Effects of the reform of the Dutch healthcare into managed competition: Results of a Delphi study among experts

Nationwide guideline implementation: a qualitative study of barriers and facilitators from the perspective of guideline organizations

BACKGROUND

Although the number of Dutch guidelines is growing, their uptake and impact in clinical practice lag behind. Dutch guideline organizations, including guideline developers, governmental agencies, health insurers and other national organizations, play a crucial role in developing, authorizing and/or supporting the use of guidelines. They influence end users' awareness, accessibility, understanding, acceptability and applicability of guidelines. In this study, we explored the barriers and facilitators that representatives of guideline organizations perceive in nationwide guideline implementation.

METHODS

In this qualitative study, we conducted semi-structured interviews with 35 representatives of 24 different guideline organizations. We employed framework analysis, using the updated Consolidated Framework for Implementation Research (CFIR), and thematic analysis to guide our data analysis and synthesis.

RESULTS

We found 45 different implementation barriers and 35 implementation facilitators. We identified seven overarching themes of interrelated barriers and facilitators that extended across the stakeholders involved and domains within the updated CFIR. These included 1) healthcare demand and resource availability, 2) implementation knowledge and expertise, 3) guideline characteristics: representation, evidence base and design, 4) partnerships and collaboration, 5) characteristics of guideline implementation planning, execution and evaluation strategies, 6) characteristics of healthcare professionals: need, capability, opportunity and motivation, and 7) legal and regulatory compliance.

CONCLUSIONS

We obtained valuable insights into the complex dynamics of barriers and facilitators perceived by guideline organizations in nationwide guideline implementation. Our findings help explain why healthcare professionals and healthcare facilities may (not), slowly or inconsistently adhere to guideline recommendations in practice. The identified barriers and facilitators provide guidance for policymakers to re-evaluate and improve nationwide quality and guideline implementation policies, to eventually improve clinical practice and health outcomes for patients.

Process and effect evaluation of a referral aid for smoking cessation counselling in primary care: Findings of a randomized controlled trial

INTRODUCTION

This study explored the use and effects of a smoking cessation referral in: 1) practice nurses (PNs), and 2) smokers. The use of evidence-based smoking cessation interventions (EBSCIs) can double the likelihood of a successful smoking cessation attempt. A referral aid was developed to aid Dutch PNs in primary care in deciding which smokers are the most suitable for EBSCI.

METHODS

Two different studies were conducted: 1) a randomized controlled trial with a process evaluation (n=82) and effect evaluation (n=285) among smoking patients recruited by PNs (n=73), and 2) a process evaluation among a subgroup of PNs (n=40) from January 2019 to September 2020.

RESULTS

Overall, the response in both groups was low. PNs found the referral aid materials clear and understandable. Smokers had similar but (slightly) less-positive opinions. The smokers in both groups did not differ in the amount of discussion and use of EBSCIs, nor on smoking abstinence.

CONCLUSIONS

Further research should assess how to better involve PNs and smokers when recruiting for an RCT and how to foster effective counselling. Additional research should also look deeper into barriers to referral of both PNs and smokers, and how to stimulate referral to EBSCIs best and help smokers to make a decision; for example by implementing a simplified strategy both within the primary care setting and outside, by involving other healthcare professionals or options outside healthcare such as the workplace and social domain.

Trial registration

The study was registered at the Netherlands Trial Register (NL7020, https://www.trialregister.nl/trial/7020).

Does competition improve hospital performance: a DEA based evaluation from the Netherlands

Many countries have introduced competition among hospitals aiming to improve their performance. We evaluate the introduction of competition among hospitals in the Netherlands over the years 2008-2015. The analysis is based on a unique longitudinal data set covering all Dutch hospitals and health insurers, as well as demographic and geographic data. We measure hospital performance using Data Envelopment Analysis and distinguish three components of competition: the fraction of freely negotiated services, market power of hospitals, and insurer bargaining power. We present new methods to define variables for each of these components which are more accurate than previously developed measures. In a multivariate regression analysis, the variables explain more than half of the variance in hospital efficiency. The results indicate that competition between hospitals and the relative fraction of freely negotiable health services are positively related to hospital efficiency. At the same time, the policy measure to steadily increase the fraction of health services contracted in competition may well have resulted in a decrease in hospital efficiency. The models show no significant association between insurer bargaining power and hospital efficiency. Altogether, the results offer little evidence that the introduction of competition for hospital care in the Netherlands has been effective.

The relations between business model efficiency and novelty, and outcome while accounting for managed competition contract: a quantitative study among Dutch physiotherapy primary healthcare organisations

Background

Since 2006, business principles have been introduced to foster efficient healthcare by way of managed competition. Managed competition is expressed by a contract between a health insurer and a physiotherapy primary healthcare organisation (PTPHO). In such a managed environment, PTPHOs have to attain treatment service quality and financial PTPHO-centred outcomes Research shows that business model designs may enhance organisation-centred outcomes. A business model is a design (efficiency or novelty) of how a firm transacts with customers, partners, and vendors; how it connects with markets. However, research on managed competition contract and business model designs, in relation to PTPHO-centred outcomes is new to the healthcare literature. PTPHOs may not know how business model designs enhance outcomes. This study aims to delineate the relations between business model efficiency and novelty, and PTPHO-centred outcomes, while accounting for managed competition contract in Dutch healthcare.

Methods

A quantitative cross-sectional design was adopted. Using a questionnaire, the relations between managed competition, business model efficiency and novelty, and PTPHO-centred outcomes were investigated among PTPHO managers (n = 138). Theory-based expectations were set up and multiple linear regression analyses were applied.

Results

Managed competition and business model efficiency show no relation with PTPHO-centred outcomes. Moderation of the business model efficiency and PTPHO-centred outcomes relation by managed competition contract is not detected. Business model novelty shows a positive relation with PTPHO-centred outcomes. Moderation of the business model novelty and PTPHO-centred outcomes relation by managed competition contract is found.

Conclusions

There seem to be positive relations between business model novelty and PTPHO-centred outcomes on its own and moderated by managed competition contract. No relations seem to exist with business model efficiency. This implies that the combination of persistent use of health insurer-driven managed competition contracts and a naturally efficient PTPHOs may have left too few means for these organisations to contribute to healthcare reforms and attain PTPHO-centred outcomes. Organisation-driven innovation could stretch system-level regulations and provide room for new business models. Optimising contracts towards organisation-driven healthcare reform, including novelty requirements and corresponding reimbursements is suggested. PTPHO managers may want to shift their attitudes towards novel business models.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08383-7.