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de Weerdt V, Ybema S, Repping S, van der Hijden E, Willems H. Do medical specialists accept claims-based Audit and Feedback for quality improvement? A focus group study. BMJ Open 2024; 14:e081063. [PMID: 38589258 PMCID: PMC11015254 DOI: 10.1136/bmjopen-2023-081063] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 02/28/2024] [Indexed: 04/10/2024] Open
Abstract
OBJECTIVES Audit and Feedback (A&F) is a widely used quality improvement (QI) intervention in healthcare. However, not all feedback is accepted by professionals. While claims-based feedback has been previously used for A&F interventions, its acceptance by medical specialists is largely unknown. This study examined medical specialists' acceptance of claims-based A&F for QI. DESIGN Qualitative design, with focus group discussions. Transcripts were analysed using discourse analysis. SETTING AND PARTICIPANTS A total of five online focus group discussions were conducted between April 2021 and September 2022 with 21 medical specialists from varying specialties (urology; paediatric surgery; gynaecology; vascular surgery; orthopaedics and trauma surgery) working in academic or regional hospitals in the Netherlands. RESULTS Participants described mixed views on using claims-based A&F for QI. Arguments mentioned in favour were (1) A&F stimulates reflective learning and improvement and (2) claims-based A&F is more reliable than other A&F. Arguments in opposition were that (1) A&F is insufficient to create behavioural change; (2) A&F lacks clinically meaningful interpretation; (3) claims data are invalid for feedback on QI; (4) claims-based A&F is unreliable and (5) A&F may be misused by health insurers. Furthermore, participants described several conditions for the implementation of A&F which shape their acceptance. CONCLUSIONS Using claims-based A&F for QI is, for some clinical topics and under certain conditions, accepted by medical specialists. Acceptance of claims-based A&F can be shaped by how A&F is implemented into clinical practice. When designing A&F for QI, it should be considered whether claims data, as the most resource-efficient data source, can be used or whether it is necessary to collect more specific data.
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Affiliation(s)
- Vera de Weerdt
- Department of Health Economics, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Sierk Ybema
- Department of Organization Sciences, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Organization Sciences, Anglia Ruskin University, Chelmsford, UK
| | - Sjoerd Repping
- Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Eric van der Hijden
- Department of Health Economics, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Zilveren Kruis Health Insurance, Leiden, The Netherlands
| | - Hanna Willems
- Department of Geriatrics, Amsterdam University Medical Centres, Amsterdam, The Netherlands
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Schippa L, Gaspar K, van der Hijden E, Koolman X. Attributing practice variation by its sources: the case of varicose veins treatments in the Netherlands. BMC Health Serv Res 2023; 23:1329. [PMID: 38037102 PMCID: PMC10690976 DOI: 10.1186/s12913-023-10328-7] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 11/14/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Unwarranted practice variation refers to regional differences in treatments that are not driven by patients' medical needs or preferences. Although it is the subject of numerous studies, most research focuses on variation at the end stage of treatment, i.e. the stage of the treating specialist, disregarding variation stemming from other sources (e.g. patient preferences, general practitioner referral patterns). In the present paper, we introduce a method that allows us to measure regional variation at different stages of the patient journey leading up to treatment. METHODS A series of logit regressions estimating the probability of (1) initial visit with the physician and (2) treatment correcting for patient needs and patient preferences. Calculating the coefficient of variation (CVU) at each stage of the patient journey. RESULTS Our findings show large regional variations in the probability of receiving an initial visit, The CVU, or the measure of dispersion, in the regional probability of an initial visit with a specialist was significantly larger (0.87-0.96) than at the point of treatment both conditional (0.14-0.25) and unconditional on an initial visit (0.65-0.74), suggesting that practice variation was present before the patient reached the specialist. CONCLUSIONS We present a new approach to attribute practice variation to different stages in the patient journey. We demonstrate our method using the clinically-relevant segment of varicose veins treatments. Our findings demonstrate that irrespective of the gatekeeping role of general practitioners (GPs), a large share of practice variation in the treatment of varicose veins is attributable to regional variation in primary care referrals. Contrary to expectation, specialists' decisions meaningfully diminish rather than increase the amount of regional variation.
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Affiliation(s)
- Luca Schippa
- Intelligence to Integrity (i2i), Amsterdam, The Netherlands
| | - Katalin Gaspar
- School of Business and Economics, Talma Institute / VU University Amsterdam, Section Health Economics, Amsterdam, The Netherlands.
- CPB Netherlands Bureau for Economic Policy Analysis, The Hague, The Netherlands.
| | - Eric van der Hijden
- School of Business and Economics, Talma Institute / VU University Amsterdam, Section Health Economics, Amsterdam, The Netherlands
- Zilveren Kruis (Achmea), Amersfoort, The Netherlands
| | - Xander Koolman
- School of Business and Economics, Talma Institute / VU University Amsterdam, Section Health Economics, Amsterdam, The Netherlands
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Steenhuis S, Hofstra G, Portrait F, Amankour F, Koolman X, van der Hijden E. The potential risk of using historic claims to set bundled payment prices: the case of physical therapy after lower extremity joint replacement. BMC Health Serv Res 2022; 22:1061. [PMID: 35986285 PMCID: PMC9392222 DOI: 10.1186/s12913-022-08410-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 07/30/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
One of the most significant challenges of implementing a multi-provider bundled payment contract is to determine an appropriate, casemix-adjusted total bundle price. The most frequently used approach is to leverage historic care utilization based on claims data. However, those claims data may not accurately reflect appropriate care (e.g. due to supplier induced demand and moral hazard effects). This study aims to examine variation in claims-based costs of post-discharge primary care physical therapy (PT) utilization after total knee and hip arthroplasties (TKA/THA) for osteoarthritis patients.
Methods
This retrospective cohort study used multilevel linear regression analyses to predict the factors that explain the variation in the utilization of post-discharge PT after TKA or THA for osteoarthritis patients, based on the historic (2015–2018) claims data of a large Dutch health insurer. The factors were structured as predisposing, enabling or need factors according to the behavioral model of Andersen.
Results
The 15,309 TKA and 14,325 THA patients included in this study received an average of 20.7 (SD 11.3) and 16.7 (SD 10.1) post-discharge PT sessions, respectively. Results showed that the enabling factor ‘presence of supplementary insurance’ was the strongest predictor for post-discharge PT utilization in both groups (TKA: β = 7.46, SE = 0.498, p-value< 0.001; THA: β = 5.72, SE = 0.515, p-value< 0.001). There were also some statistically significant predisposing and need factors, but their effects were smaller.
Conclusions
This study shows that if enabling factors (such as supplementary insurance coverage or co-payments) are not taken into account in risk-adjustment of the bundle price, they may cause historic claims-based pricing methods to over- or underestimate appropriate post-discharge primary care PT use, which would result in a bundle price that is either too high or too low. Not adjusting bundle prices for all relevant casemix factors is a risk because it can hamper the successful implementation of bundled payment contracts and the desired changes in care delivery it aims to support.
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Salampessy BH, Portrait FRM, van der Hijden E, Klink A, Koolman X. On the correlation between outcome indicators and the structure and process indicators used to proxy them in public health care reporting. Eur J Health Econ 2021; 22:1239-1251. [PMID: 34191196 PMCID: PMC8526472 DOI: 10.1007/s10198-021-01333-w] [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] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 06/02/2021] [Indexed: 06/13/2023]
Abstract
Hospital quality indicators provide valuable insights for quality improvement, empower patients to choose providers, and have become a cornerstone of value-based payment. As outcome indicators are cumbersome and expensive to measure, many health systems have relied on proxy indicators, such as structure and process indicators. In this paper, we assess the extent to which publicly reported structure and process indicators are correlated with outcome indicators, to determine if these provide useful signals to inform the public about the outcomes. Quality indicators for three conditions (breast and colorectal cancer, and hip replacement surgery) for Dutch hospitals (2011-2018) were collected. Structure and process indicators were compared to condition-specific outcome indicators and in-hospital mortality ratios in a between-hospital comparison (cross-sectional and between-effects models) and in within-hospital comparison (fixed-effects models). Systematic association could not be observed for any of the models. Both positive and negative signs were observed where negative associations were to be expected. Despite sufficient statistical power, the share of significant correlations was small [mean share: 13.2% (cross-sectional); 26.3% (between-effects); 13.2% (fixed-effects)]. These findings persisted in stratified analyses by type of hospital and in models using a multivariate approach. We conclude that, in the context of compulsory public reporting, structure and process indicators are not correlated with outcome indicators, neither in between-hospital comparisons nor in within-hospital comparisons. While structure and process indicators remain valuable for internal quality improvement, they are unsuitable as signals for informing the public about hospital differences in health outcomes.
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Affiliation(s)
- Benjamin H. Salampessy
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - France R. M. Portrait
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - Eric van der Hijden
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - Ab Klink
- Department of Political Science and Public Administration, Faculty of Social Sciences, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - Xander Koolman
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
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Gaspar K, Portrait F, van der Hijden E, Koolman X. Global budget versus cost ceiling: a natural experiment in hospital payment reform in the Netherlands. Eur J Health Econ 2020; 21:105-114. [PMID: 31529343 PMCID: PMC7058687 DOI: 10.1007/s10198-019-01114-6] [Citation(s) in RCA: 5] [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] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 08/27/2019] [Indexed: 05/19/2023]
Abstract
Global budget (GB) arrangements have become a popular method worldwide to control the rise in healthcare expenditures. By guaranteeing hospital funding, payers hope to eliminate the drive for increased production, and incentivize providers to deliver more efficient care and lower utilization. We evaluated the introduction of GB contracts by certain large insurers in Dutch hospital care in 2012 and compared health care utilization to those insurers who continued with more traditional production-based contracts, i.e., cost ceiling (CC) contracts. We used the share of GB hospital funding per postal code region to study the effect of contract types. Our findings show that having higher share of GB financing was associated with lower growth in treatment intensity, but it was also associated with higher growth in the probability of having at least one hospital visit. While the former finding is in line with our expectation, the latter is not and suggests that hospital visits may take longer to respond to contract incentives. Our study covers the years of 2010-2013 (2 years before and 2 years following the introduction of the new contracts). Therefore, our results capture only short-term effects.
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Affiliation(s)
- Katalin Gaspar
- Department of Health Sciences, Health Economics Section, Talma Institute/VU University Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - France Portrait
- Department of Health Sciences, Health Economics Section, Talma Institute/VU University Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
| | - Eric van der Hijden
- Department of Health Sciences, Health Economics Section, Talma Institute/VU University Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
- Zilveren Kruis (Achmea), Amersfoort, The Netherlands
| | - Xander Koolman
- Department of Health Sciences, Health Economics Section, Talma Institute/VU University Amsterdam, De Boelelaan 1085, 1081 HV Amsterdam, The Netherlands
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Salampessy BH, Bijlsma WR, van der Hijden E, Koolman X, Portrait FRM. On selecting quality indicators: preferences of patients with breast and colon cancers regarding hospital quality indicators. BMJ Qual Saf 2019; 29:576-585. [PMID: 31831636 PMCID: PMC7362772 DOI: 10.1136/bmjqs-2019-009818] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 05/20/2019] [Revised: 11/10/2019] [Accepted: 11/21/2019] [Indexed: 12/05/2022]
Abstract
Background There is an increasing number of quality indicators being reported publicly with aim to improve the transparency on hospital care quality. However, they are little used by patients. Knowledge on patients’ preferences regarding quality may help to optimise the information presented to them. Objective To measure the preferences of patients with breast and colon cancers regarding publicly reported quality indicators of Dutch hospital care. Methods From the existing set of clinical quality indicators, participants of patient group discussions first assessed an indicator’s suitability as choice information and then identified the most relevant ones. We used the final selection as attributes in two discrete choice experiments (DCEs). Questionnaires included choice vignettes as well as a direct ranking exercise, and were distributed among patient communities. Data were analysed using mixed logit models. Results Based on the patient group discussions, 6 of 52 indicators (breast cancer) and 5 of 21 indicators (colon cancer) were selected as attributes. The questionnaire was completed by 84 (breast cancer) and 145 respondents (colon cancer). In the patient group discussions and in the DCEs, respondents valued outcome indicators as most important: those reflecting tumour residual (breast cancer) and failure to rescue (colon cancer). Probability analyses revealed a larger range in percentage change of choice probabilities for breast cancer (10.9%–69.9%) relative to colon cancer (7.9%–20.9%). Subgroup analyses showed few differences in preferences across ages and educational levels. DCE findings partly matched with those of direct ranking. Conclusion Study findings show that patients focused on a subset of indicators when making their choice of hospital and that they valued outcome indicators the most. In addition, patients with breast cancer were more responsive to quality information than patients with colon cancer.
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Affiliation(s)
- Benjamin H Salampessy
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - Ward R Bijlsma
- Department of Healthcare Procurement, Menzis, Enschede, The Netherlands
| | - Eric van der Hijden
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - Xander Koolman
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands
| | - France R M Portrait
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam, Noord-Holland, The Netherlands
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van der Hijden E, Steenhuis S, Hofstra G, van der Wolk J, Bijlsma W, Struijs J, Koolman X. Ontwikkelingen in zorginkoop: van inkoop van verrichtingen naar inkoop van zorgbundels. ACTA ACUST UNITED AC 2019. [DOI: 10.5117/mab.93.33441] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Zorgverzekeraars en zorgaanbieders maken meestal contractafspraken op basis van een vergoeding per verrichting. Dat stimuleert echter volume van zorg in plaats van uitkomsten. Daarom passen zorgverzekeraars en zorgaanbieders steeds vaker ‘bundelinkoop’ als bekostiging toe. Dan wordt een bedrag per patiënt afgesproken. We beschrijven wat bundelinkoop is en introduceren de contractelementen. De impact van zorgbundels is dat ze door een andere verdeling van (financiële) verantwoordelijkheden uitkomsten centraal stellen, schotten doorbreken en innovatie stimuleren. Opschalen van deze methode van zorginkoop vraagt om standaardisatie van de contractelementen en uniformiteit van de bundeldefinitie per aandoening anders nemen de administratieve lasten voor zorgaanbieders toe.
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