| Sumario: | The global health care sector faces unprecedented financial strain from increasing complexity and the drive for better care. In response, health care systems are increasingly adopting value-based health care (VBHC) models to optimize outcomes relative to expenditure. Singapore, which experienced an 11% annual growth in health care costs between 2012 and 2017, initiated the National Value-Driven Care (VDC) program in 2017. This case study describes the 2019 implementation of a VDC program for ischemic stroke management at Singapore General Hospital (SGH), which addresses a condition with a substantial economic burden, estimated at US$4 billion annually in Singapore. SGH is a 1,700-bed tertiary institution and referral center for endovascular thrombectomy. The study population included ischemic stroke inpatients, based on the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification codes. The program involved four components: targeting ischemic stroke, value measure definitions, value analysis, and value optimization. A multidisciplinary team developed a Clinical Quality Index comprising clinical outcomes, efficiency metrics, and patient experience measures. Data were obtained from the electronic medical records, neurology department audits, and the finance department. Tableau software was used for data visualization and analysis, with a quarterly refresh where lower-performing areas and high-cost indicators were identified for targeted improvement initiatives. Between January 2018 and December 2023, 7,505 ischemic stroke hospitalizations were analyzed. Six value optimization projects were initiated, with four completed during the study period. Key improvements included: (1) a reduction in urinary tract infection rates from a baseline monthly median of 10% (interquartile range [IQR] 6.7%-11.9%) to 5.7% (IQR 4.0%-7.3%), resulting in an estimated cost avoidance of Singapore dollars (SGD)$70,000 (0.2% of SGD$34 million) over 1 year from February 2022 to January 2023; (2) an increase in the proportion of patients meeting the 90-minute door-to-groin puncture time target for endovascular thrombectomy, from 16.0% of 27 patients in 2018 to 82.3% of 199 patients in 2023; (3) the introduction of an abbreviated MRI protocol, leading to a 55% reduction in unit cost (to SGD$360 from SGD$800) and an estimated annual cost avoidance of SGD$400,000 (1.2% of SGD$34 million); and (4) a decrease in inappropriate carotid ultrasound orders, from 20% of all cases to 6%, resulting in an estimated annual cost avoidance of SGD$115,200 (0.3% of SGD$34 million). This value-driven approach includes a robust data system, enabling continuous monitoring of outcome measures. Through targeted interventions, notable improvements in outcomes and cost reductions were achieved without compromising safety. This comprehensive review demonstrates how value-driven care can transform health care delivery through data-driven decision-making, multidisciplinary collaboration, and focused interventions. SGH later enhanced its program by incorporating the International Consortium for Health Outcomes Measurement (ICHOM)'s set of patient-centered outcome measures for stroke from 2024 for international benchmarking and alignment with global best practices in VBHC. Stroke management efforts over 5 years have led to improvements in certain clinical outcomes and process measures, as well as a reassessment of protocols for MRI and ultrasound utilization, resulting in an overall reduction in median investigation costs per patient.
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