Regional practice variation in hysterectomy and the implementation of less invasive surgical procedures: A register-based study in the Netherlands.

INTRODUCTION: Many women experience bleeding disorders that may have an anatomical or unexplained origin. Although hysterectomy is the most definitive and common treatment, it is highly invasive and resource-intensive. Less invasive therapies are therefore advised before hysterectomy for women with fibroids or bleeding disorders. This study has two aims related to treating bleeding disorders and uterine fibroids in the Netherlands: (1) to evaluate the regional variations in prevalence and surgical approaches; and (2) to assess the associations between regional rates of hysterectomies and less invasive surgical techniques to analyze whether hysterectomy can be replaced in routine practice. MATERIAL AND METHODS: We completed a register-based study of claims data for bleeding disorders and fibroids in women between 2016 and 2020 using data from Statistics Netherlands for case-mix adjustment. Crude and case-mix adjusted regional hysterectomy rates were examined overall and by surgical approach. Coefficients of variation were used to measure regional variation and regression analyses were used to evaluate the association between hysterectomy and less invasive procedure rates across regions. RESULTS: Overall, 14 186 and 8821 hysterectomies were performed for bleeding disorders and fibroids, respectively. Laparoscopic approaches predominated (bleeding disorders 65%, fibroids 49%), followed by vaginal (bleeding disorders 24%, fibroids 5%) and abdominal (bleeding disorders 11%, fibroids 46%) approaches. Substantial regional differences were noted in both hysterectomy rates and the surgical approaches. For bleeding disorders, regional hysterectomy rates were positively associated with endometrial ablation rates (ß = 0.11; P = 0.21) and therapeutic hysteroscopy rates (ß = 0.14; P = 0.31). For fibroids, regional hysterectomy rates were positively associated with therapeutic hysteroscopy rates (ß = 0.10; P = 0.34) and negatively associated with both embolization rates (ß = -0.08; P = 0.08) and myomectomy rates (ß = -0.03; P = 0.82). CONCLUSIONS: Regional variation exists in the rates of hysterectomy and minimally invasive techniques. The absence of a significant substitution effect provides no clear evidence that minimally invasive techniques have replaced hysterectomy in clinical practice. However, although the result was not significant, embolization could be an exception based on its stronger negative association.

Attributing practice variation by its sources: the case of varicose veins treatments in the Netherlands.

BACKGROUND: Unwarranted practice variation refers to regional differences in treatments that are not driven by patients' medical needs or preferences. Although it is the subject of numerous studies, most research focuses on variation at the end stage of treatment, i.e. the stage of the treating specialist, disregarding variation stemming from other sources (e.g. patient preferences, general practitioner referral patterns). In the present paper, we introduce a method that allows us to measure regional variation at different stages of the patient journey leading up to treatment. METHODS: A series of logit regressions estimating the probability of (1) initial visit with the physician and (2) treatment correcting for patient needs and patient preferences. Calculating the coefficient of variation (CVU) at each stage of the patient journey. RESULTS: Our findings show large regional variations in the probability of receiving an initial visit, The CVU, or the measure of dispersion, in the regional probability of an initial visit with a specialist was significantly larger (0.87-0.96) than at the point of treatment both conditional (0.14-0.25) and unconditional on an initial visit (0.65-0.74), suggesting that practice variation was present before the patient reached the specialist. CONCLUSIONS: We present a new approach to attribute practice variation to different stages in the patient journey. We demonstrate our method using the clinically-relevant segment of varicose veins treatments. Our findings demonstrate that irrespective of the gatekeeping role of general practitioners (GPs), a large share of practice variation in the treatment of varicose veins is attributable to regional variation in primary care referrals. Contrary to expectation, specialists' decisions meaningfully diminish rather than increase the amount of regional variation.

Length of hospital stays and financial incentives: evidence from Dutch rehabilitation centers.

Non-linear reimbursement contracts in healthcare have been increasingly used to quantify providers' responses to financial incentives. In the present research, we utilize a large one-off increase in the reimbursement of rehabilitation care to assess to what extent providers are willing to modify their treating behavior to maximize profits. In order to disincentivize the use of short inpatient stays for rehabilitation care, Dutch policy-makers have instated a two-part stepwise tariff-schedule. A lower tariff-schedule is applied for short hospital stays (≤ 14 days), while a higher tariff-schedule is utilized for longer treatments. Switching from one schedule to the other at day 15 of inpatient care leads to a sudden and large increase in tariffs. We show that, for most care-types, patients are seldom treated in an inpatient setting for less than 15 days, while the majority of patients are discharged after the threshold. Therefore, we conclude that the financial incentive at day 15 leads to considerable distortions in treatment. However, instead of discharging all patients at the threshold point where marginal tariffs are maximized, providers tend to continue treatment indicating altruistic behavior. As healthcare payment systems move away from piecewise reimbursement (e.g., fee-for-service arrangements), and services are increasingly 'lumped' together into e.g., DRGs and bundled payments, the likelihood of such discontinuities in tariff-schedules radically increases. Our research illustrates how such discontinuities in reimbursements can lead to distortions in the amount of healthcare provided contributing to the debate on optimal healthcare contracting design.

Identification of over- and undertreatment in the Dutch national cervical cancer screening program: A data linkage study at the hospital level.

Research into the quality of cancer screening programs often lacks the perspective of clinicians, missing insights into the performance of individual hospitals. This retrospective cohort study aimed to identify guideline deviation (specifically, overtreatment and undertreatment) related to the cervical cancer screening program in Dutch hospitals by deterministically linking nationwide insurance data with pathology data for cervical intraepithelial neoplasia (CIN). We then constructed quality indicators using the Dutch CIN guideline and National Health Care Institute recommendations to assess compliance with CIN management, treatment outcomes, and follow-up, using an empirical Bayes shrinkage model to correct for case-mix variation and hospitals with few observations. Data were linked for 115,899 of 125,751 (92%) eligible women. Overtreatment was observed in the see-and-treat approach (immediate treatment) for women with low-grade referral cytology (4%; hospital range, 0%-25%), CIN ≤ 1 treatment specimens (26%; hospital range, 10%-55%), and follow-up cervix cytology ≥2 months before the guideline recommendation after treatment for CIN 2 (2%; hospital range, 0%-9%) or CIN 3 (5%; hospital range, 0%-19%). By contrast, undertreatment was observed for treatment within 3 months after a CIN 3 biopsy result (90%; hospital range 59%-100%) and follow-up ≥2 months beyond the guideline recommendation after treatments for CIN 2 (21%, hospital range 7%-48%) and CIN 3 (20%, hospital range 7%-90%). In conclusion, we found evidence of CIN overtreatment and undertreatment in all measured domains at the hospital level. Guideline adherence could be improved by implementing the developed indicators in an audit and feedback instrument for use by healthcare professionals in routine practice.

Practice variation in the stepped care approach to idiopathic heavy menstrual bleeding: A population-based study.

INTRODUCTION: Heavy menstrual bleeding (HMB) affects a quarter of all women, with half having no structural cause. Dutch guidelines recommend a stepped care approach to the management of such idiopathic HMB, starting with medication or a levonorgestrel-releasing intrauterine device (LNG-IUD), before progressing to endometrial ablation, and ultimately, hysterectomy. However, practice variation between hospitals could lead to suboptimal health outcomes and increased healthcare costs for some women. OBJECTIVES: To evaluate adherence to stepped care for women with idiopathic HMB and to identify practice variation among Dutch hospitals. STUDY DESIGN: This population-based cross-sectional study used Dutch insurance claims data from primary and secondary care for all women with idiopathic HMB referred to a gynecologist between January 2019 and December 2020. We calculated the average number of treatments in the 3 years before each treatment step at each hospital, making adjustments for age, socioeconomic status, and ethnicity. Variation in medical practice was measured by the coefficient of variation (CV). RESULTS: We studied 20,715 women treated with LNG-IUDs (56%), endometrial ablation (36%), laparoscopic hysterectomy (13%), or vaginal hysterectomy (4%) in 93 hospitals. Before endometrial ablation, on average 47% used medication (hospital range 27%-71%; CV 0.17) and 16% used an LNG-IUD (hospital range 8%-29%, CV 0.32). Before hysterectomy, 52% (hospital range 28%-65%, CV 0.16) used medication, 21% (hospital range 6%-38%, CV 0.35) used an LNG-IUD, and 23% underwent endometrial ablation (hospital range 0%-59%, CV 0.55). On average, women underwent 0.63 (hospital range 0.36-1.00, adjusted rate 0.40-0.98, CV 0.17) and 0.96 (hospital range 0.56-1.45, adjusted rate 0.56-1.44, CV 0.18) treatments before endometrial ablation and hysterectomy, respectively. CONCLUSIONS: Considerable practice variation exists among Dutch hospitals in the stepped care approach to idiopathic HMB. Improving adherence to this approach could improve quality of care and reduce costs.

Measuring Active Purchasing in Healthcare: Analysing Reallocations of Funds Between Providers to Evaluate Purchasing Systems Performance in the Netherlands.

BACKGROUND: Purchasing systems aim to improve resource allocation in healthcare markets. The Netherlands is characterized by four different purchasing systems: managed competition in the hospital market, a non-competitive single payer system for long-term care (LTC), municipal procurement for home care and social services, and self-procurement via personal budgets. We hypothesize that managed competition and competitive payer reforms boost reallocations of provider market share by means of active purchasing, ie, redistributing funds from high-quality providers to low-quality providers. METHODS: We define a Market Activity Index (MAI) as the sum of funds reallocated between providers annually. Provider expenditures are extracted from provider financial statements between 2006 and 2019. We compare MAI in six healthcare sectors under four different purchasing systems, adjusting for reforms, and market entry/exit. Next, we perform in-depth analyses on the hospital market. Using multivariate linear regressions, we relate reallocations to selective contracting, provider quality, and market characteristics. RESULTS: No difference was found between reallocations in the hospital care market under managed competition and the non-competitive single payer LTC (MAI between 2% and 3%), while MAI was markedly higher under procurement by municipalities and personal budget holders (between 5% and 15%). While competitive reforms temporarily increased MAI, no structural effects were found. Relatively low hospital MAI could not be explained by market characteristics. Furthermore, the extent of selective contracting or hospital quality differences had no significant effects on reallocations of funds. CONCLUSION: Dutch managed competition and competitive purchaser reforms had no discernible effect on reallocations of funds between providers. This casts doubt on the mechanisms advocated by managed competition and active purchasing to improve allocative efficiency.

Do patients' preferences prevail in hospital selection?: a comparison between discrete choice experiments and revealed hospital choice.

BACKGROUND: In patient choice, patients are expected to select the provider that best fits their preferences. In this study, we assess to what extent the hospital choice of patients in practice corresponds with their preferred choice. METHODS: Dutch patients with breast cancer (n = 631) and cataract (n = 1109) were recruited. We employed a discrete choice experiment (DCE) per condition to measure stated preferences and predict the distribution of patients across four hospitals. Each DCE included five attributes: patient experiences, a clinical outcome indicator, waiting time, travel distance and whether the hospital had been recommended (e.g., by the General Practitioner (GP)). Revealed choices were derived from claims data. RESULTS: Hospital quality was valued as most important in the DCE; the largest marginal rates of substitution (willingness to wait) were observed for the clinical outcome indicator (breast cancer: 38.6 days (95% confidence interval (95%CI): 32.9-44.2); cataract: 210.5 days (95%CI: 140.8-280.2)). In practice, it was of lesser importance. In revealed choices, travel distance became the most important attribute; it accounted for 85.5% (breast cancer) and 95.5% (cataract) of the log-likelihood. The predicted distribution of patients differed from that observed in practice in terms of absolute value and, for breast cancer, also in relative order. Similar results were observed in population weighted analyses. DISCUSSION: Study findings show that patients highly valued quality information in the choice for a hospital. However, in practice these preferences did not prevail. Our findings suggest that GPs played a major role and that patients mostly ended up selecting the nearest hospital.

The potential risk of using historic claims to set bundled payment prices: the case of physical therapy after lower extremity joint replacement.

BACKGROUND: One of the most significant challenges of implementing a multi-provider bundled payment contract is to determine an appropriate, casemix-adjusted total bundle price. The most frequently used approach is to leverage historic care utilization based on claims data. However, those claims data may not accurately reflect appropriate care (e.g. due to supplier induced demand and moral hazard effects). This study aims to examine variation in claims-based costs of post-discharge primary care physical therapy (PT) utilization after total knee and hip arthroplasties (TKA/THA) for osteoarthritis patients. METHODS: This retrospective cohort study used multilevel linear regression analyses to predict the factors that explain the variation in the utilization of post-discharge PT after TKA or THA for osteoarthritis patients, based on the historic (2015-2018) claims data of a large Dutch health insurer. The factors were structured as predisposing, enabling or need factors according to the behavioral model of Andersen. RESULTS: The 15,309 TKA and 14,325 THA patients included in this study received an average of 20.7 (SD 11.3) and 16.7 (SD 10.1) post-discharge PT sessions, respectively. Results showed that the enabling factor 'presence of supplementary insurance' was the strongest predictor for post-discharge PT utilization in both groups (TKA: ß = 7.46, SE = 0.498, p-value< 0.001; THA: ß = 5.72, SE = 0.515, p-value< 0.001). There were also some statistically significant predisposing and need factors, but their effects were smaller. CONCLUSIONS: This study shows that if enabling factors (such as supplementary insurance coverage or co-payments) are not taken into account in risk-adjustment of the bundle price, they may cause historic claims-based pricing methods to over- or underestimate appropriate post-discharge primary care PT use, which would result in a bundle price that is either too high or too low. Not adjusting bundle prices for all relevant casemix factors is a risk because it can hamper the successful implementation of bundled payment contracts and the desired changes in care delivery it aims to support.

Provider responses to discontinuous tariffs: evidence from Dutch rehabilitation care.

Abrupt jumps in reimbursement tariffs have been shown to lead to unintended effects in physicians' behavior. A sudden change in tariffs at a pre-defined point in the treatment can incentivize health care providers to prolong treatment to reach the higher tariff, and then to discharge patients once the higher tariff is reached. The Dutch reimbursement schedule in hospital rehabilitation care follows a two-threshold stepwise-function based on treatment duration. We investigated the prevalence of strategic discharges around the first threshold and assessed whether their share varies by provider type. Our findings suggest moderate response to incentives by traditional care providers (general and academic hospitals, rehabilitation centers and multicategorical providers), and strong response by profit-oriented independent treatment centers. When examining the variation in response based on the financial position of the organization, we found a higher probability of manipulation among providers in financial distress. Our findings provide multiple insights and possible indicators to identify provider types that may be more prone to strategic behavior.

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.

Height and marital outcomes in the Netherlands, birth years 1841-1900.

Adult body height appears to be significantly associated with marital outcomes: taller men across contexts have been found to be more likely to be married, and more likely to be married at younger ages. We are interested in exploring both outcomes individually and simultaneously, while using an unique, individual-level dataset of Dutch men and their brothers born between 1841 and 1900. To do so, we exploit survival models and cure models. While survival models yield a single estimate for the hazard (or age at) marriage, cure models yield two: one for the likelihood of marriage, and one for the hazard of first marriage. Cure models thus account for selection into marriage, while survival models do not. We find that, in the survival analyses, being in the shortest 20 % of heights is associated with later ages of marriage, relative to being average height. However, when we account for selection into marriage with cure models, we find that height is no longer associated with age at marriage. Instead, we see that height is associated with the likelihood of being married, with being in the bottom 20 % of heights associated with a 56.1 % decreased likelihood of being married, relative to being average height. We therefore conclude that height may be a gatekeeper for access to marriage, but it appears that other factors - likely related to the ability to set up an independent household - are more important in determining the timing of marriage for our research population.

The Dutch COVID-19 approach: Regional differences in a small country.

OBJECTIVES: This paper describes the first months of the COVID-19 pandemic in the Netherlands, including policies to reduce the health-related and economic consequences. The Netherlands started with containment and shifted to mitigation within three weeks when implementing a 'mild' lockdown. The initial focus was to obtain herd immunity while preventing Intensive Care Units from getting overwhelmed. METHODS: An in-depth analysis of available national and international COVID-19 data sources was conducted. Due to regional variation in COVID-19 hospitalization rates, this paper focuses on three distinct regions; the initial epicenter; the most northern provinces which - contrary to national policy - decided not to switch to mitigation; and the Bible Belt, as congregations of religious groups were initially excluded from the ban on group formation. RESULTS: On August 11th, 6,159 COVID-19 deaths were reported with at the peak an excess mortality Z-score of 21.7. As a result of the pandemic, the economy took a severe hit and is predicted to shrink 6.5% compared to projection. The hospitalization rates in the northern regions were over 70% lower compared to the rest of the country (18 versus 66 per 100,000 inhabitants). Differences between the Bible Belt and the rest of the country were hardly detectable. CONCLUSION: The Dutch have shown a way to effectively slow down transmission while allowing more personal and economic freedom than most other countries. Furthermore, the regional differences suggest that containment prevented a surge of infections in the northern provinces. The results should be interpreted with caution, due to the descriptive nature of this study.

Assessing risk of bias: a proposal for a unified framework for observational studies and randomized trials.

BACKGROUND: Evidence based medicine aims to integrate scientific evidence, clinical experience, and patient values and preferences. Individual health care professionals need to appraise the evidence from randomized trials and observational studies when guidelines are not yet available. To date, tools for assessment of bias and terminologies for bias are specific for each study design. Moreover, most tools appeal only to methodological knowledge to detect bias, not to subject matter knowledge, i.e. in-depth medical knowledge about a topic. We propose a unified framework that enables the coherent assessment of bias across designs. METHODS: Epidemiologists traditionally distinguish between three types of bias in observational studies: confounding, information bias, and selection bias. These biases result from a common cause, systematic error in the measurement or common effect of the intervention and outcome respectively. We applied this conceptual framework to randomized trials and show how it can be used to identify bias. The three sources of bias were illustrated with graphs that visually represent researchers' assumptions about the relationships between the investigated variables (causal diagrams). RESULTS: Critical appraisal of evidence started with the definition of the research question in terms of the population of interest, the compared interventions and the main outcome. Next, we used causal diagrams to illustrate how each source of bias can lead to over- or underestimated treatment effects. Then, we discussed how randomization, blinded outcome measurement and intention-to-treat analysis minimize bias in trials. Finally, we identified study aspects that can only be appraised with subject matter knowledge, irrespective of study design. CONCLUSIONS: The unified framework encompassed the three main sources of bias for the effect of an assigned intervention on an outcome. It facilitated the integration of methodological and subject matter knowledge in the assessment of bias. We hope that graphical diagrams will help clarify debate among professionals by reducing misunderstandings based on different terminology for bias.

Design characteristics of studies on medical practice variation of caesarean section rates: a scoping review.

BACKGROUND: Medical practice variation in caesarean section rates is the most studied type of practice variation in the field of obstetrics and gynaecology. This has not resulted in increased homogeneity of treatment between geographic areas or healthcare providers. Our study aim was to evaluate whether current study designs on medical practice variation of caesarean section rates were optimized to identify the unwarranted share of practice variation and could contribute to the reduction of unwarranted practice variation by meeting criteria for audit and feedback. METHODS: We searched PubMed, Embase, EBSCO/CINAHL and Wiley/Cochrane Library from inception to March 24th, 2020. Studies that compared the rate of caesarean sections between individuals, institutions or geographic areas were included. Study design was assessed on: selection procedure of study population, data source, case-mix correction, patient preference, aggregation level of analysis, maternal and neonatal outcome, and determinants (professional and organizational characteristics). RESULTS: A total of 284 studies were included. Most studies (64%) measured the caesarean section rate in the entire study population instead of using a sample (30%). (National) databases were most often used as information source (57%). Case-mix correction was performed in 87 studies (31%). The Robson classification was used in 20% of the studies following its endorsement by the WHO in 2015. The most common levels of aggregation were hospital level (35%) and grouped hospitals (35%) e.g. private versus public. The percentage of studies that assessed the relationship between variation in caesarean section rates and maternal outcome was 9%, neonatal outcome 19%, determinants (professional and organizational characteristics) 21% and patient preference 2%. CONCLUSIONS: Study designs of practice variation in caesarean sections varied considerably, raising questions about their appropriateness. Studies focused on measuring practice variation, rather than contributing to the reduction of unwarranted practice variation. Future studies should correct for differences in patient characteristics (case-mix) and patient preference to identify unwarranted practice variation. Practice variation studies could be used for audit and feedback if results are presented at lower levels of aggregation, and appeal to intrinsic motivation of physicians, for example by including the health effects on mother and child.

Unraveling the Complexity in the Design and Implementation of Bundled Payments: A Scoping Review of Key Elements From a Payer's Perspective.

Policy Points Because bundled payments are relatively new and require a different type of collaboration among payers, providers, and other actors, their design and implementation process is complex. By sorting the 53 key elements that contribute to this complexity into specific pre- and postcontractual phases as well as the actors involved in the health system, this framework provides a comprehensive overview of this complexity from a payer's perspective. Strategically, the design and implementation of bundled payments should not be approached by payers as merely the introduction of a new contracting model, but as part of a broader transformation into a more sustainable, value-based health care system. CONTEXT: Traditional fee-for-service (FFS) payment models in health care stimulate volume-driven care rather than value-driven care. To address this issue, increasing numbers of payers are adopting contracts based on bundled payments. Because their design and implementation are complex, understanding the elements that contribute to this complexity from a payer's perspective might facilitate their adoption. Consequently, the objective of our study was to identify and structure the key elements in the design and implementation of bundled payment contracts. METHODS: Two of us independently and systematically examined the literature to identify all the elements considered relevant to our objective. We then developed a framework in which these elements were arranged according to the specific phases of a care procurement process and actors' interactions at various levels of the health system. FINDINGS: The final study sample consisted of 147 articles in which we identified the 53 elements included in the framework. These elements were found in all phases of the pre- and postcontractual procurement process and involved actors at different levels of the health care system. Examples of elements that were cited frequently and are typical of bundled payment procurement, as opposed to FFS procurement, are (1) specification of care services, patients' characteristics, and corresponding costs, (2) small and heterogeneous patient populations, (3) allocation of payment and savings/losses among providers, (4) identification of patients in the bundle, (5) alignment of the existing care delivery model with the new payment model, and (6) limited effects on quality and costs in the first pilots and demonstrations. CONCLUSIONS: Compared with traditional FFS payment models, bundled payment contracts tend to introduce an alternative set of (financial) incentives, touch on almost all aspects of governance within organizations, and demand a different type of collaboration among organizations. Accordingly, payers should not strategically approach their design and implementation as merely the adoption of a new contracting model, but rather as part of a broader transformation toward a more sustainable value-based health care system, based less on short-term transactional negotiations and more on long-term collaborative relationships between payers and providers.

Global budget versus cost ceiling: a natural experiment in hospital payment reform in the Netherlands.

Global budget (GB) arrangements have become a popular method worldwide to control the rise in healthcare expenditures. By guaranteeing hospital funding, payers hope to eliminate the drive for increased production, and incentivize providers to deliver more efficient care and lower utilization. We evaluated the introduction of GB contracts by certain large insurers in Dutch hospital care in 2012 and compared health care utilization to those insurers who continued with more traditional production-based contracts, i.e., cost ceiling (CC) contracts. We used the share of GB hospital funding per postal code region to study the effect of contract types. Our findings show that having higher share of GB financing was associated with lower growth in treatment intensity, but it was also associated with higher growth in the probability of having at least one hospital visit. While the former finding is in line with our expectation, the latter is not and suggests that hospital visits may take longer to respond to contract incentives. Our study covers the years of 2010-2013 (2 years before and 2 years following the introduction of the new contracts). Therefore, our results capture only short-term effects.

On selecting quality indicators: preferences of patients with breast and colon cancers regarding hospital quality indicators.

BACKGROUND: There is an increasing number of quality indicators being reported publicly with aim to improve the transparency on hospital care quality. However, they are little used by patients. Knowledge on patients' preferences regarding quality may help to optimise the information presented to them. OBJECTIVE: To measure the preferences of patients with breast and colon cancers regarding publicly reported quality indicators of Dutch hospital care. METHODS: From the existing set of clinical quality indicators, participants of patient group discussions first assessed an indicator's suitability as choice information and then identified the most relevant ones. We used the final selection as attributes in two discrete choice experiments (DCEs). Questionnaires included choice vignettes as well as a direct ranking exercise, and were distributed among patient communities. Data were analysed using mixed logit models. RESULTS: Based on the patient group discussions, 6 of 52 indicators (breast cancer) and 5 of 21 indicators (colon cancer) were selected as attributes. The questionnaire was completed by 84 (breast cancer) and 145 respondents (colon cancer). In the patient group discussions and in the DCEs, respondents valued outcome indicators as most important: those reflecting tumour residual (breast cancer) and failure to rescue (colon cancer). Probability analyses revealed a larger range in percentage change of choice probabilities for breast cancer (10.9%-69.9%) relative to colon cancer (7.9%-20.9%). Subgroup analyses showed few differences in preferences across ages and educational levels. DCE findings partly matched with those of direct ranking. CONCLUSION: Study findings show that patients focused on a subset of indicators when making their choice of hospital and that they valued outcome indicators the most. In addition, patients with breast cancer were more responsive to quality information than patients with colon cancer.

[Translating care evaluations into practice: a suggestion based on the healthcare professional's intrinsic motivation to improve]. / Vertaling van zorgevaluaties naar de praktijk.

Scientific medical associations have made important steps in setting up integrated research agendas to narrow the huge knowledge gap about the effectiveness of accepted treatments. The ensuing care evaluations provide new insight into the value of different treatments; however, the implementation of the results of these care evaluations in practice continues to lag behind. In 2016 the Netherlands health insurers and the Netherlands patients' federation, supported by the Netherlands federation of medical specialists, started up the programme 'Leading the change'. As an integral part of this programme we held discussions with different parties to draw up measures to stimulate implementation. We advise having a comprehensive packet of measures to promote implementation. In this context it is important to make use of information-mirroring and to clarify the consequences of care evaluations for all parties involved. Implementation of new insights arising from care evaluations is in line with the responsibility associated with professional autonomy. Only if and when implementation lags behind despite stimulating measures will it be necessary to implement less voluntary measures.

Practice variation in long-term care access and use: The role of the ability to pay.

Practice variation in publicly financed long-term care (LTC) may be inefficient and inequitable, similarly to practice variation in the health care sector. Although most OECD countries spend an increasing share of their gross domestic product on LTC, it has received comparatively little attention to date compared with the health care sector. This paper contributes to the literature by assessing and comparing regional practice variation in both access to and use of institutional LTC and investigating its relation with income and out-of-pocket payment. For this, we have access to unique individual-level data covering the entire Dutch population. Even though we found practice variation in the use of LTC once access was granted, the variation between regions was still relatively small compared with international standards. In addition, we showed how a co-payment measure could be used to reduce practice variation across care office regions and income classes making the LTC system not only more efficient but also more equitable.

The marginal benefits of healthcare spending in the Netherlands: Estimating cost-effectiveness thresholds using a translog production function.

New technologies may displace existing, higher-value care under a fixed budget. Countries aim to curtail adoption of low-value technologies, for example, by installing cost-effectiveness thresholds. Our objective is to estimate the opportunity cost of hospital care to identify a threshold value for the Netherlands. To this aim, we combine claims data, mortality data and quality of life questionnaires from 2012 to 2014 for 11,000 patient groups to obtain quality-adjusted life-year (QALY) outcomes and spending. Using a fixed effects translog model, we estimate that a 1% increase in hospital spending on average increases QALY outcomes by 0.2%. This implies a threshold of €73,600 per QALY, with 95% confidence intervals ranging from €53,000 to €94,000 per QALY. The results stipulate that new technologies with incremental cost effectiveness ratios exceeding the Dutch upper reference value of €80,000 may indeed displace more valuable care.