Effectiveness and Policy Determinants of Sugar-Sweetened Beverage Taxes.

Sugar consumption is on the rise globally with detrimental (oral) health effects. There is ample evidence that sugar-sweetened beverage (SSB) taxes can efficiently reduce sugar consumption. However, evidence alone is seldom enough to implement a policy. In this article, we present a narrative synthesis of evidence, based on real-world SSB tax evaluations, and we combine this with lessons from policy development case studies. This article is structured according to the Health Policy Analysis Triangle, which identifies a policy's content and process and important contextual factors. SSB tax policy content needs to be coupled to existing problems and public sentiment, which depend on more aspects than aspects related to (oral) health alone. Whether or not to include artificially sweetened beverages, therefore, is not solely a matter of showing the evidence of their oral health impact but also dependent on the stated aim of a tax and public sentiment toward tax policies in general. SSB taxes also need to be in line with existing tax and decision-making rules. Earmarking revenue for specific (health promotion) purposes may therefore be less straightforward as it might appear. The policy process of creating context-sensitive SSB tax policy content is not easy either. Advocacy coalitions need to be formed early in the process, and stamina, expertise, and flexibility are required to get a SSB tax adopted in a specific community. This requires a meticulously considered SSB tax structure implementation process. Oral health professionals who want to lead the way in advocating for SSB taxes should realize that evidence-based arguments on potential effectiveness alone will not be enough to realize change. The oral health community can learn important lessons from other "doctor-activists" such as pulmonologists, who have successfully advocated for higher tobacco taxes by being visible in the public debate with clear messaging and robust policy proposals.

Validity of police contacts as a performance indicator for the public mental health care system in Amsterdam: an open cohort study.

PURPOSE: The Public Mental Health Care (PMHC) system is a network of public services and care- and support institutions financed from public funds. Performance indicators based on the registration of police contacts could be a reliable and useful source of information for the stakeholders of the PMHC system to monitor performance. This study aimed to provide evidence on the validity of using police contacts as a performance indicator to assess the continuity of care in the PMHC system. METHODS: Data on services received, police contacts and detention periods of 1928 people that entered the PMHC system in the city of Amsterdam were collected over a period of 51 months. Continuity of care was defined as receiving more than 90 days of uninterrupted service. The associations between police contacts and continuity were analyzed with multilevel Poisson and multivariate linear regression modeling. RESULTS: Clients had on average 2.12 police contacts per person-year. Clients with police contacts were younger, more often single, male, and more often diagnosed with psychiatric or substance abuse disorders than clients without police contacts. Incidence rates of police contacts were significantly lower for clients receiving continuous care than for clients receiving discontinuous care. The number of police contacts of clients receiving PMHC coordination per month was found to be a significant predictor of the percentage of clients in continuous care. CONCLUSION: The number of police contacts of clients can be used as a performance indicator for an urban PMHC system to evaluate the continuity of care in the PMHC system.

Lower extremity amputation rates in people with diabetes as an indicator of health systems performance. A critical appraisal of the data collection 2000-2011 by the Organization for Economic Cooperation and Development (OECD).

AIMS: Critical appraisal of secondary data made available by the OECD for the time frame 2000-2011. METHODS: Comparison of trends and variation of amputations in people with diabetes across OECD countries. Generalized estimating equations to test the statistical significance of the annual change adjusting for major potential confounders. RESULTS: A total of 26 OECD countries contributed to the OECD data collection for at least 1 year in the reference time frame, showing a decline in rates of over 40 %, from a mean of 13.2 (median 9.4, range 5.1-28.1) to 7.8 amputations per 100,000 in the general population (9.9, 1.0-18.4). The multivariate model showed an average decrease equal to -0.27 per 100,000 per year (p = 0.015), adjusted by structural characteristics of health systems, showing lower amputation rates for health systems financed by public taxation (-4.55 per 100,000 compared to insurance based, p = 0.002) and non-ICD coding mechanisms (-7.04 per 100,000 compared to ICD-derived, p = 0.001). Twelve-year decrease was stronger among insurance-based financing systems (tax based: -0.16 per 100,000, p = 0.064; insurance based: -0.36 per 100,000; p = 0.046). CONCLUSIONS: In OECD countries, amputation rates in diabetes continuously decreased over 12 years. Still, in 2011, one amputation every 7 min could be directly attributed to diabetes. Although interesting, these results should be taken with extreme caution, until common definitions are improved and data quality issues, e.g., a different ability in capturing diabetes diagnoses, are fully resolved.

The involvement of medical doctors in hospital governance and implications for quality management: a quick scan in 19 and an in depth study in 7 OECD countries.

BACKGROUND: Hospital governance is broadening its orientation from cost and production controls towards 'improving performance on clinical outcomes'. Given this new focus one might assume that doctors are drawn into hospital management across OECD countries. Hospital performance in terms of patient health, quality of care and efficiency outcomes is supposed to benefit from their involvement. However, international comparative evidence supporting this idea is limited. Just a few studies indicate that there may be a positive relationship between medical doctors being part of hospital boards, and overall hospital performance. More importantly, the assumed relationship between these so-called doctor managers and hospital performance has remained a 'black-box' thus far. However, there is an increasing literature on the implementation of quality management systems in hospitals and their relation with improved performance. It seems therefore fair to assume that the relation between the involvement of doctors in hospital management and improved hospital performance is partly mediated via quality management systems. The threefold aim of this paper is to 1) perform a quick scan of the current situation with regard to doctor managers in hospital management in 19 OECD countries, 2) explore the phenomenon of doctor managers in depth in 7 OECD countries, and 3) investigate whether doctor involvement in hospital management is associated with more advanced implementation of quality management systems. METHODS: This study draws both on a quick scan amongst country coordinators in OECD's Health Care Quality Indicator program, and on the DUQuE project which focused on the implementation of quality management systems in European hospitals. RESULTS: This paper reports two main findings. First, medical doctors fulfil a broad scope of managerial roles at departmental and hospital level but only partly accompanied by formal decision making responsibilities. Second, doctor managers having more formal decision making responsibilities in strategic hospital management areas is positively associated with the level of implementation of quality management systems. CONCLUSIONS: Our findings suggest that doctors are increasingly involved in hospital management in OECD countries, and that this may lead to better implemented quality management systems, when doctors take up managerial roles and are involved in strategic management decision making.

Towards actionable international comparisons of health system performance: expert revision of the OECD framework and quality indicators.

OBJECTIVE: To review and update the conceptual framework, indicator content and research priorities of the Organisation for Economic Cooperation and Development's (OECD) Health Care Quality Indicators (HCQI) project, after a decade of collaborative work. DESIGN: A structured assessment was carried out using a modified Delphi approach, followed by a consensus meeting, to assess the suite of HCQI for international comparisons, agree on revisions to the original framework and set priorities for research and development. SETTING: International group of countries participating to OECD projects. PARTICIPANTS: Members of the OECD HCQI expert group. RESULTS: A reference matrix, based on a revised performance framework, was used to map and assess all seventy HCQI routinely calculated by the OECD expert group. A total of 21 indicators were agreed to be excluded, due to the following concerns: (i) relevance, (ii) international comparability, particularly where heterogeneous coding practices might induce bias, (iii) feasibility, when the number of countries able to report was limited and the added value did not justify sustained effort and (iv) actionability, for indicators that were unlikely to improve on the basis of targeted policy interventions. CONCLUSIONS: The revised OECD framework for HCQI represents a new milestone of a long-standing international collaboration among a group of countries committed to building common ground for performance measurement. The expert group believes that the continuation of this work is paramount to provide decision makers with a validated toolbox to directly act on quality improvement strategies.

The influence of corporate structure and quality improvement activities on outcome improvement in residential care homes.

OBJECTIVE: To examine the impact of corporate structure and quality improvement (QI) activities on improvements in client-reported and professional indicators between 2007 and 2009. DESIGN: A cross-sectional study using organizational survey and indicator multilevel modelling to test relationships between corporate structure, QI activities and performance improvements on indicators. SETTING: In total, 169 residential care homes for the elderly in the Netherlands. MAIN OUTCOME MEASURES: Change between 2007 and 2009 in client-reported and professional indicators. RESULTS: A middle-size corporate structure was associated with QI. The QI activity 'multidisciplinary team meetings' was positively correlated with the indicator 'safety environment' for somatic and psycho-geriatric care. The QI activities 'educational material' and 'direct work instructions' were associated negatively with the indicator 'availability of personnel' for somatic clients, but positively for psycho-geriatric clients. QI activities such as 'health plan activities', 'clinical lessons' and 'financial activities' had no relationship to improved performance. For psycho-geriatric clients mainly organizational QI activities were positively associated with QI. The mediating role of the corporate structure for performing QI activities appeared stronger for the change in client-reported than for professional indicators. CONCLUSION: This study reveals associations between QI activities and corporate structure and changes in indicator performance. A corporate structure was associated with improvement in client-reported indicators, but less on professional indicators, which assumes a central policy at corporate level with impact on client-reported indicators, in contrast to a more local level approach towards activities that result in QI on professional indicators. Tailoring QI activities at the right managerial level may be important to achieve improvement.

Development and validation of an index to assess hospital quality management systems.

OBJECTIVE: The aim of this study was to develop and validate an index to assess the implementation of quality management systems (QMSs) in European countries. DESIGN: Questionnaire development was facilitated through expert opinion, literature review and earlier empirical research. A cross-sectional online survey utilizing the questionnaire was undertaken between May 2011 and February 2012. We used psychometric methods to explore the factor structure, reliability and validity of the instrument. SETTING AND PARTICIPANTS: As part of the Deepening our Understanding of Quality improvement in Europe (DUQuE) project, we invited a random sample of 188 hospitals in 7 countries. The quality managers of these hospitals were the main respondents. MAIN OUTCOME MEASURE: The extent of implementation of QMSs. RESULTS: Factor analysis yielded nine scales, which were combined to build the Quality Management Systems Index. Cronbach's reliability coefficients were satisfactory (ranging from 0.72 to 0.82) for eight scales and low for one scale (0.48). Corrected item-total correlations provided adequate evidence of factor homogeneity. Inter-scale correlations showed that every factor was related, but also distinct, and added to the index. Construct validity testing showed that the index was related to recent measures of quality. Participating hospitals attained a mean value of 19.7 (standard deviation of 4.7) on the index that theoretically ranged from 0 to 27. CONCLUSION: Assessing QMSs across Europe has the potential to help policy-makers and other stakeholders to compare hospitals and focus on the most important areas for improvement.

The use of on-site visits to assess compliance and implementation of quality management at hospital level.

OBJECTIVE: Stakeholders of hospitals often lack standardized tools to assess compliance with quality management strategies and the implementation of clinical quality activities in hospitals. Such assessment tools, if easy to use, could be helpful to hospitals, health-care purchasers and health-care inspectorates. The aim of our study was to determine the psychometric properties of two newly developed tools for measuring compliance with process-oriented quality management strategies and the extent of implementation of clinical quality strategies at the hospital level. DESIGN: We developed and tested two measurement instruments that could be used during on-site visits by trained external surveyors to calculate a Quality Management Compliance Index (QMCI) and a Clinical Quality Implementation Index (CQII). We used psychometric methods and the cross-sectional data to explore the factor structure, reliability and validity of each of these instruments. SETTING AND PARTICIPANTS: The sample consisted of 74 acute care hospitals selected at random from each of 7 European countries. MAIN OUTCOME MEASURES: The psychometric properties of the two indices (QMCI and CQII). RESULTS: Overall, the indices demonstrated favourable psychometric performance based on factor analysis, item correlations, internal consistency and hypothesis testing. Cronbach's alpha was acceptable for the scales of the QMCI (α: 0.74-0.78) and the CQII (α: 0.82-0.93). Inter-scale correlations revealed that the scales were positively correlated, but distinct. All scales added sufficient new information to each main index to be retained. CONCLUSION: This study has produced two reliable instruments that can be used during on-site visits to assess compliance with quality management strategies and implementation of quality management activities by hospitals in Europe and perhaps other jurisdictions.

Is having quality as an item on the executive board agenda associated with the implementation of quality management systems in European hospitals: a quantitative analysis.

OBJECTIVE: To assess whether there is a relationship between having quality as an item on the board's agenda, perceived external pressure (PEP) and the implementation of quality management in European hospitals. DESIGN: A quantitative, mixed method, cross-sectional study in seven European countries in 2011 surveying CEOs and quality managers and data from onsite audits. PARTICIPANTS: One hundred and fifty-five CEOs and 155 quality managers. SETTING: One hundred and fifty-five randomly selected acute care hospitals in seven European countries (Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey). Main outcome measure(s) Three constructs reflecting quality management based on questionnaire and audit data: (i) Quality Management System Index, (ii) Quality Management Compliance Index and (iii) Clinical Quality Implementation Index. The main predictor was whether quality performance was on the executive board's agenda. RESULTS: Discussing quality performance at executive board meetings more often was associated with a higher quality management system score (regression coefficient b = 2.53; SE = 1.16; P = 0.030). We found a trend in the associations of discussing quality performance with quality compliance and clinical quality implementation. PEP did not modify these relationships. CONCLUSIONS: Having quality as an item on the executive board's agenda allows them to review and discuss quality performance more often in order to improve their hospital's quality management. Generally, and as this study found, having quality on the executive board's agenda matters.

Are the Dutch long-term care organizations getting better? A trend study of quality indicators between 2007 and 2009 and the patterns of regional influences on performance.

OBJECTIVE: and setting The Dutch long-term care organizations, providing somatic care, psycho-geriatric care and home care, have to measure the quality of care through client-related and professional indicators since 2007. At the same time, competition was introduced with regional stimuli from healthcare insurers. The first aim of this study is to determine the trends of the national performance on client-related and professional quality indicators for the period 2007-09 in long-term care organizations in the Netherlands. The second aim is to determine the influence of the region on the quality performance in 2009. DESIGN AND PARTICIPANTS: We performed trend analyses on the indicators of clients of 2115 long-term care organizations. We used multivariate analyses to determine the difference in national performance between 2007 and 2009 and to calculate the influence of the region on the performance of 2009. INTERVENTION: None. MAIN OUTCOME MEASURES: Client-related and professional indicators. RESULTS: The national performance on client-related indicators for somatic care and home care increased and for psycho-geriatric care the quality performance became worse. The professional indicators for intramural care improved between 2007 and 2009. Region influences the performance. In general, organizations in the west of the Netherlands performed worse than other regions (with exception of home care). CONCLUSIONS: The study suggests that working with quality indicators in long-term care organizations for older people may lead to a better performance on several indicators. The influence of the region on the quality is significant, which could be caused by Dutch healthcare insurers.

Evaluating the effectiveness of an educational and feedback intervention aimed at improving consideration of sex differences in guideline development.

OBJECTIVES: To investigate the effect of an educational and feedback intervention to enhance consideration of sex differences in clinical guideline development. DESIGN: Preintervention and postintervention questionnaires in intervention and control groups. Content analysis of intervention guidelines and former versions. SETTING: Guideline consultants, working-group members and guideline documents of two Dutch guideline-developing organisations. MAIN OUTCOME MEASURES: Attitudes of guideline developers concerning the importance of considering sex differences and the number of the sex-specific statements in the contents of guideline documents. RESULTS: The attitude of the intervention group did not change significantly relative to the control group. Consideration of sex-related factors within the guidelines increased relative to available previous versions. CONCLUSION: Education and expert feedback may increase consideration of sex differences in guidelines. Further efforts are needed to implement and test these interventions.

Three methods of multi-source feedback compared: a plea for narrative comments and coworkers' perspectives.

BACKGROUND: Doctor performance assessments based on multi-source feedback (MSF) are increasingly central in professional self-regulation. Research has shown that simple MSF is often unproductive. It has been suggested that MSF should be delivered by a facilitator and combined with a portfolio. AIMS: To compare three methods of MSF for consultants in the Netherlands and evaluate the feasibility, topics addressed and perceived impact upon clinical practice. METHOD: In 2007, 38 facilitators and 109 consultants participated in the study. The performance assessment system was composed of (i) one of the three MSF methods, namely, Violato's Physician Achievement Review (PAR), the method developed by Ramsey et al. for the American Board of Internal Medicine (ABIM), or the Dutch Appraisal and Assessment Instrument (AAI), (ii) portfolio, (iii) assessment interview with a facilitator and (iv) personal development plan. The evaluation consisted of a postal survey for facilitators and consultants. Generalized estimating equations were used to assess the association between MSF method used and perceived impact. RESULTS: It takes on average 8 hours to conduct one assessment. The CanMEDS roles 'collaborator', 'communicator' and 'manager' were discussed in, respectively, 79, 74 and 71% of the assessment interviews. The 'health advocate role' was the subject of conversation in 35% of the interviews. Consultants are more satisfied with feedback that contains narrative comments. The perceived impact of MSF that includes coworkers' perspectives significantly exceeds the perceived impact of methods not including this perspective. CONCLUSIONS: Performance assessments based on MSF combined with a portfolio and a facilitator-led interview seem to be feasible in hospital settings. The perceived impact of MSF increases when it contains coworkers' perspectives.

Micro grants as a stimulus for community action in residential health programmes: a case study.

This paper aimed to explore the contribution of a micro grant financing scheme to community action in terms of residential health-promoting initiatives, interorganizational collaboration and public participation. The scheme was two-fold, consisting of (i) micro grants of 500-3500 Euros, which were easily obtainable by local organizations and (ii) neighbourhood health panels of community and health workers, functioning as a distributing mechanism. Data were collected using three methods: (i) observations of the neighbourhood-based health panels, (ii) in-depth interviews with policy-makers and professionals and (iii) analyses of documents and reports. This study demonstrated the three-fold role of micro grants as a vehicle to enable community action at an organizational level in terms of increased network activities between the local organizations, to set an agenda for the 'health topic' in non-traditional health agencies and to enable a number of health-promoting initiatives. Although these initiatives were attended by small groups of residents normally considered hard to reach, the actual public participation was limited. In their role as a distributing mechanism, the health panels were vital with regard to the achieved impact on the community action. However, certain limitations were also seen, which were related to the governance of the panels. This case study provides evidence to suggest that micro grants have the potential to stimulate community action at an organizational and a residential level, but with the prerequisite that grants be accompanied by increased investments in infrastructure.

Application of quality improvement strategies in 389 European hospitals: results of the MARQuIS project.

CONTEXT: This study was part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project investigating the impact of quality improvement strategies on hospital care in various countries of the European Union (EU), in relation to specific needs of cross-border patients. AIM: This paper describes how EU hospitals have applied seven quality improvement strategies previously defined by the MARQuIS study: organisational quality management programmes; systems for obtaining patients' views; patient safety systems; audit and internal assessment of clinical standards; clinical and practice guidelines; performance indicators; and external assessment. METHODS: A web-based questionnaire was used to survey acute care hospitals in eight EU countries. The reported findings were later validated via on-site survey and site visits in a sample of the participating hospitals. Data collection took place from April to August 2006. RESULTS: 389 hospitals participated in the survey; response rates varied per country. All seven quality improvement strategies were widely used in European countries. Activities related to external assessment were the most broadly applied across Europe, and activities related to patient involvement were the least widely implemented. No one country implemented all quality strategies at all hospitals. There were no differences between participating hospitals in western and eastern European countries regarding the application of quality improvement strategies. CONCLUSIONS: Implementation varied per country and per quality improvement strategy, leaving considerable scope for progress in quality improvements. The results may contribute to benchmarking activities in European countries, and point to further areas of research to explore the relationship between the application of quality improvement strategies and actual hospital performance.

Differentiating between hospitals according to the "maturity" of quality improvement systems: a new classification scheme in a sample of European hospitals.

AIM: This study, part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project focusing on cross-border patients in Europe, investigated quality policies and improvement in healthcare systems across the European Union (EU). The aim was to develop a classification scheme for the level of quality improvement (maturity) in EU hospitals, in order to evaluate hospitals according to the maturity of their quality improvement activities. METHODS: A web-based questionnaire survey designed to measure quality improvement in EU hospitals was used as the basis for the classification scheme. Items included for the development of an evaluation tool--the maturity index--were considered important contributors to quality improvement. The four-stage quality cycle (plan, do, check and act) was used to determine the level of maturity of the various items. Psychometric properties of the classification scheme were assessed, and validation analyses were performed. RESULTS: A total of 389 hospitals participated in a questionnaire survey; response rates varied by country. For a final sample of 349 hospitals, it was possible to construct a quality improvement maturity index which consisted of seven domains and 113 items. The results of independent analyses sustained the validity of the index, which was useful in differentiating between hospitals in the research sample according to the maturity of their quality improvement system (defined as the total of all quality improvement activities). DISCUSSION: Further research is recommended to develop an instrument which for use in the future as a practical tool to evaluate the maturity of hospital quality improvement systems.

Implementation of outpatient preoperative evaluation clinics: facilitating and limiting factors.

BACKGROUND: Several studies have shown that outpatient preoperative evaluation by anaesthetists increases quality of care and is cost-effective. The aim of this study was to gain insight into the factors that positively or negatively influence the implementation of outpatient preoperative evaluation clinics (OPE clinics). METHODS: After an extensive literature study and pilot interviews, we constructed written questionnaires that were sent to all Dutch hospitals. The respondents were members of the board of directors, members of the medical staff, anaesthetists, internists, and surgeons. RESULTS: Cooperation of anaesthetists was most frequently mentioned as facilitating factor for implementation of an OPE clinic across all medical specialists interviewed. Lack of finance was most frequently reported as limiting factor in all categories of hospitals (with a complete, partial, or no OPE clinic), but it was significantly more often reported in hospitals without OPE clinic (P<0.01). Perceived benefits and disadvantages, financial rewarding system, and organizational structure played a clear role in the implementation of OPE clinics. CONCLUSIONS: A variety of factors play a role in the implementation of an OPE clinic. Besides the more obvious ones, such as financing and cooperation of the professional groups involved, underlying factors, such as perceptions of the professionals involved, were found to be related to implementation of an OPE clinic. These underlying factors explain differences between different kinds of hospitals and between professional groups, regarding their resources and motivation to implement an OPE clinic.

Attention to sex-related factors in the development of clinical practice guidelines.

BACKGROUND: Clinical practice guidelines describe optimal strategies for disease prevention, diagnosis, or treatment. Increasing evidence indicates that sex-related factors may have an impact on these strategies. We examined the way in which two Dutch guideline organizations address evidence on sex factors in their guideline development methodologies. We then determined whether attention to these factors could be improved and, if so, how this could be done. METHODS: We selected seven recent guidelines on four conditions: hypertension, depression, osteoporosis, and rheumatoid arthritis. We studied information obtained from interviews with members of the guideline committees and analyzed the content of the guideline documents themselves. Our findings were discussed at an expert meeting. RESULTS: We found that all the guideline committees concerned applied an internationally accepted framework for guideline development. The proportion of male members ranged from 67% to 100%. None of the guidelines included a question (or subquestion) focusing on sex-related factors. In the literature searches no sex-specific search terms were used. Critical appraisals did not include any systematic focus on sex-related factors or effects. The number of sex-specific recommendations (relative to the total number of recommendations) ranged from 0 of 82 and 0 of 148 in the guidelines on depression to 16 of 84 in one of the guidelines on osteoporosis. CONCLUSIONS: We found that when developing guidelines, none of the committees systematically focused on sex-related factors that might be relevant to the way in which evidence is identified, appraised, or described. A number of recommendations were made with the aim to facilitate greater attention to sex-related factors in the current methods of guideline development.