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How Health Care Systems Can Advance Therapeutics

      In recent years, health care organizations worldwide have taken a ``systemness'' approach to organizational growth and clinical care integration. Defined broadly as a state of a complex system derived of interconnected elements that behave as a whole rather than distinct individual parts, the concept of systemness within health care came into focus following the 2008 to 2012 global recession as a means of limiting redundancy, curtailing costs, and streamlining processes in the health care system.
      • Lerner JC.
      President and chief executive officer introduction.
      Buy-in from participants is predicated on the belief that sacrifices to be made in one sector will benefit the greater good of the entire organization. Conceptually, an integrative health care system makes sense for both the institute and the patients it serves. For example, increasing access to care across a geographic location with shared pharmacies, laboratories, and electronic medical records reduces costs, eases patient and clinical care burden, and limits medical errors. However, at the ground level, the actual integration of a systemness approach may not always be streamlined.
      • Lee TH
      • Mohta NS
      • Prewitt E
      • et al.
      NEJM Catalyst Innovations in Care Delivery—a new journal leading the transformation of health care delivery.
      Aligning the goals, vision, and mission of multiple organizations into one united, governing system, not to mention the elimination of redundant positions that may now exist as a result of unification, can be met with resistance fueled by self-perseverance.
      In next month's Conversations With the Editor, topic editor Dr. Guiditta Callea speaks with interventional cardiologist Dr. Sergio Berti about a systemness approach to integrating outpatient transcatheter aortic valve implantation, or TAVI, into a health care system in Italy. TAVI is a minimally invasive procedure in which a collapsible new aortic valve is placed within the original valve via catherization, eliminating the need for open heart surgery. As the new valve expands, it takes over the function of regulating blood flow. First pioneered in the early 2000s, TAVI has provided frail, elderly, and medically complex patients a safer alternative to valve replacement, with a recent meta-analysis reporting aggregated survival rates at 1, 2, 3, 5, and 7 years of 83%, 75%, 65%, 48%, and 28% respectively.
      • Chakos A
      • Wilson-Smith A
      • Arora S
      • et al.
      Long-term outcomes of transcatheter aortic valve implantation (TAVI): a systematic review of 5-year survival and beyond.
      Based on positive outcomes data, the TAVI procedure has been integrated worldwide as a successful alternative to invasive open heart surgery. Dr. Berti and his team have worked to generate a streamlined approach in which outpatients are evaluated, undergo the procedure, and have reduced hospitalizations. The caregivers who assess patients for the procedure are multidisciplinary, and success of the program requires a system-wide, coordinated approach to health care.
      As highlighted in the Conversations With the Editor, the evaluation of potential candidates for the TAVI procedure is not limited to a cardiovascular assessment. Rather, patients undergo nutritional, physical, and mental assessments during a 1-day visit. The results of this integrative approach have been positive for both the institution and patients alike. In an extraordinarily orchestrated manner, Dr. Berti and his team have demonstrated how to improve therapeutic interventions using a systemness approach to care, reducing costs and improving outcomes. Each part contributes to the greater good of the whole.
      Listening to the conversation between Drs. Callea and Berti, I was struck by the philosophy of Dr. Berti's hospital, which is, ``Today, we change.'' Announced daily at the hospital, the essence of this motto is at the heart of a systemness approach. Success of any integrated system begins with the willingness of its participants to welcome and engage in change, combined with strong leadership capable of convincing its partners of the opportunities that await with change.
      • Lee TH
      • Mohta NS
      • Prewitt E
      • et al.
      NEJM Catalyst Innovations in Care Delivery—a new journal leading the transformation of health care delivery.
      As economies worldwide recover from the COVID-19 pandemic and hospitals redefine themselves in its wake, the systemness approach will become even more germane to the sustainability and delivery of health care. Our todays and tomorrows are forever changed, and health care systems are carving a path forward by taking a synergistic approach to integrating the sum of its parts for improved access, outcomes, and care.

      References

        • Lerner JC.
        President and chief executive officer introduction.
        J Ambul Care Manag. 2013; 36: 172
        • Lee TH
        • Mohta NS
        • Prewitt E
        • et al.
        NEJM Catalyst Innovations in Care Delivery—a new journal leading the transformation of health care delivery.
        N Engl J Med. 2020; 382: 80-81
      1. What is TAVR? (TAVI) [American Heart Association website]. Available at: https://www.heart.org/en/health-topics/heart-valve-problems-and-disease/understanding-your-heart-valve-treatment-options/what-is-tavr. Accessed March 1, 2020.

        • Chakos A
        • Wilson-Smith A
        • Arora S
        • et al.
        Long-term outcomes of transcatheter aortic valve implantation (TAVI): a systematic review of 5-year survival and beyond.
        Ann Cardiothorac Surg. 2017; 6: 432-443