Health Policy

Focus on designing health care structures and services for rare diseases

Carsten Schultz, Jonas Schreyögg, Tom Stargardt, Reinhard Busse — 2012-04-02

From a service research perspective, health care services heavily depend on the co-producer role of patients, on a strong collaboration of different professions and on the specific characteristics of the health care professional–patient service encounter. This leads to a dominance of individual solutions rather than standardized population-based care concepts such as disease management programmes. At the same time, health care services are highly emotional, risky, conducted under extreme stress, and patients – and sometimes also health care professionals – lack behavioural control. These aspects become even more important in the context of rare diseases where patients frequently carry expert knowledge, multi-professional treatment and care is essential, and particular challenges may arise from the fast progression of medical problems and lacking clinical guidelines.

A framework to evaluate the effects of small area variations in healthcare infrastructure on diagnostics and patient outcomes of rare diseases based on administrative data

Tom Stargardt, Jonas Schreyögg — 2012-02-20

Abstract: Introduction: Small area variations in healthcare infrastructure may result in differences in early detection and outcomes for patients with rare diseases.Methods: It is our aim to provide a framework for evaluating small area variations in healthcare infrastructure on the diagnostics and health outcomes of rare diseases. We focus on administrative data as it allows (a) for relatively large sample sizes even though the prevalence of rare diseases is very low, and (b) makes it possible to link information on healthcare infrastructure to morbidity, mortality, and utilization.Results: For identifying patients with a rare disease in a database, a combination of different classification systems has to be used due to usually multiple diseases sharing one ICD code. Outcomes should be chosen that are (a) appropriate for the disease, (b) identifiable and reliably coded in the administrative database, and (c) observable during the limited time period of the follow-up. Risk adjustment using summary scores of disease-specific or comprehensive risk adjustment instruments might be preferable over empirical weights because of the lower number of variables needed.Conclusion: The proposed framework will help to identify differences in time to diagnosis and treatment outcomes across areas in the context of rare diseases.

The influence of regional health care structures on delay in diagnosis of rare diseases: The case of Marfan Syndrome

Kathrin Roll — 2012-03-16

Abstract: Introduction: This study investigates the relative influence of the regional availability of health care resources (measured by physician densities, number of health care centers) on health care quality (measured by delay in diagnosis), based on data for the rare disease Marfan Syndrome.Methods: Administrative data from 389 patients with Marfan Syndrome were analyzed. Logistic regression models were applied for a dichotomous comparison of the dependent variable ‘time to diagnosis’ with the classifications ‘immediate’ and ‘late’ diagnosis. Physician densities of cardiologists/angiologists, ophthalmologists, orthopedists, and GPs, as well as distance to medical health care centers and sociodemographic information were entered into the models.Results: The results showed that the relationship between physician densities and probability of immediate diagnosis of Marfan Syndrome is negative linear, and quadratic for cardiologists/angiologists. This effect was significant with respect to density of cardiologists/angiologists (p=0.0097). Distance to medical health care centers was not a predictor of an immediate diagnosis.Conclusion: Marfan Syndrome faces significant problems of quality of health care, as although the requisite quantity of health care resources is available, this does not affect delay in diagnosis. Information technology might foster valuable networking among physicians treating such cases along with holistic assessment of symptoms as they occur.

Does healthcare infrastructure have an impact on delay in diagnosis and survival?

Carl Rudolf Blankart — 2012-02-01

Abstract: Introduction: The objectives of this study were to evaluate whether healthcare infrastructure impacts delay in diagnosis, and to determine whether healthcare infrastructure and delay in diagnosis impacts survival in gastric cancer.Methods: Administrative data from 2175 gastric cancer patients was analyzed using two Cox proportional hazard models with (i) delay in diagnosis and (ii) survival as dependent variables. Density of general practitioners, density of gastroenterologists, characteristics of specialty treatment centers, demographic information, and comorbidities were included in the models. Differentiation was made between urban and rural areas.Results: The likelihood of being diagnosed increased with an increase in general practitioners (p<0.0001) and gastroenterologists (p<0.0001) in rural areas. In urban areas a higher density of general practitioners reduced delay in diagnosis (p=0.0262), while a higher density of gastroenterologists did not (p=0.2480). The number of gastric cancer cases performed in hospital had a positive impact on survival (p<0.0001), while outpatient infrastructure did not.Conclusion: Delay in diagnosis can be reduced by higher availability of general practitioners and gastroenterologists in rural areas. Given the already very high density of physicians in urban areas there is no effect of additional gastroenterologists. As learning effects can be observed with increased hospital volumes, minimum volumes for treatment of gastric cancer may be defined.

Research performance of centers of expertise for rare diseases—The influence of network integration, internal resource access and operational experience

Henrike Hannemann-Weber, Maura Kessel, Carsten Schultz — 2012-03-09

Abstract: Objectives: Centers of expertise (CoE) are vital to the care and treatment of patients with rare diseases and play a central role in generating medical and scientific knowledge. This study explores the relationship between a CoEs internal resource availability, operational experience and functional network integration and its research performance.Method: Hypotheses were tested based on a sample of 64 CoEs in Europe and North America that specialize in 6 rare diseases. We collected questionnaire data related to strategic and structural antecedents and subsequently examined bibliometric data in the ISI Web of Science database to determine (1) research output by publication counts and (2) research impact by the number of citations.Results: A CoEs research performance is greatly determined by available experiences and internal resources as well as by the nature of networks. While research output increases with the number of treated patients, the amount of resources and access to R&D networks, the impact of the identified publications is not related to a CoEs availability of internal resources or to the size of its R&D network. Nevertheless, a CoEs focus on care-oriented networks increases its research impact.Conclusion: Under the guidance of different national efforts, this study aims to support a nationwide establishment of specialized CoEs for rare diseases. It emphasizes the relevance of CoEs for the generation of medical knowledge for rare diseases as well as their need for essential support through internal and external resources. The findings further show the necessity for CoEs not only to concentrate on R&D collaborations to generate completely new knowledge and opportunities but also to establish networks with operational care partners such as general practitioners, local therapists, rehabilitation centers or other hospitals.

Innovative work behavior in healthcare: The benefit of operational guidelines in the treatment of rare diseases

Maura Kessel, Henrike Hannemann-Weber, Jan Kratzer — 2012-03-14

Abstract: Objectives: Innovative work behavior is a core demand of healthcare professionals who treat patients with rare diseases. In healthcare services, determinants of innovative work behavior are not completely detected. This paper focuses on how the existence of guidelines and the flexibility of healthcare professionals in taking on extra roles in the workplace enable innovative work behavior.Method: We used survey data from 160 healthcare professionals working in Germany in the field of rare diseases, including physicians, caregivers, and therapists. A mediation model was statistically tested using linear multiple regression analysis.Results: The existence of guidelines for operational processes contributes to innovative work behavior by integrating the stages of knowledge acquisition, idea generation, and solution implementation. Individuals’ flexibility in their role ownership mediates this relationship. In addition, we found evidence that physicians are more active in acquiring knowledge, whereas nurses or therapists show more initiative in generating new ideas.Conclusion: Engaging in different roles enables healthcare professionals to demonstrate initiative for innovative work behavior aside from the completion of their daily tasks. The assumption of new roles may be encouraged by the creation of overall guidelines that raise awareness for the workers’ need to take on extra tasks and innovative behavior.

How do patients with rare diseases experience the medical encounter? Exploring role behavior and its impact on patient–physician interaction

Karolina Budych, Thomas M. Helms, Carsten Schultz — 2012-03-30

Abstract: Objectives: Empirical research shows that patients with severe illnesses prefer the physician to dominate decision processes and provide the information needed. However, in rare diseases, due to the low prevalence and the lack of expertise, the patient is forced to become knowledgeable about his own disease state. Objectives of this study were to describe the experiences of patient–physician interaction in rare diseases, to develop an empirically derived typology of interaction patterns and to explore the antecedents of these interaction patterns, with a special focus on role behavior. Building on these results, implications for health care policy are made.Methods: We designed an exploratory study as a series of semi-standardized interviews with patients suffering from rare diseases. We extracted the following six rare diseases: amyotrophic lateral sclerosis, Duchenne muscular dystrophy, epidermolysis bullosa, Marfan syndrome, neurodegeneration with brain iron accumulation and Wilson's disease. A total of 107 interviews were recorded, transcribed and analyzed thematically in accordance with the grounded theory tradition.Results: As suggested, insufficient expertise of the healthcare providers proved to be a major problem in the highly specialized treatment process of rare diseases. Here, the patient often becomes an expert in his disease. Therefore, we identified the patient-directed interaction as a widely experienced communication pattern among patients with rare diseases. Our study also showed that role discrepancies have a major impact on communication processes in this context.Conclusions: People with rare diseases often face challenges, due to the low prevalence and the resulting lack of knowledge of their healthcare providers. Communication processes in this context are mainly affected by the role behavior of both the patient and provider. The present study showed the relevance of the provider's ability to acknowledge the active role of the patient as an informed, involved and interactive partner in the treatment process. However, allowing the patient to control therapy may require a change of mind-set with some long-standing traditional roles in healthcare.

Open innovation in health care: Analysis of an open health platform

2012-03-22

Abstract: Today, integration of the public in research and development in health care is seen as essential for the advancement of innovation. This is a paradigmatic shift away from the traditional assumption that solely health care professionals are able to devise, develop, and disseminate novel concepts and solutions in health care. The present study builds on research in the field of open innovation to investigate the adoption of an open health platform by patients, care givers, physicians, family members, and the interested public. Results suggest that open innovation practices in health care lead to interesting innovation outcomes and are well accepted by participants. During the first three months, 803 participants of the open health platform submitted challenges and solutions and intensively communicated by exchanging 1454 personal messages and 366 comments. Analysis of communication content shows that empathic support and exchange of information are important elements of communication on the platform. The study presents first evidence for the suitability of open innovation practices to integrate the general public in health care research in order to foster both innovation outcomes and empathic support.

Provision and financing of assistive technology devices in Germany: A bureaucratic odyssey? The case of amyotrophic lateral sclerosis and Duchenne muscular dystrophy

Cornelia Henschke — 2012-02-21

Abstract: Objective: The regulations for financing assistive technology devices (ATDs) are complex and fragmented and, thus, might influence adequate provision of these devices to people who need multiple ATDs. This study aims to explore and analyze patients’ problems with the provision and financing of ATDs for the following two rare diseases: amyotrophic lateral sclerosis (ALS) and Duchenne muscular dystrophy (DMD).Methods: A survey was conducted by means of semi-standardized questionnaires addressing the issues of coverage decisions for ATDs and problems with provision of ATDs. Information was retrieved from ALS (n=19) and DMD (n=14) patients. Conducted interviews were transcribed verbatim and analyzed using qualitative content analysis.Results: Respondents experienced difficulties with the provision and financing of ATDs. They underlined problems such as long approval processes and a serious bureaucratic burden, which induced inadequate provision of ATDs. Experiences of ALS and DMD respondents frequently were similar, especially regarding financing decisions and the process of decision making by sickness funds.Conclusion: The results suggest that difficulties in receiving and financing ATDs are common problems among ALS and DMD patients. There is a need for an interdisciplinary approach in the provision of ATDs and their financing, which should be coordinated by case managers.

Health workers at the core of the health system: Framework and research issues

Sudhir Anand, Till Bärnighausen — 2011-12-12

Abstract: This paper presents a framework for the health system with health workers at the core. We review existing health-system frameworks and the role they assign to health workers. Earlier frameworks either do not include health workers as a central feature of system functioning or treat them as one among several components of equal importance. As every function of the health system is either undertaken by or mediated through the health worker, we place the health worker at the center of the health system.Our framework is useful for structuring research on the health workforce and for identifying health-worker research issues. We describe six research issues on the health workforce: metrics to measure the capacity of a health system to deliver healthcare; the contribution of public- vs. private-sector health workers in meeting healthcare needs and demands; the appropriate size, composition and distribution of the health workforce; approaches to achieving health-worker requirements; the adoption and adaption of treatments by health workers; and the training of health workers for horizontally vs. vertically structured health systems.

Eliminating the shortage of registered nurses in Canada: An exercise in applied needs-based planning

2011-12-16

Abstract: Objective: To demonstrate the application of a needs-based framework for health human resources (HHR) planning to illustrate the potential effects of policies on the shortage of Registered Nurses (RNs) in Canada.Methods: A simulation model was developed to simultaneously estimate the supply of and requirements for RNs based on data on the health needs of Canadians with current service delivery patterns and levels of productivity as a baseline scenario. The potential individual and cumulative effects of various policy scenarios on the ‘gap’ between these were simulated.Results: A baseline scenario estimated a shortage of about 11,000 RN FTEs in 2007 for Canada, increasing to over 60,000 by 2022. However, multifaceted approaches have the potential to eliminate the estimated shortage.Conclusions: Estimating the requirements for health human resources must explicitly consider population health needs, levels of service delivery and HHR productivity while changing supply to meet requirements involves consideration of a broad range of comprehensive interventions. Investments in improved data collection and planning tools are needed to support more effective HHR planning. The estimated Canadian shortage of RNs based on current circumstances can be resolved in the short to medium tern through modest improvements in RN retention, activity and productivity.

Turnover of registered nurses in Israel: Characteristics and predictors

2012-04-03

Abstract: Background: In an era of global and local nursing shortages, nursing turnover has negative consequences in terms of diminished quality of care, increased costs and economic losses and decreased job satisfaction.Objective: To examine the turnover rate of registered nurses in Israel by assessing the varying degree of turnover between economic sectors, between hospital and community facilities, and/or between types of hospitals; and by examining potential predicting factors of turnover among registered nurses.Methods: A national phone survey was undertaken in Israel consisting of a random sampling of registered nurses of working age (up to age 60). The subjects comprised 10% of a national database of 32,000 registered nurses.Results: The turnover rate among working nurses in Israel currently stands at 23%. In addition, 13% of employed nurses have taken a temporary leave of absence for a period greater than 6 months in the past 10 years, most up to 1 year. While job satisfaction rates were relatively high (72%), Professional satisfaction rates were 60% with no significant difference between hospital and community nurses. The turnover rate of registered nurses from a hospital setting to the community was significantly higher (p<.01) than that of community registered nurses to hospitals. Predicting factors of turnover were found to be: young age, part-time work, lack of advanced professional education, academic education and low satisfaction with the nursing profession.Conclusions: The shift of nursing workforce is mainly from hospitals to community health settings. There is a need to monitor and understand the characteristics of job and professional satisfaction among hospital nurses in order to implement crucial organizational interventions and retain hospital nursing staffs. Since young nurses, nurses working part time and nurses with no advanced professional and academic education, tend to move more than others, efforts should be targeted at these specific groups.

The working status of Japanese female physicians by area of practice: Cohort analysis of taking leave, returning to work, and changing specialties from 1984 to 2004

2011-09-12

Abstract: Background: The percentage of females in the physician workforce is increasing in Japan, as in other countries; however, the working status of female physicians has not been sufficiently investigated.Methods: Original data were obtained from the National Survey of Physicians (NSP) conducted by the Ministry of Health, Labour and Welfare, Japan, from 1984 to 2004. We examined the trend of female physicians’ areas of practice and analyzed their leave, return to work, and change in areas of practice using cohort data.Results: The percentage of female physicians has increased significantly in recent generations, especially in surgery, surgical subareas of practice, and obstetrics and gynecology. A remarkable increase was found in obstetrics and gynecology among women under 29 years old from 15.4 to 66.2%. The total number of female physicians on leave has been higher than the number of female physicians returning since 1998. The average percentage of those who changed their area of practice was high in surgery (20.7%) and low in pediatrics (5.0%) and obstetrics and gynecology (1.7%).Conclusions: A strategic plan is needed for future health policy to plan for the physician workforce, especially for the areas of practice with increasing proportions of young female physicians.

International comparison of assessments of pharmaceutical innovation

Joel Lexchin — 2012-03-09

Abstract: Introduction: This study was undertaken to compare decisions about medicines innovation made by two Canadian organizations, the Therapeutic Products Directorate (TPD) and the Human Drug Advisory Panel (HDAP), with those made by similar organizations in other countries.Methods: Assessments by TPD and HDAP were compared to those made by the Food and Drug Administration (FDA) and the drug bulletin Prescrire International, respectively.Results: Between 2004 and 2009 the TPD gave priority reviews to 46 of 137 (34%) products compared to 71 of 145 drugs (49%) by the FDA (p=0.011). Of 109 drugs in common the two agreed on the review status in 88 (weighted Kappa=0.606). In the same time period HDAP categorized 12 of 120 (10%) drugs as innovative while Prescrire did the same for 49 of 624 (8%) new drugs and new indications for older drugs (p=0.4664). Of 84 drugs in common the two agreed on the evaluation for 70 (weighted Kappa=0.319).Discussion: Differences between the different organizations may be due to a variety of factors. These differences have significant policy implications.

Stakeholder involvement in expensive drug recommendation decisions: An international perspective

2012-01-09

Abstract: Objectives: To describe stakeholder involvement in the priority setting and appeals processes across five drug reimbursement recommendation committees.Methods: We conducted qualitative case studies of how five independent drug advisory committees from Canada, Israel, England and Wales, Australia, and the USA made funding decisions for six expensive drugs. Interviews with 48 informants were conducted with committee members, patient groups, and industry representatives.Results: Different stakeholders were allowed, in varying degrees, to participate in the formal mechanisms for revisions and appeals of decisions. Participants identified a number of stakeholder groups who were already involved in the process, as well as stakeholders whom they believed should be included in the decision-making process.Conclusions: A central component of a legitimate and fair priority setting process is to make priority setting explicit and to involve both pertinent values and stakeholders in decision-making. Study participants believed that the involvement of multiple stakeholder groups within the deliberative and appeals/revisions processes would contribute to a fair and legitimate drug reimbursement process.

Stakeholders involvement by HTA Organisations: Why is so different?

Marianna Cavazza, Claudio Jommi — 2012-02-27

Abstract: Objective: To investigate stakeholder involvement by Health Technology Assessment Organisations (HTAOs) in France, Spain, England and Wales, Germany, Sweden, and The Netherlands and to examine whether this involvement depends on (i) the administrative tradition and the relevant conception of the relationship between state and society (contractarian and corporative vs. organic), (ii) the general structure of the healthcare system (HCS) (Bismarckian vs. Beveridgian system), and (iii) the role of Health Technology Assessment (HTA) and HTAOs in the HCS.Methods: Given the exploratory nature of the study, we considered interviews based on semi-structured questionnaires the most appropriate data-gathering technique. The interviews were administered to 16 key personnel in the HTAOs concerned. We have also carried out a literature review on HTAOs and stakeholders (1999–2011) using PubMed, Ebsco, JSTOR and Wiley Science.Results: In contractarian and (to a lesser extent) Bismarckian models, stakeholders are more involved. The administrative tradition and the HCS appear less important when the HTA is binding and used for regulatory purposes. In such situations, stakeholders are more intensively involved because their participation provides an opportunity for HTAOs to achieve consensus and legitimacy in advance.Conclusions: Despite the limitations of the research (we did not conduct multiple interviews for each HTAO, and key informants were not always available) and its exploratory nature, we can conclude that models of stakeholders involvement cannot easily be transferred from one country to another due to the importance of national administrative traditions and the characteristics of HCSs.

Is pharmaceutical policy evidence-informed? A case of the deregulation process of nicotine replacement therapy products in Finland

Terhi Kurko, Antti Silvast, Hannes Wahlroos, Kirsi Pietilä, Marja Airaksinen — 2012-03-15

Abstract: Objective: This qualitative study aims to identify the key dimensions of the political argumentation in the debate leading up to the deregulation of nicotine replacement therapy products (NRT) in Finland in 2006. The deregulation was introduced by the Amendment of larger package of changes in medical legislation prepared in 2005.Methods: All publicly available documents of the legislative process introducing NRT deregulation and interviews of 12 Members of Finnish Parliament conducted in spring 2006 were analyzed by inductive content analysis.Results: NRT deregulation was introduced to decision-makers as a safe intervention to increase smoking cessation and thus provide public health benefits. However, a whole variety of other features were brought into debate: NRT characteristics, principle change in prevailing medical legislation, use of evidence and the political process. Finally, the expected public health benefits of the decision were not directly informed by any evidence.Conclusions: This study provides an example of the use of public health benefits as justification for decision-making. However, the decision can include other aspects, less brought up in its preparation stage. Our study addresses the need for policymakers to critically evaluate the evidence, its suitability in decision-making context and raise awareness of the principles of evidence-informed policy-making.

Financial burden of drug expenditures in Poland

Julita Łuczak, Pilar García-Gómez — 2012-02-06

Abstract: Objectives: This paper investigates the level of catastrophic out-of-pocket pharmaceutical (OOP) expenditures and their impoverishment effect in Poland.Methods: We use data from a representative sample of Polish households covering 2000, 2003, 2005, 2007 and 2009. We estimate the incidence and intensity of catastrophic drug expenditure and its impoverishment effects using the methods introduced by Wagstaff and van Doorslaer. We obtain estimates for the full population and for the subsample of retired and chronically ill.Results: The incidence and intensity of catastrophic drug expenditures increased over the years and they are concentrated among the poor. The proportion of households that spent at least 10% of their income on pharmaceuticals reached 18% in 2009. This figure is higher than the evidence found in other countries for total health expenditure. Pharmaceutical expenditures increased poverty rates, and the evidence suggests that the poverty impact of OOP expenditures in the last decade was mainly driven by poor people becoming poorer. The effects are more conspicuous among the retired and chronically ill.Conclusions: Our findings indicate that OOP pharmaceutical expenditures in Poland are a severe financial burden and that policies aimed at both lowering the price of effective drugs and decreasing consumption of the ineffective ones are needed.

Mergers and acquisitions in Western European health care: Exploring the role of financial services organizations

Federica Angeli, Hans Maarse — 2012-03-23

Abstract: Recent policy developments in Western European health care – for example in the Netherlands – aim to enhance efficiency and curb public expenditures by strengthening the role of private sector. Mergers and acquisitions (M&As) play an important role in this respect. This article presents an analysis of 1606 acquisition deals targeting health care provider organizations in Western Europe between 1990 and 2009. We particularly investigate the role of financial services organisations as acquirers. Our analysis highlights (a) a rise of M&As in Western Europe since 2000, (b) an increase of M&As with financial service organisations acting as acquirer in absolute terms, and (c) a dominant role of the latter type of M&As in cross-border deals. To explain these developments, we make a distinction between an integration and a diversification rationale for M&As and we argue that the deals with financial services organisations in the role of acquirer are driven by a diversification rationale. We then provide arguments why health care, from the acquirer's perspective, can be considered as an interesting target in a diversification strategy and we advance reasons why health care providers may welcome this development.Although caution in drawing conclusions is needed, our findings suggest a penetration of private capital into health care provision that may be interpreted as a specific form of privatisation. Furthermore, they point to a rising internationalisation of health care. Both findings may entail far-reaching implications for health care, as they may induce both cultural privatisation and cultural internationalisation.

Dynamic analysis of interhospital collaboration and competition: Empirical evidence from an Italian regional health system

Daniele Mascia, Fausto Di Vincenzo, Americo Cicchetti — 2012-03-14

Abstract: Background: Policymakers stimulate competition in universalistic health-care systems while encouraging the formation of service provision networks among hospital organizations. This article addresses a gap in the extant literature by empirically analyzing simultaneous collaboration and competition between hospitals within the Italian National Health Service, where important procompetition reforms have been implemented.Purpose: To explore how rising competition between hospitals relates to their propensity to collaborate with other local providers.Methods: Longitudinal data on interhospital collaboration and competition collected in an Italian region from 2003 to 2007 are analyzed. Social network analysis techniques are applied to study the structure and dynamics of interhospital collaboration. Negative binomial regressions are employed to explore how interhospital competition relates to the collaborative network over time.Results: Competition among providers does not hinder interhospital collaboration. Collaboration is primarily local, with resource complementarity and differentials in the volume of activity and hospital performance explaining the propensity to collaborate.Conclusions: Formation of collaborative networks among hospitals is not hampered by reforms aimed at fostering market forces. Because procompetition reforms elicit peculiar forms of managed competition in universalistic health systems, studies are needed to clarify whether the positive association between interhospital competition and collaboration can be generalized to other health-care settings.

A new approach to the tradeoff between quality and accessibility of health care

Marit A.C. Tanke, David E. Ikkersheim — 2012-03-23

Abstract: Introduction: Quality of care is associated with patient volume. Regionalization of care is therefore one of the approaches that is suited to improve quality of care. A disadvantage of regionalization is that the accessibility of the facilities can decrease. By investigating the tradeoff between quality and accessibility it is possible to determine the optimal amount of treatment locations in a health care system. In this article we present a new model to quantitatively ‘solve’ this tradeoff. We use the condition breast cancer in the Netherlands as an example.Materials and methods: We calculated the expected quality gains in Quality Adjusted Lifetime Years (QALY's) due to stepwise regionalization using ‘volume–outcome’ literature for breast cancer. Decreased accessibility was operationalized as increased (travel) costs due to regionalization by using demographic data, drive-time information, and the national median income. The total sum of the quality and accessibility function determines the optimum range of treatment locations for this particular condition, given the ‘volume–quality’ relationship and Dutch demographics and geography.Results: Currently, 94 locations offer breast cancer treatment in the Netherlands. Our model estimates that the optimum range of treatment locations for this particular condition in the Netherlands varies from 15 locations to 44 locations.Conclusion: Our study shows that the Dutch society would benefit from regionalization of breast cancer care as possible quality gains outweigh heightened travel costs. In addition, this model can be used for other medical conditions and in other countries.

Challenging Health in All Policies, an action research study in Dutch municipalities

Mieke Steenbakkers, Maria Jansen, Hans Maarse, Nanne de Vries — 2012-03-14

Abstract: The Dutch government encourages municipalities to develop ‘Health in All Policies’ (HiAP). The development of such a policy requires inter-sectoral collaboration, however municipalities show little initiative in this regard. Operating in an advisory role, the regional Public Health Service (PHS) has supported municipalities in South-Limburg in setting up inter-sectoral collaboration. A coaching program for municipal stakeholders was developed and implemented to improve HiAP, using obesity as an example.To determine the effectiveness of this coaching program, civil servants, managers and municipal councilors were invited to fill in an Internet questionnaire prior to and at the completion of the program. By means of a log-book all activities were registered in coached municipalities and in-depth interviews were held with municipal managers. Outcomes were scored depending on the stage of HiAP proposals.Six of the nine coached municipalities showed concrete outcomes in terms of HiAP proposals. The results show that more support and involvement at each system level stimulates the development of HiAP. The program contributed positively to the implementation of HiAP interventions targeting obesity. The pretest results for coached municipalities were better compared to non-coached municipalities. However, after 30 months of coaching this positive starting position faded away. We recommend that the municipal management become more involved in the development of HiAP and advise the PHS to increasingly demonstrate their expertise. Here lies a challenge for municipalities and their regional PHS.

Empathy and the application of the ‘unbearable suffering’ criterion in Dutch euthanasia practice

Donald G. van Tol, Judith A.C. Rietjens, Agnes van der Heide — 2012-03-14

Abstract: A pivotal due care criterion for lawful euthanasia in the Netherlands is that doctors must be convinced that a patient requesting for euthanasia, suffers unbearably. Our study aims to find out how doctors judge if a patient suffers unbearably. How do doctors bridge the gap from 3rd person assessment to 1st person experience? We performed a qualitative interview study among 15 physicians, mainly general practitioners, who participated earlier in a related quantitative survey on the way doctors apply the suffering criterion. Results show that doctors follow different ‘cognitive routes’ when assessing a patients suffering in the context of a euthanasia request. Sometimes doctors do this imagining how she herself would experience the situation of the patient (‘imagine self’). Doctors may also try to adopt the perspective of the patient and imagine what the situation is like for this particular patient (‘imagine other’). Besides this we found that the (outcome of the) assessment is influenced by a doctor's private norms, values and emotions considering (the performance of) euthanasia. We conclude by arguing why doctors should be aware of both the ‘cognitive route’ followed as well as the influence of their own personal norms on the assessment of suffering in the context of euthanasia requests.

Japan's policy of promoting end-of-life care in nursing homes: Impact on facility and resident characteristics associated with the site of death

Naoki Ikegami, Sumie Ikezaki — 2012-02-13

Abstract: Objective: To evaluate the impact of the policy to encourage nursing homes to provide end-of-life care by comparing facility and resident variables associated with dying within the nursing home and not in hospitals, and by comparing life sustaining treatment (LST) respectively provided.Method: Questionnaires mailed to an 11% random sample of 653 nursing homes in 2009. Facility characteristics from 371 nursing homes (57%) and resident characteristics of the 1158 who had been discharged due to death were obtained from 241 facilities (37%).Results: Facility characteristics related to dying in nursing homes were their policy of providing end-of-life care and physicians being based in home care supporting clinics. Resident characteristics related were not having pneumonia as the cause of death, the family's preference of the nursing home as the site of death and agreement within the family. Preferences on the use of LST were adhered more in residents who had died in nursing homes.Conclusion: Although the percentage of residents dying within the facility has increased, the nursing home as a site of death still composes only 3.2% of the total. To increase the latter, nursing homes should refocus their function to providing end-of-life care to those not preferring aggressive treatment.

Measuring concerns for severity: Re-examination of a health scale with purported equal interval properties

Erik Nord — 2012-03-26

Abstract: Severity of illness is an important official criterion for priority setting in health care in a number of jurisdictions. An 8-point scale of severity and functional status has been used in a number of studies in Norway in order to estimate the strength of concerns for severity in population samples. The scale has attracted international attention and may be of interest to researchers in other countries. For confidence in interpretations of results, the scale should have equal interval properties with respect to individual utility. Close examination suggest that some deviations from equal intervals occur. These deviations do not impact significantly on earlier findings and do not prevent the scale from being a potentially useful tool in future studies of the strength of societal concerns for fairness in health care. However, further research with larger and more representative samples is encouraged.

Re: “Adverse event rates as measures of hospital performance”—Conflation and confusion with the use of the complications code

Dev Kevat, Peter Cameron — 2012-03-23

We read with interest and concern the article by Hauck et al. “Adverse event rates as measures of hospital performance.” . We believe the work has significant methodological shortcomings that render the conclusions dubious.

Adverse event rates as measures of hospital performance—A chance for organizational learning: In reply to “‘Adverse event rates as measures of hospital performance’—Conflation and confusion with the use of the complications code”

Katharina Hauck, Terri Jackson, Xueyan Zhao — 2012-03-22

Dev Kevat and Peter Cameron raise concerns about ‘methodological shortcomings’ of our recent paper that we are pleased to have an opportunity to address here. Their argument is that many complications arising while patients are hospitalised are ‘inevitable’ because they are caused by the underlying clinical condition of the patients. Therefore, they argue, hospital management has little control over the occurrence of complications, which makes them poor measures of hospital quality. We disagree for a number of reasons, and we further argue that consistent routine monitoring of in-hospital complications is one of the most important tools for improving patient safety and quality of care.

2012-05-01