Newspaper Coverage of Hospitals During a Prolonged Health Crisis: Longitudinal Mixed Methods Study.

BACKGROUND: It is important for health organizations to communicate with the public through newspapers during health crises. Although hospitals were a main source of information for the public during the COVID-19 pandemic, little is known about how this information was presented to the public through (web-based) newspaper articles. OBJECTIVE: This study aims to examine newspaper reporting on the situation in hospitals during the first year of the COVID-19 pandemic in the Netherlands and to assess the degree to which the reporting in newspapers aligned with what occurred in practice. METHODS: We used a mixed methods longitudinal design to compare internal data from all hospitals (n=5) located in one of the most heavily affected regions of the Netherlands with the information reported by a newspaper covering the same region. The internal data comprised 763 pages of crisis meeting documents and 635 minutes of video communications. A total of 14,401 newspaper articles were retrieved from the LexisNexis Academic (RELX Group) database, of which 194 (1.3%) articles were included for data analysis. For qualitative analysis, we used content and thematic analyses. For quantitative analysis, we used chi-square tests. RESULTS: The content of the internal data was categorized into 12 themes: COVID-19 capacity; regular care capacity; regional, national, and international collaboration; human resources; well-being; public support; material resources; innovation; policies and protocols; finance; preparedness; and ethics. Compared with the internal documents, the newspaper articles focused significantly more on the themes COVID-19 capacity (P<.001), regular care capacity (P<.001), and public support (P<.001) during the first year of the pandemic, whereas they focused significantly less on the themes material resources (P=.004) and policies and protocols (P<.001). Differences in attention toward themes were mainly observed between the first and second waves of the pandemic and at the end of the third wave. For some themes, the attention in the newspaper articles preceded the attention given to these themes in the internal documents. Reporting was done through various forms, including diary articles written from the perspective of the hospital staff. No indication of the presence of misinformation was found in the newspaper articles. CONCLUSIONS: Throughout the first year of the pandemic, newspaper articles provided coverage on the situation of hospitals and experiences of staff. The focus on themes within newspaper articles compared with internal hospital data differed significantly for 5 (42%) of the 12 identified themes. The discrepancies between newspapers and hospitals in their focus on themes could be attributed to their gatekeeping roles. Both parties should be aware of their gatekeeping role and how this may affect information distribution. During health crises, newspapers can be a credible source of information for the public. The information can also be valuable for hospitals themselves, as it allows them to anticipate internal and external developments.

Toward a Theory of Organizational DNA: Routines, Principles, and Beliefs (RPBs) for Successful and Sustainable Organizational Change.

Organizational change is a key mechanism to ensure the sustainability of healthcare systems. However, healthcare organizations are persistently difficult to change, and literature is riddled with examples of failed change endeavors. In this chapter, we attempt to unravel the underlying causes for failed organizational change. We distinguish three types of change with different levels of depth that require different change approaches. Transformations are the deepest forms of change where beliefs and principles need to be modified to successfully influence routines. Renewals are deep forms of change where principles need to be modified to successfully influence routines. Improvements are shallow forms of change where only modifications at the level of routines are needed. Using deoxyribonucleic acid (DNA) as our metaphor, we propose a theory of "organizational DNA" to understand organizations and these three types of organizational changes. We posit that organizations are made up of a double helix consisting of a so-called "social string," which contains the "soft" interaction or communication among the organization's members, and a so-called "technical string," which contains "hard" organizational aspects such as structure and technology. Ladders of organizational nucleotides (i.e., Routines, Principles, and Beliefs) connect this double helix in various combinations. Together, the double helix and accompanying nucleotides make up the DNA of an organization. Without knowledge of the architecture of organizational DNA and whether a change addresses beliefs, principles, and/or routines, we believe that organizational change is constrained and based on luck rather than change management expertise. Following this metaphor, we show that organizational change fails when it attempts to change one part of the DNA (e.g., routines) in a way that renders it incompatible with the connecting components (e.g., principles and beliefs). We discuss how the theory can be applied in practice using an exemplar case.

Back to the Future: What Healthcare Organizations Need to Thrive in the Face of Persistent Environmental Uncertainty.

While uncertainty has always been a feature of the healthcare environment, its pace and scope are rapidly increasing, fueled by myriad factors such as technological advancements, the threat and frequency of disruptive events, global economic developments, and increasing complexity. Contemporary healthcare organizations thus persistently face what is known as "deep uncertainty," which obscures their ability to predict outcomes of strategic action and decision-making, presenting them with novel challenges and threatening their survival. Persistent, deep uncertainty challenges us to revisit and reconsider how we think about uncertainty and the strategic actions needed by organizations to thrive under these circumstances. Simply put, how can healthcare organizations thrive in the face of deeply uncertain environments? We argue that healthcare organizations need to employ both adaptive and creative strategic approaches in order to effectively meet patients' needs and capture value in the long-term future. The chapter concludes by offering two ways organizations can build the dynamic capabilities needed to employ such approaches.

Return to sender: Unraveling the role of structural and social network ties in patient sharing networks.

Healthcare is increasingly delivered through networks of organizations. Well-structured patient sharing networks are known to have positive associations with the quality of delivered services. However, the drivers of patient sharing relations are rarely studied explicitly. In line with recent developments in network and integration theorizing, we hypothesize that structural and social network ties between organizations are uniquely associated with a higher number of shared patients. We test these hypotheses using a Bayesian zero-dispersed Poisson regression model within the Additive and Multiplicative Effects Framework based on administrative claims data from 732,122 dermatological patients from the Netherlands in 2017. Our results indicate that 2.6% of all dermatological patients are shared and that the amount of shared patients is significantly associated with structural (i.e. emergency contracts) and social (i.e. shared physicians) ties between organizations, confirming our hypotheses. We also find some evidence that patients are shared with more capable organizations. Our findings highlight the role of relational ties in the way health services are delivered. At the same time, they also raise some potential anti-trust concerns.

The impact of a multi-hospital network on the inequality in odds of receiving resection or ablation for synchronous colorectal liver metastases.

BACKGROUND: This study investigates whether inequalities in the utilization of resection and/or ablation for synchronous colorectal liver metastases (SCLM) between patients diagnosed in expert and non-expert hospitals changed since a multi-hospital network started. MATERIALS AND METHODS: Patients diagnosed with SCLM between 2009 and 2020 were included. The likelihood of receiving ablation and/or resection was analyzed in the prenetwork (2009-2012), startup (2013-2016), and matured-network (2017-2020) periods. RESULTS: Nationwide, 13.981patients were diagnosed between 2009 and 2020, of whom 1.624 were diagnosed in the network. Of patients diagnosed in the network's expert hospitals, 36.7% received ablation and/or resection versus 28.3% in nonexpert hospitals (p < 0.01). The odds ratio (OR) of receiving ablation and/or resection for patients diagnosed in expert versus nonexpert hospitals increased from 1.38 (p = 0.581, pre-network), to 1.66 (p = 0.108, startup), to 2.48 (p = 0.090, matured-network). Nationwide, the same trend occurred (respectively OR 1.41, p = 0.011; OR 2.23, p < 0.001; OR 3.20, p < 0.001). CONCLUSIONS: Patients diagnosed in expert hospitals were more likely to receive ablation and/or resection for SCLM than patients diagnosed in non-expert hospitals. This difference increased over time despite the startup of a multi-hospital network. Establishing a multi-hospital network did not have an effect on reducing the existing unequal odds of receiving specialized treatment. SYNOPSIS: Specialized oncology treatments are increasingly provided through multi-hospital networks. However, scant empirical evidence on the effectiveness of these networks exists. This study analyzes whether a regional multi-hospital network was able to improve equal access to specialized oncology treatments.

Two sides of the same coin? Absolute income and perceived income inadequacy as social determinants of health.

BACKGROUND: Absolute income is commonly used in studies of health inequalities, however it does not reflect spending patterns, debts, or expectations. These aspects are reflected in measures concerning perceived income inadequacy. While health inequities by absolute income or perceived income inadequacy are well established, few studies have explored the interplay of absolute income and perceived income inadequacy in relation to health. METHODS: Multiple data sources were linked into a nationally representative dataset (n = 445,748) of Dutch adults (18 +). The association between absolute income, perceived income inadequacy and health (self-reported health, chronic disease and psychological distress) was tested using logistic and Poisson regressions, controlling for various potential confounders (demographics, education) and mastery. Interactions were tested to check the association between perceived income inadequacy and health for different absolute income groups. RESULTS: Perceived income inadequacy was reported at every absolute income group (with 42% of individuals in the lowest income group and 5% of individuals in the highest income group). Both absolute income and perceived income inadequacy were independently associated with health. The adjusted relative risk (RR) for lowest absolute income group is 1.11 (1.08-1.1.14) and 1.28 (1.24-1.32) for chronic disease and self-reported health respectively, and the Odds Ratio (OR) for psychological distress is 1.28 (1.16-1.42). For perceived income inadequacy the RR's were 1.41 (1.37-1.46) and 1.49 (1.44-1.54) and the OR for psychological distress is 3.14 (2.81-3.51). Mastery appeared to be an important mediator for the relationship between perceived income inadequacy, poor self-rated health and psychological distress. CONCLUSIONS: Absolute income and perceived income inadequacy reflect conceptually different aspects of income and are independently associated with health outcomes. Perceived income inadequacy may be accounted for in health inequality studies, alongside measures of absolute income. In policy-making, targeting perceived income inadequacy might have potential to reduce health inequalities.

Involving Health Professionals in the Development of Quality and Safety Dashboards: Qualitative Study.

BACKGROUND: Dashboards are an important tool for hospitals to improve quality and safety performance. However, implementing quality and safety dashboards often does not increase performance due to a lack of use by health professionals. Including health professionals in the development process of quality and safety dashboards can improve their use in practice. Yet, it remains unclear how a development process involving health professionals can be executed successfully. OBJECTIVE: The aim of this study is twofold: (1) to delineate how a process whereby health professionals are included in the development of quality and safety dashboards can be facilitated and (2) to identify the factors that are important to consider in order to make that process successful. METHODS: We conducted a qualitative, in-depth exploratory case study in which we analyzed 150 pages of internal documents and interviewed 13 staff members regarding the development of quality and safety dashboards within 2 care pathways of a hospital that has experience in such development. The data were analyzed inductively using the constant comparative method. RESULTS: We found that the development of quality and safety dashboards in collaboration with health professionals was facilitated through a five-stage process: (1) familiarizing participants with dashboards and the development process; (2) brainstorming about potential indicators to be included in the dashboard; (3) prioritizing, defining, and selecting indicators to be included in the dashboard; (4) examining how the indicators can be visualized; and (5) implementing the dashboard and following up on its use. To enhance the success of the process, 3 factors were deemed important. The first is to create and maintain broad involvement, ensuring that various professions are represented and take ownership of the dashboard. Here, potential barriers include gaining engagement from peers not directly involved in the process and maintaining involvement after the initial implementation of the dashboard. Second, unburdening, whereby quality and safety staff facilitate a structured process that has little additional burden for professionals. For this, time management and a lack of collaboration with departments responsible for delivering the data might be an issue. Lastly, focusing on relevance for health professionals, which refers to the inclusion of indicators with value for health professionals. For this factor, a lack of consensus on how indicators should be defined and registered might be a barrier. CONCLUSIONS: Health care organizations seeking to develop quality and safety dashboards in collaboration with health professionals can use a 5-stage process. To enhance the success of the process, organizations are advised to focus on 3 key factors. For each of the key factors, potential barriers should be taken into account. Engaging in this process and attaining the key factors could increase the likelihood that the dashboards are used in practice.

A Social Network Analysis of Influences on Residents' Value-Based Decisions.

PURPOSE: To ensure a value-based health care system, it is becoming increasingly important that residents are trained in making value-based decisions. This study explored the social network influencing residents' value-based decisions. METHOD: To explore the social network influencing residents' value-based decisions, the authors used a semistructured individual and mini-group interviewing approach and participatory visual mapping. In total, 17 residents across 13 different specialties were interviewed from the southeastern postgraduate medical education and training region of the Netherlands, May-November 2021. Two researchers independently coded the transcribed data using an integrated inductive thematic approach. Subsequently, social network analysis was used to visualize the results. RESULTS: Residents indicated that their value-based decisions were influenced by direct actors who influenced decisions related to patients and indirect actors who shaped decisions related to patients without directly modifying them. Different interaction-aspects (i.e., personal, situational, and institutional) further affected residents' ability to make value-based decisions. Thus, residents' value-based decisions were a product of the interplay between various interactions with actors and different interaction-aspects. Residents defined value-based decisions differently, even within an interview. CONCLUSIONS: These results suggest residents' value-based decisions are influenced by a multitude of actors, including hierarchically superior colleagues who can directly alter decisions and patients (and their families) and nurses with whom residents consider it important to maintain good relationships. In addition, more experienced actors, mainly from the medical and nursing profession, contribute most to learning. Furthermore, residents' value-based decisions are deeply underpinned by the hidden curriculum. However, many senior physicians may not have received sufficient training in the concept of value-based health care. Consequently, an approach of formally educating residents in value-based health care will likely have limited effects unless social influences in day-to-day clinical settings reinforce its importance.

Use it or lose it? Identifying reasons for the low use of psychosocial support by hospital staff.

BACKGROUND: Psychosocial support programs are a way for hospitals to support the mental health of their staff. However, while support is needed, utilization of support by hospital staff remains low. This study aims to identify reasons for non-use and elements that are important to consider when offering psychosocial support. METHODS: This mixed-method, multiple case study used survey data and in-depth interviews to assess the extent of psychosocial support use, reasons for non-use and perceived important elements regarding the offering of psychosocial support among Dutch hospital staff. The study focused on a time of especially high need, namely the COVID-19 pandemic. Descriptive statistics were used to assess frequency of use among 1514 staff. The constant comparative method was used to analyze answers provided to two open-ended survey questions (n = 274 respondents) and in-depth interviews (n = 37 interviewees). RESULTS: The use of psychosocial support decreased from 8.4% in December 2020 to 3.6% by September 2021. We identified four main reasons for non-use of support: deeming support unnecessary, deeming support unsuitable, being unaware of the availability, or feeling undeserving of support. Furthermore, we uncovered four important elements: offer support structurally after the crisis, adjust support to diverse needs, ensure accessibility and awareness, and an active role for supervisors. CONCLUSIONS: Our results show that the low use of psychosocial support by hospital staff is shaped by individual, organizational, and support-specific factors. These factors can be targeted to increase use of psychosocial support, whereby it is important to also focus on the wider hospital workforce in addition to frontline staff.

Getting our hopes up: How actors perceive network effectiveness and why it matters.

Health care's grand challenges, such as continuously increasing costs, challenge the sustainability of health systems. Purpose-oriented networks are considered a favorable mode of organization to address these grand challenges. Therefore, it is crucial that they are effective. While network effectiveness is a heavily theorized, multi-dimensional concept that is often measured as a perception of actors, little is known about how network actors perceive effectiveness in practice and how this influences their behavior. In this study, we explored how network actors perceive network effectiveness using 32 interviews with representatives from network member organizations and regulatory agencies actor, 28 h of network meeting observations, and 1.272 pages of documents such as meeting minutes and media outlets. Our results show that actors primarily see hard outcomes (e.g. changes in cost or quality of care) as effectiveness but given the temporal nature of these goals and difficulties quantifying them, they resort to the collaborative process as a proxy to assess effectiveness. Actors engage in networks to solve grand challenges. However, conforming to expectations and environmental pressures also play a substantial role for actors to (continue to) participate in networks. In the absence of hard outcomes, actors legitimize their continued participation in networks using the collaborative process of networks. Actors therefore take purpose-oriented networks for granted as a legitimate way of organizing. Besides attempting to solve grand challenges, networks thus also seem to be adopted because of powerful institutional rules that function as rationalized myths, to gain legitimacy. Future research should be aware of and further unravel the institutional pressures in networks.

Through the looking glass: Confronting health care management's biggest challenges in the wake of a crisis.

BACKGROUND: The challenges brought on by the pandemic triggered a renewed scholarly focus on managing during crises. Now, 3 years on, having covered the initial crisis response, it is important to reevaluate what the crisis has taught us about health care management more generally. In particular, it is useful to consider the persistent challenges that continue to face health care organizations in the wake of a crisis. PURPOSE: The present article aims to identify the biggest challenges that currently face health care managers in order to formulate a postcrisis research agenda. METHODOLOGY/APPROACH: We employ an exploratory qualitative study, utilizing in-depth interviews with hospital executives and management to explore the persistent challenges facing managers in practice. RESULTS: Our qualitative inquiry reveals three key challenges that extend beyond the crisis and are salient for health care managers and organizations in the years to come. Specifically, we identify the centrality of human resource constraints (amidst increasing demand), the necessity of collaboration (amidst competition), and a need to reconsider the approach to leadership (utility of humility). CONCLUSION: We conclude by drawing upon relevant theories such as paradox theory to formulate a research agenda for health care management scholars that can support the creation of novel solutions and approaches to persistent challenges in practice. PRACTICE IMPLICATIONS: We identify several implications for organizations and health systems, including the need to eliminate competition and the importance of building human resource management capacities within organizations. In highlighting areas for future research, we provide organizations and managers with useful and actionable insights to address their most persistent challenges in practice.

So Happy Together: A Review of the Literature on the Determinants of Effectiveness of Purpose-Oriented Networks in Health Care.

While purpose-oriented networks are widely recognized as organizational forms to address wicked problems in health care such as increasing demands and expenditure, the associated literature is fragmented. We therefore reviewed empirical studies to identify the determinants of the effectiveness of these networks. Our search yielded 3,657 unique articles, of which 19 met our eligibility criteria. After backward snowballing and expert consultation, 33 articles were included. Results reveal no less than 283 determinants of effective health care networks. The majority of these determinants are processual and involving professionals from the operational level is particularly salient. In addition, most studies relate determinants to process outcomes (e.g., improved collaboration or sustainability of the network) and only a few to members' perception of whether the network attains its goals. We urge future research to adopt configurational approaches to identify which sets of determinants are associated with networks' ability to attain their goal of addressing wicked problems.

Let's Talk About it: The Utility of Formalized Support for Medical Residents.

Medical residents are significantly impacted by burnout and depression. Recent events have only further increased the pressure and demands on the healthcare sector, intensifying the burden facing residents and posing a threat to residents' well-being. As a result, significant efforts are being made to provide formalized support and well-being programs. Yet, emergent evidence indicates that residents do not sufficiently utilize this form of support. Considering the organizational investment and focus on formalized support programs, we conducted a mixed-method study to investigate residents' utilization of formalized well-being support, and potential reasons for non-use. Our study was conducted during a period of increased work burden and stress for medical residents, where formalized support was specifically offered and targeted to medical staff. Our findings confirm earlier results of low support utilization and point to the importance of informal support mechanisms, in particular peer support. We conclude by discussing the role of managers and educational programs in facilitating a positive cultural shift to promote and support residents in seeking support.

Charting a Course: A Research Agenda for Studying the Governance of Health Care Networks.

Networked forms of organizing in health care are increasingly viewed as an effective means of addressing "wicked", multifaceted health and societal challenges. This is because networks attempt to address these challenges via collaborative approaches in which diverse stakeholders together define the problem(s) and implement solutions. Consequently, there has been a sharp increase in the number and types of networks used in health care. Despite this growth, our understanding of how these networks are governed has not kept pace. The purpose of this chapter is to chart a research agenda for scholars who are interested in studying health care network governance (i.e., the systems of rules and decision-making within networks), which is of particular importance in deliberate networks between organizations. We do so based on our knowledge of the literature and interviews with subject matter experts, both of which are used to identify core network governance concepts that represent gaps in our current knowledge. Our analysis identified various conceptualizations of networks and of their governance, as well as four primary knowledge gaps: "bread and butter" studies of network governance in health care, the role of single organizations in managing health care networks, governance through the life-cycle stages of health care networks, and governing across the multiple levels of health care networks. We first seek to provide some conceptual clarity around networks and network governance. Subsequently, we describe some of the challenges that researchers may confront while addressing the associated knowledge gaps and potential ways to overcome these challenges.

Regional differences in healthcare costs further explained: The contribution of health, lifestyle, loneliness and mastery.

Healthcare costs in the Netherlands are rising and vary considerably among regions. Explaining regional differences in healthcare costs can help policymakers in targeting appropriate interventions in order to restrain costs. Factors usually taken into account when analyzing regional differences in healthcare costs are demographic structure and socioeconomic status (SES). However, health, lifestyle, loneliness and mastery have also been linked to healthcare costs. Therefore, this study analyzes the contribution of health, lifestyle factors (BMI, alcohol consumption, smoking and physical activity), loneliness, and mastery to regional differences in healthcare costs. Analyses are performed in a linked dataset (n = 334,721) from the Dutch Public Health Services, Statistics Netherlands, the National Institute for Public Health and the Environment (year 2016), and the healthcare claims database Vektis (year 2017) with Poisson and zero-inflated binomial regressions. Regional differences in general practitioner consult costs remain significant even after taking into account health, lifestyle, loneliness, and mastery. Regional differences in costs for mental, pharmaceutical, and specialized care are less pronounced and can be explained to a large extent. For total healthcare costs, regional differences are mostly explained through the factors included in this study. Hence, addressing lifestyle factors, loneliness and mastery can help policymakers in restraining healthcare costs. In this study, the region of Zuid-Limburg represents the reference region. Use compare regions for health and healthcare costs (Regiovergelijker gezondheid en zorgkosten) in order to select all other Dutch regions as reference region. Supplementary Information: The online version of this article (10.1007/s12508-022-00369-4) contains supplementary material, which is available to authorized users.

There and back again. Examining the development of employee commitment during a prolonged crisis.

To effectively function and adapt in crises, healthcare organizations rely on the skills and commitment of their workforce. Yet, our current understanding of how employees' workplace commitment is affected by and evolves throughout the course of a crisis remains limited. In this paper, we explore the commitment of hospital staff to an important workplace target, the COVID-19 crisis response, and show how this commitment develops over time. We report on an exploratory case study of hospital staff in a heavily hit region of the Netherlands. We conducted interviews with hospital executives, management, medical and support staff to uncover the issues hospitals faced in recruiting staff to provide COVID-19 care throughout the first and second wave of the crisis. Our findings suggest that while staff initially exhibited high levels of commitment to aiding in the crisis effort, staff were perceived to exhibit lower levels of commitment in the second wave, complicating the provision of COVID-19 care. We unveil three contributing factors to this shift, namely: competing demands, energy depletion and a lack of support and appreciation. Our findings suggest that while staff were initially willing to dedicate themselves and take responsibility for the crisis effort, as their other more stable commitments became more salient in the second wave, their willingness to dedicate limited resources to the crisis effort decreased. In our discussion, we examine the implications of our findings for the literature on workplace commitment, and advance our understanding of employee workplace commitment during crises.

To Uncertainty and Beyond: Identifying the Capabilities Needed by Hospitals to Function in Dynamic Environments.

Hospitals operate in increasingly complex and dynamically uncertain environments. To understand how hospital organizations can cope with such profound uncertainty, this article presents a multiple case study of five hospitals during the COVID-19 crisis in a heavily hit region of the Netherlands. We find that hospitals make adaptations in five key categories, namely: reorganization, decision-making, human resources, material resources, and planning. These adaptations offer insights into the core capabilities needed by hospitals to cope with dynamic uncertainty. Our findings highlight the need for hospitals to become more flexible without sacrificing efficiency. Organizations can accomplish this by building in more sensing and seizing capabilities to be better prepared for and respond to environmental change. Furthermore, transforming capabilities allow organizations to be more resilient and responsive in the face of ongoing uncertainty. We make recommendations on how hospitals can build these capabilities and address the core challenges they face in this pursuit.

If you say so: A mixed-method study of hospital mergers and quality of care.

BACKGROUND: Despite a lack of supporting evidence, hospitals continue to merge in pursuit of quality improvements. PURPOSE: We seek to develop a more thorough understanding of the quality effects of hospital mergers by integrating various theoretical perspectives using a mixed-methods design. METHODOLOGY: Quantitatively, we tested the quality effect of all consummated hospital mergers in the Netherlands between 2008 and 2014 on 15 quality indicators (with 82 measurements at hospital, department, and disease levels) using a difference-in-difference approach with Bonferroni correction. Qualitatively, we conducted three comparative case studies to examine how hospital executives, managers, and medical professionals perceive the quality impact of hospital mergers. RESULTS: Our quantitative results reveal few significant effects of hospital mergers on quality of care at all levels. After applying Bonferroni correction, two quality indicators are negatively associated with hospital mergers. However, the qualitative results indicate that hospital staff have positive perceptions of the mergers' quality implications, resulting from scale and shock effects. CONCLUSION: The perceptions of hospital staff regarding mergers diametrically oppose their measurable effects. However, the operationalization of quality by hospital staff members differs considerably from the way it is quantitatively measured. The positive perceptions of hospital staff toward mergers could further contribute to the institutionalization of mergers as a quality improvement strategy. PRACTICE IMPLICATIONS: Hospital managers seeking measurable quality improvements should be wary of merging, despite potential positive perceptions toward it within the organization. In case they do decide to merge, mitigating difficulties in the postmerger integration processes seem most pertinent to achieve measurable effects.

Is Loneliness an Undervalued Pathway between Socio-Economic Disadvantage and Health?

Loneliness is a growing public health issue. It is more common in disadvantaged groups and has been associated with a range of poor health outcomes. Loneliness may also form an independent pathway between socio-economic disadvantage and poor health. Therefore, the aim of this study was to explore the contribution of loneliness to socio-economic health inequalities. These contributions were studied in a Dutch national sample (n = 445,748 adults (≥19 y.o.)) in Poisson and logistic regression models, controlling for age, gender, marital status, migration background, BMI, alcohol consumption, smoking, and physical activity. Loneliness explained 21% of socioeconomic health inequalities between the lowest and highest socio-economic groups in self-reported chronic disease prevalence, 27% in poorer self-rated health, and 51% in psychological distress. Subgroup analyses revealed that for young adults, loneliness had a larger contribution to socioeconomic gaps in self-rated health (37%) than in 80+-year-olds (16%). Our findings suggest that loneliness may be a social determinant of health, contributing to the socioeconomic health gap independently of well-documented factors such as lifestyles and demographics, in particular for young adults. Public health policies targeting socioeconomic health inequalities could benefit from integrating loneliness into their policies, especially for young adults.

Does Loneliness Have a Cost? A Population-Wide Study of the Association Between Loneliness and Healthcare Expenditure.

Objectives: Loneliness has been associated with unhealthy behavior, poorer health, and increased morbidity. However, the costs of loneliness are poorly understood. Methods: Multiple sources were combined into a dataset containing a nationally representative sample (n = 341,376) of Dutch adults (18+). The association between loneliness and total, general practitioner (GP), specialized, pharmaceutical, and mental healthcare expenditure was tested using Poisson and Zero-inflated negative binomial models, controlling for numerous potential confounders (i.e., demographic, socioeconomic, lifestyle-related factors, self-perceived health, and psychological distress), for four age groups. Results: Controlling for demographic, socioeconomic, and lifestyle-related factors, loneliness was indirectly (via poorer health) associated with higher expenditure in all categories. In fully adjusted models, it showed a direct association with higher expenditure for GP and mental healthcare (0.5 and 11.1%, respectively). The association with mental healthcare expenditure was stronger in younger than in older adults (for ages 19-40, the contribution of loneliness represented 61.8% of the overall association). Conclusion: Loneliness contributes to health expenditure both directly and indirectly, particularly in younger age groups. This implies a strong financial imperative to address this issue.