Sirpa Arvonen’s research while affiliated with Helsinki University Central Hospital and other places

HealthyWeighHub (HWH) is a 12-month coaching and education service designed to help patients with obesity make permanent life changes, launched and expanded gradually in Helsinki University Hospital (HUS) Healthvillage since 2016. We examined the direct secondary care cost benefits of HWH, measured with potential capacity freed (PCF) compared to conventional group coaching (CGC). Costs included health care, patient co-payments and travelling expenses. First, we evaluated the PCF actualized in the first two years from 2016 to 2018 in the HUS Specific Catchment Area (HUS ERVA). Then, we predicted the PCF at Finnish national level, if HWH was implemented gradually over the five years from 2018 to 2022, aimed at treating 1 % of adults with obesity annually in 2022. HWH’s actualized PCF was €2.69 million compared to CGC in the first two years in HUS ERVA. If the patients who received CGC had been treated with HWH instead, total PCF could have been €3.71 million. At Finnish national level, providing CGC to 1 % of adults with obesity was predicted to cost €28.0 million (€5.08 per capita) annually in 2022. With HWH predicted cost was €7.31 million (€1.33 per capita), meaning an annual PCF of €20.7 million (€3.75 per capita) in 2022 and cumulative five-year PCF of €57.5 million (€10.43 per capita). Compared to CGC, HWH is estimated to enable treatment of approximately 3.8-times more patients with obesity at the same cost. HWH can be more affordable than CGC and a potentially efficient tool to combat the obesity epidemic. Future evaluations should examine HWH’s effectiveness and impact on the indirect costs associated with weight loss and long-term illness.

Background: Virtual hospital 2.0 (VH2.0, Virtuaalisairaala 2.0) platform, a joint project between all Finnish university hospitals [1] is an essential part of a key governmental wellbeing project of customer-responsive services in Finland [2–3]. VH2.0 produces and implements client-oriented digital special care services to various stakeholders (e.g. patients, providers) in Virtual village (Terveyskylä [4]). On national level, five-year cumulative potential health care capacity freed with VH2.0 was estimated at €1.3 billion [5]. Here, eHealth service (digital care path) for specific indication was assessed in terms of predictive cost-benefit analysis. Aim: Predictive cost-benefit modelling of VH2.0 digital care path for insulin-dependent diabetes patients. Methods: The health economic evaluation (HEE) considered clinical and economic viewpoints and was based on the PICOSTEPS principle, which reports the content of HEE in its order of importance [6]. PICOSTEPS has been used in e.g. the Finnish Current Care Criteria [7], real-world data (RWD) based [8] and modelled [6] HEEs. Patients: All individuals with insulin-dependent diabetes who are expected to use specialized care services in 1) the Kuopio University Hospital Catchment Area (KUH ERVA) or 2) Finland generally. Intervention: Modelled VH2.0 operational change (prediction) with the examined digital care path including e.g. e-messages, e-appointments, a virtual meeting and material available for patients. Comparator: Modelled conventional practice (prediction) based on population and morbidity information and Finnish RWD. Outcome: Predicted health care capacity freed (PHCCF, year 2017 real value) at KUH ERVA and at Finnish national level available for other uses within the health care system, allowed by the digital care path. Setting: Dynamic cost-benefit modelling covering the predicted changes in the patient cohorts based on the population structures and morbidity. Time: First five years from year 2018 to 2022 in annual cycles; assuming digital care path implementation was initiated in the beginning of year 2018 and completed gradually in three years at the KUH ERVA level and in four years at the national level. No discounting of PHCCF was done. Effects: Expected over-time changes in population structure and morbidity, resource use (e.g., clinician and nurse visits, letters and calls, inpatient days, e-appointments, e-messages, travelling, patient fees) and unit costs based on the RWD and expert information. Perspective: Third-party payer including only direct health care and travelling costs. Sensitivity analyses: The gradual implementation of digital care path in two or five years. Results: At the KUH ERVA level, the average annual PHCCF with digital care path was estimated at €0.125 million for the first five years, summing up to total estimated five-year PHCCF of €0.626 million (27.5 % of the total included conventional practice costs). At the national Finnish level, average annual PHCCF with digital care path was estimated at €0.577 million for the first five years, summing up to total estimated five-year PHCCF of €2.89 million (23.2 % of the total included conventional practice costs). The five most important key value drivers for the PHCCF were physician visits, nurse visits, patient fees, travelling and nurse calls. Conclusions: VH2.0 digital care path for insulin-dependent diabetes patients potentially frees substantial capacity for other purposes. From the perspective of opportunity costs such technological revolution is very valuable and the capacity freed can produce significant effectiveness elsewhere [9]. References: [1] www.virtuaalisairaala2.fi [2] valtioneuvosto.fi/en/implementation-of-the-government-programme [3] valtioneuvosto.fi/documents/10184/321857/Government+action+plan+28092017+en.pdf [4] www.terveyskyla.fi/ [5] Väätäinen et al. Virtual hospital 2.0 – modelled cost-benefit assessment. eHealth2018. [6] Soini et al. ClinicoEconomics and Outcomes Research 2018;10:279–92. [7] http://www.kaypahoito.fi/web/kh/suositukset/suositus?id=nix02465&suositusid=hoi50062 [8] Soini et al. Clinical Therapeutics 2017;39:537–57.e10. [9] Hallinen et al. Vaihtoehtoiskustannukset ja kustannusvaikuttavuus tuotantoteknologian muuttuessa: esimerkkinä eteisvärinän antikoagulaatiohoito. Terveystaloustiede 2012. Helsinki: THL, 69–73.

Background: Virtual hospital 2.0 (VH2.0, Virtuaalisairaala 2.0) platform, a joint project between all Finnish university hospitals [1] is an essential part of the Finnish governmental wellbeing project of customer-responsive services [2–3]. Virtual village (Terveyskylä [4]) of VH2.0 produces and implements client-oriented digital special care services to various stakeholders (e.g. patients, providers). Five-year cumulative potential health care capacity freed in Finland with VH2.0 was estimated at €1.3 billion [5]. Here, a specific VH2.0 digital care path (HealthyWeightHub, HWH) was evaluated in terms of observed local and predicted national cost-benefit. The examined HWH path is a 12-month long coaching and education service, designed to help obese patients to make permanent life changes, first launched in October of 2016. Aim: Cost-benefit evaluation and prediction of VH2.0 HWH care path locally and in Finland, respectively. Methods: This cost-benefit research was based on the PICOSTEPS principle, which reports the content of health economic evaluation (HEE) in its order of importance [6]. PICOSTEPS was developed during Finnish Current Care Criteria work [7] and has been used in real-world data (RWD) based [8] and predictive [6] HEEs. Patients: Adult obese individuals in 1) the Helsinki University Hospital Catchment Area (HUS ERVA) or 2) Finland generally. Intervention: VH2.0 HWH path. Comparator: Conventional group coaching. Outcome: Estimated and predicted potential health care capacity freed (PHCCF, year 2017 real value) at HUS ERVA and Finnish national level, allowed by the digital care path, respectively. Setting: 1) Retrospective examination of treated patients at HUS ERVA level and 2) predictive modelling at Finnish national level. Prediction assuming HWH was implemented at national level in 2018 and the national goal was to treat 1 % of the obese patients annually by 2022. Time: 1) Two years between October 2016 and October 2018 at HUS ERVA level retrospective examination; 2) Five-years from year 2018 to 2022 in annual cycles for the predicted PHCCF at national level, assuming digital care path implementation was initiated in the beginning of year 2018 and completed gradually in five years. Effects: Expected resource use (e.g., treatment, travelling, patient fees) and unit costs based on the RWD and expert information. Perspective: Third-party payer covering only direct health care costs and travelling. Sensitivity analyses: Half or twice as many obese patients are treated in 2022. Results: HWH saved €2.69 million over the two years between October 2016 and October 2018 at the HUS ERVA level, compared to a hypothetical scenario where patients treated with HWH had received conventional group coaching instead of HWH. If the patients who received group coaching had also been treated with HWH, additional €1.02 million could have been saved in the same time period at the HUS ERVA level. At Finnish national level, treating 1 % of the obese patients with conventional group coaching would cost approximately €24.3 million in 2022. Treating same number of patients with HWH was estimated to cost €6.35 million, resulting in annual PHCCF of €18.0 million in 2022. The cumulative five-year PHCCF would be €50.7 million at Finnish national level, compared to conventional group coaching. Conversely, approximately 3.8 times more obese patients could be provided care with HWH than possible with conventional group coaching. Conclusions: HWH is potentially very cost-saving and allows provision of weight control treatment for larger populations than previously possible. While providing nation-wide conventional group coaching for large proportion of obese patients was not feasible, HWH allows more efficient use of resources targeted at combating increasing obesity epidemic. The findings are further highlighted by the fact that analyses did not include productivity costs or indirect costs associated weight loss and treatment of long-term sickness (e.g. diabetes). References: [1] www.virtuaalisairaala2.fi [2] valtioneuvosto.fi/en/implementation-of-the-government-programme [3] valtioneuvosto.fi/documents/10184/321857/Government+action+plan+28092017+en.pdf [4] www.terveyskyla.fi/ [5] Väätäinen et al. Virtual hospital 2.0 – modelled cost-benefit assessment. eHealth2018. [6] Soini et al. ClinicoEconomics and Outcomes Research 2018;10:279–92. [7] http://www.kaypahoito.fi/web/kh/suositukset/suositus?id=nix02465&suositusid=hoi50062 [8] Soini et al. Clinical Therapeutics 2017;39:537–57.e10.

Background: Virtual Hospital 2.0 (VH2.0, Virtuaalisairaala 2.0) and its platform are essential parts of a key governmental wellbeing project of customer-responsive services in Finland and based on a joint project of all Finnish university hospitals [1–3]. VH2.0 produces and implements client-oriented digital special care services to patients, providers and other stakeholders in Virtual village (Terveyskylä [4]). The five-year cumulative potential health care capacity freed with VH2.0 in Finland was estimated at €1.3 billion [5]. Here, eHealth service (digital care path) for specific indication was assessed using cost-benefit analysis for predictions. Aim: Predict the cost-benefit of the VH2.0 digital care path for women with endometriosis. Methods: The study considered clinical and economic viewpoints and was based on the PICOSTEPS principle, which reports the content of health economic evaluation (HEE) in its order of importance [6]. E.g. the Finnish Current Care Criteria [7], real-world data (RWD) based [8] and modelled [6] HEEs have used PICOSTEPS. Patients: All individuals with endometriosis who are expected to use specialized care services in 1) the Turku University Hospital Catchment Area (TYKS ERVA) or 2) Finland generally. Intervention: Modelled VH2.0 operational change predictions with the examined digital care path for women with endometriosis, including e.g. e-appointments with nurses. Comparator: Modelled conventional practice predictions based on population and morbidity information and Finnish RWD. Outcome: Predicted health care capacity freed (PHCCF, year 2017 real value) at TYKS ERVA and at Finnish national level available for other uses within the health care system, allowed by the digital care path. Setting: Dynamic cost-benefit modelling estimating the predicted changes in the patient cohorts based on the population structures and morbidity. Time: First five-years from year 2018 to 2022 in annual cycles; assuming digital care path implementation was initiated in the beginning of year 2018 and completed gradually in three years at the TYKS ERVA level and in four years in national level. No discounting of PHCCF was done. Effects: Expected over-time changes in population structure and morbidity, resource use (e.g. clinician visits, nurse and clinician calls, e-appointments, travelling, patient fees) and unit costs based on the RWD and expert information. Perspective: Third-party payer limited to direct health care and travelling costs. Sensitivity analyses: The gradual implementation of the digital care path for the endometriosis patients in two or five years. Results: At the TYKS ERVA level, the average annual PHCCF with endometriosis digital care path was estimated at €0.036 million for the first five years, summing up to total estimated five-year PHCCF of €0.179 million. The change in total costs was 14.4 % of the total conventional practice health care costs included. At the national Finnish level, average annual PHCCF was estimated at €0.203 million for the first five years, summing up to total estimated five-year PHCCF of €1.02 million (12.7% of the total included conventional practice costs). The most important value drivers for PHCCF were revisits to a clinician and nurse calls. Conclusions: VH2.0 digital care path for women with endometriosis potentially frees noteworthy capacity for other purposes. From the perspective of opportunity costs such technological change is very valuable and the capacity freed can produce significant effectiveness for other patients elsewhere [9]. References: [1] www.virtuaalisairaala2.fi [2] valtioneuvosto.fi/en/implementation-of-the-government-programme [3] valtioneuvosto.fi/documents/10184/321857/Government+action+plan+28092017+en.pdf [4] www.terveyskyla.fi/ [5] Väätäinen et al. Virtual hospital 2.0 – modelled cost-benefit assessment. eHealth2018. [6] Soini et al. ClinicoEconomics and Outcomes Research 2018;10:279–92. [7] http://www.kaypahoito.fi/web/kh/suositukset/suositus?id=nix02465&suositusid=hoi50062 [8] Soini et al. Clinical Therapeutics 2017;39:537–57.e10. [9] Hallinen et al. Vaihtoehtoiskustannukset ja kustannusvaikuttavuus tuotantoteknologian muuttuessa: esimerkkinä eteisvärinän antikoagulaatiohoito. Terveystaloustiede 2012. Helsinki: THL, 69–73.

Context: Virtual hospital 2.0 (VH2.0, www.virtuaalisairaala2.fi), a joint project between Finnish university hospitals, is novel, client-oriented digital specialised care service practice for citizens, patients and professionals. Currently 85 patient groups and some 80,000 visitors/month use existing 20 houses of VH2.0 Health Village (www.terveyskyla.fi). Rationale: VH2.0's mid-term health economic evaluation. Description: Dynamic cost-benefit modelling from payer perspective predicting potential healthcare capacity freed (PHCF, 2016 value) by VH2.0 at Helsinki university hospital (HUS) and in Finland. Expected over-time changes in population structure, resource use (visits, letters, calls, e-appointments, e-messages, travelling) and unit costs were simulated for VH2.0 and current practice from year 2017 to 2021. Achievements/theme: At the HUS level, the average predicted annual PHCF with VH2.0 was around €42 million for first five years, summing up to around €208 million in five years. Most important key value drivers were treatment calls, revisits, and treatment visits. Average predicted annual PHCF with VH2.0 was around €261 million at national level for first five years, summing up to around €1.3 billion in five years. Most important drivers were revisits, treatment calls, and travelling. Conclusion: VH2.0 aims to improve the equality of the citizens by increasing the availability and quality of healthcare services for all Finns with novel digital care and eHealth service practice. Our prediction demonstrates that VH2.0 has substantial PHCF, available for these purposes. From the perspective of opportunity costs, such technological revolution can produce significant effectiveness elsewhere. However, evaluation, assessment and implementation of the best digital care and eHealth practices are warranted.

Background Finnish on-line Health village environment, so-called HUS-MAP©, was used to develop on-line information for rheumatic patients. Objectives To face the challenge of increasing demand for rheumatological care without additional resources a new virtual client-orientated service was developed. Methods In Finland, an on-line Health village environment, so-called HUS-MAP©, has been developed to offer virtual digital information to citizens, patients, and healthcare professionals. By using this HUS-MAP© environment, we provide information and support to citizens and patients who need information on different rheumatic diseases and various unspecified aches and musculoskeletal pains. The study group consisted of participants from every university hospital in Finland, from local authorities; rheumatologists, other specialists, general practitioners, nurses, special professionals such as physical therapists, and patients. Information provided was based on updated international and Finnish guidelines on rheumatic diseases. After the information was reviewed and accepted by our study group, it was fed into a special program and published on-line in the Health village environment. Results E-service for citizens and patients was opened in March 2017. Detailed description of symptoms, diagnosis and therapy of various rheumatic diseases, such as rheumatoid arthritis, spondyloarthritis, connective tissue diseases and vasculitis are available. Early diagnosis and treatment to remission when possible is emphasised. The service aids to identify, by using symptom navigator and questionnaires for back pain, as well as swollen and painful joints those who may have a rheumatic disease and guide patients to find medical services without delay. Already 60 500 persons have visited our website. Conclusions Finnish e-service, rheumaticdiseases.fi, offers an easy way to reach people and increase citizen’s awareness on their own health. By guiding people to search for care the service may reduce delays in diagnosis of rheumatic diseases and the onset of therapy Acknowledgements To patients and healthcare professionals workin in Finnish Helathvillage.fi-rheumaticdisease.fi Disclosure of Interest None declared