Researchers interacting with Policymakers, Managers and Professionals

1. Researchers interacting with Policymakers, Managers and Professionals Niek Klazinga Limerick, August 31, 2007

2. What is Health Services / Systems Research? • Who wants to know what and why? • Examples • General conclusions

3. Definition 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

4. 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

5. Health Services Research a 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

6. Systematic way of knowledge production Valid knowledge Generalizable knowledge Applicable knowledge Focused on functioning of health care services and health systems What is Health Services Research?

7. Descriptive questions Explorative questions Testing questions Instrumental questions Theoretical interpretative questions Types of questions in HSR

8. Literature study Interviews, observations, focus groups Questionnaires Case studies Trend analyses / cohorts Pre-post studies Case-control studies Quasi-experimental design RCT Methods in HSR

9. Organisation Process Intervention Outcomes OBJECT OF STUDY

10. THEORETICAL PERSPECTIVES • Quality of Care • Managerial / Administrative • Innovation / Change • Learning organization • Professionalization theory

11. Experimental Economic Managerial Developmental Øvretveit 1998 EVALUATION RESEARCH

12. Interaction with policymakers, managers and professionals on: • research goals • research design • data-collection • reporting

13. Example Dutch Performance Framework for the Health System 2002 - 2007

14. Table 1.1 Conditions under which performance measurement is 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

15. Dutch Performance Framework • start policy process • functions • conceptual choices • indicator development • interaction researchers, policy • makers and the health care field

16. Balanced scorecard Lalonde-model Financial perspective Genetic layout Performance: Health Care: prevention, cure, care and welfare Internal business processes perspective Consumer perspective Health Environment factors Lifestyle Innovation perspective Population Health information Management information

17. Financial perspective • health system costs • allocative efficiency • vertical equity • financial accessibility • financial viability of financiers and care providers • Consumer perspective • effectiveness • patient safety • patient centeredness • 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 • 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

18. Lessons learned • phases of conceptualization, ownership • and 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

21. State Dutch Health Care System goals (3) Indicatordomains (15) Indicators (125) Keyfindings (120) Summary A B

22. Main performance fields from a macro perspective • 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

23. Chapter 2. Quality2.2 Effectiveness of preventionPercentage of (adolescent) smokersPercentage of (adolescent) people with overweightLevel of participation in population surveys and screeningsVaccination rate (National Vaccination Programme (RVP), influenza vaccination, hepatitis B)Percentage of patients with diabetes with good glucose controlEffectiveness of lifestyle advice in primary carePercentage of schools that offer effective lifestyle programmesPercentage of employers (companies) with an occupational health policy Health 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 mortality 2.3 Effectiveness of curePercentage 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 syndromePercentage of cases in which general practitioners prescribe according to guidelinesPercentage of referrals by general practitioners to medical specialistsPercentage of referrals by general practitioners to other primary care workers In-hospital mortality for heart failure In hospital mortality for pneumoniaIn-hospital mortality for bypass surgeryHospital Standardized Mortality ratio30-days mortality following acute myocardial infarction30-days mortality following strokeAsthma 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 rate Percentage of (over) 65-year old hip fracture patients with surgery initiated within 48 hoursNumber of diabetes-related major amputations in 100,000 diabetics aged 18-75

24. 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 residentsPercentages of patients with decubitus with home care or in nursing homesJudgements of the Health Care Inspectorate on nursing home carePercentage 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 reachedChanges in mental and social functioning of patientsDevelopment of the number of suicides and suicide attemptsPercentage 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 safetyPercentage of general practitioners and pharmacists that participate in Farmacotherapeutic Consultations Medication monitoring in pharmaciesVolume of high-risk surgery in hospitalsIncidence of serious adverse effects of blood transfusionPrevalence of decubitus in hospitalsPrevalence of decubitus in long-term care facilities 2.8 Quality systemsPercentage of institutions that have been certified or accreditedPercentage of institutions that have the necessary quality documentsPercentage of institutions that use special protocols or guidelines that outline procedures for risky or complex processesPercentage of institutions that use (sub-)systems for feedback of patients and consumers 2.9 InnovationsInvestments in development and research in the care sector; international comparisonNumber of biotechnology patents in theNetherlandsUtilization and speed of diffusion of minimally non- invasive surgical techniques Use of process innovations, such as ‘integrated care pathways’ and ‘CVA integrated care’Application of ICT in various health care sectorsDevelopment in the ratio of surgical day-treatments to the total number of surgical treatments

25. Chapter 3. Access 3.2 Patient choices in the access to careActual 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 targetsNumber 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 minutesNumber of urgent callers to out-of-hours general practitioner centres who are answered by an expert within one minute Number 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 Treeknorm 3.5 Accessibility according to needComparison 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 inequalityCare 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 uninsuredCosts of care for citizens Volume of co-payments and out-of-pocket paymentsTax refunds because of medical expensesAdditional care costs of chronically ill patientsUse of financial compensation provisions by chronically ill patientsPercentage of the family income that is spent on medical expenses by high- versus low- income groupsShare of the total healthcare costs in the Netherlands paid by high- and low-income groups separately (income solidarity in health care) 3.7 Geographical accessibilityAccessibility 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 Personnel Number of vacancies in the health care sector that are hard to fill Rate of sickness absence in health careCurrent unfilled vacanciesDegree to which the current intake of care providers has been tuned to developments in care demand Number of people that is not registered with a general practitioner or dentist 3.9 Professions and trainingNumber of doctors and nurses per 100,000 inhabitantsProfessional 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 assistantsNumber of practice assistants with a higher vocational trainingNumber of experienced graduate physician assistants and nurse practitioners, and number in trainingQualification level of care and nursing staffPercentage of Dutch people who provide informal care

26. 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 sourceShare of health care expenditure in the Gross Domestic ProductShare of health care expenditure in the increase in the Gross Domestic ProductPrice development in health care Development in care volumeCosts of care per capita 4.3 Health care marketVariation 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 careDevelopment 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 wholeNumber of hospital discharges per fte hospital employee 4.5 Financial position of care institutionsProfitabilitySolvencyLiquidityReserves for acceptable costsLevel of participation in the Guarantee Fund for the Care Sector

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30. Figure 12b. Breast cancer, 5-year relative survival rates. (data for two years when available) Draft; not for publication

31. Lessons 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

34. Interaction with policymakers, managers and professionals on: • performance agenda and system reform • international benchmaking (OECD) • patient experiences (CQ-Index/CAHPS) • hospital performance (PATH) • professional performance (Aire)

35. General 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