Reporting health services research to a broader public: An exploration of inconsistencies and reporting inadequacies in societal publications.

INTRODUCTION: Little is known about the accuracy of societal publications (e.g. press releases, internet postings or professional journals) that are based on scientific work. This study investigates a) inconsistencies between scientific peer-reviewed health services research (HSR) publications and non-scientific societal publications and b) replication of reporting inadequacies from these scientific publications to corresponding societal publications. METHODS: A sample of HSR publications was drawn from 116 publications authored in 2016 by thirteen Dutch HSR institutions. Societal publications corresponding to scientific publications were identified through a systematic internet search. We conducted a qualitative, directed content analysis on societal publications derived from the scientific publications to assess both reporting inadequacies and determine inconsistencies. Descriptive frequencies were calculated for all variables. Odds ratios were used to investigate whether inconsistencies in societal publications were less likely when the first scientific author was involved. RESULTS: We identified 43 scientific and 156 societal publications. 94 societal publications (60.3%), (associated with 32 scientific publications (74.4%)) contained messages that were inconsistent with the scientific work. We found reporting inadequacies in 22 scientific publications (51.2%). In 45 societal publications (28.9%), we found replications of these reporting inadequacies. The likelihood of inconsistencies between scientific and societal publications did not differ when the latter explicitly involved the first scientific author, (OR = 1.44, CI: 0.76-2.74); were published on the institute's or funder's website, (OR = 1.32, CI: 0.57-3.06); published with no involvement of a scientific author, (OR = 0.52, CI: 0.25-1.07). CONCLUSION: To improve societal publications, one should examine both the consistency with scientific research publications and ways to prevent replication of scientific reporting inadequacies. HSR institutions, funders, and scientific and societal publication platforms should invest in a supportive publication culture to further incentivise the responsible and skilled involvement of researchers in writing both scientific and societal publications.

The association between the workload of general practitioners and patient experiences with care: results of a cross-sectional study in 33 countries.

BACKGROUND: The workload of general practitioners (GPs) and dissatisfaction with work have been increasing in various Western countries over the past decades. In this study, we evaluate the relation between the workload of GPs and patients' experiences with care. METHODS: We collected data through a cross-sectional survey among 7031 GPs and 67,873 patients in 33 countries. Dependent variables are the patient experiences on doctor-patient communication, accessibility, continuity, and comprehensiveness of care. Independent variables concern the workload measured as the GP-reported work hours per week, average consultation times, job satisfaction (an indicator of subjective workload), and the difference between the workload measures of every GP and the average in their own country. Finally, we evaluated interaction effects between workload measures and what patients find important in a country and the presence of a patient-list system. Relationships were determined through multilevel regression models. RESULTS: Patients of GPs who are happier with their work were found to experience better communication, continuity, access, and comprehensiveness. When GPs are more satisfied compared to others in their country, patients also experience better quality. When GPs work more hours per week, patients also experience better quality of care, but not in the area of accessibility. A longer consultation time, also when compared to the national average, is only related to more comprehensive care. There are no differences in the relationships between countries with and without a patient list system and in countries where patients find the different quality aspects more important. CONCLUSIONS: Patients experience better care when their GP has more work hours, longer consultation times, and especially, a higher job satisfaction.

An expert-based mapping of healthcare system strategies to support rational drug prescribing in primary care across 13 European countries.

BACKGROUND: Irrational prescribing has received increasing attention among policy-makers to improve drug safety and effectiveness while avoiding economic waste. The policies intended to rationalise prescribing have been grouped by WHO under a taxonomy, classifying them into two types of strategies - (1) targeted approaches (micro level) and (2) system-oriented approaches (macro level). The extent to which countries implement strategies and the existing types is currently unknown. This paper explores the following research question via expert opinions: to what extent have European countries implemented strategies to support rational prescribing (targeted and system oriented) and what are the types implemented? METHODS: We assessed the available information on policies intended to promote rational prescribing. We used the WHO taxonomy to explore our research question as the basis for a standardised questionnaire. The data were collected between August 2018 and April 2019. The questionnaire consisted of questions that solicited the opinion of experts on the implementation of prescribing control mechanisms in primary care in their respective countries. Experts were identified through the literature and relevant networks. The questionnaire was sent to 17 identified country experts from 17 different countries; 15 responded and 13 were used in our analysis. Answers were validated through follow-up correspondence, interviews and presentation at an OECD meeting. RESULTS: Expert-reported data shows that all 13 countries included in our study have several mechanisms in place for enhancing rational prescribing in primary care. All approaches were reported to have been implemented in at least two countries. We identified two groups of countries, namely a small group of countries (n = 3) with fewer mechanisms in place and a larger group of countries (n = 10) with a large number of strategies with accompanying instruments at both the micro and macro levels. CONCLUSIONS: The data reported by the experts suggests that all 13 countries included in our study have several mechanisms in place for enhancing rational prescribing in primary care on both the micro and macro levels. With respect to the extent of mechanisms being in place, two groups of countries were identified. This initial mapping of strategies forms a basis for more in-depth research to be able to assess the impact of bundles of strategies on system and targeted level on rational drug prescribing in primary care in Europe.

Individual, institutional, and scientific environment factors associated with questionable research practices in the reporting of messages and conclusions in scientific health services research publications.

BACKGROUND: Health Services Research findings (HSR) reported in scientific publications may become part of the decision-making process on healthcare. This study aimed to explore associations between researcher's individual, institutional, and scientific environment factors and the occurrence of questionable research practices (QRPs) in the reporting of messages and conclusions in scientific HSR publications. METHODS: We employed a mixed-methods study design. We identified factors possibly contributing to QRPs in the reporting of messages and conclusions through a literature review, 14 semi-structured interviews with HSR institutional leaders, and 13 focus-groups amongst researchers. A survey corresponding with these factors was developed and shared with 172 authors of 116 scientific HSR publications produced by Dutch research institutes in 2016. We assessed the included publications for the occurrence of QRPs. An exploratory factor analysis was conducted to identify factors within individual, institutional, and environmental domains. Next, we conducted bivariate analyses using simple Poisson regression to explore factors' association with the number of QRPs in the assessed HSR publications. Factors related to QRPs with a p-value < .30 were included in four multivariate models tested through a multiple Poisson regression. RESULTS: In total, 78 (45%) participants completed the survey (51.3% first authors and 48.7% last authors). Twelve factors were included in the multivariate analyses. In all four multivariate models, a higher score of "pressure to create societal impact" (Exp B = 1.28, 95% CI [1.11, 1.47]), was associated with higher number of QRPs. Higher scores on "specific training" (Exp B = 0.85, 95% CI [0.77-0.94]) and "co-author conflict of interest" (Exp B = 0.85, 95% CI [0.75-0.97]) factors were associated with a lower number of QRPs. Stratification between first and last authors indicated different factors were related to the occurrence of QRPs for these groups. CONCLUSION: Experienced pressure to create societal impact is associated with more QRPs in the reporting of messages and conclusions in HSR publications. Specific training in reporting messages and conclusions and awareness of co-author conflict of interests are related to fewer QRPs. Our results should stimulate awareness within the field of HSR internationally on opportunities to better support reporting in scientific HSR publications.

Figure Interpretation Assessment Tool-Health (FIAT-health) 2.0: from a scoring instrument to a critical appraisal tool.

BACKGROUND: Statistics are frequently used in health advocacy to attract attention, but are often misinterpreted. The Figure Interpretation Assessment Tool-Health (FIAT-Health) 1.0 was developed to support systematic assessment of the interpretation of figures on health and health care. This study aimed to test and evaluate the FIAT-Health 1.0 amongst its intended user groups, and further refine the tool based on our results. METHODS: Potential users (N = 32) were asked to assess one publicly reported figure using the FIAT-Health 1.0, and to justify their assessments and share their experience in using the FIAT-Health. In total four figures were assessed. For each figure, an expert on the specific topic (N = 4) provided a comparative assessment. The consistency of the answers was calculated, and answers to the evaluation questions were qualitatively analysed. A qualitative comparative analysis of the justifications for assessment by the experts and potential users was made. Based on the results, a new version of the FIAT-Health was developed and tested by employees (N = 27) of the National Institute for Public Health and the Environment (RIVM), and approved by the project's advisory group. In total sixty-three participants contributed. RESULTS: Potential users using the FIAT-Health 1.0 and experts gave similar justifications for their assessments. The justifications provided by experts aligned with the items of the FIAT-Health. Seventeen out of twenty-six dichotomous questions were consistently answered by the potential users. Numerical assessment questions showed inconsistencies in how potential users responded. In the evaluation, potential users most frequently mentioned that thanks to its structured approach, the FIAT-Health contributed to their awareness of the main characteristics of the figure (n = 14), but they did find the tool complex (n = 11). The FIAT-Health 1.0 was revised from a scoring instrument into a critical appraisal tool: the FIAT-Health 2.0, which was tested and approved by employees of the RIVM and the advisory group. CONCLUSION: The tool was refined according to the results of the test and evaluation, transforming the FIAT-Health from a quantitative scoring instrument into an online qualitative appraisal tool that has the potential to aid the better interpretation and public reporting of statistics on health and healthcare.

Statistics in Dutch policy debates on health and healthcare.

BACKGROUND: The notion of 'fact-free politics' is debated in Europe and the United States of America and has particular relevance for the use of evidence to underpin health and healthcare policies. To better understand how evidence on health and healthcare is used in the national policy-making process in the Netherlands, we explore how different statistics are used in various policy debates on health and healthcare in the Dutch government and parliament. METHODS: We chose eight ongoing policy debates as case studies representing the subject categories of morbidity, lifestyle, healthcare expenditure and healthcare outcomes, including (1) breast cancer screening rates, prevalence and incidence, (2) dementia prevalence and incidence, (3) prevalence of alcohol use by pregnant women, (4) mobility and school sports participation in children, (5) costs of smoking, (6) Dutch national healthcare expenditure, (7) hospital mortality rates, and (8) bedsore prevalence. Using selected keywords for each policy debate case, we performed a document search to identify documentation of the debates (2014-2016) on the websites of the Dutch government and parliament. We retrieved 163 documents and examined the policy debate cases through a content analyses approach. RESULTS: Sources of the statistics used in policy debates were primarily government funded. We identified two distinct functions, i.e. rhetorical and managerial use of statistics. The function of the debate is rhetorical when the specific statistic is used for agenda-setting or to convince the reader of the importance of a topic. The function of the debate is managerial when statistics determine planning, monitoring or evaluation of policy. When evaluating a specific policy, applied statistics were mostly the result of routine or standardised data collection. When policy-makers use statistics for a managerial function, the policy debate mirrors terms derived from scientific debates. CONCLUSION: While statistics used for rhetorical functions do not seem to invite critical reflection, when the function of the debate is managerial, i.e. to plan, monitor or evaluate healthcare, their construction does receive attention. Considering the current role of statistics in rhetorical and managerial debates, there is a need to be cautious of too much leniency towards the technocratic process in exchange for the democratic debate.

Occurrence and nature of questionable research practices in the reporting of messages and conclusions in international scientific Health Services Research publications: a structured assessment of publications authored by researchers in the Netherlands.

OBJECTIVES: Explore the occurrence and nature of questionable research practices (QRPs) in the reporting of messages and conclusions in international scientific Health Services Research (HSR) publications authored by researchers from HSR institutions in the Netherlands. DESIGN: In a joint effort to assure the overall quality of HSR publications in the Netherlands, 13 HSR institutions in the Netherlands participated in this study. Together with these institutions, we constructed and validated an assessment instrument covering 35 possible QRPs in the reporting of messages and conclusions. Two reviewers independently assessed a random sample of 116 HSR articles authored by researchers from these institutions published in international peer-reviewed scientific journals in 2016. SETTING: Netherlands, 2016. SAMPLE: 116 international peer-reviewed HSR publications. MAIN OUTCOME MEASURES: Median number of QRPs per publication, the percentage of publications with observed QRP frequencies, occurrence of specific QRPs and difference in total number of QRPs by methodological approach, type of research and study design. RESULTS: We identified a median of six QRPs per publication out of 35 possible QRPs. QRPs occurred most frequently in the reporting of implications for practice, recommendations for practice, contradictory evidence, study limitations and conclusions based on the results and in the context of the literature. We identified no differences in total number of QRPs in papers based on different methodological approach, type of research or study design. CONCLUSIONS: Given the applied nature of HSR, both the severity of the identified QRPs, and the recommendations for policy and practice in HSR publications warrant discussion. We recommend that the HSR field further define and establish its own scientific norms in publication practices to improve scientific reporting and strengthen the impact of HSR. The results of our study can serve as an empirical basis for continuous critical reflection on the reporting of messages and conclusions.

Are people's health care needs better met when primary care is strong? A synthesis of the results of the QUALICOPC study in 34 countries.

AIM: This article synthesises the results of a large international study on primary care (PC), the QUALICOPC study. BACKGROUND: Since the Alma Ata Declaration, strengthening PC has been high on the policy agenda. PC is associated with positive health outcomes, but it is unclear how care processes and structures relate to patient experiences. METHODS: Survey data were collected during 2011-2013 from approximately 7000 PC physicians and 70 000 patients in 34, mainly European, countries. The data on the patients are linked to data on the PC physicians within each country and analysed using multilevel modelling. FINDINGS: Patients had more positive experiences when their PC physician provided a broader range of services. However, a broader range of services is also associated with higher rates of hospitalisations for uncontrolled diabetes, but rates of avoidable diabetes-related hospitalisations were lower in countries where patients had a continuous relationship with PC physicians. Additionally, patients with a long-term relationship with their PC physician were less likely to attend the emergency department. Capitation payment was associated with more positive patient experiences. Mono- and multidisciplinary co-location was related to improved processes in PC, but the experiences of patients visiting multidisciplinary practices were less positive. A stronger national PC structure and higher overall health care expenditures are related to more favourable patient experiences for continuity and comprehensiveness. The study also revealed inequities: patients with a migration background reported less positive experiences. People with lower incomes more often postponed PC visits for financial reasons. Comprehensive and accessible care processes are related to less postponement of care. CONCLUSIONS: The study revealed room for improvement related to patient-reported experiences and highlighted the importance of core PC characteristics including a continuous doctor-patient relationship as well as a broad range of services offered by PC physicians.

Shared decision making between patient and GP about referrals from primary care: Does gatekeeping make a difference?

Primary care faces challenging times in many countries, mainly caused by an ageing population. The GPs' role to match patients' demand with medical need becomes increasingly complex with the growing multiple conditions population. Shared decision-making (SDM) is recognized as ideal to the treatment decision making process. Understanding GPs' perception on SDM about patient referrals and whether patients' preferences are considered, becomes increasingly important for improving health outcomes and patient satisfaction. This study aims to 1) understand whether countries vary in how GPs perceive SDM, in patients' referral, 2) describe to what extent SDM in GPs' referrals differ between gatekeeping and non-gatekeeping systems, and 3) identify what factors GPs consider when referring to specialists and describing how this differs between gatekeeping and non-gatekeeping systems. Data were collected between October 2011 and December 2013 in 32 countries through the QUALICOPC study (Quality and Costs of Primary Care in Europe). The first question was answered by assessing GPs' perception on who takes the referral decision. For the second question, a multilevel logistic model was applied. For the third question we analysed the GPs' responses on what patient logistics and need arguments they consider in the referral process. We found: 1) variation in GPs reported SDM- 90% to 35%, 2) a negative correlation between gatekeeper systems and SDM-however, some countries strongly deviate and 3) GPs in gatekeeper systems more often consider patient interests, whereas in non-gatekeeping countries the GP's value more own experience with specialists and benchmarking information. Our findings imply that GPs in gatekeeper systems seem to be less inclined to SDM than GPs in a non-gatekeeping system. The relation between gatekeeping/non-gatekeeping and SDM is not straightforward. A more contextualized approach is needed to understand the relation between gatekeeping as a system design feature and its relation with and/or impact on SDM.

Improving interpretation of publically reported statistics on health and healthcare: the Figure Interpretation Assessment Tool (FIAT-Health).

BACKGROUND: Policy-makers, managers, scientists, patients and the general public are confronted daily with figures on health and healthcare through public reporting in newspapers, webpages and press releases. However, information on the key characteristics of these figures necessary for their correct interpretation is often not adequately communicated, which can lead to misinterpretation and misinformed decision-making. The objective of this research was to map the key characteristics relevant to the interpretation of figures on health and healthcare, and to develop a Figure Interpretation Assessment Tool-Health (FIAT-Health) through which figures on health and healthcare can be systematically assessed, allowing for a better interpretation of these figures. METHODS: The abovementioned key characteristics of figures on health and healthcare were identified through systematic expert consultations in the Netherlands on four topic categories of figures, namely morbidity, healthcare expenditure, healthcare outcomes and lifestyle. The identified characteristics were used as a frame for the development of the FIAT-Health. Development of the tool and its content was supported and validated through regular review by a sounding board of potential users. RESULTS: Identified characteristics relevant for the interpretation of figures in the four categories relate to the figures' origin, credibility, expression, subject matter, population and geographical focus, time period, and underlying data collection methods. The characteristics were translated into a set of 13 dichotomous and 4-point Likert scale questions constituting the FIAT-Health, and two final assessment statements. Users of the FIAT-Health were provided with a summary overview of their answers to support a final assessment of the correctness of a figure and the appropriateness of its reporting. CONCLUSIONS: FIAT-Health can support policy-makers, managers, scientists, patients and the general public to systematically assess the quality of publicly reported figures on health and healthcare. It also has the potential to support the producers of health and healthcare data in clearly communicating their data to different audiences. Future research should focus on the further validation of the tool in practice.

Cost Variation in Diabetes Care across Dutch Care Groups?

OBJECTIVE: The introduction of bundled payment for diabetes care in the Netherlands led to the origination of care groups. This study explored to what extent variation in health care costs per patient can be attributed to the performance of care groups. Furthermore, the commonly applied simple mean aggregation was compared with the more advanced generalized linear mixed model (GLMM) to benchmark health care costs per patient between care groups. DATA SOURCE: Dutch 2009 nationwide insurance claims data of diabetes type 2 patients (104,544 patients, 50 care groups). STUDY DESIGN: Both a simple mean aggregation and a GLMM approach was applied to rank care groups, using two different health care costs variables: total treatment health care costs and diabetes-specific specialist care costs per diabetes patient. PRINCIPAL FINDINGS: Care groups varied slightly in the first and mainly in the second indicator. Care group variation was not explained by composition. Although the ranking methods were correlated, some care groups' rank positions differed, with consequences on the top-10 and the low-10 positions. CONCLUSIONS: Differences between care groups exist when an appropriate indicator and a sophisticated aggregation technique is used. Currently applied benchmarking may have unfair consequences for some care groups.

Trends towards stronger primary care in three western European countries; 2006-2012.

BACKGROUND: Strong primary care systems are believed to have an important role in dealing with healthcare challenges. Strengthening primary care systems is therefore a common policy goal for many countries. This study aims to investigate whether the Netherlands, the UK and Germany have strengthened their primary care systems in 2006-2012. METHOD: For this cross-sectional study, data from the International Health Policy surveys of the Commonwealth Fund in 2006, 2009 and 2012 were used. The surveys represent the experiences and perspectives of primary care physicians with their primary care system. The changes over time were researched in three areas: organization of primary care processes, use of IT in primary care and use of benchmarking and financial incentives for performance improvement. RESULTS: Regarding organization of primary care processes, in all countries the use of supporting personnel in general practice increased, but at the same time practice accessibility decreased. IT services were most advanced in the UK. The UK and the Netherlands showed increased use of performance feedback information. German GPs were least satisfied with how their system works across the 2006-2012 timeframe. CONCLUSION: All three countries show trends towards stronger primary care systems, although in different areas. Coordination and comprehensive care through the assignment of assisting personnel and use of disease management programs improved in all countries. In the Netherlands and the UK, informational continuity is in part ensured through better IT services. All countries showed increasing difficulties upholding primary care accessibility.

Reporting and use of the OECD Health Care Quality Indicators at national and regional level in 15 countries.

QUALITY PROBLEM OR ISSUE: OECD member states are involved since 2003 in a project coordinated by the OECD on Health Care Quality Indicators (HCQI). All OECD countries are biennially requested by the OECD to deliver national data on the quality indicators for international benchmarking purposes. INITIAL ASSESSMENT: Currently, there is no knowledge whether the OECD HCQI information is used by the countries themselves for healthcare system accountability and improvement purposes. CHOICE OF SOLUTION: The objective of the study is to explore the reporting and use of OECD HCQI in OECD member-states. IMPLEMENTATION: Data were collected through a questionnaire sent to all OECD member-states containing factual questions on the reporting on all OECD HCQ-indicators. Responses were received between June and December 2014. In this timeframe, two reminders were sent to the participants. The work progress was presented during HCQI Meetings in November 2014 and May 2015. EVALUATION: Fifteen countries reported to have a total of 163 reports in which one or more HCQIs were reported. One hundred and sixteen were national and 47 were regional reports. Forty-nine reports had a general system focus, 80 were disease specific, 10 referred to a specific type of care setting, 22 were thematic and 2 were a combination of two (disease specific for a particular type of care and thematic for a specific type of care). Most reports were from Canada: 49. All 15 countries use one or more OECD indicators. LESSONS LEARNED: The OECD quality indicators have acquired a clear place in national and regional monitoring activities. Some indicators are reported more often than others. These differences partly reflect differences between healthcare systems. Whereas some indicators have become very common, such as cancer care indicators, others, such as mental healthcare and patient experience indicators are relatively new and require some more time to be adopted more widely.

The impact of primary care organization on avoidable hospital admissions for diabetes in 23 countries.

OBJECTIVE: Diabetes is a so-called ambulatory care sensitive condition. It is assumed that by appropriate and timely primary care, hospital admissions for complications of such conditions can be avoided. This study examines whether differences between countries in diabetes-related hospitalization rates can be attributed to differences in the organization of primary care in these countries. DESIGN: Data on characteristics of primary care systems were obtained from the QUALICOPC study that includes surveys held among general practitioners and their patients in 34 countries. Data on avoidable hospitalizations were obtained from the OECD Health Care Quality Indicator project. Negative binomial regressions were carried out to investigate the association between characteristics of primary care and diabetes-related hospitalizations. SETTING: A total of 23 countries. SUBJECTS: General practitioners and patients. MAIN OUTCOME MEASURES: Diabetes-related avoidable hospitalizations. RESULTS: Continuity of care was associated with lower rates of diabetes-related hospitalization. Broader task profiles for general practitioners and more medical equipment in general practice were associated with higher rates of admissions for uncontrolled diabetes. Countries where patients perceive better access to care had higher rates of hospital admissions for long-term diabetes complications. There was no association between disease management programmes and rates of diabetes-related hospitalization. Hospital bed supply was strongly associated with admission rates for uncontrolled diabetes and long-term complications. CONCLUSIONS: Countries with elements of strong primary care do not necessarily have lower rates of diabetes-related hospitalizations. Hospital bed supply appeared to be a very important factor in this relationship. Apparently, it takes more than strong primary care to avoid hospitalizations. KEY POINTS: Countries with elements of strong primary care do not necessarily have lower rates of diabetes-related avoidable hospitalization. Hospital bed supply is strongly associated with admission rates for uncontrolled diabetes and long-term complications. Continuity of care was associated with lower rates of diabetes-related hospitalization. Better access to care, broader task profiles for general practitioners, and more medical equipment in general practice was associated with higher rates of admissions for diabetes.

Accessible and continuous primary care may help reduce rates of emergency department use. An international survey in 34 countries.

BACKGROUND: Part of the visits to emergency departments (EDs) is related to complaints that may well be treated in primary care. OBJECTIVES: (i) To investigate how the likelihood of attending an ED is related to accessibility and continuity of primary care. (ii) To investigate the reasons for patients to visit EDs in different countries. METHODS: Data were collected within the EU Seventh Framework project Quality and Costs in Primary Care (QUALICOPC) in 31 European countries, Australia, New Zealand and Canada. The data were collected between 2011 and 2013 and contain survey data from 60991 patients and 7005 GPs, within 7005 general practices. OUTCOME MEASURE: whether the patient visited the ED in the previous year (yes/no). Multilevel logistic regression analyses were carried out to analyse the data. RESULTS: Some 29.4% had visited the ED in the past year. Between countries, the percentages varied between 18% and 40%. ED visits show a significant and negative relation with better accessibility of primary care. Patients with a regular doctor who knows them personally were less likely to attend EDs. Only one-third of all patients who visited an ED indicated that the main reason for this was that their complaint could not be treated by a GP. CONCLUSIONS: Good accessibility and continuity of primary care may well reduce ED use. In some countries, it may be worthwhile to invest in more continuous relationships between patients and GPs or to eliminate factors that hamper people to use primary care (e.g. for costs or travelling).

Incorporating shared savings programs into primary care: from theory to practice.

BACKGROUND: In several countries, health care policies gear toward strengthening the position of primary care physicians. Primary care physicians are increasingly expected to take accountability for overall spending and quality. Yet traditional models of paying physicians do not provide adequate incentives for taking on this new role. Under a so-called shared savings program physicians are instead incentivized to take accountability for spending and quality, as the program lets them share in cost savings when quality targets are met. We provide a structured approach to designing a shared savings program for primary care, and apply this approach to the design of a shared savings program for a Dutch chain of primary care providers, which is currently being piloted. METHODS: Based on the literature, we defined five building blocks of shared savings models that encompass the definition of the scope of the program, the calculation of health care expenditures, the construction of a savings benchmark, the assessment of savings and the rules and conditions under which savings are shared. We apply insights from a variety of literatures to assess the relative merits of alternative design choices within these building blocks. The shared savings program uses an econometric model of provider expenditures as an input to calculating a casemix-corrected benchmark. RESULTS: The minimization of risk and uncertainty for both payer and provider is pertinent to the design of a shared savings program. In that respect, the primary care setting provides a number of unique opportunities for achieving cost and quality targets. Accountability can more readily be assumed due to the relatively long-lasting relationships between primary care physicians and patients. A stable population furthermore improves the confidence with which savings can be attributed to changes in population management. Challenges arise from the institutional context. The Dutch health care system has a fragmented structure and providers are typically small in size. CONCLUSION: Shared savings programs fit the concept of enhanced primary care. Incorporating a shared savings program into existing payment models could therefore contribute to the financial sustainability of this organizational form.

Propensity to seek healthcare in different healthcare systems: analysis of patient data in 34 countries.

BACKGROUND: Some people have a lower threshold to seek care for certain symptoms than others. This study aims to investigate what factors are associated with patients' propensity to seek care. In addition, this study explores whether patients' propensity to seek care is associated with their actual health care utilization. We hypothesized that higher scores for propensity to seek care will lead to more general practitioners (GP) consultations, but to lower rates of avoidable hospitalization. METHODS: Propensity to seek care and GP utilization were measured by the Patient Experience Questionnaire of the QUALICOPC study, a survey among 61,931 patients that recently visited GP services in 34 countries. Propensity to seek care was estimated by two questions: one question focusing on health care seeking behavior for serious symptoms and the other question focused minor complaints. Data on country level rates of avoidable hospitalization for CHF, COPD, asthma and diabetes were obtained from the OECD health care quality indicators project. RESULTS: Beside patient characteristics, various organizational factors, such as better accessible and continuous primary care, and better experienced communication between patient and GPs was associated with a higher propensity to seek care for both severe and minor complaints. A higher propensity to seek care was associated with a slightly higher health care utilization in terms of GP visits, with no differences between the severity of the experienced symptoms (OR 1.08 for severe complaints and OR 1.05 for minor complaints). At country level, no association was found between propensity to seek care and rates of avoidable hospitalization for CHF, COPD, asthma and diabetes, possibly due to low statistical power at country level. CONCLUSIONS: The organization of primary care and patients' perceived communication with their GP were found to be highly correlated with patients' decision to seek health care for minor or severe complaints, suggesting that characteristics of healthcare systems directly influence patients' care seeking behavior, potentially leading to overuse or underuse of health services. However, we also observed that patients' propensity to seek care is only weakly associated with more GP use.

Organizational aspects of primary care related to avoidable hospitalization: a systematic review.

BACKGROUND: Often used indicators for the quality of primary care are hospital admissions rates for conditions which are potentially avoidable by well-functioning primary care. Such hospitalizations are frequently termed as ambulatory care sensitive conditions (ACSCs). OBJECTIVE: We aim to investigate which characteristics of primary care organization influence avoidable hospitalization for chronic ACSCs. METHODS: MEDLINE, Embase and SciSearch were searched for publications on avoidable hospitalization and primary care. Studies were included if peer reviewed, written in English, published between January 1997 and November 2013, conducted in high income countries, identified hospitalization for ACSC as outcome measures and researched organization characteristics of primary care. A risk of bias assessment was performed to assess the quality of the articles. FINDINGS: A total of 1778 publications were reviewed, of which 49 met inclusion criteria. Twenty-two primary care factors were found. Factors were clustered into four primary care clusters: system-level characteristics, accessibility, structural and organizational characteristics and organization of the care process. Adequate physician supply and better longitudinal continuity of care reduced avoidable hospitalizations. Furthermore, inconsistent results were found on the effectiveness of various disease management programs in reducing hospitalization rates. CONCLUSIONS: Available evidence suggests that strong primary care in terms of adequate primary care physician supply and long-term relationships between primary care physicians and patients reduces hospitalizations for chronic ACSCs. There is a lack of evidence for the positive effects of many other organizational primary care aspects, such as specific disease management programs.

The Dutch Health Care Performance Report: seven years of health care performance assessment in the Netherlands.

In 2006, the first edition of a monitoring tool for the performance of the Dutch health care system was released: the Dutch Health Care Performance Report (DHCPR). The Netherlands was among the first countries in the world developing such a comprehensive tool for reporting performance on quality, access, and affordability of health care. The tool contains 125 performance indicators; the choice for specific indicators resulted from a dialogue between researchers and policy makers. In the 'policy cycle', the DHCPR can rationally be placed between evaluation (accountability) and agenda-setting (for strategic decision making). In this paper, we reflect on important lessons learned after seven years of health care system performance assessment. These lessons entail the importance of a good conceptual framework for health system performance assessment, the importance of repeated measurement, the strength of combining multiple perspectives (e.g., patient, professional, objective, subjective) on the same issue, the importance of a central role for the patients' perspective in performance assessment, how to deal with the absence of data in relevant domains, the value of international benchmarking and the continuous exchange between researchers and policy makers.

Accountable Care Organizations: how to dress for success.

Accountable Care Organizations (ACOs) need to reconsider their provider configuration and make it capable of managing clinical and financial risk. To that aim, their management must decide which medical procedures are done by the ACO itself, and which are contracted out to market providers. Making this decision requires a balanced treatment of market and firm organization, recognizing that each has properties that can turn into relative strengths. Such a balanced treatment is lacking in the ACO debate. Using the transaction cost theory, we provide such a balanced treatment of market and firm organization, and discuss implications for the design of ACOs and accountable care initiatives in general.