On the correlation between outcome indicators and the structure and process indicators used to proxy them in public health care reporting.

Hospital quality indicators provide valuable insights for quality improvement, empower patients to choose providers, and have become a cornerstone of value-based payment. As outcome indicators are cumbersome and expensive to measure, many health systems have relied on proxy indicators, such as structure and process indicators. In this paper, we assess the extent to which publicly reported structure and process indicators are correlated with outcome indicators, to determine if these provide useful signals to inform the public about the outcomes. Quality indicators for three conditions (breast and colorectal cancer, and hip replacement surgery) for Dutch hospitals (2011-2018) were collected. Structure and process indicators were compared to condition-specific outcome indicators and in-hospital mortality ratios in a between-hospital comparison (cross-sectional and between-effects models) and in within-hospital comparison (fixed-effects models). Systematic association could not be observed for any of the models. Both positive and negative signs were observed where negative associations were to be expected. Despite sufficient statistical power, the share of significant correlations was small [mean share: 13.2% (cross-sectional); 26.3% (between-effects); 13.2% (fixed-effects)]. These findings persisted in stratified analyses by type of hospital and in models using a multivariate approach. We conclude that, in the context of compulsory public reporting, structure and process indicators are not correlated with outcome indicators, neither in between-hospital comparisons nor in within-hospital comparisons. While structure and process indicators remain valuable for internal quality improvement, they are unsuitable as signals for informing the public about hospital differences in health outcomes.

Information and communication technology enabling partnership in person-centred diabetes management: building a theoretical framework from an inductive case study in The Netherlands.

OBJECTIVES: The aim of this paper is to construct a theoretical framework for information and communication technology (ICT)-enabled partnership towards diabetes management. DESIGN: We conducted an inductive case study and held interviews on the development and use of an artificial pancreas (AP) system for diabetes management. SETTING: The study was carried out in the Netherlands with users of an AP system. PARTICIPANTS: We interviewed six patients with type 1 diabetes, five healthcare professionals (two medical specialists and three diabetes nurses), and one policy advisor from the Ministry of Health, Welfare and Sport. RESULTS: We built a new theoretical framework for ICT-enabled person-centred diabetes management, covering the central themes of self-managing the disease, shared analysing of (medical) data and experiencing the partnership. We found that ICT yielded new activities of data sharing and a new role for data professionals in the provision of care as well as contributed to carefree living thanks to the semiautomated management enabled by the device. Our data suggested that to enable the partnership through ICT, organisational adjustments need to be made such as the development of new ICT services and a viable financial model to support these services. CONCLUSION: The management of diabetes through ICT requires an adjustment of the partnership between persons with the chronic condition and the healthcare professional(s) in such a way that the potential for self-managing the condition by analysing the newly available (medical) data (from the AP system) together leads to an experience of partnership between patients and healthcare professionals.

Cure for increasing health care costs: The Bernhoven case as driver of new standards of appropriate care.

Containing costs is a major challenge in health care. Cost and quality are often seen as trade-offs, but high quality and low costs can go hand-in-hand as waste exists in unnecessary and unfounded care. In the Netherlands, two healthcare insurers and a hospital collaborate to improve quality of care and decrease healthcare costs. Their aim is to reduce unnecessary care by shifting the business model and culture from a focus on volume to a focus on quality. Key drivers to support this are taking time for integrated diagnosis ('first time right'), the right care at the right place and shared decision making between doctor and patient. Conditions to realize this are 1) contract innovation between the hospital and insurers to move away from fee-for-service reimbursement, 2) a culture change within the organization with emphasis on collaboration and empowerment of medical leadership and physicians to change daily practice, and 3) a reorganization of the hospital organization structure from a large number of medical departments to four business units related to the fundamental underlying patient need (acute care, solution shop, intervention unit and chronic care). Results from this whole-system-approach experiment show it is possible to provide better care (as experienced by patients) with lower volumes (16% lower DRG claims after 3 years) and provides valuable lessons for further healthcare reform.

Maldistribution or scarcity of nurses? The devil is in the detail.

AIMS: The goal of this paper was to improve our understanding of nursing shortages across the variety of health care sectors and how this may affect the agenda for addressing nursing shortages. A health care sector comprises a number of health care services for one particular type of patient care, for example, the hospital care sector. BACKGROUND: Most Western countries are shifting health care services from hospital care towards community and home care, thus increasing nursing workforce challenges in home and community care. In order to implement appropriate policy responses to nursing workforce challenges, we need to know if these challenges are caused by maldistribution of nurses and/or the scarcity of nurses in general. EVALUATION: Focusing on the Netherlands, we reviewed articles based on data of a labour market research programme and/or data from the Dutch Employed Persons' Insurance Administration Agency. The data were analysed using a data synthesis approach. KEY ISSUES: Nursing shortages are unevenly distributed across the various health care sectors. Shortages of practical nurses are caused by maldistribution, with a long-term projected surplus of practical nurses in hospitals and projected shortages in nursing/convalescent homes and home care. Shortages of first-level registered nurses are caused by general scarcity in the long term, mainly in hospitals and home care. CONCLUSIONS: Nursing workforce challenges are caused by a maldistribution of nurses and the scarcity of nurses in general. To implement appropriate policy responses to nursing workforce challenges, integrated health care workforce planning is necessary. IMPLICATIONS FOR NURSING MANAGEMENT: Integrated workforce planning models could forecast the impact of health care transformation plans and guide national policy decisions on transitioning programmes. Effective transitioning programmes are required to address nursing shortages and to diminish maldistribution. In addition, increased recruitment and retention as well as new models of care are required to address the scarcity of nurses in general.

ParkinsonNet: A Low-Cost Health Care Innovation With A Systems Approach From The Netherlands.

ParkinsonNet, a low-cost innovation to optimize care for patients with Parkinson disease, was developed in 2004 as a network of physical therapists in several regions in the Netherlands. Since that time, the network has achieved full national reach, with 70 regional networks and around 3,000 specifically trained professionals from 12 disciplines. Key elements include the empowerment of professionals who are highly trained and specialized in Parkinson disease, the empowerment of patients by education and consultation, and the empowerment of integrated multidisciplinary teams to better address and manage the disease. Studies have found that the ParkinsonNet approach leads to outcomes that are at least as good as, if not better than, outcomes from usual care. One study found a 50 percent reduction in hip fractures and fewer inpatient admissions. Other studies suggest that ParkinsonNet leads to modest but important cost savings (at least US$439 per patient annually). These cost savings outweigh the costs of building and maintaining the network. Because of ParkinsonNet's success, the program has now spread to several other countries and serves as a model of a successful and scalable frugal innovation.

The arduous quest for translating health care productivity gains into cost savings. Lessons from their evolution at economic scoring agencies in the Netherlands and the US.

We analyze the assessments of recent health reforms by the Congressional Budget Office (CBO) in the United States and the Bureau for Economic Policy Analysis (CPB) in the Netherlands. Both reforms aim to capitalize on productivity gains, which is appealing for policymakers because of the potential for cost savings while maintaining - or enhancing - quality and access. These measures however generally translate into more health care, rather than care that is affordable and appropriate. Scoring agencies therefore have rightfully been reluctant to assign significant savings to these measures. Thus with regard to cost savings, both agencies instead have favored more traditional policy measures in the past. They are however increasingly mapping out loose ends and dilemmas for payers, including information asymmetries, reputation issues and provider business models that contradict the goals of policymakers. This calls for further exploring this avenue and the development of more integrated agendas that might commit actors and the spread of best practices.

Information and Communication Technologies to Support Chronic Disease Self-Management: Preconditions for Enhancing the Partnership in Person-Centered Care.

OBJECTIVE: In order to alleviate the pressure on health care systems exerted by the growing prevalence of chronic diseases, information and communication technologies (ICT) are being introduced to enable self-management of chronic diseases by supporting partnerships between patients and health care professionals. This move towards chronic disease self-management is accompanied by a shift in focus on integrating the patient with his or her perceptions on the chronic disease as a full-fledged partner into the health care system. This new perspective has been described as "person-centered care" (PCC). To date, information and communication technologies only partially build on the principles of PCC. This paper examines the preconditions of ICT to enable a person-centered approach to chronic disease management. METHODS: Using cancer treatment as a case study for ICT-enabled PCC, we conducted a comparative analysis of thirteen scientific studies on interventions presented as ICT-enabled PCC for cancer treatment, to answer the research question: What are the preconditions of ICT-enabled PCC in chronic disease management? Based on the intended and actual outcomes, we distilled in several analytic steps the preconditions of ICT-enabled PCC for chronic disease self-management. RESULTS: We distinguished four user-related preconditions of ICT-enabled PCC: (shared) decision making, personalized ICT, health-related quality of life, and efficiency. CONCLUSIONS: We argue that these four preconditions together can improve people's self-management of chronic diseases by strengthening the partnership between the patient and the healthcare professional. Moreover, the study revealed a discrepancy between intended and reported actual outcomes in terms of realizing person-centered care.

A living model of managed competition: a conversation with Dutch health minister Ab Klink. Interview by Alain Enthoven.

As of 2006, the Netherlands requires all citizens to buy a standard package of health benefits from private insurers. The government subsidizes premiums for those with low incomes and requires insurers to accept all purchasers. This mixed private-public approach to universal coverage has emerged as a potential reform model for the United States. In this November 2007 interview, Dutch health minister Ab Klink discussed his country's system with Alain Enthoven. Enthoven is one of the chief architects of the "managed competition" model that laid the groundwork for the Clinton administration reform proposal in the 1990s and pending legislation in the Senate, as well as the current Dutch approach.