IPU for Metabolic Syndrome and Obesity

To implement the value agenda, a value-based healthcare program for Metabolic Syndrome and Obesity was built at the Center of treatment for metabolic and obese patient (CTO) of the Santa Casa de Misericordia in Porto Alegre, RS – Brazil. Motivated by healthcare sustainability and patient centricity, the institution built a
value agenda encompassing five mutually reinforcing elements: the integrated unit of practice (IPU), outcome and cost measurement for each patient, payment bundle for the care cycle, integrated care delivery systems with different stakeholders, and digital solutions to support all value proposition in 5 different dimensions (monitoring, outcomes, TDABC costs, patient engagement, international benchmark).

Creation of the IPU enable CTO to redesign patient journey improving clinical management of patients with expansion of agendas and multidisciplinary professionals involved. Timing to refer to the second line of treatment (surgical management) was also optimized through a strong clinical approach with weekly case discussions. Patient is then navigated through the institution and once referred, Bari+ plays an important role to give protagonism to patient in decision making. Furthermore, the medical care protocols are managed by the Quality sector and patients are monitored during the journey by the Value Management Office (VMO). According to the international guidelines, the patient will be managed to the surgical arm if Body mass index (BMI) >35 with comorbidities, or BMI> 40 or if BMI 30-34.9 with clinical treatment failure for diabetes type II.

From a patient perspective, patient-reported outcomes were measured using the BODY-Q, an instrument consisting of 18 independently functioning scales and an obesity-specific symptom checklist measuring appearance, health-related quality of life (HR-QOL), and healthcare experience. Data were collected through telephone and online interviews (REDCap).

From a health sustainability perspective, costs were evaluated in VMO BI, but since surgical episode comprises almost 80% of costs, Time-Driven Activity Based Costing (TDABC) methodology was used to assess costs of surgical episode. As an interface with industry, a new payment model was proposed involving a single
payment for bariatric surgery covering pre-operative work and ending 90 days after discharge with gain sharing agreement based on reoperation and ICU utilization. Before the implementation of IPU, data were unstructured, preventing reliable and critical analysis of outcomes and performance. Outcomes such as length of stay and mortality were not assessed. Compared to pre-implementation scenario, it is possible to state that length of stay was reduced by up to 1.3 days, and the number of procedures in addition to the main one increased by 64.0%.

After almost 1 year of project, it’s possible to state that IPU implementation was successful, with increase in appointments in clinical management (with endocrinologist, nutritionist and psychologist), optimized LOS, ICU utilization and complication rate during hospital stay (2 days, 0,4% and 0,9% respectively) and also reduced resource utilization after 30-days of surgery showing efficacy of treatment (6,7% of ER visit, 2,4$ of readmission, 0% of reoperation, 0% mortality, 2,7% late complications). Mean average of % weight loss in 30 and 90 days were 9,1 and 15,6, respectively.