https://thesis.eur.nl/col/3897/ List of Publications en https://thesis.eur.nl/pub/4374/ Mon, 01 Jan 2007 00:00:01 GMT <div>Wolbers, D.</div> Master Thesis HEPLABSTRACT Only 3-5% of the Indians are insured under some kind of health insurance. A mechanism that is developed in order to bring the poor in a community health insurance scheme is CHAT (Choosing Healthplans All Togethers). In a CHAT experiment each participant has to select a health insurance package individually and as a group with a budget of Rs. 600 (±US$13). Till now two CHAT experiments have been conducted in India. This research is based on the second CHAT experiment, which was conducted in Maharastra, Karnataka and Rajasthan. The objective of this research is to see whether the decisions made could be explained and predicted. Therefore two analyses have been conducted. First, the individual choice has been analyzed. The results show that the choice for the three major benefits is highly influenced by the state the individual lives in. A probable explanation for this is that the health care services differ between the three states. The choice for the minor benefits is highly influenced by the selection of the major benefits. This result leads to the conclusion that the choice for the minor benefits highly depends on the remaining budget. Therefore three suggestion have been proposed in order to adjust the CHAT experiment in such a manner that this effect could be narrowed down. First, the participants could be asked to prioritize their selected benefits. Second, in the post-questionnaire of the CHAT experiment participants could be asked why a certain benefit has been selected and a third suggestion is that the budget of the participants and groups should not be fixed in advance, but instead the participants and groups are free to decide their own budget. The second analysis that has been conducted, was to see whether the background characteristics of the individuals correlate with a so-called matching-score (which shows the similarity between the individual and the group choice). Unfortunately the results show that only eight variables have a correlation coefficient that is statistically significant and the correlation is extremely weak (between -0.1 and 0.1). This leads to the conclusion that in fact non of the background characteristics could explain why some individuals have a higher matching-score than other individuals. Overall, the conclusion is that the choices could not be explained and predicted accurate. This is probably because the CHAT exercise is not suitable for this kind of analyses. The main goal of the CHAT exercise is to bring the poor into a community based health insurance scheme and not to predict and explain the choices made. https://thesis.eur.nl/pub/4364/ Mon, 01 Jan 2007 00:00:01 GMT <div>Filko, M.</div> Abstract This paper performs new and more robust tests of the QALY model when health varies over time. Our tests require no confounding assumptions and are robust to violations of expected utility. Our results support the use of QALYs at the aggregate level, i.e. in economic evaluations of health care. At the individual level, the support for QALYs is less convincing. The individual data are, however, largely consistent with a more general QALY-type model that remains tractable in applications. Keywords: QALY, QALYs, utility independence, economic evaluation of health care, decision under risk JEL classification: I10 https://thesis.eur.nl/pub/4362/ Mon, 01 Jan 2007 00:00:01 GMT <div>Buddingh', K.L.</div> Samenvatting Deze scriptie is geschreven voor het ministerie van Volksgezondheid, Welzijn en Sport, directie Publieke Gezondheid. De aanleiding is het besluitvormingsprobleem van preventie en public health. De hoofdvraag luidt: Wat zijn de besluitvormingscriteria in public health? De deelvragen zijn als volgt geformuleerd: Wat is een besluitvormingscriterium? Wat is het verschil tussen besluitvormingscriteria voor cure en voor preventie? Hoe kunnen besluitvormingscriteria geordend worden in de beleidscontext? Door middel van een kwalitatieve studie is antwoord gegeven op de genoemde vragen. Literatuuronderzoek en interviews waren onderdeel van de studie. Een besluitvormingscriterium kan gezien worden als een toetssteen. Het criterium moet gedefinieerd en geoperationaliseerd zijn. Er zijn 23 zeer diverse criteria benoemd. Een ander kenmerk van de criteria is dat ze onderling nauw samen hangen binnen het besluitvormingsproces. De besluitvorming kan over alle mogelijke interventies in de public health gaan. Het besluitvormingsperspectief is bepalend voor de interpretatie van het beleidsprobleem en de criteria. Dit wordt nader uitgewerkt. Een besluit op basis van een bepaald criterium herbergt een vaak impliciete keuze voor een verdelingsprincipe zoals het utilitarianisme, socialisme of het ‘fair innings’ concept. Alle criteria zijn van toepassing op cure en preventie, maar de operationalisatie en prioritering verschilt. Kosten-effectiviteitsanalyse wordt verschillend uitgevoerd bij cure en preventie. Ziektelast wordt bij preventie op bevolkingsniveau bekeken en bij cure op het identificeerbare individuele niveau. Politiek gezien ligt preventie heel anders dan cure, omdat het handelt over niet identificeerbare individuen en de lange termijn. Een nog uit te voeren case-analyse zou moeten aantonen welke criteria in het verleden doorslaggevend zijn geweest bij implementatie van curatieve of preventieve interventies en welke andere verschillen aan te geven zijn tussen besluitvorming voor cure en preventie. De in literatuur en interviews geïdentificeerde criteria zijn geordend op basis van wetenschappelijke achtergrond en de “hardheid” binnen besluitvorming. Politiek is onvoorspelbaar, incidentie en ziektelast zijn meetbaar en daardoor harde criteria. De lijst van 23 criteria is gecomprimeerd tot tien criteria, de 13 andere criteria zijn een verondersteld onderdeel van de tien hoofdcriteria. Het schema is opgebouwd uit een Assessment fase en drie Appraisal fases: Institutioneel Beleidskader, Maatschappelijk Beleidskader en Normatief Beleidskader. Een case-analyse, het HPV-vaccin, is beschreven aan de hand van het schema. De besluitvorming ten aanzien van het HPV vaccin is omschreven in termen van de beleidscyclus en elementen van beleid. Hierbij bleek dat er nog veel onzekerheden blijven bestaan over de onderzochte criteria. Bij besluitvorming moeten onzekerheden blijkbaar ingecalculeerd blijven worden. De Gezondheidsraad brengt een advies uit over opname van het HPV-vaccin in het RVP. Het schema geeft een goede leidraad om inzicht en overzicht te krijgen in de aspecten van besluitvorming en het besluitvormingsstadium. Hierdoor is het eenvoudiger om succes en faalfactoren te benoemen en besluiten te nemen waarbij de risico’s expliciet benoemd zijn. Dit kan de evaluatie en het effectief bijstellen van beleid sterk bevorderen. De veelheid van actoren bij een beleidsproces belemmert besluitvorming, maar een besluit uitstellen of een slecht compromis is geen goed alternatief. Het sociaal-constructivisme is aangedragen als mogelijke verklarende theorie voor de subjectieve preferenties die beleidsmakers en onderzoekers met zich meebrengen bij de uitvoer van hun werk. Het kwantificeren van verbanden tussen criteria kan de ontwikkeling van besluitvormingssystematiek ten goede komen. Een discrete choice analysis zou uitgevoerd kunnen worden om de subjectieve preferenties van beleidsmakers expliciet te maken. Dit kan aanleiding geven tot een representatieve hiërarchie van besluitvormingscriteria. Het is aanbevolen om de efficiëntie van preventie en cure te 6 vergelijken. Verbeterde toegankelijkheid van alle uitgevoerde kosten-effectiviteitsstudies zou nieuwe onderzoeksvoorstellen besluitvorming kunnen verbeteren. Een studie naar de kosten-effectiviteit van intersectoraal volksgezondheidsbeleid ligt als uitdaging te wachten. De onderliggende ethische verdelingsprincipes zouden nader uitgewerkt kunnen worden, opdat de gevolgen van keuzesystematiek inzichtelijker wordt gemaakt. Deze aanbevelingen kunnen bijdragen aan de nadere ontwikkeling van systematisch en consistent public health beleid. https://thesis.eur.nl/pub/4370/ Tue, 01 May 2007 00:00:01 GMT <div>Kortram, Z.</div> Abstract Objective: Various economic evaluations have been conducted on interventions aimed at decreasing obesity. These interventions are changing dietary patterns, behavioural modification, increasing physical activity, surgery or a programme including the previous mentioned interventions. Yet it is hard to assess what the actual quality is of these economic evaluations as most assessment tools are of a qualitative nature. In this thesis the quality of the economic evaluations on obesity is assessed in a quantitative manner. Methods: The economic evaluations (abstracts) on obesity are selected in the NHS Economics Evaluations Database and the quality of these studies is assessed by using the assessment tool of Chiou et al. (2003). This quality assessment tool consists of sixteen criteria which all have their own weight. If a study could fulfil a criterion which was set, the entire weight was appointed. If the criterion could be addressed partially, half of the weight was appointed. None of the weight was appointed if the study could not fulfil the criterion. The sum of the weight of the sixteen criteria reflects the quality of the economic evaluation. To test the association between the characteristics of the economic evaluations and the quality, univariate, bivariate and multivariate analyses were performed. The characteristics are the year of publication, the category of intervention, the type of study, the country in which the study was performed, the location in which the study was performed and the resource of funding. Results: In the NHS EED 34 economic evaluations on interventions aimed at decreasing obesity were selected. These studies were published from 1995 until 2006 and had a mean quality score of 51.9 with a range of 24.1 – 75.8 (SD 13.28). Most studies were not able to fulfil the criteria entirely, because valuable information necessary to draw a conclusion was missing, the choice of the economic model was not discussed, statistical or sensitivity analyses were not performed and the resource of funding was not mentioned. Multivariate analyses showed that the year of publication is positively associated with the quality of the publication, meaning that if time progresses with one year, the quality of the article increases with 1.5 points. The location in which the study was performed was also associated with the quality of the publications. European publications on obesity interventions had a higher quality score, of 14.46 points on average, than non-European countries and thus were of better quality. In the univariate analyses the type of study was associated with the quality of the economic evaluations. The resource of funding was not associated with the quality of the studies, but articles which were funded by pharmaceutical companies did have a higher score than the studies funded by health research organisations. The category of intervention did not have an influence on the quality of the study. Critical appraisal of economic evaluations Quantifying the quality of economic evaluations on obesity May 2007 Master Thesis HEPL Z. Kortram 272598 4 Statistical analyses show a correlation between certain items and the characteristics, but the associations are mostly due to a natural association with the characteristics. A separate item cannot determine the quality of the publication. Conclusion: The main conclusions which can be drawn are the following: • The quality of the economic evaluations on obesity increases as time progresses. • Studies which are based on previous publications have a higher quality than those which are based on a single study. • The location in which an evaluation is performed also affects the quality of the evaluation. • A single criterion of the assessment tool can yet not be used separately to determine the quality of the economic evaluation. The mean quality score of the articles shows that on average the economic evaluations on obesity interventions are not of high quality. But the use of the quality assessment tool can give more insight in the areas in which improvements can be made. The quality assessment tool can be useful before a research is conducted or an article is submitted, but afterwards the tool is also useful to assess the quality of the actual publication. This tool can also affect current policies and improve the way in which interventions aimed at decreasing obesity are implemented in the current interventions programmes. Discussion: There are several recommendations which can be made. More information is needed on the type of scale which is most useful when appointing the weight. It can also be relevant to know what information can be gathered when the assessment tool is used in other disease areas. Perhaps it would be useful to determine if the assessment tool can be adjusted to the disease or risk factor which is examined. https://thesis.eur.nl/pub/4478/ Tue, 01 May 2007 00:00:01 GMT <div>Kortram, Z</div> https://thesis.eur.nl/pub/4366/ Fri, 01 Jun 2007 00:00:01 GMT <div>Jonkman, A.</div> Summary The aim of this research was to investigate the difference in quality of health care between a GPs’ practice and an individual GP’s practice. The angle of research and the results are based on the patients’ judgments. From literature and statistics of de Dutch organization for GPs (NHG) it appears that a growing number of GPs start cooperating in order to reduce the work pressure and create opportunities to turn to a part time job. Unfortunately, little research has been conducted as to the influence of the cooperation on the quality of health care, whereas this quality as judged by the patients becomes more and more important for providers of care. Quality of care can be defined in several ways. The first is the classic definition which mainly deals with quality control. The second way is the corporate approach in which promotion of quality is most important. This research focuses on the latter one. The results of this research can be used by GPs who participated in the research to improve the quality of their care. The definition for quality of care in this research is the definition of Donabedian: “Quality of care is the level of agreement between criteria of good care (desired care) and the actual care provided.” To measure and compare the quality of care between the two different practices we used a survey. This survey consisted of seven parts from which was expected that they would affect the patients’ satisfaction. The parts were: social intercourse, working method, treatment, information, organization of the practice, the surgery and cooperation between GPs and their assistants. From this research it appears that the quality of care does not differ between the two types of practices investigated. Furthermore it can be concluded that the GPs’ practice might have a few more possibilities as far as certain facilities is concerned, for example employing more doctor’s assistants. This, however, is not always considered an advantage because the patients have to communicate with more and more people and this consequently increases the risk of making mistakes as a result of miscommunication. It is of the utmost importance for a GPs’ practice to optimise the cooperation within a practice. On top of that it should be made as simple and transparent as possible so as to reduce the possibility of making errors. When looking at the results one should bear in mind that this research was only conducted in two practices which makes it less reliable. Differences now ascribed to the kind of practice might also be caused by other factors such as the GP’s personality. It would be advisable to repeat this research in more practices so that a more balanced and trustworthy picture can be deduced concerning the influence of a practice on patients’ satisfaction.Samenvatting In dit onderzoek is bekeken in hoeverre de kwaliteit van zorg, vanuit patiëntenperspectief, verschilt tussen een groepspraktijk en een solopraktijk. Uit de literatuur en cijfers van het NHG blijkt namelijk dat steeds meer huisartsen gaan samenwerken om de werkdruk te verminderen en mogelijkheden te creëren om parttime te gaan werken. Er is echter weinig onderzoek gedaan naar de invloed van deze samenwerking op de kwaliteit van zorg. Terwijl de kwaliteit van zorg, zoals beoordeeld door patiënten steeds belangrijker wordt voor zorgverleners. Kwaliteit van zorg kan op verschillende manieren worden bekeken, als eerste is er de klassieke benadering die gaat over kwaliteitsbewaking. Daarnaast kan de bedrijfskundige benadering worden toegepast waarbij kwaliteitsbevordering centraal staat. Dit onderzoek was vooral gericht op de kwaliteitsbevordering. De resultaten van dit onderzoek kunnen door de huisarts(en)praktijken waarbij het onderzoek is uitgevoerd worden gebruikt om hun kwaliteit van zorg te verbeteren. Als definitie voor kwaliteit van zorg is in dit onderzoek de volgende definitie van Donabedian gebruikt: “Kwaliteit is de mate van overeenkomst tussen criteria van goede zorg (wenselijke zorg) en de praktijk van die zorg (feitelijke zorg)”. Om de kwaliteit van zorg in de huisarts(en)praktijken te meten en te vergelijken is gebruik gemaakt van een survey. Deze survey bestond uit zeven onderdelen waarvan verwacht werd dat zij invloed zouden hebben op de patiënttevredenheid. Deze onderdelen zijn: bejegening, werkwijze, behandeling, informatievoorziening, organisatie van de praktijk, de praktijkruimte en samenwerking tussen medewerkers van de huisarts(en)praktijk. Uit dit onderzoek blijkt dat de door patiënten ervaren kwaliteit van zorg in de onderzochte huisarts(en)praktijken niet van elkaar verschilt. Verder kan worden geconcludeerd dat de groepspraktijk misschien meer mogelijkheden heeft wat voorzieningen betreft, bijvoorbeeld meer inzet van praktijkverpleegkundigen. Maar dat dit door de patiënten niet altijd als positief wordt ervaren omdat zij daardoor met meer mensen te maken hebben en er een grotere kans op fouten bestaat door afstemmingsproblemen. Belangrijk voor een groepspraktijk is dus de samenwerking binnen de praktijk goed te organiseren en zo simpel en overzichtelijk mogelijk te maken zodat de kans op fouten wordt verkleind. Belangrijk is om bij deze conclusies in gedachten te houden dat het onderzoek slechts in twee praktijken is uitgevoerd en daardoor niet betrouwbaar is. Verschillen die nu worden toegeschreven aan de praktijkvorm kunnen ook door andere factoren, zoals de persoonlijkheid van een huisarts worden veroorzaakt. Aanbeveling is daarom dit onderzoek te herhalen in meer praktijken om zo een duidelijker beeld te krijgen over de invloed van praktijkvorm op de patiënttevredenheid in de huisarts(en)praktijk. https://thesis.eur.nl/pub/4365/ Mon, 04 Jun 2007 00:00:01 GMT <div>Hoefman, R.</div> Summary Health care services can enable persons with a physical disability to live independently. Research showed that not all persons with a need for these services, actually used them. Our study investigated whether persons may not apply for these services, because submitting an application is difficult for them. Whether the social network of physically disabled persons enables persons to submit an application has also been studied. The research questions used to study these subjects are: -‘To what degree is the application for health care services a bottleneck for physically disabled persons?’ and; -‘Does the social network exert influence on the application for health care services of physically disabled persons?’ These research questions have been studied with two data sets (Amenities and Services Utilization Survey 2003 and Amenities and Services Utilization Survey for the Physically Disabled 2004) of the Social and Cultural Planning Office of the Netherlands (Sociaal en Cultureel Planbureau). The last research question has been studied in two different ways, because of shortcomings in the secondary data. The first approach investigated whether physically disabled persons received support of their social network when submitting an application, if so, from whom and why. The second approach used the Andersen model (1995) to study the relation between the presence of a social network and the application for professional home care and housing adaptations. The use of professional home care has also been studied due to shortcomings in the secondary data. In addition, the second approach investigated which groups of variables of the Andersen model explained the variance in the utilization of professional home care and the application for housing adaptations most. Moreover, it has been investigated whether having problems with submitting an application is directly related to the actual use of and application for professional home care and housing adaptations. Both research questions have been examined with bivariate analysis and multivariate logistic analysis. Our results showed that submitting an application for health care services was a bottleneck for many physically disabled persons. Often, persons were not well informed on the application process, especially elderly persons and those with a low educational level did not search information. The majority of physically disabled persons, in particular middle aged persons, elderly, women, those with a low educational level and those with a low income, did not use the internet to search information. In addition, submitting an application could be a bottleneck, because many physically disabled people, especially those with a moderate disability, shied away from applying for health care services. Moreover, some had difficulties with or could not even perform administrative activities needed to submit an application. This particularly applied to those with a severe physical disability and those with a low educational level. The first approach showed that a social network positively exerted influence on the application for health care services, because many people with a physical disability received support of their social network when submitting an application. Receiving support was associated with severe physical disability, old age and a low educational level. Persons, in particular elderly and single persons, mainly received this support, because they did not know how or where to apply for health care services. Often, a child or parent lent support. This especially related to young adults, elderly, women, single persons, and those who have a ‘stronger’ social network. A partner also lent support, in particular to the ones who did not receive support of a child or parent. Not all physically disabled persons could rely on their social network for support. This especially applied to persons younger than 75 years and singles. Next, our results showed that not all persons who want to use professional home care or housing adaptations submitted an application for this. Persons who applied for professional home care in particular are those with a severe physical. Especially elderly and those who do not shy away from submitting an application applied for housing adaptations. Associated with the utilization of professional home care were severe physical disability, old age, gender, low income, not having a partner and not shying away from submitting an application. The second approach also showed that a social network positively exerted influence on the use of professional home care and the application for housing adaptations. More persons with a physical disability who often have contact with their family used professional home care. Moreover, more single persons who live near by their family applied for housing adaptations than others. In addition, our results indicated that predisposing characteristics and to a less degree enabling resources explained the use of professional home care and the application for housing adaptations 7 most, even more than need. Therefore, next research on the use of and application for health care services should include social network characteristics. To reduce the inequality in the utilization of professional home care and the application for housing adaptations, information on health care services and the application process should be actively distributed in different ways to both potential users of these services and to their social network. Further, local governments have to lend support to persons who cannot submit an application themselves and lack social support. Lastly, it is desirable to aim these policies at specific groups without many resources, such as persons with a low educational level or single persons. https://thesis.eur.nl/pub/4471/ Fri, 10 Aug 2007 00:00:01 GMT <div>Dukker, A.J.</div> https://thesis.eur.nl/pub/4363/ Fri, 10 Aug 2007 00:00:01 GMT <div>Dukker, A.J.</div> In this master thesis an analysis has been performed about the use of competitive bidding to purchase home-care in the Netherlands. Competitive bidding is being used by purchasers as allocation mechanism to select providers for contracting and with that making enough health services available for their insureds or citizens. The research question that has been answered, is the following: “Under which conditions is competitive bidding a useful purchasing method for home-care in the Netherlands?” The master thesis has been started by executing a study of literature to the general process of purchasing health services and distinguishes three different stages: selecting, contracting and financing. It has become clear that those three stages are related to each other in each purchasing process. When choosing competitive bidding as purchasing method to select providers for contracting, the purchaser should be aware of picking a way of financing that does correlate with the incentives the competitive environment brings along. For example, when competitive bidding is meant to increase competition and with that efficiency, it would not be correct to award contracts with duration of 10 years and pay providers by fee-for-service, which decreases competition and may lead to supplier induced demand, which may even cause an increase in total costs. After having described the general process of purchasing health services, a study of literature has been performed to the different types of competitive bidding and its use in other developed countries. The purpose of competitive bidding is most often to increase competition on the market to reduce costs or improve the level of quality of care. The stages of the purchasing method are the following: specification of the health service, selection of winning bidders, determination of reimbursement, monitoring and evaluation. All stages must be included to make competitive bidding a successful purchasing method and it should be used when the health services are suitable to being purchased by competitive bidding. The health services should therefore (i) not needed to be delivered with urgency; (ii) be possible to specify in detail, including goals, activities and expected outcome; (iii) not be highly specialised or top-clinical; (iiii) needed to be provided for only a short time. The study of literature also provided lessons from other countries that should be considered to become aware of the possible effects and consequences. For instance, the level of competition on the market must be high enough, because providers with an economic dominating position do not experience incentives to operate more efficient and reduce their production costs. Another lesson that can be learned is that when providers are not monitored adequately, they may experience an incentive of reducing their level of quality of care, while reducing their production costs. The study of literature was ended by creating a checklist 4 that has been used later on to score the Dutch home-care market and the use of competitive bidding by Dutch purchasers. The master thesis has been continued with an analysis of the current market for home-care in the Netherlands. Home-care is the umbrella term for all sorts of care that is provided to clients who live independently with some professional support. Two relevant purchasers in two different contexts are present for home-care in kind: municipalities purchasing housekeeping services financed by the Social support act (WMO) and regional care offices purchasing the rest of the types of home-care financed by the Exceptional Medical Expenses Act (AWBZ). It has become clear that the concentration on the market for home-care in kind is too high, meaning that the competition level among providers is low. The goal of purchasers is to increase competition and stimulate incumbents to reduce their production costs while maintaining or improving the quality of care. New providers should therefore be stimulated to join the bidding procedure. However, the context of the AWBZ has significant entry barriers such as the monopsonistic position of regional care offices and the fact that only 10% of the total production volume is being allocated by competitive bidding (while the rest is being guaranteed to incumbents). The context of the WMO does not come up with certain entry barriers and most municipalities have contracted 3 to 5 providers in a mix of incumbents and entrants. Municipalities seem to have succeeded to increase the level of competition in the market for housekeeping services. The quality of care has been measured by means of process quality indicators; output quality indicators are not yet developed. After the analysis of the home-care market, attention is paid to the preliminary results of the use of competitive bidding in the Netherlands. Regional care offices have been using competitive bidding for two years now to allocate 10% of the total production volume to entrants and incumbents that are willing to grow. The rest of the production volume is being guaranteed to incumbents to make sure all clients in need of long term care can stay with the provider they are familiar with. An increase in efficiency can be observed: more volume is being purchased for the same amount of resources. The increase in efficiency can be explained as result of the use of competitive bidding, but also as result from the Covenant the Ministry of VWS has agreed with the present parties in the market. The concentration on the market is still too high and the NZa states that prices can still be lowered if providers are more stimulated to reduce their production costs. The development on the level of quality is not known, although more providers have become certificated in the last two years, which is positive, but does not guarantee a high level of provided quality and therefore an improvement or reductions in the level cannot be measured accurately. Municipalities have been purchasing home-care for the first time, since the home-care type housekeeping services has been transferred from the AWBZ to the WMO in January 2007. Municipalities are obliged to use competitive bidding according to the European directive on public 5 procurement, just like regional care offices. They seem to have succeeded to increase the competition on the market for housekeeping services, although the concentration on the market is still unknown and the element of subcontracting is expected to have large effects on the market and must therefore also become transparent. The market has changed significantly by the mentioned transfer, because it had became possible for cleaning companies to join the bidding procedure for housekeeping services and incumbents have lost the freedom to be able to decide which type of housekeeping services was needed by their clients. Because of that, incumbents are currently dealing with too less low-educated (cheap) personnel and too much overqualified personnel to answer the indicated need for home-care of clients accurately, resulting in financial problems and the risk of discontinuity of care, waiting lists and less available capacity although it has been contracted. The quality of provided housekeeping services is also mainly measured by process quality indicators. The checklist that was created as result of the study of literature is used to be able to draw conclusions about whether competitive bidding is a useful method to purchase home-care under the current market conditions in the Netherlands. The following conclusions are drawn: - Home-care is suitable to be purchased by competitive bidding. Chronically ill clients in need of long term home-care may experience a burden when the indicated care is delivered by another provider each contract period, but there is no evidence about actually harming clients in that case. The absence of output quality indicators causes a risk, because providers cannot be monitored whether they have actually delivered the level of quality they have promised when bidding on a contract. This may create the incentive to providers to reduce their level of quality of care while reducing their production costs. - The concentration on the market for home-care financed by the AWBZ is too high to create incentives to stimulate providers to reduce their production costs. The existing entry barriers may prevent new providers to enter the market and increase competition. Regional care offices and the NZa should make an effort to reduce the entry barriers by for instance performing a study about whether guaranteeing such a high percentage of production volume to incumbents is really necessary. - The inexperienced municipalities were able to lower the prices on average. In the next year it will become clear whether the prices are too low and lead to bankruptcies. Municipalities should focus on developing purchasing skills by learning from their hired external consultants. They should also perform studies to the level of concentration on the market and the amount and effects of subcontracting. Stabilising the market while maintaining the increased level of competition in the market and support the contracted providers that deal with personnel problems are also relevant recommendations when becoming experienced purchasers. - All purchasers should develop output quality indicators to prevent cheap providers lowering their quality to an unacceptable level in the interests of clients. https://thesis.eur.nl/pub/4475/ Sat, 01 Sep 2007 00:00:01 GMT <div>Filko, M</div> https://thesis.eur.nl/pub/4479/ Thu, 01 Nov 2007 00:00:01 GMT <div>Man, W</div> https://thesis.eur.nl/pub/4372/ Thu, 01 Nov 2007 00:00:01 GMT <div>Man, W.</div> https://thesis.eur.nl/pub/4368/ Sat, 01 Dec 2007 00:00:01 GMT <div>Kolff, N.J.</div> Summary Cross-border health care is an issue of growing importance in the European Union. It offers health care services and products to patients in other countries than the country which covers their residency or insurance. Through rulings of the European Court of Justice, the possibilities for patients to receive cross-border care have been clarified. Although data on patient mobility within the EU is limited, the extent of cross-border health care is estimated to be around 1% of total health care expenditure in the EU. The numbers of patients seeking cross-border care can vary enormously per border and the direction can be either unidirectional or bidirectional depending on the border. Though cross-border care is unlikely to become a dominant activity in any country’s health care system, there is scope for increased patient mobility. ZorgSaam hospitals believes that there is greater scope for crossborder care and therefore wishes to attract Belgian patients. One of the ways through which patients seek cross-border care, is through their GP. The role of GPs is important in two ways: as referrers they can channel patients, and as the professionals that patients usually trust most and being the first contact point, GPs can influence patients’ choices about where to be treated. This has lead to the following main research question of this study: How can ZorgSaam increase referrals from Belgian GPs? In order to be able to answer this question, the concept of cross-border care has first been looked into. The conceptual model that followed from this consists the interlinked elements of the institutional factors, processes, contextual factors and actors on various levels (European, national, regional). This model helped develop the research method used. This method consisted of semi-structured interviews held with GPs in the border region (most of whom had Dutch patients and therefore had some experience with ZorgSaam) and interviews with representatives of two leading mutualities. GPs were asked about their referral decision making. Both groups were asked about possible enablers and barriers of cross-border care and their attitude towards it. From the results it can be concluded that, GPs and representatives of the mutualities have a positive attitude towards cross-border care as long as it is of benefit to the patients. The GPs do not perceive any real advantages for Belgian patients to cross the border to seek care in a ZorgSaam hospital, other than the extra choice it provides for patients. However, there is adequate hospital care available in Belgium. The GPs have therefore never referred their patients to ZorgSaam. The results have also given some insight into the other barriers and enablers of cross-border care. The enabling factors are the cultural and linguistic similarities and the short distance to a ZorgSaam hospital from Belgium. However, as the GPs remarked: “It is not so much the distance to Terneuzen that is the problem; it is rather the idea that you are going abroad that is the problem”. That going abroad is the problem, is made evident by other barriers found. The unfamiliarity with the Dutch health care system, differences in organisation within Dutch hospitals and ICT applications and the unfamiliarity with Dutch specialists too are reasons for Belgian GPs not to refer their patients to ZorgSaam. Many of the barriers found are similar to those factors that determine whereto GPs generally refer their patients. Therefore ZorgSaam will need to compete with Belgian hospitals on these factors. For ZorgSaam to be able to increase the referrals from Belgian GPs it will be necessary that they improve the relationship between GPs and ZorgSaam specialists. Provide information to GPs (and patients) concerning the possibilities and procedures of cross-border care, and what patients can expect from ZorgSaam. It has also been suggested that ZorgSaam not only puts effort in attracting Belgian patients, but also those Dutch patients that are now more orientated towards Belgian health care services. 4 Management summary Objective Cross-border health care, is of growing importance and through rulings of the European Court of Justice, the possibilities for patients to receive cross-border care have been clarified. Though cross-border care is not or is unlikely to become a great phenomena, there is scope for increased patient mobility. ZorgSaam hospitals believes that there is greater scope for cross-border care and therefore wishes to attract Belgian patients. One of the ways through which patients seek cross-border care, is through their GP. The role of GPs is important in two ways: as referrers they can channel patients, and as the professionals that patients usually trust most and being the first contact point, GPs can influence patients’ choices about where to be treated. This has lead to the following main research question of this study: How can ZorgSaam increase referrals from Belgian GPs? Recommendations Based on this study, the following recommendations can be made: • ZorgSaam should improve the relationship between Belgian GPs and specialist o Inviting Belgian GPs to functions specifically aimed at them that are held at convenient hours. This will allow Belgian GPs to get acquainted with ZorgSaam specialists o Encouraging ZorgSaam specialists to present at refresher courses organised by Belgian GP associations. This too will allow Belgian GPs to get acquainted with ZorgSaam specialists o Enabling GPs to have direct contact with ZorgSaam specialists by handing out a phone list with direct contact numbers. This will ease the working relationship between GPs and specialists o Creating an understanding of the differences in the organisation of hospitals, making it easier for Belgian GPs and ZorgSaam specialists to work together • Providing Belgian GPs with information concerning cross-border care: when can patients seek cross-border care, how should they go about it, what is the procedure, what can patients and GPs expect • ICT solutions reducing the administrative burden put on GPs when they refer patients to ZorgSaam • Not only aiming to attract Belgian patients, but also aiming to attract Dutch patients who are now more Belgium orientated. Thus showing Belgian GPs that ZorgSaam can also provide adequate care to Belgian patients Motivation Interviews were held with Belgian GPs in the border region with Zeeuws-Flanders. These interviews have covered the perceived enablers and barriers to receiving health care in the Netherlands and the practical barriers they have encountered when having referred patients to the Netherlands. Interviews were also held with representatives of two leading mutualities to get a better insight in the barriers and enablers of cross-border care and differences between the health care systems of Belgium and the Netherlands. Analysis of the data was qualitative in nature. The results have shown that both GPs as well as the representatives of the mutualities are generally favourable towards cross-border care, as long as it benefits the patient. Various barriers have been mentioned by the both the Belgian GPs as well as the representatives of the mutualities. These barriers are concerned with the several elements of cross-border care discussed in the theoretical framework of this study. They include the lack of knowledge concerning the possibilities and procedures of cross-border care, differences between systems and the organisation within hospitals, cultural differences and distance. By taking away these barriers, ZorgSaam could increase the referrals from Belgian GPs. However, not all barriers can be influenced by actions of ZorgSaam https://thesis.eur.nl/pub/9029/ Tue, 01 Jan 2008 00:00:01 GMT <div>Kok, R.</div> Health system performance is mostly measured in terms of health outcomes. While health outcomes can be seen as a measure for outcome utility, they do not measure process utility. Yet a large share of overall health care expenditures is used to respond to patients' wishes, even though this may not affect health outcomes. We argue that the WHO concept of responsiveness can be used to capture process utility. Moreover, when paired with a hierarchical ordered probit, it can be corrected for the subjectivity of responses. We improve the correction technique and use much better data to compare the process utility of 56 health care systems. https://thesis.eur.nl/pub/4614/ Wed, 21 May 2008 00:00:01 GMT <div>Keizer, M.</div> https://thesis.eur.nl/pub/4609/ Tue, 01 Jul 2008 00:00:01 GMT <div>Bijlhout, D.</div> https://thesis.eur.nl/pub/4616/ Tue, 01 Jul 2008 00:00:01 GMT <div>Vries, A. de</div> https://thesis.eur.nl/pub/4611/ Fri, 01 Aug 2008 00:00:01 GMT <div>Bouddiouan, Z.</div> https://thesis.eur.nl/pub/8515/ Fri, 01 Aug 2008 00:00:01 GMT <div>Dijk, D. van</div> Introduction The pressure on the health care industry is ever rising. While trying to maintain and improve the safety, effectiveness, patient centeredness, and timeliness the costs of health care must be kept from rising. Amongst others standardisation, skill-mix change, and information technology are all presented as the solution to health care’s problems. Clinical pathways, considered a form of standardisation, will evidently bring skill-mix change, and information technology support seems promising. There is however little known about the relationship between these concepts. This study tried to, describe recent insights concerning clinical pathways and the concepts of standardisation, skill-mix change and information technology in the literature, study how clinical pathways change practice by performing a case study, and investigate how information technology can help implement and use clinical pathways. Literature study Although generally accepted definitions of clinical pathways do not exist, there is general understanding that clinical pathways will not suffice on their own in changing health care by for instance bringing evidence into practice. Several authors identify therefore additional design principles, which can be summarised by Berg’s (2005) four additional design principles: (1) a thorough restructuring and delegation of tasks, (2) the application of integrated planning, (3) the use of indicators about the functioning of the care programs, and (4) implementing process-supporting information technology. These principles link clinical pathways with standardisation, skill-mix change and information technology. Concluding it seems evident that (introducing) clinical pathways comes with skill-mix change in the health care workforce while standardising health care delivery. Information technology can play an important role in facilitating these processes and vice versa. Case study Clinical pathways were studied in practice in the NHS setting in England at an independent sector treatment centre and two NHS Foundation Trusts by site visits and interviews. The nursing staff’s role was empowered by the clinical pathways and it gave them more control over the journey of the patient. Fear for “cookbook” medicine seems unfounded; in effect evidence-based practice can maximise the effect of clinical judgement and does not eliminate the need for professional judgement. To what extent clinical pathways are really evidence-based is a point of discussion, for instance clinical pathways are rarely tested empirically. Another point of interest is the fact that clinical pathways are often developed by professionals extracted from the primary process, which may lead to medically effective, but unpractical standards. The relationship between information technology and clinical pathways including additional changes that come with implementing and using pathways (e.g. standardisation, skill-mix) works both ways. For information technology to work it requires a standardisation of work processes and clinical pathways require information technology in order to standardise health care as information technology requires standardised use. https://thesis.eur.nl/pub/4612/ Thu, 28 Aug 2008 00:00:01 GMT <div>Ende, D. van der</div>