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patients about what’s important to them before deciding on the new protocol. “Standardization is very consistent with an agenda that pushes for more shared decision making and getting patients involved in the design of care delivery,” Dr. Skootsky notes. To enhance the value of the care it provides for common conditions, the UCLA Department of Urology has conducted research on patients’ preferences and their experiences with treatment at UCLA. The initiative began with a focus on benign prostatic hyperplasia (BPH), a noncancerous enlargement of the prostate that is common as men get older and can lead to bothersome urinary symptoms. “We were offering at least five surgical therapies for that indication, and patients were often confused about what to do, which was a source of dissatisfaction for many of them,” says Christopher Saigal, MD ’94 (RES ’00, FEL ’01), MPH, vice chair of the department, who has headed the effort. The survey of patients revealed some surprising findings that led to changes, Dr. Saigal says. For one, patients were more concerned than the UCLA urologists realized about having to use catheters at home after surgery. To address that concern, the department created a video on catheter management that became the most-widely visited page on its website, drawing thousands of views each month. The department also instituted shared-decision-making processes to assist patients in coming to treatment choices consistent with their preferences and the evidence, and it produced a video for referring physicians on how to optimally manage patients with BPH prior to referral for potential surgery. Finally, drawing from the EHR database, dashboards have been created for individual physicians comparing their outcomes across BPH therapies. Measures include infection rates, emergency-room visits, hospital-readmission rates and the rate of patients returning to medical therapy, as well as each physician’s costs for delivering each service. This enables the physicians to make value- based recommendations to their patients, Dr. Saigal notes. Similar efforts are underway for prostate- and bladder-cancer treatments. “Standardized protocols, enabled by the immense amount of observational data we’re getting through electronic health records, can make a big impact on improving care,” Dr. Saigal says. “But they have to be informed by patient input and designed with patients’ goals in mind. Patients have different preferences, and the pathways must incorporate those.” Daniel Hommes, MD, PhD, director of the UCLA Center for Inflammatory Bowel Diseases and quality director of UCLA’s Division of Digestive Diseases, says that the value-based care pathways his group has instituted are “creating structure out of organized chaos.” For a variety of chronic diseases — starting with inflammatory bowel disease and then moving on to conditions that include other gastrointestinal disorders, as well as diabetes, chronic back pain and rheumatoid arthritis — Dr. Hommes’ team has employed national and international practice guidelines as frameworks for standardized-care pathways. Using these as starting points, providers learn on a patient-by-patient basis which elements are most effective and where more emphasis needs to be placed. Then they adjust their patient’s care plan each year through a feedback loop informed by a “value quotient” — a measure that incorporates the annual burden of the patient’s disease, patient- defined quality of life and work productivity, divided by the cost of the care. “When patients are running around from doctor to doctor getting all kinds of tests, that’s organized chaos,” Dr. Hommes says. “We start from the literature. Then we fine-tune the patient’s care each year based on the value quotient. We need those standardized-care pathways to capture meaningful data that will enable us to move toward personalized-care pathways.” The idea that standardization can be used to enhance care based on patient preferences and experiences isn’t surprising to Dr. Yeh. “This isn’t one-size-fits all. The goal of standardization is to make sure the right patient is getting the right care in the right place at the right time for the right cost,” he says. “People complain that standardization promotes ‘cookbook medicine.’ What’s wrong with having a cookbook? Try to find one household that doesn’t have one.” “Standardization is very consistent with an agenda that pushes for more shared decision making and getting patients involved in the design of care delivery.” Standardization makes for a more- consistent product, and that “almost by definition, means higher quality,” says Dr. Samuel A. Skootsky. Photo: Ann Johansson Dan Gordon is a regular contributor to U Magazine. U MAGAZINE 31