Reimbursement of care does not equal the distribution of hospital resources: an explorative case study on a missing link among Dutch hospitals.

BACKGROUND: Affordability and accessibility of hospital care are under pressure. Research on hospital care financing focuses primarily on incentives in the financial system outside the hospital. It is notable that little is known about (incentives in) internal funding in hospitals. Therefore, our study focuses on the budget allocation in hospitals: the distribution model. Based on our hypothesis that the reimbursement and distribution models in hospitals might interact, we gain knowledge about-, and insight into, the interaction of different reimbursement and distribution models used in Dutch hospitals, and how they affect the financial output of hospital care. METHODS: An online survey with 22 questions was conducted among financial senior management as an expert group in 49 Dutch hospitals. RESULTS: Ultimately, 38 of 49 approached experts fully completed the survey, which amounts to 78% of the hospitals we approached and 60% of all Dutch hospitals. The results on the reimbursement model indicate price * volume with adjusted prices above a maximum cap as the most common dominant contract type. On the internal distribution model, 75-80% of the experts reported incremental budgeting as the dominant budgeting method. Results on the interaction between the reimbursement and the distribution model show that both general and specific changes in contract agreements are only partially incorporated in hospital budgets. In 28 out of 31 hospitals with self-employed medical specialists, a relation is reported between the reimbursement model and the contracts with the Medical Consultant Group(s) in which the medical specialists are united. CONCLUSIONS: Our results in Dutch setting indicate a limited interaction between the reimbursement model and the distribution model. This lack of congruence between both models might limit the desired effects of incentives in contractual agreements aimed at the financial output. This applies to different reimbursement and distribution models. Further research into the various interactions and incentives, as visualized in our conceptual framework, could result in evidence-based advice for achieving affordable and accessible hospital care.

Intranasal vaccination with protein bodies elicit strong protection against Streptococcus pneumoniae colonization.

Protein bodies (PBs) are particles consisting of insoluble, aggregated proteins with potential as a vaccine formulation. PBs can contain high concentrations of antigen, are stable and relatively resistant to proteases, release antigen slowly and are cost-effective to manufacture. Yet, the capacity of PBs to provoke immune responses and protection in the upper respiratory tract, a major entry route of respiratory pathogens, is largely unknown. In this study, we vaccinated mice intranasally with PBs comprising antigens from Streptococcus pneumoniae and evaluated the level of protection against nasopharyngeal colonization. PBs composed of the α-helical domain of pneumococcal surface protein A (PspAα) provided superior protection against colonization with S. pneumoniae compared to soluble PspAα. Immunization with soluble protein or PBs induced differences in antibody binding to pneumococci as well as a highly distinct antigen-specific nasal cytokine profile upon in vivo stimulation with inactivated S. pneumoniae. Moreover, immunization with PBs composed of conserved putative pneumococcal antigens reduced colonization by S. pneumoniae in mice, both as a single- and as a multi-antigen formulation. In conclusion, PBs represent a vaccine formulation that elicits strong mucosal immune responses and protection. The versatility of this platform offers opportunities for development of next-generation vaccine formulations.

Dutch surgeons' views on the volume-outcome mechanism in surgery: A qualitative interview study.

OBJECTIVE: To contribute to a better understanding of volume-outcome relationships in surgery by exploring Dutch surgeons' views on the underlying mechanism. DESIGN: A qualitative study based on face-to-face semi structured interviews and an inductive content analysis approach. SETTING: Interviews were conducted in eight hospitals in the Netherlands (2 university, 4 teaching and 2 general). PARTICIPANTS: Twenty surgeons (gastrointestinal, vascular and trauma). MAIN OUTCOME MEASURE(S): Dutch surgeons' views on volume-outcome relationships in surgery and the underlying mechanism. RESULTS: The majority of surgeons believed volume is related to outcomes after surgery. Interviewees highlighted the importance of both focus and skills when describing the underlying mechanism. Focus was visible on three levels: hospital, surgeon and team. Focus on a hospital level referred to investing in specific infrastructure and dedicated personnel. Surgeons described both the benefits and downsides of surgeons' increased focus to a certain surgical subspeciality. And their experiences on the importance of working with fixed, procedure-specific teams. The positive influence of caseload on technical and nontechnical skills was acknowledged, as well as the benefits of combining skills by operating together. Although a basic skill set should be maintained, this does not necessarily require high volume. CONCLUSIONS: Focus and skills are important explanatory factors in volume-outcome relationships according to Dutch surgeons. This suggests that both high- and low-volume providers should enable specialized, fixed teams for complex surgeries and focus on maintenance of both their technical and nontechnical skills. By uncovering the underlying mechanism, imperfect quality indicators such as volume can be supplemented or replaced.

[Volume standards: quality through quantity? relationship between treatment volume and outcomes not well founded]. / Volumenormen: kwaliteit door kwantiteit?

Three domains are accepted as indicators that make the quality of hospital care quantifiable and transparent: process, structure and outcome. In recent years volume thresholds for surgical interventions have been added as new quality indicators, rendering the assumption that more volume leads to better outcomes. This assumption has been established for many procedures in peer-reviewed literature since the 1970s. Although there is consensus about the fact that volume is a proxy measure for other factors influencing the outcome of care, available research does not shed much light on the mechanisms underlying the volume-outcome relationship. Moreover, the methodological quality of the available research has several limitations. Despite the incomplete substantiation, volume thresholds are now embedded in 'risk-based' supervision by the health inspectorate as well as purchasing policies by health insurers.

A novel method for high-pressure freezing of adherent cells for frozen hydrated sectioning and CEMOVIS.

With the development of Cryo Electron Microscopy Of Vitreous Sections (CEMOVIS), imaging cells in a close to native state has become a reality. However with the commonly used carriers for high-pressure freezing and cryo-sectioning, adherent grown cells either need to be detached from their substrate. Here a new method is presented for high-pressure freezing adherent growing cells for frozen-hydrated sectioning and CEMOVIS. Cells are cultured on golden grids, containing a carbon coated Formvar film, and frozen on a membrane carrier which provides the grids with the structural support needed to withstand the strain of trimming and cryo-sectioning. This method was successfully tested for the two different types of high-pressure freezers, those using a pressure chamber (HPM010, EMHPF, Wohlwend Compact 01/02, HPM100) and those directly pressurizing the sample (EMPact series).