The positive impact of a care-physical activity initiative for people with a low socioeconomic status on health, quality of life and societal participation: a mixed-methods study.

BACKGROUND: Overweight and obesity rates are increasing worldwide, particularly among people with a low socioeconomic status (SES). Care-physical activity (care-PA) initiatives may improve participants' lifestyles and thereby lower overweight and obesity rates. A two-year care-PA initiative specifically developed for citizens with a low SES, X-Fittt 2.0, was offered free of charge to participants, and included 12 weeks of intensive guidance and sports sessions, and 21 months of aftercare. Here, we study the impact of X-Fittt 2.0 on health, quality of life (QoL) and societal participation using a mixed-methods design. METHODS: Questionnaires and body measurements were taken from 208 participants at the start of X-Fittt 2.0 (t0) and after 12 weeks (t1), one year (t2) and two to three years (t3). We also held 17 group discussions (t1, n = 71) and 68 semi-structured interviews (t2 and t3). Continuous variables were analysed using a linear mixed-model analysis (corrected for gender, age at t0, height, education level and employment status at the different time points), while we used descriptive statistics for the categorical variables. Qualitative data were analysed using a thematic analysis. RESULTS: Body weight was significantly lower at all three post-initiative time points compared with the baseline, with a maximum of 3.8 kg difference at t2. Body Mass Index, waist circumference, blood pressure and self-perceived health only significantly improved during the first 12 weeks. A positive trend regarding paid work was observed, while social visits decreased. The latter might be explained by the COVID-19 pandemic, as lockdowns limited social life. Furthermore, participants reported increased PA (including sports) and a few stopped smoking or drinking alcohol. Participants mentioned feeling healthier, fitter and more energetic. Additionally, participants' self-esteem and stress levels improved, stimulating them to become more socially active. However, the participants also mentioned barriers to being physically active, such as a lack of money or time, or physical or mental health problems. CONCLUSIONS: X-Fittt 2.0 improved the health, QoL and societal participation of the participants. Future initiatives should take into account the aforementioned barriers, and consider a longer intervention period for more sustainable results. More complete data are needed to confirm the findings.

Density of Patient-Sharing Networks: Impact on the Value of Parkinson Care.

BACKGROUND: Optimal care for Parkinson's disease (PD) requires coordination and collaboration between providers within a complex care network. Individual patients have personalised networks of their own providers, creating a unique informal network of providers who treat ('share') the same patient. These 'patient-sharing networks' differ in density, ie, the number of identical patients they share. Denser patient-sharing networks might reflect better care provision, since providers who share many patients might have made efforts to improve their mutual care delivery. We evaluated whether the density of these patient-sharing networks affects patient outcomes and costs. METHODS: We analysed medical claims data from all PD patients in the Netherlands between 2012 and 2016. We focused on seven professional disciplines that are commonly involved in Parkinson care. We calculated for each patient the density score: the average number of patients that each patient's providers shared. Density scores could range from 1.00 (which might reflect poor collaboration) to 83.00 (which might reflect better collaboration). This score was also calculated at the hospital level by averaging the scores for all patients belonging to a specific hospital. Using logistic and linear regression analyses we estimated the relationship between density scores and health outcomes, healthcare utilization, and healthcare costs. RESULTS: The average density score varied considerably (average 6.7, SD 8.2). Adjusted for confounders, higher density scores were associated with a lower risk of PD-related complications (odds ratio [OR]: 0.901; P<.001) and with lower healthcare costs (coefficients: -0.018, P=.005). Higher density scores were associated with more frequent involvement of neurologists (coefficient 0.068), physiotherapists (coefficient 0.052) and occupational therapists (coefficient 0.048) (P values all <.001). CONCLUSION: Patient sharing networks showed large variations in density, which appears unwanted as denser networks are associated with better outcomes and lower costs.

Variation in practice and outcomes after inguinal hernia repair: a nationwide observational study.

BACKGROUND: Inguinal hernia repair has often been used as a showcase to illustrate practice variation in surgery. This study determined the degree of hospital variation in proportion of patients with an inguinal hernia undergoing operative repair and the effect of this variation on clinical outcomes. METHODS: A nationwide, longitudinal, database study was performed in all hospitals in the Netherlands between 2013 and 2015. Patients with inguinal hernias were collected from the Diagnosis-Related-Group (DRG) database. The case-mix adjusted operation rate in patients with a new DRG determines the observed variation. Hospital variation in case-mix adjusted inguinal hernia repair-rates was calculated per year. Clinical outcomes after surgery were compared between hospitals with high and low adjusted operation-rates. RESULTS: In total, 95,637 patients were included. The overall operation rate was 71.6%. In 2013-2015, the case-mix adjusted performance of inguinal hernia repairs in hospitals with high rates was 1.6-1.9 times higher than in hospitals with low rates. Moreover, in hospitals with high adjusted rates of inguinal hernia repair the time to surgery was shorter, more laparoscopic procedures were performed, less emergency department visits were recorded post-operatively, while more emergency department visits were recorded when patients were treated conservatively compared to hospitals with low adjusted operation rates. CONCLUSION: Hospital variation in inguinal hernia repair in the Netherlands is modest, operation-rates vary by less than two-fold, and variation is stable over time. Hernia repair in hospitals with high adjusted rates of inguinal hernia repair are associated with improved outcomes.

How the logics of the market, bureaucracy, professionalism and care are reconciled in practice: an empirical ethics approach.

BACKGROUND: In the Netherlands, the for-profit sector has gained a substantial share of nursing home care within just a few years. The ethical question that arises from the growth of for-profit care is whether the market logic can be reconciled with the provision of healthcare. This question relates to the debate on the Moral Limits of Markets (MLM) and commodification of care. METHODS: The contribution of this study is twofold. Firstly, we construct a theoretical framework from existing literature; this theoretical framework differentiates four logics: the market, bureaucracy, professionalism, and care. Secondly, we follow an empirical ethics approach; we used three for-profit nursing homes as case studies and conducted qualitative interviews with various stakeholders. RESULTS: Four main insights emerge from our empirical study. Firstly, there are many aspects of the care relationship (e.g. care environment, personal relationships, management) and every aspect of the relationship should be considered because the four logics are reconciled differently for each aspect. The environment and conditions of for-profit nursing homes are especially commodified. Secondly, for-profit nursing homes pursue a different professional logic from the traditional, non-profit sector - one which is inspired by the logic of care and which contrasts with bureaucratic logic. However, insofar as professionals in for-profit homes are primarily responsive to residents' wishes, the market logic also prevails. Thirdly, a multilevel approach is necessary to study the MLM in the care sector since the degree of commodification differs by level. Lastly, it is difficult for the market to engineer social cohesion among the residents of nursing homes. CONCLUSIONS: The for-profit nursing home sector does embrace the logic of the market but reconciles it with other logics (i.e. logic of care and logic of professionalism). Importantly, for-profit nursing homes have created an environment in which care professionals can provide person-oriented care, thereby reconciling the logic of the market with the logic of care.

Hospital Variation in Cholecystectomies in The Netherlands: A Nationwide Observational Study.

BACKGROUND: Practice variation generally raises concerns about the quality of care. This study determined the longitudinal degree of hospital variation in proportion of patients with gallstone disease undergoing cholecystectomy, while adjusted for case-mix, and the effect on clinical outcomes. METHODS: A nationwide, longitudinal, database study was performed in all hospitals in the Netherlands in 2013-2015. Patients with gallstone disease were collected from the diagnosis-related group database. Hospital variation in case-mix-adjusted cholecystectomy rates was calculated per year. Clinical outcomes after cholecystectomy were compared between hospitals in the lowest/highest 20th percentile of the distribution of adjusted cholecystectomy rates in all 3 subsequent years. RESULTS: In total, 96,673 patients with gallstones were included. The cholecystectomy rate was 73.6%. In 2013-2015, the case-mix-adjusted performance of cholecystectomies was in hospitals with high rates 1.5-1.6 times higher than in hospitals with low rates. Hospitals with a high adjusted cholecystectomy rate had a higher laparoscopy rate, shorter time to surgery, and less emergency department visits after a cholecystectomy compared to hospitals with a low-adjusted cholecystectomy rate. CONCLUSION: Hospital variation in cholecystectomies in the Netherlands is modest, cholecystectomy rates varies by <2-fold, and variation is stable over time. Cholecystectomies in hospitals with high adjusted cholecystectomy rates are associated with improved outcomes.

Effective elements of care-physical activity initiatives for adults with a low socioeconomic status: A concept mapping study with health promotion experts.

In care-physical activity (care-PA) initiatives, primary care and sports are combined to stimulate PA among adults at risk of lifestyle related diseases. Preliminary results from Dutch care-PA initiatives for adults with a low socioeconomic status (SES) indicate a decrease in participants' body weight and an improved quality of life, however, the elements that make these initiatives successful are yet to be identified. In total, 19 Dutch health promotion experts participated in our concept mapping (CM) of the effective elements of care-PA initiatives for adults with a low SES. The experts identified 111 effective elements of these initiatives, which were grouped into 11 clusters, focusing on: 1) approaching participants within the care-PA initiative, 2) barriers experienced throughout the initiative, 3) long-term implementation, 4) customizing the care-PA initiative to the target population, 5) social support, 6) structure and guidance, 7) the professionals within the care-PA initiative, 8) the accessibility of the care-PA initiative, 9) targeted behaviour and progression, 10) recruitment and administration, and 11) intersectoral collaboration. CM was useful for creating a valuable overview of these effective elements. Our results could be used to improve the development and implementation of future care-PA initiatives for adults with a low SES.

Regional variation in hospital care at the end-of-life of Dutch patients with lung cancer exists and is not correlated with primary and long-term care.

OBJECTIVE: To examine the regional variation in hospital care utilization in the last 6 months of life of Dutch patients with lung cancer and to test whether higher degrees of hospital utilization coincide with less general practitioner (GP) and long-term care use. DESIGN: Cross-sectional claims data study. SETTING: The Netherlands. PARTICIPANTS: Patients deceased in 2013-2015 with lung cancer (N = 25 553). MAIN OUTCOME MEASURES: We calculated regional medical practice variation scores, adjusted for age, gender and socioeconomic status, for radiotherapy, chemotherapy, CT-scans, emergency room contacts and hospital admission days during the last 6 months of life; Spearman Rank correlation coefficients measured the association between the adjusted regional medical practice variation scores for hospital admissions and ER contacts and GP and long-term care utilization. RESULTS: The utilization of hospital services in high-using regions is 2.3-3.6 times higher than in low-using regions. The variation was highest in 2015 and lowest in 2013. For all 3 years, hospital care was not significantly correlated with out-of-hospital care at a regional level. CONCLUSIONS: Hospital care utilization during the last 6 months of life of patients with lung cancer shows regional medical practice variation over the course of multiple years and seems to increase. Higher healthcare utilization in hospitals does not seem to be associated with less intensive GP and long-term care. In-depth research is needed to explore the causes of the variation and its relation to quality of care provided at the level of daily practice.

Increasing the Legitimacy of Tough Choices in Healthcare Reimbursement: Approach and Results of a Citizen Forum in The Netherlands.

BACKGROUND: Some studies in the Netherlands have gauged public views on principles for healthcare priority setting, but they fall short of comprehensively explaining the public disapproval of several recent reimbursement decisions. OBJECTIVE: To obtain insight into citizens' preferences and identify the criteria they would propose for decisions pertaining to the benefits package of basic health insurance. METHODS: Twenty-four Dutch citizens were selected for participation in a Citizen Forum, which involved 3 weekends. Deliberations took place in small groups and in plenary, guided by 2 moderators, on the basis of 8 preselected case studies, which participants later compared and prioritized under the premise that not all treatments can or need to be reimbursed. Participants received opportunities to inform themselves through written brochures and live interactions with 3 experts. RESULTS: The Citizen Forum identified 16 criteria for inclusion or exclusion of treatments in the benefits package; they relate to the condition (2 criteria), treatment (11 criteria), and individual characteristics of those affected by the condition (3 criteria). In most case studies, it was a combination of criteria that determined whether or not participants favored inclusion of the treatment under consideration in the benefits package. Participants differed in their opinion about the relative importance of criteria, and they had difficulty in operationalizing and trading off criteria to provide a recommendation. CONCLUSIONS: Informed citizens are prepared to make and, to a certain extent, capable of making reasoned choices about the reimbursement of health services. They realize that choices are both necessary and possible. Broad public support and understanding for making tough choices regarding the benefits package of basic health insurance is not automatic: it requires an investment.

Public needs for information disclosure on healthcare performance: Different determinants between Japan and the Netherlands.

The accumulated healthcare performance data related to unwarranted practice variations are not necessarily disseminated to patients and citizens. To clarify the needs for public disclosure, we explored Japanese and Dutch citizens' preferences and values towards information disclosure and healthcare disparity.Online opt-in survey was conducted and we asked citizens their preference to know about the healthcare performance indicators of regions and hospitals, and their attitudes towards healthcare equity. After a descriptive statistical analysis, Chi-squared automatic interaction detection tree analysis was performed to explore the socio-demographic determinants which were associated with positive value for information disclosure and healthcare equity. Then, we compared the combination of attributes of the highest and the lowest subgroups of each country and compared within and between countries. Last, logistic regression analysis was performed to further evaluate the impact of each determinant.Significant differences were observed between the 2 countries (Japan [JPN] 1038; Netherlands [NL] 1040). The crucial attributes identified were age, sex, educational background, and living area (JPN), along with age and sex (NL). Japanese comprised multiple subgroups with heterogeneous values, showed relatively low interest in knowing the information, and seemed to accept healthcare inequality, especially among urban males aged 20 to 59 years. Contrarily, Dutch people mostly showed high interest in both items. Female and older respondents valued information disclosure highly across countries.To share healthcare performance knowledge and empowering the public, historical, cultural, and socio-demographic context including health literacy of citizens' subgroups should be considered in making comprehensive public reports.

Do independent treatment centers offer more value than general hospitals? The case of cataract care.

OBJECTIVE: To identify differences between independent treatment centers (ITCs) and general hospitals (GHs) regarding costs, quality of care, and efficiency. DATA SOURCES: Anonymous claims data (2013-2015) were used. We also obtained quality indicators from a semipublic platform. STUDY DESIGN: This study uses a comparative multilevel analysis, controlling for case mix, to evaluate the performance of ITCs and GHs for patients diagnosed with cataract. DATA COLLECTION: Reimbursement claims were extracted from existing claims databases of the largest Dutch health insurer. Quality indicators were obtained by external agencies through a mixed-mode survey. PRINCIPAL FINDINGS: There are no stark differences in complexity of cases for cataract care. ITCs seem to perform surgeries more frequently per care pathway, but conduct a lower number of health care activities per surgical claim. Total average costs are lower in ITCs compared with GHs, but when adjusted for case mix, the differences in costs are lower. The findings with the adjusted quality differences suggest that ITCs outperform GHs on patient satisfaction, but patients' outcomes are similar. CONCLUSION: This finding supports the postulation-based on the focus factory theory-that ITCs can provide more value for cataract care than GHs.

Predicting life expectancy with a long short-term memory recurrent neural network using electronic medical records.

BACKGROUND: Life expectancy is one of the most important factors in end-of-life decision making. Good prognostication for example helps to determine the course of treatment and helps to anticipate the procurement of health care services and facilities, or more broadly: facilitates Advance Care Planning. Advance Care Planning improves the quality of the final phase of life by stimulating doctors to explore the preferences for end-of-life care with their patients, and people close to the patients. Physicians, however, tend to overestimate life expectancy, and miss the window of opportunity to initiate Advance Care Planning. This research tests the potential of using machine learning and natural language processing techniques for predicting life expectancy from electronic medical records. METHODS: We approached the task of predicting life expectancy as a supervised machine learning task. We trained and tested a long short-term memory recurrent neural network on the medical records of deceased patients. We developed the model with a ten-fold cross-validation procedure, and evaluated its performance on a held-out set of test data. We compared the performance of a model which does not use text features (baseline model) to the performance of a model which uses features extracted from the free texts of the medical records (keyword model), and to doctors' performance on a similar task as described in scientific literature. RESULTS: Both doctors and the baseline model were correct in 20% of the cases, taking a margin of 33% around the actual life expectancy as the target. The keyword model, in comparison, attained an accuracy of 29% with its prognoses. While doctors overestimated life expectancy in 63% of the incorrect prognoses, which harms anticipation to appropriate end-of-life care, the keyword model overestimated life expectancy in only 31% of the incorrect prognoses. CONCLUSIONS: Prognostication of life expectancy is difficult for humans. Our research shows that machine learning and natural language processing techniques offer a feasible and promising approach to predicting life expectancy. The research has potential for real-life applications, such as supporting timely recognition of the right moment to start Advance Care Planning.

Care-physical activity initiatives in the neighbourhood: study protocol for mixed-methods research on participation, effective elements, impact, and funding methods.

BACKGROUND: In the Netherlands, people with a low socioeconomic status (SES) live approximately 6 years less and are less engaged in physical activity (PA) than high SES citizens. This contributes to the persistent health inequalities between low and high SES citizens. Care-PA initiatives are deemed effective for stimulating PA and improving health and participation among peoples with a low SES. In those initiatives, multiple sectors (e.g. sports, health insurers, municipalities) collaborate to connect primary care and PA at neighbourhood level. This study focuses on two Dutch municipalities that aim to invest in Health in All Policies (HiAP) and care-PA initiatives to improve the health of people with low SES. The aim is to gain insight into (1) the short-term (3 months) and long-term (1 year) outcomes of participating in care-PA initiatives for low SES citizens in terms of health, quality of life, and societal participation, (2) the effective elements that contribute to these outcomes, (3) the direct and perceived societal costs and benefits of care-PA initiatives, and (4) alternative ways to fund integrated care, prevention, and care-PA initiatives at neighbourhood level. METHODS: The study will be built on a mixed-methods design guided by action research to continuously facilitate participatory processes and practical solutions. To assess outcomes, body measurements and questionnaires will be used as part of a pre-test/post-test design. Focus groups and interviews will be conducted to gain an in-depth understanding of outcomes and action elements. Action elements will be explored by using multiple tools: concept mapping, the logic model, and capacity mapping. Direct and perceived societal costs will be measured by administrative data from healthcare insurers (before-after design) and the effectiveness arena. An alternative funding model will be identified based on literature study, expert meetings, and municipal workshops. DISCUSSION: Initiatives addressing multiple factors at different levels in an integral way are a challenge for evaluation. Multi-methods and tools are required, and data need to be interpreted comprehensively in order to contribute to a contextual insight into what works and why in relation to HiAP and care-PA initiatives.

Medical practice variation: public reporting a first necessary step to spark change.

From previous work, we know that medical practice varies widely, and that unwarranted variation signals low value for patients and society. We also know that public reporting helps to create awareness of the need for quality improvement. Despite the availability of rich data, most Western countries have no routine surveillance of the geographic distribution of utilization, costs, and outcomes of healthcare, including trends in variation over time. This paper highlights the role of transparent public reporting as a necessary first step to spark change and reduce unwarranted variation. Two recent examples of public reporting are presented to illustrate possible ways to reduce unwarranted variation and improve care. We conclude by introducing the Value Improvement Cycle, which underscores that reporting is only a necessary first step, and suggests a path toward developing a multi-stakeholder approach to change.

Do private hospitals outperform public hospitals regarding efficiency, accessibility, and quality of care in the European Union? A literature review.

European countries have enhanced the scope of private provision within their health care systems. Privatizing services have been suggested as a means to improve access, quality, and efficiency in health care. This raises questions about the relative performance of private hospitals compared with public hospitals. Most systematic reviews that scrutinize the performance of the private hospitals originate from the United States. A systematic overview for Europe is nonexisting. We fill this gap with a systematic realist review comparing the performance of public hospitals to private hospitals on efficiency, accessibility, and quality of care in the European Union. This review synthesizes evidence from Italy, Germany, the United Kingdom, France, Greece, Austria, Spain, and Portugal. Most evidence suggests that public hospitals are at least as efficient as or are more efficient than private hospitals. Accessibility to broader populations is often a matter of concern in private provision: Patients with higher social-economic backgrounds hold better access to private hospital provision, especially in private parallel systems such as the United Kingdom and Greece. The existing evidence on quality of care is often too diverse to make a conclusive statement. In conclusion, the growth in private hospital provision seems not related to improvements in performance in Europe. Our evidence further suggests that the private (for-profit) hospital sector seems to react more strongly to (financial) incentives than other provider types. In such cases, policymakers either should very carefully develop adequate incentive structures or be hesitant to accommodate the growth of the private hospital sector.

How do treatment aims in the last phase of life relate to hospitalizations and hospital mortality? A mortality follow-back study of Dutch patients with five types of cancer.

PURPOSE: The purpose of this study is to describe and compare the relation between treatment aims, hospitalizations, and hospital mortality for Dutch patients who died from lung, colorectal, breast, prostate, or pancreatic cancer. METHODS: A mortality follow-back study was conducted within a sentinel network of Dutch general practitioners (GPs), who recorded the end-of-life care of 691 patients who died from one of the abovementioned cancer types between 2009 and 2015. Differences in care by type of cancer were analyzed using multilevel analyses to control for clustering within general practices. RESULTS: Among all cancer types, patients with prostate cancer most often and patients with pancreatic cancer least often had a palliative treatment aim a month before death (95% resp. 84%). Prostate cancer patients were also least often admitted to hospital in the last month of life (18.5%) and least often died there (3.1%), whereas lung cancer patients were at the other end of the spectrum with 41.8% of them being admitted to hospital and 22.6% dying in hospital. Having a palliative treatment aim and being older were significantly associated with less hospital admissions, and having a palliative treatment aim, having prostate cancer, and dying in a more recent year were significantly associated with less hospital deaths. CONCLUSION: There is large variation between patients with different cancer types with regard to treatment aims, hospital admissions, and hospital deaths. The results highlight the need for early initiation of GP palliative care to support patients from all cancer types to stay at the place they prefer as long as possible.

'Reframing Healthcare Services through the Lens of Co-Production' (RheLaunCh): a study protocol for a mixed methods evaluation of mechanisms by which healthcare and social services impact the health and well-being of patients with COPD and CHF in the USA and The Netherlands.

INTRODUCTION: The USA lags behind other high-income countries in many health indicators. Outcome differences are associated with differences in the relative spending between healthcare and social services at the national level. The impact of the ratio and delivery of social and healthcare services on the individual patient's health is however unknown. 'Reframing Healthcare Services through the Lens of Co-Production' (RheLaunCh) will be a cross-Atlantic comparative study of the mechanisms by which healthcare and social service delivery may impact patient health with chronic conditions. Insight into these mechanisms is needed to better and cost-effectively organise healthcare and social services. METHODS: We designed a mixed methods study to compare the socioeconomic background, needs of and service delivery to patients with congestive heart failure and chronic obstructive pulmonary disease in the USA and the Netherlands. We will conduct: (1) a literature scan to compare national and regional healthcare and social service systems; (2) a retrospective database study to compare patient's socioeconomic and clinical characteristics and the service use and spending at the national, regional and hospital level; (3) a survey to compare patient perceived quality of life, receipt and experience of service delivery and ability of these services to meet patient needs; and (4) multiple case studies to understand what patients need to better govern their quality of life and how needs are met by services. ETHICS AND DISSEMINATION: Ethics approval was granted by the ethics committee of the Radboud University Medical Center (2016-2423) in the Netherlands and by the Human Subjects Research Committee of the Hennepin Health Care System, Inc. (HSR #16-4230) in the USA. Multiple approaches will be used for dissemination of results, including (inter)national research presentations and peer-reviewed publications. A website will be established to support the development of a community of practice.

What Influences Patients' Decisions When Choosing a Health Care Provider? Measuring Preferences of Patients with Knee Arthrosis, Chronic Depression, or Alzheimer's Disease, Using Discrete Choice Experiments.

OBJECTIVE: To investigate what influences patients' health care decisions and what the implications are for the provision of information on the quality of health care providers to patients. DATA SOURCES/STUDY SETTING: Dutch patient samples between November 2006 and February 2007. STUDY DESIGN: Discrete choice experiments were conducted in three patient groups to explore what influences choice for health care providers. DATA COLLECTION: Data were obtained from 616 patients with knee arthrosis, 368 patients with chronic depression, and 421 representatives of patients with Alzheimer's disease. PRINCIPAL FINDINGS: The three patients groups chose health care providers on a different basis. The most valued attributes were effectiveness and safety (knee arthrosis); continuity of care and relationship with the therapist (chronic depression); and expertise (Alzheimer's disease). Preferences differed between subgroups, mainly in relation to patients' choice profiles, severity of disease, and some background characteristics. CONCLUSIONS: This study showed that there is substantial room for (quality) information about health care providers in patients' decision processes. This information should be tailor-made, targeting specific patient segments, because different actors and factors play a part in their search and selection process.