Value-Based Model: A new perspective in Medical Decision-making

The problem of how to use financial resources beneficially in health care, despite limited budgets, reduced personnel, and inadequate time, goes beyond the realm of health economists (1). How do we use existing resources to prioritize one health program over another? Does a specific program provide a real and measurable improvement in terms of perceived health-related quality of life (HRQOL)? What decisions should we make? In the recent years, the HRQOL index has become an asset for evaluating patient health status in health programs, therapies, and clinical trials (2). Created as a specific psychological construct for use in health contexts, the HRQOL index is now widely used and evaluated by health economists, epidemiologists, clinicians, and nurses. Today, the notion that health status is not only determined by survival or absence of disease but also closely related to quality of health is universally accepted (3, 4). Health-related quality of life has been defined as the functional effect of a medical condition and/or treatment on a patient. Thus, HRQOL is a subjective and multidimensional parameter that encompasses physical and occupational functioning, psychological state, social interaction, and somatic sensation (5). Health is perceived by the person as a state that lies beyond the presence of a disease or the severity of a condition. HRQOL is influenced by several factors that include not only psychological and emotional aspects, individual behavior, and attitudes but also personal experiences, culture, and religious beliefs (6, 7). Owing to this subjectivity, patients with the same medical condition may have very different perceptions of HRQOL. For example, patients with some hematological conditions, such as hemophilia, may experience a good HRQOL despite having several disease-related complications, whereas others with the same disorder but better clinical conditions may perceive a poor HRQOL (8-12). Similar results have been obtained in patients with other chronic conditions, such as back pain (13, 14). Evaluation of HRQOL has been encouraged over the last two decades to obtain a broader perspective of health status in patients and to identify which therapeutic choices and programs to pursue (15). Health economists may use the HRQOL construct as a deciding factor in applying economic analyses. For example, in cost-benefit, cost-effectiveness, or cost-utility analyses, HRQOL may represent one indicator for measuring effectiveness (e.g., success of a health program, specific treatment, or regulatory policy) (16). In this context, effectiveness may be measured as a final outcome, such as the number of life-years gained or number of lives saved, by applying a certain program or proposing a certain treatment. Alternatively, it may be measured as an intermediate outcome in a health program, such as the number of days lost from school or work, perceived HRQOL, treatment satisfaction, or psycho-emotional well-being (17). The HRQOL construct focuses on the patient's perceived state of health as a reference value in evaluating programs and making medical decisions. In this light, we wish to discuss the potential of the HRQOL and psychological science in a new medical paradigm that has been recently described as an alternative approach to the traditional paradigm of evidence-based medicine, namely, the value-based medicine approach.