researchers interacting with policymakers, managers and professionals

Dept Social Medicine

Researchers interacting with Researchers interacting with Policymakers, Managers Policymakers, Managers

and Professionalsand Professionals

Niek KlazingaLimerick, August 31, 2007


• What is Health Services / Systems Research?

• Who wants to know what and why?

• Examples

• General conclusions


Definition IoMDefinition IoM• Health Services Research is a multidisciplinary field of inquiry,• basic and applied,• that examines the use, costs, quality, accessibility, delivery, organization, financing and outcomes of health care• to increase the knowledge and understanding of the structure, processes and effects of health services• for individuals and populations

Field and Lohrs 1995 JECP


Health Services Research is the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviours effect access to health care, the quality and cost of health care and ultimately our health and well-being.

Lohr, Steiwachs 2002


Health Services Research Health Services Research a working modela working model

• describe health services in terms of structure, process, outcome

• consider medical practice (health services) as one determinant of health status together with genotype, social and physical environment and behaviour

• examples studies of structure (manpower, organization, financing) studies of structure and process (influence insurance system on use) studies of structure and outcome (mortality in teaching/non teaching hospitals) studies of process (appropriateness hospitalization) studies of process and outcome (compliance and symptoms) studies of outcome

Starfield 1973 NEJM


What is Health Services What is Health Services Research?Research?

• Systematic way of knowledge production

• Valid knowledge• Generalizable knowledge• Applicable knowledge• Focused on functioning of health care

services and health systems


Types of questions in HSRTypes of questions in HSR

• Descriptive questions• Explorative questions• Testing questions• Instrumental questions• Theoretical interpretative

questions


Methods in HSRMethods in HSR• Literature study• Interviews, observations, focus

groups• Questionnaires• Case studies• Trend analyses / cohorts• Pre-post studies• Case-control studies• Quasi-experimental design• RCT


OBJECT OF STUDYOBJECT OF STUDY

• Organisation

• Process

• Intervention

• Outcomes


THEORETICAL PERSPECTIVESTHEORETICAL PERSPECTIVES

• Quality of Care

• Managerial / Administrative

• Innovation / Change

• Learning organization

• Professionalization theory


EVALUATION RESEARCHEVALUATION RESEARCH

• Experimental

• Economic

• Managerial

• Developmental

Øvretveit 1998


Interaction with policymakers,Interaction with policymakers,managers and professionals on:managers and professionals on:

• research goals

• research design

• data-collection

• reporting


Example Dutch PerformanceExample Dutch Performance

Framework for the Health SystemFramework for the Health System

2002 - 20072002 - 2007


Table 1.1 Conditions under which performance measurementTable 1.1 Conditions under which performance measurement is possible and problematicis possible and problematic

Performance measurement possible Performance measurement problematic

An organization has products An organization has obligations

and is highly value-oriented Products are simple Products are multiple An organization is product-oriented An organization is process-oriented Autonomous production Co-production: products are

generated together with others Products are isolated Products are interwoven Causalities are known Causalities are unknown Quality definable in Quality not definable in performance indicators performance indicators Uniform products Variety of products Environment is stable Environment is dynamic

Source: Managing performance in the public sector. De Bruijn H. (2002), p. 13


Dutch Performance FrameworkDutch Performance Framework

• start policy process• functions• conceptual choices• indicator development• interaction researchers, policy makers and the health care field


Financialperspective

Consumerperspective

Innovationperspective

Internal businessprocessesperspective

HealthHealth Care: prevention, cure,care and welfare

Lifestyle

Population Healthinformation Management information

Lalonde-modelLalonde-model Balanced scorecardBalanced scorecard

Geneticlayout

Environmentfactors

Performance:


Internal business processes perspective

• performance of care financiers• quality of health care delivery process• availability of choice of insurer and provider• concentration of care provision• human resources (1) : availability, vacancies,

and staff satisfaction• substitution of care between professions and

between care delivery settings

Consumer perspective

• effectiveness

• patient safety

• patient centeredness

Innovation perspective

• allocation of funds for learning and growth• diffusion of new technologies• information infrastructure• human resources (2): innovative working

environment, and professionals in training • development and diffusion of organisational

innovations• industry initiated research and development

activities in health care

Financial perspective

• health system costs

• allocative efficiency

• vertical equity

• financial accessibility

• financial viability of financiers and care providers


Lessons learnedLessons learned

• phases of conceptualization, ownershipand execution

• link with health care reforms• link with sectoral organization of the

department of health• link with information policies• link with accountability agenda• link with international developments


HEALTH How healthy are the Dutch?

NON-HEALTHCARE DETERMINANTS OF HEALTHAre the non-healthcare factors that also determine health as well as if/how healthcare is

used changing favorably?

HEALTH SYSTEM DESIGN AND CONTEXTWhat are the important design and contextual information that may be specific to the Dutch health system and which are

necessary for interpreting the quality of healthcare?

E

Q

U

I

T

Y

End-of-life care

Living with illness or disability

Getting better

Staying healthy

AccessibilityPatient-centeredness

SafetyEffectiveness

Healthcare Needs

Cost AccessQuality

Dimensions of Healthcare Performance

HEALTHCARE SYSTEM PERFORMANCEHow does the healthcare system perform? What is the level of care across the range of patient care needs? What does this

performance cost?

Efficiency(Value for money)


System goals (3)

Indicatordomains (15)

Indicators (125)

Keyfindings (120)

Summary

State Dutch Health CareState Dutch Health Care

A

B


Accessibility

• Freedom of choice • Waiting times• Accessibility in line with demand• Financial barriers for citizens• Concentration of supply• Development of health care professions

Quality:

• Effectiveness• Safety • Consumers and patient satisfaction• Accreditation• Innovation

Financial sustainability

• Development of macro costs• Monitoring the market• Productivity• Financial position of health care suppliers

Main performance fields from a macro Main performance fields from a macro perspectiveperspective


Chapter 2. Quality

2.2 Effectiveness of preventionPercentage of (adolescent) smokers

Percentage of (adolescent) people with overweightLevel of participation in population surveys and screenings

Vaccination rate (National Vaccination Programme (RVP), influenza vaccination, hepatitis B)Percentage of patients with diabetes with good glucose control

Effectiveness of lifestyle advice in primary carePercentage of schools that offer effective lifestyle programmes

Percentage of employers (companies) with an occupational health policyHealth protection: consumers’ trust in food safety, emergency treatment of home accidents and an indicator for medical assistance in accidents and disasters

Percentage of high-risk youth that is reached by adolescent health carePercentage of deprived areas with an intersectoral approach to health (no information available)

Perinatal mortality2.3 Effectiveness of cure

Percentage of cases in which general practitioners do not prescribe medicines they are advised against to prescribe for a particular syndromePercentage of cases in which general practitioners prescribe medicines that are advised for a specific syndrome

Percentage of cases in which general practitioners prescribe according to guidelinesPercentage of referrals by general practitioners to medical specialists

Percentage of referrals by general practitioners to other primary care workers In-hospital mortality for heart failureIn hospital mortality for pneumonia

In-hospital mortality for bypass surgeryHospital Standardized Mortality ratio

30-days mortality following acute myocardial infarction30-days mortality following stroke

Asthma mortality per 100,000 people aged 5-39Breast cancer mortality per 100,000 womenColon cancer mortality per 100,000 people

Cervical cancer mortality per 100,000 womenBreast cancer 5-year survival rateColon cancer 5-year survival rate

Cervical cancer 5-year survival ratePercentage of (over) 65-year old hip fracture patients with surgery initiated within 48 hours

Number of diabetes-related major amputations in 100,000 diabetics aged 18-75


2.4 Effectiveness of long-term carePercentage of people with impairments who indicate that the appliances supplied solve their problems

Percentage of people with somatic complaints who return to their own environment after a stay in a nursing home (as an indicator of the scope of temporary stay function of nursing homes)

Clients’ experiences with home care, nursing homes and care for the disabledVolume of possibly preventable health care problems (such as falls) in nursing home residents

Percentages of patients with decubitus with home care or in nursing homesJudgements of the Health Care Inspectorate on nursing home care

Percentage of home care or nursing home patients who are admitted to a hospital at least once a yearNumber of psychogeriatric patients who live in a small-scale residential care facility

2.5 Effectiveness of care for mental and substance-use conditionsResult of prevention measures and target groups that are reached

Changes in mental and social functioning of patientsDevelopment of the number of suicides and suicide attempts

Percentage of the target group that is reached by care professionalsDevelopment of the number of discharges in mental health care and substance-use care

2.6 Consumers’ experiences with health careGeneral consumers’ trust: do Dutch people have faith in the health care system, irrespective of their actual use of care?

Experiences of consumers: what is opinion of care consumers on the care received? 2.7 Patient safety

Percentage of general practitioners and pharmacists that participate in Farmacotherapeutic Consultations Medication monitoring in pharmacies

Volume of high-risk surgery in hospitalsIncidence of serious adverse effects of blood transfusion

Prevalence of decubitus in hospitalsPrevalence of decubitus in long-term care facilities

2.8 Quality systemsPercentage of institutions that have been certified or accredited

Percentage of institutions that have the necessary quality documentsPercentage of institutions that use special protocols or guidelines that outline procedures for risky or complex processes

Percentage of institutions that use (sub-)systems for feedback of patients and consumers2.9 Innovations

Investments in development and research in the care sector; international comparisonNumber of biotechnology patents in the Netherlands

Utilization and speed of diffusion of minimally non- invasive surgical techniquesUse of process innovations, such as ‘integrated care pathways’ and ‘CVA integrated care’

Application of ICT in various health care sectors

Development in the ratio of surgical day-treatments to the total number of surgical treatments


Chapter 3. Access3.2 Patient choices in the access to care

Actual use of a number of new choices in care: personal care budget and health insurerWishes of citizens with respect to choices (of health care professional, sources of information and forms of care)

3.3 Accessibility of acute carePercentage of urgent ambulance rides that meets response time targets

Number of urgent ambulance rides that exceeds the standard response time (15 minutes)Number of people who are able to reach the nearest emergency department or out-of-hours primary care centre by car within 30 minutes

Number of urgent callers to out-of-hours general practitioner centres who are answered by an expert within one minuteNumber of people waiting for an organ transplant

3.4 Waiting timesPercentage of patients who are satisfied with the speed with which they are seen by a general practitioner, specialist or dentist

Number of people who wait for care (scope of the waiting list)(Expected) time to treatment (waiting time)

Number of people who have to wait for care longer than the Treeknorm3.5 Accessibility according to need

Comparison of care utilization by low and high educated populations, corrected for health inequalityComparison of care utilization by immigrants and the native population, corrected for health inequality

Care utilization in deprived areas of large cities and by marginal groupsSatisfaction of asylum seekers with medical care

3.6 Financial accessibilityInsurance status of the population, including the number of uninsured

Costs of care for citizensVolume of co-payments and out-of-pocket payments

Tax refunds because of medical expensesAdditional care costs of chronically ill patients

Use of financial compensation provisions by chronically ill patientsPercentage of the family income that is spent on medical expenses by high- versus low- income groups

Share of the total healthcare costs in the Netherlands paid by high- and low-income groups separately (income solidarity in health care)3.7 Geographical accessibility

Accessibility of facilities by required travel time and by number of care facilities per municipality or regionNumber of inpatient and outpatient facilities per region per 10,000 inhabitants

3.8 PersonnelNumber of vacancies in the health care sector that are hard to fill

Rate of sickness absence in health careCurrent unfilled vacancies

Degree to which the current intake of care providers has been tuned to developments in care demandNumber of people that is not registered with a general practitioner or dentist

3.9 Professions and trainingNumber of doctors and nurses per 100,000 inhabitants

Professional ratios: Number of one type of care provider to another type of care provider (e.g. number of dental hygienists to a dentist)Medical-technical tasks carried out by doctor assistants

Number of practice assistants with a higher vocational trainingNumber of experienced graduate physician assistants and nurse practitioners, and number in training

Qualification level of care and nursing staffPercentage of Dutch people who provide informal care


Chapter 4. Costs

4.2 Macro costsHealth care expenditure according to the Health Budget (BKZ) (Ministry of Health, Welfare and Sports)

Health care expenditure according to the Health Accounts (Statistics Netherlands)Health care expenditure according to the System of Health Accounts (OECD)

Expenditure on the different care sectorsExpenditure on BKZ-relevant care by financing source

Share of health care expenditure in the Gross Domestic ProductShare of health care expenditure in the increase in the Gross Domestic Product

Price development in health careDevelopment in care volume

Costs of care per capita4.3 Health care market

Variation in insurance premiums (health insurance market)Market concentrations of care providers and insurers (health insurance market/ health care purchase market)

Access barriers to the health care market (all sub-markets)Care purchased by insurers (health care purchase market)

Vertical integration (all sub-markets)Mobility of insured persons (health insurance market)Risk selection by insurers (health insurance market)

Transfer of costs (health insurance market)4.4 Productivity of health care

Development of production volume in six care sectors, divided by the number of employees in fte and corrected for reduction of working hoursRecent developments in labour productivity in hospitals compared to recent developments in labour productivity of the Dutch economy as a whole

Number of hospital discharges per fte hospital employee4.5 Financial position of care institutions

ProfitabilitySolvencyLiquidity

Reserves for acceptable costsLevel of participation in the Guarantee Fund for the Care Sector

Dept Social MedicineDraft; not for publication


Figure 12b. Breast cancer, 5-year relative survival rates. (data for two years when available)

Draft; not for publication


Lessons learned 2Lessons learned 2

• major information challenges• keeping the links with the policy makers• more need for trends and benchmarking• better visualization• revival BSC• revival link to strategy and policy


Interaction with policymakers,Interaction with policymakers,managers and professionals on:managers and professionals on:

• performance agenda and system reform

• international benchmaking (OECD)

• patient experiences (CQ-Index/CAHPS)

• hospital performance (PATH)

• professional performance (Aire)


General conclusionsGeneral conclusions

• agreement on goals, timing and generalizability

• agreement on theories and concepts

• study design should fit the question

• interaction on data-collection and reporting

• infrastructure R & D in the health system

• applying principles knowledge management

and learning in the health system

researchers interacting with policymakers, managers and professionals

Documents

days mortality

breast cancer mortality

dutch health system

general practitioners

health system design

level of care

quality of healthcare

women colon cancer mortality