Come misurare la qualità che genera valore in cure palliative

[Autom. eng. transl.] In 2006, the American economists Porter and Teisberg argued that by defining and measuring the objectives to be achieved for a specific condition and directing the care provided towards achieving those results would have optimized the relationship Outcome/Costs, increasing the overall value of the treatment path (1.2). This concept was later revived and expanded by Berwick in 2008, who introduced the concept of Triple Aim in which, alongside the objectives of the best outcome for the patient and at the lowest possible cost, he added a population dimension to identify the right metric and the right services to offer (3). Finally, in 2014 Bodenheimer proposed the "quadruple aim", which for valuable healthcare considered four areas to be fundamental: outcomes, costs, patient experience and healthcare provider experience (4). A medicine based on value (Value-Based Medicine - VBM), which therefore is the use of resources in an equitable way, sustainable and transparent, with the aim of offering the best care to everyone both in terms of health outcomes and terms of experience, therefore manages to bring together key principles of cost-effectiveness studies and based medicine on evidence and patient-centred care (5). In fact, four pillars of Value can be distinguished: personal value, relating to the adherence of a treatment to the personal objectives and values ​​of the patient; the technical value, which indicates appropriateness of the resources used according to the outcomes achieved; the allocative value, which underlines the importance of investing resources present in an equitable manner; the social value, relating to the ability of a health intervention to strengthen the social participation of individuals, thus empowering both the individual and the population as a whole (6). Looking at palliative care, which since its birth and definition aims at "active and total care" (Law of 15 March 2010 n. 38, Art.2) by taking charge not only of the patient but of the entire family unit, the benefit is clear brought about by the application of the logic of VBM: with regard to Personal value, at the end of life the objectives often go agreed with the patient or family unit in relation to their values; the appropriateness of an action diagnosis/treatment/rehabilitation, within the technical value, has a cost/benefit ratio that changes in the patient undergoing treatment palliative; regarding the allocative value, the end-of-life setting must for example be chosen based on equity criteria; finally, for the social value, team action that takes place in palliative care, also including social workers, volunteers, caregiver and assisted could promote social connections leading to empowerment of the assisted unit and of the company (7). The transition from evidence-based to value-based medicine implies paradigm shifts that are anything but simple they need to be adequately focused and measured. In the field of palliative care, there are already various experiences documented in the scientific literature that suggest some objectives that can be measured within the four areas of the quadruple aim. Patient outcomes may refer, for example, to better pain control, less use of intensive care or inappropriate hospital admissions, lower onset of depression or pressure ulcers (8,9). The patient's experience can be described by the place of death consistent with one's values, by the openness of the structure to visits from relatives or friends, from the experience directly reported by the patient or caregiver (8,9) . The experience of healthcare workers can instead be assessed by measuring the level of burnout, the training offered, of team work e