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Steinmann G, van de Bovenkamp H, de Bont A, Delnoij D. Value-based health care in translation: From global popularity to primary care for Dutch elderly patients. Sociol Health Illn 2023. [PMID: 37966700 DOI: 10.1111/1467-9566.13728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 10/25/2023] [Indexed: 11/16/2023]
Abstract
In this article we examine the fragmented interpretation and implementation of a remarkably popular concept, value-based health care (VBHC). By building on a case study of a project team working on the development of value-based primary care services for elderly patients, we shed new light on the way in which VBHC transitions from theory to practice. The concept of 'translation' is used to theoretically frame our analysis. Between June 2021 and May 2022, we gathered data through participant observation (50 h), semi-structured interviews (n = 20) and document analysis (n = 16). Our findings show how VBHC inspired new ways of working, and that, in line with previous studies, parts of the original concept have been neglected, while others have been modified. We identified three reasons for VBHC's locally varied applications: VBHC transforms to enable a growing support base, the originally radical idea is applied conservatively and the concept tends to get mixed up with other policy objectives. In all, VBHC appears to be successful in catalysing cross-disciplinary interaction aimed at improving value for patients.
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Affiliation(s)
- Gijs Steinmann
- Health Care Governance, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Health Services Research, Faculty of Health, Medicine & Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Hester van de Bovenkamp
- Health Care Governance, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Antoinette de Bont
- Tilburg School of Social and Behavioral Sciences, Tilburg University, Tilburg, The Netherlands
| | - Diana Delnoij
- Health Care Governance, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Zorginstituut Nederland, Diemen, The Netherlands
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2
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Carboni C, Wehrens R, van der Veen R, de Bont A. Eye for an AI: More-than-seeing, fauxtomation, and the enactment of uncertain data in digital pathology. Soc Stud Sci 2023; 53:712-737. [PMID: 37154611 PMCID: PMC10543128 DOI: 10.1177/03063127231167589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Artificial Intelligence (AI) tools are being developed to assist with increasingly complex diagnostic tasks in medicine. This produces epistemic disruption in diagnostic processes, even in the absence of AI itself, through the datafication and digitalization encouraged by the promissory discourses around AI. In this study of the digitization of an academic pathology department, we mobilize Barad's agential realist framework to examine these epistemic disruptions. Narratives and expectations around AI-assisted diagnostics-which are inextricable from material changes-enact specific types of organizational change, and produce epistemic objects that facilitate to the emergence of some epistemic practices and subjects, but hinder others. Agential realism allows us to simultaneously study epistemic, ethical, and ontological changes enacted through digitization efforts, while keeping a close eye on the attendant organizational changes. Based on ethnographic analysis of pathologists' changing work processes, we identify three different types of uncertainty produced by digitization: sensorial, intra-active, and fauxtomated uncertainty. Sensorial and intra-active uncertainty stem from the ontological otherness of digital objects, materialized in their affordances, and result in digital slides' partial illegibility. Fauxtomated uncertainty stems from the quasi-automated digital slide-making, which complicates the question of responsibility for epistemic objects and related knowledge by marginalizing the human.
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Affiliation(s)
- Chiara Carboni
- Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Rik Wehrens
- Erasmus University Rotterdam, Rotterdam, The Netherlands
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3
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Kushniruk A, Timmermans J, de Bont A, de Mul M. Diversity in Stakeholder Groups in Generative Co-design for Digital Health: Assembly Procedure and Preliminary Assessment. JMIR Hum Factors 2023; 10:e38350. [PMID: 36787170 PMCID: PMC9975926 DOI: 10.2196/38350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 10/28/2022] [Accepted: 12/11/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Diverse knowledge and ways of thinking are claimed to be important when involving stakeholders such as patients, care professionals, and care managers in a generative co-design (GCD) process. However, this claim is rather general and has not been operationalized; therefore, the influence of various stakeholders on the GCD process has not been empirically tested. OBJECTIVE In this study, we aimed to take the first step in assessing stakeholder diversity by formulating a procedure to assemble a group of diverse stakeholders and test its influence in a GCD process. METHODS To test the procedure and assess its influence on the GCD process, a case was selected involving a foundation that planned to develop a serious game to help people with cancer return to work. The procedure for assembling a stakeholder group involves snowball sampling and individual interviews, leading to the formation of 2 groups of stakeholders. Thirteen people were identified through snowball sampling, and they were briefly interviewed to assess their knowledge, inference experience, and communication skills. Two diverse stakeholder groups were formed, with one more potent than the other. The influence of both stakeholder groups on the GCD process was qualitatively assessed by comparing the knowledge output and related knowledge processing in 2 identical GCD workshops. RESULTS Our hypothesis on diverse stakeholders was confirmed, although it also appeared that merely assessing the professional background of stakeholders was not sufficient to reach the full potential of the GCD process. The more potently diverse group had a stronger influence on knowledge output and knowledge processing, resulting in a more comprehensive problem definition and more precisely described solutions. In the less potently diverse group, none of the stakeholders had experience with abduction-2 inferencing, and this did not emerge in the GCD process, suggesting that at least one stakeholder should have previous abduction-2 experience. CONCLUSIONS A procedure to assemble a stakeholder group with specific criteria to assess the diversity of knowledge, ways of thinking, and communication can improve the potential of the GCD process and the resulting digital health.
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Affiliation(s)
| | - Job Timmermans
- Department of Military Management Studies, Netherlands Defence Academy, Breda, Netherlands
| | - Antoinette de Bont
- Tilburg School of Social & Behavioral Sciences, Tilburg University, Tilburg, Netherlands
| | - Marleen de Mul
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
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Rimon-Zarfaty N, Kostenzer J, Sismuth LK, de Bont A. Between "Medical" and "Social" Egg Freezing : A Comparative Analysis of Regulatory Frameworks in Austria, Germany, Israel, and the Netherlands. J Bioeth Inq 2021; 18:683-699. [PMID: 34783957 PMCID: PMC8724162 DOI: 10.1007/s11673-021-10133-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 07/05/2021] [Indexed: 05/30/2023]
Abstract
Egg freezing has led to heated debates in healthcare policy and bioethics. A crucial issue in this context concerns the distinction between "medical" and "social" egg freezing (MEF and SEF)-contrasting objections to bio-medicalization with claims for oversimplification. Yet such categorization remains a criterion for regulation. This paper aims to explore the "regulatory boundary-work" around the "medical"-"social" distinction in different egg freezing regulations. Based on systematic documents' analysis we present a cross-national comparison of the way the "medical"-"social" differentiation finds expression in regulatory frameworks in Austria, Germany, Israel, and the Netherlands. Findings are organized along two emerging themes: (1) the definition of MEF and its distinctiveness-highlighting regulatory differences in the clarity of the definition and in the medical indications used for creating it (less clear in Austria and Germany, detailed in Israel and the Netherlands); and (2) hierarchy of medical over social motivations reflected in usage and funding regulations. Blurred demarcation lines between "medical" and "social" are further discussed as representing a paradoxical inclusion of SEF while offering new insights into the complexity and normativity of this distinction. Finally, we draw conclusions for policymaking and the bioethical debate, also concerning the related cryopolitical aspects.
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Affiliation(s)
- Nitzan Rimon-Zarfaty
- Department of Medical Ethics and History of Medicine, University Medical Centre Göttingen, Humboldtallee 36, 37073, Göttingen, Lower Saxony, Germany.
- Department of Human Resource Management Studies, Sapir Academic College, D.N. Hof Ashkelon, 7915600, Hof Ashkelon, Israel.
| | - Johanna Kostenzer
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, P.O. Box 1738, 3000 DR, The Netherlands
| | - Lisa-Katharina Sismuth
- Department of Medical Ethics and History of Medicine, University Medical Centre Göttingen, Humboldtallee 36, 37073, Göttingen, Lower Saxony, Germany
| | - Antoinette de Bont
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, P.O. Box 1738, 3000 DR, The Netherlands
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5
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Kleinhout-Vliek T, de Bont A, Boer B. Necessity under construction - societal weighing rationality in the appraisal of health care technologies. Health Econ Policy Law 2021; 16:457-472. [PMID: 32955010 PMCID: PMC8460450 DOI: 10.1017/s1744133120000341] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 06/29/2020] [Accepted: 07/31/2020] [Indexed: 11/26/2022]
Abstract
Health care coverage decisions may employ many different considerations, which are brought together across two phases. The assessment phase examines the available scientific evidence, such as the cost-effectiveness, of the technology. The appraisal then contextualises this evidence to arrive at an (advised) coverage decision, but little is known about how this is done.In the Netherlands, the appraisal is set up to achieve a societal weighing and is the primary place where need- and solidarity-related ('necessity') argumentations are used. To elucidate how the Dutch appraisal committee 'constructs necessity', we analysed observations and recordings of two appraisal committee meetings at the National Health Care Institute, the corresponding documents (five), and interviews with committee members and policy makers (13 interviewees in 12 interviews), with attention to specific necessity argumentations.The Dutch appraisal committee constructs necessity in four phases: (1) allowing explicit criteria to steer the process; (2) allowing patient (representative) contributions to challenge the process; (3) bringing new argumentations in from outside and weaving them together; and (4) formulating recommendations to societal stakeholders. We argue that in these ways, the appraisal committee achieves societal weighing rationality, as the committee actively uses argumentations from society and embeds the decision outcome in society.
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Affiliation(s)
- Tineke Kleinhout-Vliek
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, the Netherlands
| | - Antoinette de Bont
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, the Netherlands
| | - Bert Boer
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, the Netherlands
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van Schothorst-van Roekel J, Weggelaar-Jansen AMJWM, Hilders CCGJM, Wallenburg I, de Bont A. Role of Dutch internal policy advisors in a hospital quality improvement programme and their influence on nurses' role development: a qualitative study. BMJ Open 2021; 11:e051998. [PMID: 34489293 PMCID: PMC8422484 DOI: 10.1136/bmjopen-2021-051998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Nurses are vital in providing and improving quality of care. To enhance the quality improvement (QI) competencies of nurses, hospitals in the Netherlands run developmental programmes generally led by internal policy advisors (IPAs). In this study, we identify the roles IPAs play during these programmes to enhance the development of nurses' QI competencies and studied how these roles influenced nurses and management. DESIGN An exploratory ethnographical study comprising observations, informal conversations, semistructured interviews, focus groups and a strategy evaluation meeting. SETTING A teaching hospital in an urban region in the Netherlands. PARTICIPANTS IPAs (n=7) in collaboration with four teams of nurses (n=131), team managers (n=4), senior managers (n=4) and the hospital director (n=1). RESULTS We identified five distinct advisory roles that IPAs perform in the hospital programme: gatekeeper, connector, converter, reflector and implementer. In describing these roles, we provide insights into how IPAs help nurses to develop QI competencies. The IPA's professional background was a driving force for nurses' QI role development. However, QI development was threatened if IPAs lost sight of different stakeholders' interests and consequently lost their credibility. QI role development among nurses was also threatened if the IPA took on all responsibility instead of delegating it timely to managers and nurses. CONCLUSIONS We have shown how IPAs' professional background and advisory knowledge connect organisational, managerial and professional aims and interests to enhance professionalisation of nurses.
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Affiliation(s)
| | | | - Carina C G J M Hilders
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
| | - Iris Wallenburg
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
| | - Antoinette de Bont
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
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7
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van Tuyl L, Vrijhoef B, Laurant M, de Bont A, Batenburg R. Broadening the scope of task shifting in the organisation of healthcare. International Journal of Care Coordination 2021. [DOI: 10.1177/20534345211039988] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Task shifting in healthcare has mainly been initiated and studied as a way to react to/or mitigate workforce shortages. Here, we define task shifting as the structural redistribution of tasks, usually including responsibilities and competencies between different professions. As such, task shifting is commonly focused on highly specialised and trained professionals who hand-over specific, standardised tasks to professionals with lower levels of education. It is expected that this type of task shifting will lead to efficiency and cost savings to healthcare organisations. Yet, there are more benefits to task shifting, in particular its contribution to integrated patient-centred quality of care and a tailored system that meets the changing care demands in society. Hence the importance to broaden the scope of task shifting, its goals, manifestations and how task shifting plays a role in addressing both the strengths and weaknesses in the healthcare system. In this focus piece, trends and conditions for task shifting and its (un)anticipated effects are discussed. We argue that, only when designed to face specific complexities at the workplace and taking into account the balance between specialists and generalists, task shifting may substantially contribute to enhanced quality of care that meets the changing needs of society.
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Affiliation(s)
- Lilian van Tuyl
- Nivel (Netherlands Institute for Health Services Research), The Netherlands
| | - Bert Vrijhoef
- Maastricht University, The Netherlands
- Panaxea, The Netherlands
| | - Miranda Laurant
- HAN University of Applied Sciences, The Netherlands
- Radboud University Medical Center, The Netherlands
| | | | - Ronald Batenburg
- Nivel (Netherlands Institute for Health Services Research), The Netherlands
- Radboud University Nijmegen, The Netherlands
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8
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Kostenzer J, Bos AM, Bont AD, Exel JV. Unveiling the controversy on egg freezing in The Netherlands: A Q-methodology study on women's viewpoints. Reprod Biomed Soc Online 2021; 12:32-43. [PMID: 33319082 PMCID: PMC7726258 DOI: 10.1016/j.rbms.2020.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 08/17/2020] [Accepted: 09/29/2020] [Indexed: 06/01/2023]
Abstract
Preserving the option to conceive through egg freezing (oocyte cryopreservation) is surrounded by value conflicts and diverse viewpoints, particularly when non-medical or so-called 'social' reasons are involved. The debate is controversial and shaped by normative perceptions of the life course, including concepts regarding reproductive ageing, gender, motherhood and biomedicalization. To unravel the controversy and systematically identify the variety of viewpoints on egg freezing, a Q-methodology study was conducted in The Netherlands between December 2018 and October 2019. Thirty-four women of reproductive age participated in the study. They ranked 40 statements according to their level of agreement, and explained their ranking during follow-up interviews. Data were analysed using by-person factor analysis and interpreted using both quantitative and qualitative data. Four viewpoints, of which the fourth was bipolar, were identified: (1) cautious about egg freezing technology; (2) my body, my choice; (3) egg freezing is unnatural; and (4) have children and have them early. The distinct viewpoints illustrate different prioritizations of values and normative dimensions of biomedical innovations. By knowing more about the prevalent opinions on egg freezing and the surrounding controversy, policy makers and practitioners can make better informed decisions in terms of promoting and providing patient-centred infertility care. The findings furthermore stimulate continuing scholarly work on egg freezing and other innovations in reproductive medicine which may continue to disrupt normative standards.
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Affiliation(s)
- Johanna Kostenzer
- Erasmus University Rotterdam, Erasmus School of Health Policy and Management, Rotterdam, the Netherlands
| | - Annelies M.E. Bos
- University Medical Centre Utrecht, Department of Reproductive Medicine and Gynaecology, Utrecht, the Netherlands
| | - Antoinette de Bont
- Erasmus University Rotterdam, Erasmus School of Health Policy and Management, Rotterdam, the Netherlands
| | - Job van Exel
- Erasmus University Rotterdam, Erasmus School of Health Policy and Management, Rotterdam, the Netherlands
- Erasmus University Rotterdam, Erasmus School of Economics, Rotterdam, the Netherlands
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9
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Kostenzer J, de Bont A, van Exel J. Women's viewpoints on egg freezing in Austria: an online Q-methodology study. BMC Med Ethics 2021; 22:4. [PMID: 33407392 PMCID: PMC7789674 DOI: 10.1186/s12910-020-00571-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 12/21/2020] [Indexed: 01/02/2023] Open
Abstract
Background Egg freezing has emerged as a technology of assisted reproductive medicine that allows women to plan for the anticipated loss of fertility and hence to preserve the option to conceive with their own eggs. The technology is surrounded by value-conflicts and is subject to ongoing discussions. This study aims at contributing to the empirical-ethical debate by exploring women’s viewpoints on egg freezing in Austria,
where egg freezing for social reasons is currently not allowed. Methods Q-methodology was used to identify prevailing viewpoints on egg freezing. 46 female participants ranked a set of 40 statements onto a 9-column forced choice ranking grid according to the level of agreement. Participants were asked to explain their ranking in a follow-up survey. By-person factor analysis was used to identify distinct viewpoints which were interpreted using both the quantitative and the qualitative data. Results Three distinct viewpoints were identified: (1) “women should decide for themselves”, (2) “we should accept nature but change policy”, and (3) “we need an informed societal debate”. These viewpoints provide insights into how biomedical innovations such as egg freezing are perceived by women in Austria and illustrate the normative tensions regarding such innovations. Conclusions Acknowledging the different prioritizations of values regarding assisted reproductive technologies is important to better understand the underlying normative tensions in a country where egg freezing for social reasons is currently not allowed. The study adds new empirical insights to the ongoing debate by outlining and discussing viewpoints of those directly affected: women. Following up on the lay persons perspective is particularly important in the context of future biomedical innovations that may challenge established norms and create new tensions. It therefore also adds to the societal debate and supports evidence-informed policy making in that regard.
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Affiliation(s)
- Johanna Kostenzer
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands.
| | - Antoinette de Bont
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands
| | - Job van Exel
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands.,Erasmus School of Economics, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands
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10
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Wehrens R, Sihag V, Sülz S, van Elten H, van Raaij E, de Bont A, Weggelaar-Jansen AM. Understanding the Uptake of Big Data in Health Care: Protocol for a Multinational Mixed-Methods Study. JMIR Res Protoc 2020; 9:e16779. [PMID: 33090113 PMCID: PMC7644380 DOI: 10.2196/16779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 07/17/2020] [Accepted: 07/21/2020] [Indexed: 11/25/2022] Open
Abstract
Background Despite the high potential of big data, their applications in health care face many organizational, social, financial, and regulatory challenges. The societal dimensions of big data are underrepresented in much medical research. Little is known about integrating big data applications in the corporate routines of hospitals and other care providers. Equally little is understood about embedding big data applications in daily work practices and how they lead to actual improvements for health care actors, such as patients, care professionals, care providers, information technology companies, payers, and the society. Objective This planned study aims to provide an integrated analysis of big data applications, focusing on the interrelations among concrete big data experiments, organizational routines, and relevant systemic and societal dimensions. To understand the similarities and differences between interactions in various contexts, the study covers 12 big data pilot projects in eight European countries, each with its own health care system. Workshops will be held with stakeholders to discuss the findings, our recommendations, and the implementation. Dissemination is supported by visual representations developed to share the knowledge gained. Methods This study will utilize a mixed-methods approach that combines performance measurements, interviews, document analysis, and cocreation workshops. Analysis will be structured around the following four key dimensions: performance, embedding, legitimation, and value creation. Data and their interrelations across the dimensions will be synthesized per application and per country. Results The study was funded in August 2017. Data collection started in April 2018 and will continue until September 2021. The multidisciplinary focus of this study enables us to combine insights from several social sciences (health policy analysis, business administration, innovation studies, organization studies, ethics, and health services research) to advance a holistic understanding of big data value realization. The multinational character enables comparative analysis across the following eight European countries: Austria, France, Germany, Ireland, the Netherlands, Spain, Sweden, and the United Kingdom. Given that national and organizational contexts change over time, it will not be possible to isolate the factors and actors that explain the implementation of big data applications. The visual representations developed for dissemination purposes will help to reduce complexity and clarify the relations between the various dimensions. Conclusions This study will develop an integrated approach to big data applications that considers the interrelations among concrete big data experiments, organizational routines, and relevant systemic and societal dimensions. International Registered Report Identifier (IRRID) DERR1-10.2196/16779
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Affiliation(s)
- Rik Wehrens
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Vikrant Sihag
- Rotterdam School of Management, Erasmus University Rotterdam, Rotterdam, Netherlands.,Department of Industrial Engineering & Innovation Sciences, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Sandra Sülz
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Hilco van Elten
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Erik van Raaij
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands.,Rotterdam School of Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Antoinette de Bont
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Anne Marie Weggelaar-Jansen
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands.,School of Medical Physics and Engineering, University of Technology Eindhoven, Eindhoven, Netherlands
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11
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Felder M, van de Bovenkamp H, Meerding WJ, de Bont A. Who contextualises clinical epidemiological evidence? A political analysis of the problem of evidence-based medicine in the layered Dutch healthcare system. Health Policy 2020; 125:34-40. [PMID: 33051022 DOI: 10.1016/j.healthpol.2020.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 09/01/2020] [Accepted: 09/20/2020] [Indexed: 12/20/2022]
Abstract
We critically examine the discussion on the role of evidence-based medicine (EBM) in healthcare governance. We take the institutionally layered Dutch healthcare system as our case study. Here, different actors are involved in the regulation, provision and financing of healthcare services. Over the last decades, these actors have related to EBM to inform their actor specific roles. At the same time, EBM has increasingly been problematised. To better understand this problematisation, we organised focus groups and interviews. We noticed that particularly EBM's reductionist epistemology and its uncritical use by 'professional others' are considered problematic. However, our analysis also reveals that something else seems to be at stake. In fact, all the actors involved underwrite EBM's reductionist epistemology and emphasise that evidence should be contextualised. They however do so in different ways and with different contexts in mind. Moreover, the ways in which some actors contextualise evidence has consequences for the ways in which others can do the same. We therefore emphasise that behind EBM's scientific problematisation lurks a political issue. A dispute over who should contextualise evidence how, in a layered healthcare system with interdependent actors that cater to both individual patients and the public. We urge public administration scholars and policymakers to open-up the political confrontation between healthcare actors and their sometimes irreconcilable, yet evidence-informed perspectives.
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Affiliation(s)
- Martijn Felder
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands.
| | - Hester van de Bovenkamp
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands
| | | | - Antoinette de Bont
- Erasmus School of Health Policy & Management, Erasmus University, Rotterdam, the Netherlands
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12
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Steinmann G, van de Bovenkamp H, de Bont A, Delnoij D. Redefining value: a discourse analysis on value-based health care. BMC Health Serv Res 2020; 20:862. [PMID: 32928203 PMCID: PMC7488985 DOI: 10.1186/s12913-020-05614-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 07/31/2020] [Indexed: 11/11/2022] Open
Abstract
Background Today’s remarkable popularity of value-based health care (VBHC) is accompanied by considerable ambiguity concerning the very meaning of the concept. This is evident within academic publications, and mirrored in fragmented and diversified implementation efforts, both within and across countries. Method This article builds on discourse analysis in order to map the ambiguity surrounding VBHC. We conducted a document analysis of publicly accessible, official publications (n = 22) by actors and organizations that monitor and influence the quality of care in the Netherlands. Additionally, between March and July 2019, we conducted a series of semi-structured interviews (n = 23) with national stakeholders. Results Our research revealed four discourses, each with their own perception regarding the main purpose of VBHC. Firstly, we identified a Patient Empowerment discourse in which VBHC is a framework for strengthening the position of patients regarding their medical decisions. Secondly, in the Governance discourse, VBHC is a toolkit to incentivize providers. Thirdly, within the Professionalism discourse, VBHC is a methodology for healthcare delivery. Fourthly, in the Critique discourse, VBHC is rebuked as a dogma of manufacturability. We also show, however, that these diverging lines of reasoning find common ground: they perceive shared decision-making to be a key component of VBHC. Strikingly, this common perception contrasts with the pioneering literature on VBHC. Conclusions The four discourses will profoundly shape the diverse manners in which VBHC moves from an abstract concept to the practical provision and administration of health care. Moreover, our study reveals that VBHC’s conceptual ambiguity largely arises from differing and often deeply rooted presuppositions, which underlie these discourses, and which frame different perceptions on value in health care. The meaning of VBHC – including its perceived implications for action – thus depends greatly on the frame of reference an actor or organization brings to bear as they aim for more value for patients. Recognizing this is a vital concern when studying, implementing and evaluating VBHC.
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Affiliation(s)
- Gijs Steinmann
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, Rotterdam, 3000, DR, The Netherlands.
| | - Hester van de Bovenkamp
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, Rotterdam, 3000, DR, The Netherlands
| | - Antoinette de Bont
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, Rotterdam, 3000, DR, The Netherlands
| | - Diana Delnoij
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, PO Box 1738, Rotterdam, 3000, DR, The Netherlands
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Kleinhout-Vliek T, de Bont A, Boysen M, Perleth M, van der Veen R, Zwaap J, Boer B. Around the Tables - Contextual Factors in Healthcare Coverage Decisions Across Western Europe. Int J Health Policy Manag 2020; 9:390-402. [PMID: 32610740 PMCID: PMC7557427 DOI: 10.15171/ijhpm.2019.145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/17/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Across Western Europe, procedures and formalised criteria for taking decisions on the coverage (inclusion in the benefits basket or equivalent) of healthcare technologies vary substantially. In the decision documents, which display the justification of, the rationale for, these decisions, national healthcare institutes may employ ‘contextual factors,’ defined here as situation-specific considerations. Little is known about how the use of such contextual factors compares across countries. We describe and compare contextual factors as used in coverage decisions generally and 4 decision documents specifically in Belgium, England, Germany, and the Netherlands. Methods: Four group interviews with 3 experts from the national healthcare institute of each country, document and web site analysis, and a workshop with 1 to 2 of these experts per country were followed by the examination of the documents of 4 specific decisions taken in each of the 4 countries, sampled to vary widely in type of technology and decision outcome. Results: From the available decision documents, we conclude that in every country studied, contextual factors are established ‘around the table,’ ie, in deliberation. All documents examined feature contextual factors, with similar contextual factor patterns leading to similar decisions in different countries. The Dutch decisions employ the widest variety of factors, with the exception of the societal functioning of the patient, which is relatively common in Belgium, England, and Germany. Half of the final decisions were taken in another setting, with the consequence that no documentation was retrievable for 2 decisions. Conclusion: First, we conclude that in these countries, contextual factors are actively integrated in the decision document, and that this is achieved in deliberation. Conceptualising contextual factors as both situation-specific and actively-integrated affords insight into practices of contextualisation and provides an encouragement for exchange between decision-makers on more qualitative aspects of decisions. Second, the decisions that lacked a publicly accessible justification of the final decision document raised questions on the decisions’ legitimacy. Further research could address patterning of contextual factors, elucidate why some factors may remain implicit, and how decisions without a publicly available decision document may enable or restrain decision-making practice.
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Affiliation(s)
- Tineke Kleinhout-Vliek
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Antoinette de Bont
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Meindert Boysen
- National Institute for Health and Care Excellence (NICE), London, UK
| | - Matthias Perleth
- Federal Joint Committee (Gemeinsamer Bundesausschuss), Berlin, Germany
| | - Romke van der Veen
- Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Jacqueline Zwaap
- National Health Care Institute (Zorginstituut Nederland), Diemen, The Netherlands
| | - Bert Boer
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Stevens M, Wehrens R, de Bont A. Epistemic virtues and data-driven dreams: On sameness and difference in the epistemic cultures of data science and psychiatry. Soc Sci Med 2020; 258:113116. [PMID: 32599412 DOI: 10.1016/j.socscimed.2020.113116] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/27/2020] [Accepted: 06/04/2020] [Indexed: 11/19/2022]
Abstract
Data science and psychiatry have diverse epistemic cultures that come together in data-driven initiatives (e.g., big data, machine learning). The literature on these initiatives seems to either downplay or overemphasize epistemic differences between the fields. In this paper, we study the convergence and divergence of the epistemic cultures of data science and psychiatry. This approach is more likely to capture where and how the cultures differ and gives insights into how practitioners from both fields find ways to work together despite their differences. We introduce the notions of "epistemic virtues" to focus on epistemic differences ethnographically, and "trading zones" to concentrate on how differences are negotiated. This leads us to the following research question: how are epistemic differences negotiated by data science and psychiatry practitioners in a hospital-based data-driven initiative? Our results are based on an ethnographic study in which we observed a Dutch psychiatric hospital department developing prediction models of patient outcomes based on machine learning techniques (September 2017 - February 2018). Many epistemic virtues needed to be negotiated, such as completeness or selectivity in data inclusion. These differences were traded locally and temporarily, stimulated by shared epistemic virtues (such as a systematic approach), boundary objects and socialization processes. Trading became difficult when virtues were too diverse, differences were enlarged by storytelling and parties did not have the time or capacity to learn about the other. In the discussion, we argue that our combined theoretical framework offers a fresh way to study how cooperation between diverse practitioners goes and where it can be improved. We make a call for bringing epistemic differences into the open as this makes a grounded discussion possible about the added value of data-driven initiatives and the role they can play in healthcare.
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Affiliation(s)
- Marthe Stevens
- Department of Health Care Governance, Erasmus School of Health Policy & Management, P.O. Box 1738, 3000, DR, Rotterdam, the Netherlands.
| | - Rik Wehrens
- Department of Health Care Governance, Erasmus School of Health Policy & Management, P.O. Box 1738, 3000, DR, Rotterdam, the Netherlands.
| | - Antoinette de Bont
- Department of Health Care Governance, Erasmus School of Health Policy & Management, P.O. Box 1738, 3000, DR, Rotterdam, the Netherlands.
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Rutten-van Mölken M, Leijten F, Hoedemakers M, Tsiachristas A, Verbeek N, Karimi M, Bal R, de Bont A, Islam K, Askildsen JE, Czypionka T, Kraus M, Huic M, Pitter JG, Vogt V, Stokes J, Baltaxe E. Strengthening the evidence-base of integrated care for people with multi-morbidity in Europe using Multi-Criteria Decision Analysis (MCDA). BMC Health Serv Res 2018; 18:576. [PMID: 30041653 PMCID: PMC6057041 DOI: 10.1186/s12913-018-3367-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 07/08/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Evaluation of integrated care programmes for individuals with multi-morbidity requires a broader evaluation framework and a broader definition of added value than is common in cost-utility analysis. This is possible through the use of Multi-Criteria Decision Analysis (MCDA). METHODS AND RESULTS This paper presents the seven steps of an MCDA to evaluate 17 different integrated care programmes for individuals with multi-morbidity in 8 European countries participating in the 4-year, EU-funded SELFIE project. In step one, qualitative research was undertaken to better understand the decision-context of these programmes. The programmes faced decisions related to their sustainability in terms of reimbursement, continuation, extension, and/or wider implementation. In step two, a uniform set of decision criteria was defined in terms of outcomes measured across the 17 programmes: physical functioning, psychological well-being, social relationships and participation, enjoyment of life, resilience, person-centeredness, continuity of care, and total health and social care costs. These were supplemented by programme-type specific outcomes. Step three presents the quasi-experimental studies designed to measure the performance of the programmes on the decision criteria. Step four gives details of the methods (Discrete Choice Experiment, Swing Weighting) to determine the relative importance of the decision criteria among five stakeholder groups per country. An example in step five illustrates the value-based method of MCDA by which the performance of the programmes on each decision criterion is combined with the weight of the respective criterion to derive an overall value score. Step six describes how we deal with uncertainty and introduces the Conditional Multi-Attribute Acceptability Curve. Step seven addresses the interpretation of results in stakeholder workshops. DISCUSSION By discussing our solutions to the challenges involved in creating a uniform MCDA approach for the evaluation of different programmes, this paper provides guidance to future evaluations and stimulates debate on how to evaluate integrated care for multi-morbidity.
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Affiliation(s)
- Maureen Rutten-van Mölken
- School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Fenna Leijten
- School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Maaike Hoedemakers
- School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Apostolos Tsiachristas
- School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nick Verbeek
- School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Milad Karimi
- School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Roland Bal
- School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Antoinette de Bont
- School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Kamrul Islam
- Department of Economics, University of Bergen, Bergen, Norway
| | | | | | | | - Mirjana Huic
- Agency for Quality and Accreditation in Health Care and Social Welfare, Zagreb, Croatia
| | | | - Verena Vogt
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
| | - Jonathan Stokes
- Manchester Centre for Health Economics, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Manchester, UK
| | - Erik Baltaxe
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - on behalf of the SELFIE consortium
- School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
- Department of Economics, University of Bergen, Bergen, Norway
- Institute for Advanced Studies, Vienna, Austria
- Agency for Quality and Accreditation in Health Care and Social Welfare, Zagreb, Croatia
- Syreon Research Institute, Budapest, Hungary
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
- Manchester Centre for Health Economics, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Manchester, UK
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
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Schepman S, Valentijn P, Bruijnzeels M, Maaijen M, de Bakker D, Batenburg R, de Bont A. Do project management and network governance contribute to inter-organisational collaboration in primary care? A mixed methods study. BMC Health Serv Res 2018; 18:427. [PMID: 29879971 PMCID: PMC5992666 DOI: 10.1186/s12913-018-3169-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 04/30/2018] [Indexed: 11/13/2022] Open
Abstract
Background The need for organisational development in primary care has increased as it is accepted as a means of curbing rising costs and responding to demographic transitions. It is only within such inter-organisational networks that small-scale practices can offer treatment to complex patients and continuity of care. The aim of this paper is to explore, through the experience of professionals and patients, whether, and how, project management and network governance can improve the outcomes of projects which promote inter-organisational collaboration in primary care. Methods This paper describes a study of projects aimed at improving inter-organisational collaboration in Dutch primary care. The projects' success in project management and network governance was monitored by interviewing project leaders and board members on the one hand, and improvement in the collaboration by surveying professionals and patients on the other. Both qualitative and quantitative methods were applied to assess the projects. These were analysed, finally, using multi-level models in order to account for the variation in the projects, professionals and patients. Results Successful network governance was associated positively with the professionals’ satisfaction with the collaboration; but not with improvements in the quality of care as experienced by patients. Neither patients nor professionals perceived successful project management as associated with the outcomes of the collaboration projects. Conclusions This study shows that network governance in particular makes a difference to the outcomes of inter-organisational collaboration in primary care. However, project management is not a predictor for successful inter-organisational collaboration in primary care. Electronic supplementary material The online version of this article (10.1186/s12913-018-3169-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sanneke Schepman
- NIVEL, Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN, Utrecht, the Netherlands.
| | - Pim Valentijn
- Department of Health Services Research, School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, PO Box 616, 6200MD, Maastricht, the Netherlands.,Integrated Care Evaluation, Essenburgh Research & Consultancy, Hierden, The Netherlands
| | - Marc Bruijnzeels
- Jan van Es Institute, Netherlands Expert Centre Integrated Primary Care, Randstad 2145-a, 1314 BG, Almere, The Netherlands
| | - Marlies Maaijen
- Institute of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR, Rotterdam, the Netherlands
| | - Dinny de Bakker
- NIVEL, Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN, Utrecht, the Netherlands
| | - Ronald Batenburg
- NIVEL, Netherlands Institute for Health Services Research, PO Box 1568, 3500 BN, Utrecht, the Netherlands.,Department of Sociology, Radboud University Nijmegen, P.O. Box 9104, 6500 HE, Nijmegen, the Netherlands
| | - Antoinette de Bont
- Institute of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR, Rotterdam, the Netherlands
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Rutz S, van de Bovenkamp H, Buitendijk S, Robben P, de Bont A. Inspectors' responses to adolescents' assessment of quality of care: a case study on involving adolescents in inspections. BMC Health Serv Res 2018; 18:226. [PMID: 29606117 PMCID: PMC5880074 DOI: 10.1186/s12913-018-2998-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 03/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Users of care services are increasingly participating in inspections of the quality of care. In practice, incorporating service users' views is difficult, as users may have other views on good care than inspectors and thus give information that does not fit the inspectors' assessment criteria. This study compared the views on good care of young care users (adolescents) and inspectors, seeking to understand what the differences and similarities mean to incorporating the users' views in inspections. METHODS We conducted a single-case study combining document analysis with a meeting with inspectors. The selected case came from a Dutch inspectorate and involved a thematic inspection of care for children growing up poor. RESULTS Inspectors and adolescents agree on the importance of timely care, creating opportunities for personal development, and a respectful relationship. The views on quality of care differ with regard to sharing information, creating solutions, and the right moment to offer help. We identified three ways inspectors deal with the differences: 1) prioritize their own views, 2) pass the problem onto others to solve, and 3) separate the differing perspectives. With similar viewpoints, inspectors use the adolescents' views to support their assessments. When viewpoints conflict, information from adolescents does not affect the inspectors' judgments. Explanations are related to the vulnerability of the adolescents involved, the inspectorate's organizational rules and routines and the external regulatory context. CONCLUSIONS Service user involvement in inspections potentially impacts the quality of care. Yet, conflicts between the views of service users and inspectors are not easily overcome in the regulatory context.
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Affiliation(s)
- Suzanne Rutz
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands
- Joint Inspectorate Social Domain, Utrecht, The Netherlands
- Health and Youth Care Inspectorate, Utrecht, The Netherlands
| | - Hester van de Bovenkamp
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands
| | | | - Paul Robben
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Antoinette de Bont
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands
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Felder M, van de Bovenkamp H, de Bont A. Politics of policy learning: Evaluating an experiment on free pricing arrangements in Dutch dental care. Evaluation (Lond) 2018; 24:6-25. [PMID: 29568225 PMCID: PMC5836526 DOI: 10.1177/1356389017750194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
In Dutch healthcare, new market mechanisms have been introduced on an experimental basis in an attempt to contain costs and improve quality. Informed by a constructivist approach, we demonstrate that such experiments are not neutral testing grounds. Drawing from semi-structured interviews and policy texts, we reconstruct an experiment on free pricing in dental care that turned into a critical example of market failure, influencing developments in other sectors. Our analysis, however, shows that (1) different market logics and (2) different experimental logics were reproduced simultaneously during the course of the experiment. We furthermore reveal how (3) evaluation and political life influenced which logics were reproduced and became taken as the lessons learned. We use these insights to discuss the role of evaluation in learning from policy experimentation and close with four questions that evaluators could ask to better understand what is learned from policy experiments, how, and why.
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Affiliation(s)
- Martijn Felder
- Martijn Felder, Erasmus School of Health Policy & Management, Erasmus University, P.O. Box. 1738, 3000 DR, Rotterdam, The Netherlands.
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Leijten FR, Struckmann V, van Ginneken E, Czypionka T, Kraus M, Reiss M, Tsiachristas A, Boland M, de Bont A, Bal R, Busse R, Rutten-van Mölken M. The SELFIE framework for integrated care for multi-morbidity: Development and description. Health Policy 2018; 122:12-22. [DOI: 10.1016/j.healthpol.2017.06.002] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 05/31/2017] [Accepted: 06/12/2017] [Indexed: 12/17/2022]
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de Bont A, van Exel J, Coretti S, Ökem ZG, Janssen M, Hope KL, Ludwicki T, Zander B, Zvonickova M, Bond C, Wallenburg I. Reconfiguring health workforce: a case-based comparative study explaining the increasingly diverse professional roles in Europe. BMC Health Serv Res 2016; 16:637. [PMID: 27825345 PMCID: PMC5101691 DOI: 10.1186/s12913-016-1898-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 11/02/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Over the past decade the healthcare workforce has diversified in several directions with formalised roles for health care assistants, specialised roles for nurses and technicians, advanced roles for physician associates and nurse practitioners and new professions for new services, such as case managers. Hence the composition of health care teams has become increasingly diverse. The exact extent of this diversity is unknown across the different countries of Europe, as are the drivers of this change. The research questions guiding this study were: What extended professional roles are emerging on health care teams? How are extended professional roles created? What main drivers explain the observed differences, if any, in extended roles in and between countries? METHODS We performed a case-based comparison of the extended roles in care pathways for breast cancer, heart disease and type 2 diabetes. We conducted 16 case studies in eight European countries, including in total 160 interviews with physicians, nurses and other health care professionals in new roles and 600+ hours of observation in health care clinics. RESULTS The results show a relatively diverse composition of roles in the three care pathways. We identified specialised roles for physicians, extended roles for nurses and technicians, and independent roles for advanced nurse practitioners and physician associates. The development of extended roles depends upon the willingness of physicians to delegate tasks, developments in medical technology and service (re)design. Academic training and setting a formal scope of practice for new roles have less impact upon the development of new roles. While specialised roles focus particularly on a well-specified technical or clinical domain, the generic roles concentrate on organising and integrating care and cure. CONCLUSION There are considerable differences in the number and kind of extended roles between both countries and care pathways. The main drivers for new roles reside in the technological development of medical treatment and the need for more generic competencies. Extended roles develop in two directions: 1) specialised roles and 2) generic roles.
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Affiliation(s)
- Antoinette de Bont
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Job van Exel
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Silvia Coretti
- Postgraduate School of Health Economics and management (ALTEMS), Universita Cattolica del Sacro Cuore School of Economics, Milan, Italy
| | - Zeynep Güldem Ökem
- Faculty of Economics and Administrative Sciences, TOBB University of Economics and Technology, Ankara, Turkey
| | - Maarten Janssen
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | | | - Tomasz Ludwicki
- Faculty of Management, the University of Warsaw, Warsaw, Poland
| | - Britta Zander
- Faculty of Economics and Management, Technische Universität Berlin, Berlin, Germany
| | - Marie Zvonickova
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Christine Bond
- Division of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland
| | - Iris Wallenburg
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - On behalf of the MUNROS Team
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
- Postgraduate School of Health Economics and management (ALTEMS), Universita Cattolica del Sacro Cuore School of Economics, Milan, Italy
- Faculty of Economics and Administrative Sciences, TOBB University of Economics and Technology, Ankara, Turkey
- Uni Research Rokkan Centre, Bergen, Norway
- Faculty of Management, the University of Warsaw, Warsaw, Poland
- Faculty of Economics and Management, Technische Universität Berlin, Berlin, Germany
- Third Faculty of Medicine, Charles University, Prague, Czech Republic
- Division of Applied Health Sciences, University of Aberdeen, Aberdeen, Scotland
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Bond C, Bruhn H, de Bont A, van Exel J, Busse R, Sutton M, Elliott R. The iMpact on practice, oUtcomes and costs of New roles for health pROfeSsionals: a study protocol for MUNROS. BMJ Open 2016; 6:e010511. [PMID: 27118286 PMCID: PMC4853978 DOI: 10.1136/bmjopen-2015-010511] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/29/2016] [Accepted: 03/21/2016] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION The size and composition of the European Union healthcare workforce are key drivers of expenditure and performance; it now includes new health professions and enhanced roles for established professions. This project will systematically analyse how this has contributed to health service redesign, integration and performance in 9 European countries (Scotland, England, Netherlands, Germany, Italy, Czech Republic, Poland, Norway, and Turkey(i)). This paper describes the protocol for collection of survey data in 3 distinct care pathways, and sets it in the context of the wider programme. METHODS Questionnaires will be distributed to healthcare professionals (n=14,580), managers (n=3564) and patients (n=19,440) in 3 care pathways (breast cancer; type 2 diabetes; and coronary heart disease) within 12 hospitals and associated primary care settings in each country. Questionnaire topics will include demography, the different professionals working on the care pathway, the tasks they do and the time taken, their decision-making abilities when considering skill mix, specialisation and integration of care. Patient satisfaction, healthcare utilisation and preferences will be explored. In later work, register data and data from patient records will be used to record clinical outcomes. Data will also be collected on workforce and procedure costs. Descriptive analysis will identify the different models of care and multivariate analysis will establish the most clinically and cost-effective models. ETHICS AND DISSEMINATION This protocol was approved by ethical committees in each country. Findings will be disseminated through national/international clinical, health services research and health workforce conferences, and publications in national/international peer-reviewed journals.
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Affiliation(s)
- Christine Bond
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Hanne Bruhn
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Antoinette de Bont
- Institute of Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
| | - Job van Exel
- Institute of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - Reinhard Busse
- Department of Health Care Management, Technische Universität Berlin, Berlin, Germany
| | - Matthew Sutton
- Institute of Population Health, University of Manchester, Manchester, UK
| | - Robert Elliott
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Otte-Trojel T, Rundall TG, de Bont A, van de Klundert J. Can relational coordination help inter-organizational networks overcome challenges to coordination in patient portals? International Journal of Healthcare Management 2016. [DOI: 10.1080/20479700.2015.1101911] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Terese Otte-Trojel
- Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands
| | | | - Antoinette de Bont
- Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands
| | - Joris van de Klundert
- Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands
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Otte-Trojel T, Rundall TG, de Bont A, van de Klundert J, Reed ME. The organizational dynamics enabling patient portal impacts upon organizational performance and patient health: a qualitative study of Kaiser Permanente. BMC Health Serv Res 2015; 15:559. [PMID: 26674529 PMCID: PMC4682282 DOI: 10.1186/s12913-015-1208-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Accepted: 12/03/2015] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Patient portals may lead to enhanced disease management, health plan retention, changes in channel utilization, and lower environmental waste. However, despite growing research on patient portals and their effects, our understanding of the organizational dynamics that explain how effects come about is limited. METHODS This paper uses qualitative methods to advance our understanding of the organizational dynamics that influence the impact of a patient portal on organizational performance and patient health. The study setting is Kaiser Permanente, the world's largest not-for-profit integrated delivery system, which has been using a portal for over ten years. We interviewed eighteen physician leaders and executives particularly knowledgeable about the portal to learn about how they believe the patient portal works and what organizational factors affect its workings. Our analytical framework centered on two research questions. (1) How does the patient portal impact care delivery to produce the documented effects?; and (2) What are the important organizational factors that influence the patient portal's development? RESULTS We identify five ways in which the patient portal may impact care delivery to produce reported effects. First, the portal's ability to ease access to services improves some patients' satisfaction as well as changes the way patients seek care. Second, the transparency and activation of information enable some patients to better manage their care. Third, care management may also be improved through augmented patient-physician interaction. This augmented interaction may also increase the 'stickiness' of some patients to their providers. Forth, a similar effect may be triggered by a closer connection between Kaiser Permanente and patients, which may reduce the likelihood that patients will switch health plans. Finally, the portal may induce efficiencies in physician workflow and administrative tasks, stimulating certain operational savings and deeper involvement of patients in medical decisions. Moreover, our analysis illuminated seven organizational factors of particular importance to the portal's development--and thereby ability to impact care delivery: alignment with financial incentives, synergy with existing IT infrastructure and operations, physician-led governance, inclusive decision making and knowledge sharing, regional flexibility to implementation, continuous innovation, and emphasis on patient-centered design. CONCLUSIONS These findings show how organizational dynamics enable the patient portal to affect care delivery by summoning organization-wide support for and use of a portal that meets patient needs.
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Affiliation(s)
- Terese Otte-Trojel
- Institute of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands. .,NNIT, Public and Healthcare Advisory, Østmarken, 3A, 2800, Soeborg, Denmark.
| | - Thomas G Rundall
- School of Public Health, University of California, Berkeley, Berkeley, CA, USA.
| | - Antoinette de Bont
- Institute of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Joris van de Klundert
- Institute of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Mary E Reed
- Kaiser Permanente Division of Research, Oakland, CA, USA.
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Valentijn PP, Ruwaard D, Vrijhoef HJM, de Bont A, Arends RY, Bruijnzeels MA. Collaboration processes and perceived effectiveness of integrated care projects in primary care: a longitudinal mixed-methods study. BMC Health Serv Res 2015; 15:463. [PMID: 26450573 PMCID: PMC4598962 DOI: 10.1186/s12913-015-1125-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/30/2015] [Indexed: 01/17/2023] Open
Abstract
Background Collaborative partnerships are considered an essential strategy for integrating local disjointed health and social services. Currently, little evidence is available on how integrated care arrangements between professionals and organisations are achieved through the evolution of collaboration processes over time. The first aim was to develop a typology of integrated care projects (ICPs) based on the final degree of integration as perceived by multiple stakeholders. The second aim was to study how types of integration differ in changes of collaboration processes over time and final perceived effectiveness. Methods A longitudinal mixed-methods study design based on two data sources (surveys and interviews) was used to identify the perceived degree of integration and patterns in collaboration among 42 ICPs in primary care in The Netherlands. We used cluster analysis to identify distinct subgroups of ICPs based on the final perceived degree of integration from a professional, organisational and system perspective. With the use of ANOVAs, the subgroups were contrasted based on: 1) changes in collaboration processes over time (shared ambition, interests and mutual gains, relationship dynamics, organisational dynamics and process management) and 2) final perceived effectiveness (i.e. rated success) at the professional, organisational and system levels. Results The ICPs were classified into three subgroups with: ‘United Integration Perspectives (UIP)’, ‘Disunited Integration Perspectives (DIP)’ and ‘Professional-oriented Integration Perspectives (PIP)’. ICPs within the UIP subgroup made the strongest increase in trust-based (mutual gains and relationship dynamics) as well as control-based (organisational dynamics and process management) collaboration processes and had the highest overall effectiveness rates. On the other hand, ICPs with the DIP subgroup decreased on collaboration processes and had the lowest overall effectiveness rates. ICPs within the PIP subgroup increased in control-based collaboration processes (organisational dynamics and process management) and had the highest effectiveness rates at the professional level. Conclusions The differences across the three subgroups in terms of the development of collaboration processes and the final perceived effectiveness provide evidence that united stakeholders’ perspectives are achieved through a constructive collaboration process over time. Disunited perspectives at the professional, organisation and system levels can be aligned by both trust-based and control-based collaboration processes. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1125-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Pim P Valentijn
- Jan van Es Institute, Netherlands Expert Centre Integrated Primary Care, Wisselweg 33, 1314 CB, Almere, The Netherlands. .,Scientific Centre for Care and Welfare (Tranzo), Tilburg University, Tilburg, The Netherlands.
| | - Dirk Ruwaard
- Department of Health Services Research, School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Hubertus J M Vrijhoef
- Scientific Centre for Care and Welfare (Tranzo), Tilburg University, Tilburg, The Netherlands. .,Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.
| | - Antoinette de Bont
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Rosa Y Arends
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands.
| | - Marc A Bruijnzeels
- Jan van Es Institute, Netherlands Expert Centre Integrated Primary Care, Wisselweg 33, 1314 CB, Almere, The Netherlands.
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Otte-Trojel T, de Bont A, Rundall TG, van de Klundert J. What do we know about developing patient portals? a systematic literature review. J Am Med Inform Assoc 2015; 23:e162-8. [PMID: 26335985 DOI: 10.1093/jamia/ocv114] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 06/29/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Numerous articles have reported on the development of patient portals, including development problems and solutions. We review these articles to inform future patient portal development efforts and to provide a summary of the evidence base that can guide future research. MATERIALS AND METHODS We performed a systematic review of relevant literature to answer 5 questions: (1) What categories of problems related to patient portal development have been defined? (2) What causal factors have been identified by problem analysis and diagnosis? (3) What solutions have been proposed to ameliorate these causal factors? (4) Which proposed solutions have been implemented and in which organizational contexts? (5) Have implemented solutions been evaluated and what learning has been generated? Through searches on PubMed, ScienceDirect and LISTA, we included 109 articles. RESULTS We identified 5 main problem categories: achieving patient engagement, provider engagement, appropriate data governance, security and interoperability, and a sustainable business model. Further, we identified key factors contributing to these problems as well as solutions proposed to ameliorate them. While about half (45) of the 109 articles proposed solutions, fewer than half of these solutions (18) were implemented, and even fewer (5) were evaluated to generate learning about their effects. DISCUSSION Few studies systematically report on the patient portal development processes. As a result, the review does not provide an evidence base for portal development. CONCLUSION Our findings support a set of recommendations for advancement of the evidence base: future research should build on existing evidence, draw on principles from design sciences conveyed in the problem-solving cycle, and seek to produce evidence within various different organizational contexts.
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Affiliation(s)
- Terese Otte-Trojel
- Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands
| | - Antoinette de Bont
- Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands
| | - Thomas G Rundall
- School of Public Health, University of California Berkeley, Berkeley, California, USA
| | - Joris van de Klundert
- Institute of Health Policy and Management, Erasmus University Rotterdam, The Netherlands
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Otte-Trojel T, de Bont A, Rundall TG, van de Klundert J. Response to Randell et al. “Using realist reviews to understand how health IT works, for whom, and in what circumstances”. J Am Med Inform Assoc 2015; 22:e218. [DOI: 10.1093/jamia/ocu008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 10/18/2014] [Indexed: 11/13/2022] Open
Affiliation(s)
- Terese Otte-Trojel
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, PA 3062, The Netherlands
| | - Antoinette de Bont
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, PA 3062, The Netherlands
| | - Thomas G. Rundall
- School of Public Health, University of California Berkeley, Berkeley, CA 94704, USA
| | - Joris van de Klundert
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, PA 3062, The Netherlands
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Valentijn PP, Vrijhoef HJM, Ruwaard D, de Bont A, Arends RY, Bruijnzeels MA. Exploring the success of an integrated primary care partnership: a longitudinal study of collaboration processes. BMC Health Serv Res 2015; 15:32. [PMID: 25609186 PMCID: PMC4310187 DOI: 10.1186/s12913-014-0634-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Accepted: 12/08/2014] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Forming partnerships is a prominent strategy used to promote integrated service delivery across health and social service systems. Evidence about the collaboration process upon which partnerships evolve has rarely been addressed in an integrated-care setting. This study explores the longitudinal relationship of the collaboration process and the influence on the final perceived success of a partnership in such a setting. The collaboration process through which partnerships evolve is based on a conceptual framework which identifies five themes: shared ambition, interests and mutual gains, relationship dynamics, organisational dynamics and process management. METHODS Fifty-nine out of 69 partnerships from a national programme in the Netherlands participated in this survey study. At baseline, 338 steering committee members responded, and they returned 320 questionnaires at follow-up. Multiple-regression-analyses were conducted to explore the relationship between the baseline as well as the change in the collaboration process and the final success of the partnerships. RESULTS Mutual gains and process management were the most significant baseline predictors for the final success of the partnership. A positive change in the relationship dynamics had a significant effect on the final success of a partnership. CONCLUSIONS Insight into the collaboration process of integrated primary care partnerships offers a potentially powerful way of predicting their success. Our findings underscore the importance of monitoring the collaboration process during the development of the partnerships in order to achieve their full collaborative advantage.
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Affiliation(s)
- Pim P Valentijn
- Jan van Es Institute, Netherlands Expert Centre Integrated Primary Care, Randstad 2145-a, 1314 BG, Almere, The Netherlands.
- Scientific Centre for Care and Welfare (Tranzo), Tilburg University, Tilburg, The Netherlands.
| | - Hubertus J M Vrijhoef
- Scientific Centre for Care and Welfare (Tranzo), Tilburg University, Tilburg, The Netherlands.
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore.
| | - Dirk Ruwaard
- Department of Health Services Research, School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | - Antoinette de Bont
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Rosa Y Arends
- Department of Psychology, Health & Technology, University of Twente, Enschede, The Netherlands.
| | - Marc A Bruijnzeels
- Jan van Es Institute, Netherlands Expert Centre Integrated Primary Care, Randstad 2145-a, 1314 BG, Almere, The Netherlands.
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Otte-Trojel T, de Bont A, van de Klundert J, Rundall TG. Characteristics of patient portals developed in the context of health information exchanges: early policy effects of incentives in the meaningful use program in the United States. J Med Internet Res 2014; 16:e258. [PMID: 25447837 PMCID: PMC4260079 DOI: 10.2196/jmir.3698] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 08/21/2014] [Accepted: 09/13/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND In 2014, the Centers for Medicare & Medicaid Services in the United States launched the second stage of its Electronic Health Record (EHR) Incentive Program, providing financial incentives to providers to meaningfully use their electronic health records to engage patients online. Patient portals are electronic means to engage patients by enabling secure access to personal medical records, communication with providers, various self-management tools, and administrative functionalities. Outcomes of patient portals have mainly been reported in large integrated health systems. This may now change as the EHR Incentive Program enables and supports the use of patient portals in other types of health systems. In this paper, we focus on Health Information Exchanges (HIE): entities that facilitate data exchange within networks of independent providers. OBJECTIVE In response to the EHR Incentive Program, some Health Information Exchanges in the United States are developing patient portals and offering them to their network of providers. Such patient portals hold high value for patients, especially in fragmented health system contexts, due to the portals' ability to integrate health information from an array of providers and give patients one access point to this information. Our aim was to report on the early effects of the EHR incentives on patient portal development by HIEs. Specifically, we describe the characteristics of these portals, identify factors affecting adoption by providers during the 2013-2014 time frame, and consider what may be the primary drivers of providers' adoption of patient portals in the future. METHODS We identified four HIEs that were developing patient portals as of spring 2014. We collected relevant documents and conducted interviews with six HIE leaders as well as two providers that were implementing the portals in their practices. We performed content analysis on these data to extract information pertinent to our study objectives. RESULTS Our findings suggest that there are two primary types of patient portals available to providers in HIEs: (1) portals linked to EHRs of individual providers or health systems and (2) HIE-sponsored portals that link information from multiple providers' EHRs. The decision of providers in the HIEs to adopt either one of these portals appears to be a trade-off between functionality, connectivity, and cost. Our findings also suggest that while the EHR Incentive Program is influencing these decisions, it may not be enough to drive adoption. Rather, patient demand for access to patient portals will be necessary to achieve widespread portal adoption and realization of potential benefits. CONCLUSIONS Optimizing patient value should be the main principle underlying policies intending to increase online patient engagement in the third stage of the EHR Incentive Program. We propose a number of features for the EHR Incentive Program that will enhance patient value and thereby support the growth and sustainability of patient portals provided by Health Information Exchanges.
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Affiliation(s)
- Terese Otte-Trojel
- Health Services Management & Organization, Institute of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, Netherlands.
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Otte-Trojel T, de Bont A, Rundall TG, van de Klundert J. How outcomes are achieved through patient portals: a realist review. J Am Med Inform Assoc 2014; 21:751-7. [PMID: 24503882 DOI: 10.1136/amiajnl-2013-002501] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To examine how patient portals contribute to health service delivery and patient outcomes. The specific aims were to examine how outcomes are produced, and how variations in outcomes can be explained. METHODS We used a realist review method, which aims to describe how 'an intervention works, for whom, and in what circumstances' by analyzing patterns between context, mechanism, and outcomes. We reviewed 32 evaluation studies of patient portals published since 2003. RESULTS The reviewed evaluations indicate that as a complement to existing health services, patient portals can lead to improvements in clinical outcomes, patient behavior, and experiences. Four different mechanisms are reported to yield the reported outcome improvements. These are patient insight into personal health information, activation of information, interpersonal continuity of care, and service convenience. The vast majority of evaluations were conducted in integrated health service networks in the USA, and we detected no substantial variation in outcomes across these networks. DISCUSSION AND CONCLUSIONS Patient portals may impact clinical outcomes and health service delivery through multiple mechanisms. Given the relative uniformity of evaluation contexts, we were not able to detect patterns in how patient portals work in different contexts. Nonetheless, it appears from the overwhelming proportion of patient portal evaluations coming from integrated health service networks, that these networks provide more fertile contexts for patient portals to be effective. To improve the understanding of how patient portals work, future evaluations of patient portals should capture information about mechanisms and context that influence their outcomes.
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Affiliation(s)
- Terese Otte-Trojel
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Antoinette de Bont
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Thomas G Rundall
- School of Public Health, University of California-Berkeley, Berkeley, California, USA
| | - Joris van de Klundert
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Backhaus R, van Exel J, de Bont A. Employees' views on home-based, after-hours telephone triage by Dutch GP cooperatives. Int J Emerg Med 2013; 6:42. [PMID: 24188407 PMCID: PMC4177141 DOI: 10.1186/1865-1380-6-42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 10/17/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dutch out-of-hours (OOH) centers find it difficult to attract sufficient triage staff. They regard home-based triage as an option that might attract employees. Specially trained nurses are supposed to conduct triage by telephone from home for after-hours medical care. The central aim of this research is to investigate the views of employees of OOH centers in The Netherlands on home-based telephone triage in after-hours care. METHODS The study is a Q methodology study. Triage nurses, general practitioners (GPs) and managers of OOH centers ranked 36 opinion statements on home-based triage. We interviewed 10 participants to help develop and validate the statements for the Q sort, and 77 participants did the Q sort. RESULTS We identified four views on home-based telephone triage. Two generally favor home-based triage, one highlights some concerns and conditions, and one opposes it out of concern for quality. The four views perceive different sources of credibility for nurse triagists working from home. CONCLUSION Home-based telephone triage is a controversial issue among triage nurses, GPs and managers of OOH centers. By identifying consensus and dissension among GPs, triagists, managers and regulators, this study generates four perspectives on home-based triage. In addition, it reveals the conditions considered important for home-based triage.
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Affiliation(s)
| | | | - Antoinette de Bont
- Institute of Health Policy and Management, Erasmus University Rotterdam, P,O, Box 1738, 3000 DR, Rotterdam, The Netherlands.
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Wallenburg I, Helderman JK, de Bont A, Scheele F, Meurs P. Negotiating authority: a comparative study of reform in medical training regimes. J Health Polit Policy Law 2012; 37:439-467. [PMID: 22323238 DOI: 10.1215/03616878-1573085] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Recently the medical profession has faced increased outside pressure to reform postgraduate medical training programs to better equip young doctors for changing health care needs and public expectations. In this article we explore the impact of reform on professional self-governance by conducting a comparative historical-institutional analysis of postgraduate medical training reform in the United Kingdom and the Netherlands. In both countries the medical training regime has shifted from professional self-regulation to coregulation. Yet there are notable differences in each country that cannot be explained solely by diverging institutional contexts. They also result from the strategic actions by the actors involved. Based on an assessment of the recent literature on institutional transformation, this article shows how strategic actions set negotiating authority processes into motion, producing new and sometimes surprising institutional arrangements that can have profound effects on the distribution and allocation of authority in the medical training regime. It stresses the need to study the interactions among political context, the properties of institutions, and negotiating authority processes, as they are crucially important to understanding institutional transformation.
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Niazkhani Z, Pirnejad H, de Bont A, Aarts J. CPOE in Non-Surgical Versus Surgical Specialties: A Qualitative Comparison of Clinical Contexts in the Medication Process. Open Med Inform J 2010; 4:206-13. [PMID: 21594008 PMCID: PMC3096890 DOI: 10.2174/1874431101004010206] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Revised: 10/01/2009] [Accepted: 11/13/2009] [Indexed: 11/22/2022] Open
Abstract
Background: Computerized provider order entry (CPOE) systems are implemented in various clinical contexts of a hospital. To identify the role of the clinical context in CPOE use, we compared the impact of a CPOE system on the medication process in both non-surgical and surgical specialties. Methods: We conducted a qualitative study of surgical and non-surgical specialties in a 1237-bed, academic hospital in the Netherlands. We interviewed the clinical end users of a computerized medication order entry system in both specialty types and analyzed the interview transcripts to elicit qualitative differences between the clinical contexts, clinicians’ attitudes, and specialty-specific requirements. Results: Our study showed that the differences in clinical contexts between non-surgical and surgical specialties resulted in a disparity between clinicians’ requirements when using CPOE. Non-surgical specialties had a greater medication workload, greater and more diverse information needs to be supported in a timely manner by the system, and thus more intensive interaction with the CPOE system. In turn these factors collectively influenced the perceived impact of the CPOE system on the clinicians’ practice. The non-surgical clinicians expressed less positive attitudes compared to the surgical clinicians, who perceived their interaction with the system to be less intensive and less problematic. Conclusion: Our study shows that clinicians’ different attitudes towards the system and the perceived impact of the system were largely grounded in the clinical context of the units. The study suggests that not merely the CPOE system, the technology itself, influences the perceptions of its users and workflow-related outcomes. The interplay between technology and clinical context of the implementation environment also matters. System design and redesigning efforts should take account of different units’ specific requirements in their particular clinical contexts.
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Affiliation(s)
- Zahra Niazkhani
- Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
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Wallenburg I, van Exel J, Stolk E, Scheele F, de Bont A, Meurs P. Between trust and accountability: different perspectives on the modernization of postgraduate medical training in the Netherlands. Acad Med 2010; 85:1082-90. [PMID: 20505413 DOI: 10.1097/acm.0b013e3181dc1f0f] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
PURPOSE Postgraduate medical training was reformed to be more responsive to changing societal needs. In the Netherlands, as in various other Western countries, a competency-based curriculum was introduced reflecting the clinical and nonclinical roles a modern doctor should fulfill. It is still unclear, however, what this modernization process exactly comprises and what its consequences might be for clinical practice and medical work. METHOD The authors conducted a Q methodological study to investigate which different perspectives exist on the modernization of postgraduate medical training among actors involved. RESULTS The authors found four distinct perspectives, reflecting the different features of medical training. The accountability perspective stresses the importance of formal regulations within medical training and the monitoring of results in order to be more transparent and accountable to society. According to the educational perspective, medical training should be more formalized and directed at the educational process. The work-life balance perspective stresses the balance between a working life and a private life, as well as the changing professional relationship between staff members and residents. The trust-based perspective reflects the classic view of medical training in which role modeling and trust are considered most important. CONCLUSIONS The four perspectives on the modernization of postgraduate medical training show that various aspects of the modernization process are valued differently by stakeholders, highlighting important sources of agreement and disagreement between them. An important source of disagreement is diverging expectations of the role of physicians in modern medical practice.
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Affiliation(s)
- Iris Wallenburg
- Institute of Health Policy and Management, Erasmus University, Rotterdam, the Netherlands
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Stolk EA, de Bont A, van Halteren AR, Bijlmer RJ, Poley MJ. Role of health technology assessment in shaping the benefits package in The Netherlands. Expert Rev Pharmacoecon Outcomes Res 2009; 9:85-94. [PMID: 19371181 DOI: 10.1586/14737167.9.1.85] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In many countries of the Western world, the role of health technology assessment (HTA) in funding decisions of medical technologies is increasing. HTAs are expected to support decision-makers in delineating the collectively funded benefits package. To maximize their potential, it is essential that assessments are valid, reliable and timely, and that it is transparent how information provided in assessments is used in decision-making. Against this background, this article aims to review the current state of affairs regarding the use of HTA in the area of medical specialist care in The Netherlands and to evaluate strengths and weaknesses of the HTA-based system for priority setting. The reason to do so was the introduction of a new hospital financing system in The Netherlands, which allowed for expansion of the HTA system that already existed for pharmaceuticals to medical specialist care. A comprehensive account of the HTA system for medical specialist care was created using the so-called Hutton framework, followed by an exploration of its strengths and weaknesses. An important lesson to be learned from the early Dutch experiences with HTA in the area of medical specialist care is that the nature and complexity of health technologies in this area create practical problems regarding the amount and quality of available data needed to make the HTA-based system work. This hampers an unambiguous interpretation of assessment data and thus calls for stronger requirements regarding transparency and stakeholder participation. Future work focusing on the role of HTA in funding decisions is needed to provide insights in best practices for HTA systems in circumstances where a delicate balance needs to be achieved between promoting innovation, supporting effective and timely decision-making and preventing the coverage of technologies that represent a waste of resources.
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Affiliation(s)
- Elly A Stolk
- Institute for Medical Technology Assessment, and Institute of Health Policy and Management, Erasmus MC, Rotterdam, The Netherlands.
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de Bont A, Bal R. Telemedicine in interdisciplinary work practices: on an IT system that met the criteria for success set out by its sponsors, yet failed to become part of every-day clinical routines. BMC Med Inform Decis Mak 2008; 8:47. [PMID: 18954428 PMCID: PMC2615749 DOI: 10.1186/1472-6947-8-47] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2007] [Accepted: 10/27/2008] [Indexed: 11/15/2022] Open
Abstract
Background Information systems can play a key role in care innovations including task redesign and shared care. Many demonstration projects have presented evidence of clinical and cost effectiveness and high levels of patient satisfaction. Yet these same projects often fail to become part of everyday clinical routines. The aim of the paper is to gain insight into a common paradox that a technology can meet the criteria for success set out at the start of the project yet fail to become part of everyday clinical routines. Methods We evaluated a telecare service set up to reduce the workload of ophthalmologists. In this project, optometrists in 10 optical shops made digital images to detect patients with glaucoma which were further assessed by trained technicians in the hospital. Over a period of three years, we conducted interviews with the project team and the users about the workability of the system and its integration in practice. Beside the interviews, we analyzed record data to measure the quality of the images. We compared the qualitative accounts with these measurements. Results According to our measurements, the quality of the images was at least satisfactory in 90% of the cases, i.e. the images could be used to screen the patients – reducing the workload of the ophthalmologist considerably. However, both the ophthalmologist and the optometrists became increasingly dissatisfied respectively with the perceived quality of the pictures and the perceived workload. Through a detailed analysis of how the professionals discussed the quality of the pictures, we re-constructed how the notion of quality of the images and being a good professional were constructed and linked. The IT system transformed into a quality system and, at the same time, transformed the notions of being a good professional. While a continuous dialogue about the quality of the pictures became an emblem for the quality of care, this dialogue was hindered by the system and the way the care process was structured. Conclusion To conceptualize what telemedicine does in interdisciplinary work practices, a fine-tuned analysis is needed to assess how IT systems re-shape the social relations between professional groups. Such transformations should not be exclusively attributed to the technology itself or to the professionals working with it. Instead we need to assess these technologies through an empirically grounded study of the sociotechnical functioning of telemedicine.
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Affiliation(s)
- Antoinette de Bont
- Department of Health Policy and Management, Erasmus University Medical Center, Post box 1738, 3000 DR Rotterdam, the Netherlands.
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Niazkhani Z, Pirnejad H, de Bont A, Aarts J. Evaluating inter-professional work support by a computerized physician order entry (CPOE) system. Stud Health Technol Inform 2008; 136:321-326. [PMID: 18487751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Physician-centered design for computerized physician order entry (CPOE) systems overlooks the collaborative, multi-professional nature of medical work. We analyzed the compatibility of the conceptual model of inter-professional workflow underlying a CPOE system with real-life workflow in the medication ordering and administration process. We conducted twenty-three semi-structured interviews with key informant users and analyzed the handwritten documents and computerized printouts used in daily work in a Dutch academic medical center. The interview transcripts were analyzed on the basis of three conceptual themes in the inter-professional workflow: division of tasks, flow of information, and task coordination. The CPOE system fundamentally reorganized the existing work procedures of the three professional groups involved, mainly by reassigning tasks and by reallocating areas of expertise. Although the system improved the flow of medication-related information from physicians to nurses or pharmacists, this flow was only in one direction; the system did not allow information transactions in the reverse direction. It also failed to coordinate the medication-related tasks of professionals from different disciplines. To maintain the necessary level of coordination, the professionals had been obliged to consider additional methods of communication, such as phone calls or face-to-face discussion. We identified several workflow integration issues after the implementation of a CPOE system. Our insights into these issues can help ensure that system design or redesign properly integrates all professional groups' tasks, information, and areas of expertise into those of the physicians. Only then can these systems support the actual inter-professional workflow in the medication process.
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Affiliation(s)
- Zahra Niazkhani
- Institute of Health Policy and Management (iBMG), Erasmus University Medical Center, Rotterdam, the Netherlands.
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de Bont A, Stoevelaar H, Bal R. Databases as policy instruments. About extending networks as evidence-based policy. BMC Health Serv Res 2007; 7:200. [PMID: 18062824 PMCID: PMC2194767 DOI: 10.1186/1472-6963-7-200] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2007] [Accepted: 12/07/2007] [Indexed: 11/10/2022] Open
Abstract
Background This article seeks to identify the role of databases in health policy. Access to information and communication technologies has changed traditional relationships between the state and professionals, creating new systems of surveillance and control. As a result, databases may have a profound effect on controlling clinical practice. Methods We conducted three case studies to reconstruct the development and use of databases as policy instruments. Each database was intended to be employed to control the use of one particular pharmaceutical in the Netherlands (growth hormone, antiretroviral drugs for HIV and Taxol, respectively). We studied the archives of the Dutch Health Insurance Board, conducted in-depth interviews with key informants and organized two focus groups, all focused on the use of databases both in policy circles and in clinical practice. Results Our results demonstrate that policy makers hardly used the databases, neither for cost control nor for quality assurance. Further analysis revealed that these databases facilitated self-regulation and quality assurance by (national) bodies of professionals, resulting in restrictive prescription behavior amongst physicians. Conclusion The databases fulfill control functions that were formerly located within the policy realm. The databases facilitate collaboration between policy makers and physicians, since they enable quality assurance by professionals. Delegating regulatory authority downwards into a network of physicians who control the use of pharmaceuticals seems to be a good alternative for centralized control on the basis of monitoring data.
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Affiliation(s)
- Antoinette de Bont
- ErasmusMC, Institute of Health Policy and Management, Postbox 1738, 3000 DR Rotterdam, The Netherlands.
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Abstract
Recent medical informatics and sociological literature has painted the image of a new type of patient--one that is reflexive and informed, with highly specified information needs and perceptions, as well as highly developed skills and tactics for acquiring information. Patients have been re-named "reflexive consumers." At the same time, literature about the questionable reliability of web-based information has suggested the need to create both user tools that have pre-selected information and special guidelines for individuals to use to check the individual characteristics of the information they encounter. In this article, we examine suggestions that individuals must be assisted in developing skills for "reflexive consumerism" and what these particular skills should be. Using two types of data (discursive data from websites and promotional items, and supplementary data from interviews and ethnographic observations carried out with those working to sustain these initiatives), we examine how users are directly addressed and discussed. We argue that these initiatives prescribe skills and practices that extend beyond finding and assessing information on the internet and demonstrate that they include ideals of consumerism and citizenship.
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Affiliation(s)
- Samantha Adams
- Department of Health Policy and Management, Erasmus University Medical Center, Postbus 1738, Woudestein, L Building, 3000DR Rotterdam, The Netherlands
| | - Antoinette de Bont
- Department of Health Policy and Management, Erasmus University Medical Center, Postbus 1738, Woudestein, L Building, 3000DR Rotterdam, The Netherlands
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Niezen M, de Bont A, Stolk E, Eyck A, Niessen L, Stoevelaar H. Conditional reimbursement within the Dutch drug policy. Health Policy 2007; 84:39-50. [PMID: 17207886 DOI: 10.1016/j.healthpol.2006.11.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2006] [Revised: 11/08/2006] [Accepted: 11/14/2006] [Indexed: 11/26/2022]
Abstract
In The Netherlands, conditional reimbursement is considered to be a promising approach to achieving more effective and efficient pharmaceutical care. Because of its formal status and nationwide regulation, conditional reimbursement may allow governments to better control medical decision-making. To evaluate the effects of conditional reimbursement on medicine use and its performance as a policy tool, we compared observed volumes of medicine use with expected volumes. In addition, we mapped the annual growth by analysing trends in the volumes of use of all conditionally reimbursed drugs; starting with the year the drug entered the market (using macro-level data). Next we explored five cases in depth (using micro-level data) in order to explore what fraction of individual prescriptions met the requirements. We also performed qualitative research (document analysis, interviews (N=65)) in order to obtain the stakeholders' perspectives on how the measure functions, as well as to interpret the case studies data further. The findings suggest that conditional reimbursement may be an effective policy instrument, but that several changes are needed to optimize its impact. These changes are predominantly related to transparency (e.g. conditions are set following clear procedures and criteria), legitimacy (conditions should be consistent with criteria for prioritization), feasibility of procedures to control appropriate use, and timely and appropriate commitment of the stakeholders.
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Affiliation(s)
- Maartje Niezen
- Institute of Health Policy and Management, Erasmus MC, Rotterdam, The Netherlands.
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Jansen YJFM, de Bont A, Foets M, Bruijnzeels M, Bal R. Tailoring intervention procedures to routine primary health care practice; an ethnographic process evaluation. BMC Health Serv Res 2007; 7:125. [PMID: 17683627 PMCID: PMC1959520 DOI: 10.1186/1472-6963-7-125] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2007] [Accepted: 08/07/2007] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Tailor-made approaches enable the uptake of interventions as they are seen as a way to overcome the incompatibility of general interventions with local knowledge about the organisation of routine medical practice and the relationship between the patients and the professionals in practice. Our case is the Quattro project which is a prevention programme for cardiovascular diseases in high-risk patients in primary health care centres in deprived neighbourhoods. This programme was implemented as a pragmatic trial and foresaw the importance of local knowledge in primary health care and internal, or locally made, guidelines. The aim of this paper is to show how this prevention programme, which could be tailored to routine care, was implemented in primary care. METHODS An ethnographic design was used for this study. We observed and interviewed the researchers and the practice nurses. All the research documents, observations and transcribed interviews were analysed thematically. RESULTS Our ethnographic process evaluation showed that the opportunity of tailoring intervention procedures to routine care in a pragmatic trial setting did not result in a well-organised and well-implemented prevention programme. In fact, the lack of standard protocols hindered the implementation of the intervention. Although it was not the purpose of this trial, a guideline was developed. Despite the fact that the developed guideline functioned as a tool, it did not result in the intervention being organised accordingly. However, the guideline did make tailoring the intervention possible. It provided the professionals with the key or the instructions needed to achieve organisational change and transform the existing interprofessional relations. CONCLUSION As tailor-made approaches are developed to enable the uptake of interventions in routine practice, they are facilitated by the brokering of tools such as guidelines. In our study, guidelines facilitated organisational change and enabled the transformation of existing interprofessional relations, and thus made tailoring possible. The attractive flexibility of pragmatic trial design in taking account of local practice variations may often be overestimated.
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Affiliation(s)
- Yvonne JFM Jansen
- Institute of Health Policy and Management, Erasmus MC Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Antoinette de Bont
- Institute of Health Policy and Management, Erasmus MC Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Marleen Foets
- Institute of Health Policy and Management, Erasmus MC Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Marc Bruijnzeels
- Stichting Lijn 1 Haaglanden, PO Box 138, 2270 ACVoorburg, The Netherlands
| | - Roland Bal
- Institute of Health Policy and Management, Erasmus MC Rotterdam, PO Box 1738, 3000 DR Rotterdam, The Netherlands
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de Mul M, de Bont A, Berg M. IT-supported skill-mix change and standardisation in integrated eyecare: lessons from two screening projects in The Netherlands. Int J Integr Care 2007; 7:e15. [PMID: 17627297 PMCID: PMC1894676 DOI: 10.5334/ijic.189] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2006] [Revised: 03/22/2007] [Accepted: 04/11/2007] [Indexed: 11/20/2022] Open
Abstract
Introduction Information Technology (IT) has the potential to significantly support skill-mix change and, thereby, to improve the efficiency and effectiveness of integrated care. Theory and methods IT and skill-mix change share an important precondition: the standardisation of work processes. Standardisation plays a crucial role in IT-supported skill-mix change. It is not a matter of more or less standardisation than in the ‘old’ situation, but about creating an optimal fit. We used qualitative data from our evaluation of two integrated-care projects in Dutch eyecare to identify domains where this fit is important. Results While standardisation was needed to delegate screening tasks from physicians to non-physicians, and to assure the quality of the integrated-care process as a whole, tensions arose in three domains: the performance of clinical tasks, the documentation, and the communication between professionals. Unfunctional standardisation led to dissatisfaction and distrust between the professionals involved in screening. Discussion and conclusion Although the integration seems promising, much work is needed to ensure a synergistic relationship between skill-mix change and IT. Developing IT-supported skill-mix change by means of standardisation is a matter of tailoring standardisation to fit the situation at hand, while dealing with the local constraints of available technology and organisational context.
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Affiliation(s)
- Marleen de Mul
- Institute of Health Policy and Management, Erasmus Medical Centre, Rotterdam, The Netherlands.
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Jansen YJFM, Bal R, Bruijnzeels M, Foets M, Frenken R, de Bont A. Coping with methodological dilemmas; about establishing the effectiveness of interventions in routine medical practice. BMC Health Serv Res 2006; 6:160. [PMID: 17166255 PMCID: PMC1713235 DOI: 10.1186/1472-6963-6-160] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2006] [Accepted: 12/13/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this paper is to show how researchers balance between scientific rigour and localisation in conducting pragmatic trial research. Our case is the Quattro Study, a pragmatic trial on the effectiveness of multidisciplinary patient care teams used in primary health care centres in deprived neighbourhoods of two major cities in the Netherlands for intensified secondary prevention of cardiovascular diseases. METHODS For this study an ethnographic design was used. We observed and interviewed the researchers and the practice nurses. All gathered research documents, transcribed observations and interviews were analysed thematically. RESULTS Conducting a pragmatic trial is a continuous balancing act between meeting methodological demands and implementing a complex intervention in routine primary health care. As an effect, the research design had to be adjusted pragmatically several times and the intervention that was meant to be tailor-made became a rather stringent procedure. CONCLUSION A pragmatic trial research is a dynamic process that, in order to be able to assess the validity and reliability of any effects of interventions must also have a continuous process of methodological and practical reflection. Ethnographic analysis, as we show, is therefore of complementary value.
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Affiliation(s)
- Yvonne JFM Jansen
- Institute of Health Policy and Management, Erasmus MC Rotterdam, P.O.Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Roland Bal
- Institute of Health Policy and Management, Erasmus MC Rotterdam, P.O.Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Marc Bruijnzeels
- Stichting Lijn 1 Haaglanden, P.O.Box 138, 2270 ACVoorburg, The Netherlands
| | - Marleen Foets
- Institute of Health Policy and Management, Erasmus MC Rotterdam, P.O.Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Rianne Frenken
- Institute of Health Policy and Management, Erasmus MC Rotterdam, P.O.Box 1738, 3000 DR Rotterdam, The Netherlands
| | - Antoinette de Bont
- Institute of Health Policy and Management, Erasmus MC Rotterdam, P.O.Box 1738, 3000 DR Rotterdam, The Netherlands
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de Bont A, Zandwijken G, Stolk E, Niessen L. Prioritisation by physicians in the Netherlands--the growth hormone example in drug reimbursement decisions. Health Policy 2006; 80:369-77. [PMID: 16684580 DOI: 10.1016/j.healthpol.2006.03.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2005] [Accepted: 03/31/2006] [Indexed: 10/24/2022]
Abstract
Drug treatment and reimbursement is an area of ever growing complexity in health priority setting. This paper assesses the National Registry of Growth Hormone Treatment (LRG) responsible for making prioritisation decisions in the Dutch drug reimbursement system in the treatment of growth hormone, using the framework for fairness. We used qualitative research consisting of semi-structured interviews and focus group sessions combined with quantitative methods to audit the decisions of the forum. The rationing decisions of the forum demonstrate accountability for reasonableness by the conditions for transparency, relevance, and appeal. Most rationales for the decisions are public and transparent. The patients and paediatricians see decisions made by the LRG as clinical and therefore relevant decisions. They also refer to extensive appeal procedures. The case also raises important issues regarding the legitimacy of expert-based priority setting as the cyclic nature of guideline development conflicts with the need for maintaining strict rationing criteria. In 13% of the patients, the sick funds did cover treatment as the forum advised them to do, but according to guideline criteria it may be unlikely that these patients have growth hormone deficiency. According to the LRG, however, only 2% of the decisions are inconsistent with the guidelines, as some criteria on what to do in case of more uncertainty, shifted. For the forum, it seems rather unthinkable to go against the professional norms, in spite of formal national regulations. For the Health Care Insurance Board (CVZ), it was not considered possible to go against national regulations, especially as professional norms have shifted without informing policy makers and patient representatives.
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Affiliation(s)
- Antoinette de Bont
- Department of Health Policy & Management, Erasmus MC, Post Box 1738, 3000 DR Rotterdam, The Netherlands.
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Abstract
INTRODUCTION In the discussion about helping lay end users find reliable health-related information on the web, lay assessment practices of the reliability of information are often dismissed as insufficient. It is suggested that patients do not check important background information (authors, dates) for the medical content on websites. However, little effort has been made to understand how lay practices enable patients to assess information reliability in respect to their specific health situations. OBJECTIVE This paper draws upon ethnographic research among Dutch patients to understand lay assessment practices. METHODS We conducted qualitative interviews and observed patient search practices. Patients were asked to describe and then repeat the last searches they had conducted. They were also given standardized questions for searching for information. RESULTS Patients did not utilize special user tools (checklists, seals, portals) to assist in searching for and evaluating information. However, we saw explicit strategies for checking information within their established patterns of searching, such as on and offline triangulation of information and checking information provider information and dates. CONCLUSION Although patients do not follow standardized checklists, this is not to say that they are not assessing information. Their assessment processes are more extensive than current literature suggests.
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Affiliation(s)
- Samantha Adams
- Erasmus University Medical Center, Department of Health Policy and Management (BMG), Postbus 1738, 3000 DR Rotterdam, The Netherlands.
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