Outcomes that matter to patients derive more value from health budgets

The five-year survival rate - of around 95 per cent - for cancer patients having their prostate gland removed at Martini-Klinik in Hamburg, is in line with the rest of Germany.

But although that obviously is an important measure of the clinic’s performance, it says nothing about the quality of life of men who have had a radical prostatectomy.  

Removing the prostate can lead to urinary incontinence and erectile dysfunction. It turns out that around 43 per cent of men undergoing radical prostatectomy in Germany as a whole suffer incontinence one year after surgery. At the Martini-Klinik the figure is 6.5 per cent.

Similarly, three quarters of German patients report severe erectile dysfunction after one year, compared to just over one third for Martini-Klinik patients.

These impressive outcomes have caught the attention of management consultants, analysts, and of Michael Porter, the Harvard economist whose work underpins value-based healthcare.

At the core of this approach is understanding of the outcomes that matter to patients. “Martini-Klinik is a pioneer and role model for the implementation of value-based health care,” Porter told Healthy Measures. “The Klinik is organised around an important medical condition, prostate cancer, with a multidisciplinary team dedicated to the care of prostate patients.”

Porter praises the Hamburg centre’s record of measuring and reporting outcomes that matter to both patients and clinicians and the way in which surgeons apply outcomes data to drive further improvements. “Martini-Klinik has shown that if you measure what matters, you can become the best in your field and that doing so attracts patients from all over Germany and more broadly in Europe,” he said.

Porter believes specialisation is the best way to achieve excellence. For procedures such as prostatectomy, high volume and focus are strongly linked to better results.

Hartwig Huland, co-founder of Martini-Klinik concurs. “A urology department would typically do around 100 prostatectomies per year, whereas the biggest US centres, such as the Mayo Clinic and Johns Hopkins Hospital would do between 800 and 1,000, Huland said. “Last year we did 2,308.”

Despite - or maybe because of - the high throughput, patient satisfaction is high. “The best question to ask is, ‘Would you recommend this to a friend or your brother?’ For years, we’ve had 98 to 100 per cent positive responses,” Huland said.

Integrated practice

Huland cites three main reasons for the clinic’s success: specialisation, studying patient-reported outcomes, and the egalitarian nature of the surgical faculty, all of whom get a job for life.

“Our clinic reflects Michael Porter’s idea of the integrated practice unit, a specialised centre with all relevant services in once place,’ said Huland. “We offer imaging, radiotherapy, surgery, complementary medicine, oncologist therapy for advanced disease. Everything under one roof.”

This is a fundamental shift from how most hospitals are organised. Instead of having an imaging department, radiation therapy and surgery departments used by all specialties, integrated practice organises services around diseases. Patients receive all the care they need at a prostate cancer centre – or diabetes or stroke clinic – rather than being shunted from department to department around the hospital.

The power of data

One of the core resources at Martini-Klinik is a database of long-term outcomes that dates back 25 years to 1992. Patients are contacted every year and asked a set of standard questions. “You can learn a lot from your patients, but you need a biostatistician on board to analyse the data,” said Huland. “We do between 50 and 70 research publications per year based on information from our database.”

Outcomes data can be used to improve surgeons’ performance. The Martini-Klinik’s 11 surgeons sit down every six months to compare results. The on-site biostatistician adjusts the data to account for case mix. If one specialist does a large number of complex cases while another surgeon mainly handles routine patients that is accounted for in making comparisons.

“If somebody is particularly good, we may adopt their approach, so that we all improve. If a surgeon is not doing so well on a particular type of patient, a colleague can look over their shoulder for a while,” Huland said.

Huland and the co-founder of Martini-Klinik Markus Graefen were instrumental in the development of the Standard Set of outcomes for localised prostate cancer developed by the International Consortium for Health Outcome Measures (ICHOM), co-founded by Porter to bring his theories to life.

“This is a guide to what should be documented before and after treatment,” Huland said. “It was put together by 28 experts and was the fourth disease addressed by ICHOM since it was founded five years ago.”

Charlotte Roberts, vice president for standardisation at ICHOM, says the standard set is accelerating the comprehensive measurement of outcomes, enabling global comparisons and allowing prostate cancer centres around in the world to learn from each other. 

“Huland’s experience with outcome measurement and quality improvement at the Martini-Klinik was invaluable in making these recommendations, and many institutions can learn from their approach to value-based healthcare and improving outcomes,” Roberts said.

The Martini-Klinik prostate cancer story is being replicated in other disorders, according to Jens Deeberg-Wittram, executive director at the consultancy Boston Consulting Group and founding president of ICHOM .

“Look at how eating disorders are managed at Germany's Schön Klinik, joint replacement at the Hoag Institute in Southern California or cataract surgery in India’s Aravind eye hospital. All are showing [better] outcomes over [other providers] by focusing on one medical condition, measuring outcomes and providing integrated and multidisciplinary care,” he said. “This strategy will pay off. In the long run, governments and payers will reimburse providers for achieving better outcomes rather than higher case numbers.”

Jobs for life

The third defining feature of the clinic is its flat organisational structure. Abandoning the traditional university hospital hierarchy, all of the Martini-Klinik’s specialists are of equal rank. “Our faculty members all have a lifelong position here,” said Huland. “They are all high-volume specialist surgeons who have done more than 1,000 procedures.”

In addition, the clinic has an associated faculty of radiologists, radiation oncologists, an oncologist, a pathologist, an anaesthesiologist, and a psycho-oncologist, all of whom specialise in prostate cancer but remain members of their own departments.

“There are several advantages to providing prostate-cancer specific counselling,” according to Alexander Krüger, a psycho-oncologist at the clinic. “This service is embedded in the active oncological treatment and aftercare.”

Patients sometimes face psychosocial stressors directly linked to prostate cancer including a sense of existential threat, treatment anxieties, fear of incontinence or worries about sexuality and virility. “Treating these stresses and strains in a professional way requires interdisciplinary cooperation and special psycho-oncological knowledge,” Krüger said.

Visiting surgeons

The influence of Huland and his colleagues extends beyond Hamburg. “We often have visiting surgeons from China, the Netherlands, Scandinavia and from other centres in Germany who want to study our organisation or our operative technique, which can be followed live on a screen we have set up outside the operating room.”

One of the inevitable problems the Martini-Klinik faces is keeping up with demand. Call for an appointment today and you will probably wait three months. Most patients come from Germany but around 9 per cent are from abroad, including a large contingent of Norwegian patients, thanks to a collaboration with a Norwegian Hospital Group.

By the end of 2017, an additional two surgeons will be recruited, bringing the total number of procedures up to 3,000 per year. At present, the clinic has a maximum of five theatres but plans to construct a new building in order to expand capacity.