs was recommended. Following this study, statistical analysis of 473,252 VFs was undertaken to investigate trends in initial identification and progression rates whilst also narrowing their parameters within the health economic model. Consequently, the average level of glaucomatous vision loss at diagnosis was found to be improving by 0.11 dB per year on average whilst proportions of patients with ‘advanced’ loss at diagnosis fell significantly from 30% to 21%. Average progression rates were found to have fallen from -0.11 dB per year to -0.06 dB per year whilst average rates of loss in older eyes (>70 years) were found to progress faster than in younger eyes (<60 years). Furthermore, testing frequency was found not to vary by visual impairment risk factors. The constructed health economic model was subsequently updated to incorporate the more narrowly defined parameter distributions whilst also being re-specified to incorporate societal costs of visual impairment to count the true costs of the disease. This resulted in an improved ICER of £11,382. In conclusion, it is likely that implementing the proposed guidelines of 6 VFs in the first two years is more cost-effective than annual monitoring. This argument is further reinforced once societal costs are accounted for however a scoping study to examine the required costs of improving the glaucoma monitoring infrastructure is required

Diabetes-Related Complication in Canada; Prevalence of Complication, Their Association with Determinants and Future Potential Cost-Effectiveness of Pharmacy-Based Intervention

In the 21st century, diabetes mellitus (DM) emerged as one of the most prevalent non-communicable diseases, and poses a major problem for every health system in the world. Its global prevalence has more than doubled in the last three decades. As diabetes has become more prevalent, the health programming designed to target diabetes patients has remained inadequate and only heightened the burden. This heightened burden has manifested itself in the increased risk of complications common among patients with diabetes. These complications vary widely, and are typically categorized as either micro-vascular or macro-vascular depending upon the size of blood vessels that are compromised. Due to the havoc that can ensue by either type of complication, the increased risk of diabetes-related complications has been recognized as a serious threat to population health. To gain insight into the threat posed and how it will likely present in the Canadian population, patient’s data from the diabetes component of Survey on Living with Chronic Diseases in Canada (SLCDC-DM-2011) was analyzed. This analysis revealed that among Canadian diabetes patients, 80.26 percent reported having at least one type of diabetes-related complication. The most frequently reported complications were high blood pressure (54.65%), cataracts (29.52%), poor circulation (21.68%), and heart disease (19.4%). This analysis also revealed the predictive role of socio-economic factors associated with diabetes-related complications in Canada. Being married, having a higher income, and having a higher level of education were protective against most complications. In contrast, low levels of physical activity and high levels of HbA1C were important risk factors for many diabetes–related complications. Identifying common diabetes-related complications, protective factors and risk factors is useful for combating the threat posed by diabetes-related complications. To combat this threat in practice, healthcare professionals will play a significant role in the control and management of diabetes and its complications. Diabetes is a chronic disease that needs long-term treatment, and thus multi-disciplinary teams will be required. Increasingly, pharmacists are being determined as having a prominent position on these teams due to their accessibility to the Canadian population, and their expanding scope of practice. This profession has contributed positively to the long-term prognosis of patients with diabetes, in part, by aiding in the control and management of the disease. This aid oftentimes comes in the form of pharmacy-based interventions. Pharmacy-based interventions include a variety of services aimed at enabling patients with diabetes to have better control of their condition. I conducted a systematic review and meta-analysis to evaluate the effects of pharmacy-based interventions on clinical and non-clinical outcomes associated with diabetes-related complications. Four main databases were searched. Based upon my meta-analysis, the standardized absolute mean difference in reduction of HbA1C (%) from baseline to the time of the last follow-up significantly favoured patients in the pharmacy-based intervention group compared to those receiving care as usual (0.96%; 95% CI 0.71: 1.22, P<0.001). In addition, the standardized absolute mean difference in reduction of BMI unit (kg/m2) was 0.61 (95% CI 0.20: 1.03, P<0.001) in favour of the pharmacy-based intervention group. Both of these results demonstrate the positive effect pharmacy-based interventions can have on clinical outcomes. However, there is a dearth of evidence about the effects of pharmacy-based interventions on non-clinical outcomes, including health care utilization and quality of life. Therefore, it was not possible to evaluate non-clinical outcomes associated with diabetes-related complications in the same way. Each year healthcare expenses incurred from diabetes and its complications total more than US$827 billion. This health care cost is significant, and is only expected to grow alongside diabetes’ increasing prevalence. In light of this, a debate over the comparative effectiveness of the different strategies used to manage diabetes and its complications has been sparked. The development of analytic models that can be used as tools in determining budget prioritization and cost-effectiveness of interventions is beginning to be prioritized. To conduct an economic evaluation of these interventions, simulation models are necessary. These models estimate health outcomes, such as life years saved or Quality Adjusted Life Years (QALYs) gained, and account for the costs and health consequences associated with diabetes, its complications and risk factors. I developed a hybrid (agent-based/system dynamic) individual-level micro simulation model using 2,931 patient records from the SLCDC-2011. This model extrapolated the effects of pharmacy-based interventions on health outcomes, costs and health-related quality of life (HRQOL) over time through time-varying risk factors of diabetes-related complications. The treatment effects of pharmacy-based interventions were modeled as reductions in HbA1c levels, BMI, systolic blood pressure and LDL, all of which can affect the risk of progressing long-term complications. The annual costs of diabetes-related complications, as well as, costs associated with pharmacy-based intervention from a societal prospective, were also considered. Using this data, the micro-simulation model was able to estimate the expected number of major health events (heart failure, stroke, amputation, and blindness), QALYs over a patient’s lifetime, the patient’s economic burden on the health care system, and the extent to which pharmacy-based intervention can modify these outcomes. Deterministic and probabilistic sensitivity analyses were conducted to evaluate the uncertainty around the results. Based on the results from my micro-simulation model, a pharmacy–based intervention could avert a total of 155 deaths associated with complications, 19 heart failures, 159 strokes, 24 amputations and 29 blindness events in a population of 2,931 patients over the next 50 years. In addition, the intervention could add 1,246 additional life-years (0.42 per patients) and 953 additional quality-adjusted life-years (0.32 per patients). The intervention would also be cost-effective in comparison to usual care, as indicated by the incremental discounted cost per QALY gained ($3928). Overall, these results suggest that an integrated pharmacy-based intervention could be a cost-effective strategy to control and manage diabetes-related complications in Canada. This is promising and has important public health implications that should not be ignored