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van Alphen A, Lekkerkerker C, van Exel J, Baatenburg de Jong R, Ahaus K. Patients' perspectives on ethical principles to fairly allocate scarce surgical resources during the COVID-19 pandemic in the Netherlands: a Q-methodology study. BMJ Open 2024; 14:e086681. [PMID: 39313289 PMCID: PMC11429350 DOI: 10.1136/bmjopen-2024-086681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 09/04/2024] [Indexed: 09/25/2024] Open
Abstract
OBJECTIVES During the COVID-19 pandemic, healthcare professionals were faced with prioritisation dilemmas due to limited surgical capacity. While the views of healthcare professionals on fair allocation have been given considerable attention, the views of patients have been overlooked. To address this imbalance, our study aimed to identify which ethical principles are most supported by patients regarding the fair allocation of surgical resources. DESIGN A Q-methodology study was conducted. Participants ranked ordered 20 statements covering different viewpoints on fair allocation according to their point of view, followed by an interview. Principal component analysis followed by varimax rotation was used to identify subgroups who broadly agreed in terms of their rankings. SETTING The setting of this study was in the Netherlands. PARTICIPANTS 16 patient representatives were purposively sampled. RESULTS Two perspectives were identified, both of which supported utilitarianism. In perspective 1, labelled as 'clinical needs and outcomes', resource allocation should aim to maximise the health gains based on individual patient characteristics. In perspective 2, labelled as 'population outcomes and contribution to society', allocation should maximise health gains as with perspective 1, but this should also consider societal gains. CONCLUSIONS There was a broad agreement among patient representatives that utilitarianism should be the guiding ethical principle for fair allocation of scarce surgical resources. The insights gained from this study should be integrated into policymaking and prioritisation strategies in future healthcare crises.
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Affiliation(s)
- Anouk van Alphen
- Department of Otorhinolaryngology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Caroline Lekkerkerker
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Rob Baatenburg de Jong
- Department of Otorhinolaryngology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Kees Ahaus
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Scheefhals ZTM, de Vries EF, Struijs JN, Numans ME, van Exel J. Stakeholder perspectives on payment reform in maternity care in the Netherlands: A Q-methodology study. Soc Sci Med 2024; 340:116413. [PMID: 38000174 DOI: 10.1016/j.socscimed.2023.116413] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/29/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023]
Abstract
Based on theoretical notions, there is consensus that alternative payment models to the common fee-for-service model have the potential to improve healthcare quality through increased collaboration and reduced under- and overuse. This is particularly relevant for maternity care in the Netherlands because perinatal mortality rates are relatively high in comparison to other Western countries. Therefore, an experiment with bundled payments for maternity care was initiated in 2017. However, the uptake of this alternative payment model remains low, as also seen in other countries, and fee-for-service models prevail. A deeper understanding of stakeholders' perspectives on payment reform in maternity care is necessary to inform policy makers about the obstacles to implementing alternative payment models and potential ways forward. We conducted a Q-methodology study to explore perspectives of stakeholders (postpartum care managers, midwives, gynecologists, managers, health insurers) in maternity care in the Netherlands on payment reform. Participants were asked to rank a set of statements relevant to payment reform in maternity care and explain their ranking during an interview. Factor analysis was used to identify patterns in the rankings of statements. We identified three distinct perspectives on payment reform in maternity care. One general perspective, broadly supported within the sector, focusing mainly on outcomes, and two complementary perspectives, one focusing more on equality and one focusing more on collaboration. This study shows there is consensus among stakeholders in maternity care in the Netherlands that payment reform is required. However, stakeholders have different views on the purpose and desired design of the payment reform and set different conditions. Working towards payment reform in co-creation with all involved parties may improve the general attitude towards payment reform, may enhance the level of trust among stakeholders, and may contribute to a higher uptake in practice.
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Affiliation(s)
- Zoë T M Scheefhals
- Department of National Health and Healthcare, Center for Public Health, Healthcare and Society, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands; Department of Public Health and Primary Care, Health Campus The Hague, Leiden University Medical Center, The Hague, the Netherlands.
| | - Eline F de Vries
- Department of Health Economics and Healthcare, Center for Public Health, Healthcare and Society, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.
| | - Jeroen N Struijs
- Department of National Health and Healthcare, Center for Public Health, Healthcare and Society, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands; Department of Public Health and Primary Care, Health Campus The Hague, Leiden University Medical Center, The Hague, the Netherlands.
| | - Mattijs E Numans
- Department of Public Health and Primary Care, Health Campus The Hague, Leiden University Medical Center, The Hague, the Netherlands.
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, Rotterdam, the Netherlands.
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Geurkink TH, Marang-van de Mheen PJ, Nagels J, Poolman RW, Nelissen RG, van Bodegom-Vos L. Impact of Active Disinvestment on Decision-Making for Surgery in Patients With Subacromial Pain Syndrome: A Qualitative Semi-structured Interview Study Among Hospital Sales Managers and Orthopedic Surgeons. Int J Health Policy Manag 2023; 12:7710. [PMID: 38618816 PMCID: PMC10590240 DOI: 10.34172/ijhpm.2023.7710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 07/31/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Withdrawal of reimbursement for low-value care through a policy change, ie, active disinvestment, is considered a potentially effective de-implementation strategy. However, previous studies have shown conflicting results and the mechanism through which active disinvestment may be effective is unclear. This study explored how the active disinvestment initiative regarding subacromial decompression (SAD) surgery for subacromial pain syndrome (SAPS) in the Netherlands influenced clinical decision-making around surgery, including the perspectives of orthopedic surgeons and hospital sales managers. METHODS We performed 20 semi-structured interviews from November 2020 to October 2021 with ten hospital sales managers and ten orthopedic surgeons from twelve hospitals across the Netherlands as relevant stakeholders in the active disinvestment process. The interviews were video-recorded and transcribed verbatim. Inductive thematic analysis was used to analyse interview transcripts independently by two authors and discrepancies were resolved through discussion. RESULTS Two overarching themes were identified that negatively influenced the effect of the active disinvestment initiative for SAPS. The first theme was that the active disinvestment represented a "Too small piece of the pie" indicating little financial consequences for the hospital as it was merely used in negotiations with healthcare insurers to reduce costs, required a disproportionate amount of effort from hospital staff given the small saving-potential, and was not clearly defined nor enforced in the overall healthcare insurer agreements. The second theme was "They [healthcare insurer] got it wrong," as the evidence and guidelines had been incorrectly interpreted, the active disinvestment was at odds with clinician experiences and beliefs and was perceived as a reduction in their professional autonomy. CONCLUSION The two overarching themes and their underlying factors highlight the complexity for active disinvestment initiatives to be effective. Future de-implementation initiatives including active disinvestment should engage relevant stakeholders at an early stage to incorporate their different perspectives, gain support and increase the probability of success.
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Affiliation(s)
- Timon H. Geurkink
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Perla J. Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Jochem Nagels
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Rudolf W. Poolman
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Rob G.H.H. Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
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Bongaerts THG, Büchner FL, Crone MR, van Exel J, Guicherit OR, Numans ME, Nierkens V. Perspectives on cancer screening participation in a highly urbanized region: a Q-methodology study in The Hague, the Netherlands. BMC Public Health 2022; 22:1925. [PMID: 36243684 PMCID: PMC9571478 DOI: 10.1186/s12889-022-14312-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 10/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Netherlands hosts, as many other European countries, three population-based cancer screening programmes (CSPs). The overall uptake among these CSPs is high, but has decreased over recent years. Especially in highly urbanized regions the uptake rates tend to fall below the minimal effective rate of 70% set by the World Health Organization. Understanding the reasons underlying the decision of citizens to partake in a CPS are essential in order to optimize the current screening participation rates. The aim of this study was to explore the various perspectives concerning cancer screening among inhabitants of The Hague, a highly urbanized region of the Netherlands. METHODS A Q-methodology study was conducted to provide insight in the prevailing perspectives on partaking in CSPs. All respondents were inhabitants of the city of The Hague, the Netherlands. In an online application they ranked a set of 31 statements, based on the current available literature and clustered by the Integrated Change model, into a 9-column forced ranking grid according to level of agreement, followed by a short survey. Respondents were asked to participate in a subsequent interview to explain their ranking. By-person factor analysis was used to identify distinct perspectives, which were interpreted using data from the rankings and interviews. RESULTS Three distinct perspectives were identified: 1). "Positive about participation", 2). "Thoughtful about participation", and 3). "Fear drives participation". These perspectives provide insight into how potential respondents, living in an urbanized region in the Netherlands, decide upon partaking in CSPs. CONCLUSIONS Since CSPs will only be effective when participation rates are sufficiently high, it is essential to have insight into the different perspectives among potential respondents concerning partaking in a CSP. This study adds new insights concerning these perspectives and suggests several ideas for future optimization of the CSPs.
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Affiliation(s)
- Thomas H G Bongaerts
- Health Campus The Hague, Leiden University Medical Center, The Hague, The Netherlands. .,Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.
| | - Frederike L Büchner
- Health Campus The Hague, Leiden University Medical Center, The Hague, The Netherlands.,Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Matty R Crone
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Erasmus Centre for Health Economics Research, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Onno R Guicherit
- University Cancer Center Leiden - The Hague, at Haaglanden Medical Center, The Hague, The Netherlands
| | - Mattijs E Numans
- Health Campus The Hague, Leiden University Medical Center, The Hague, The Netherlands.,Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Vera Nierkens
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
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Rotteveel AH, Lambooij MS, Over EAB, Hernández JI, Suijkerbuijk AWM, de Blaeij AT, de Wit GA, Mouter N. If you were a policymaker, which treatment would you disinvest? A participatory value evaluation on public preferences for active disinvestment of health care interventions in the Netherlands. HEALTH ECONOMICS, POLICY, AND LAW 2022; 17:428-443. [PMID: 35670359 DOI: 10.1017/s174413312200010x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Currently, it is not known what attributes of health care interventions citizens consider important in disinvestment decision-making (i.e. decisions to discontinue reimbursement). Therefore, this study aims to investigate the preferences of citizens of the Netherlands toward the relative importance of attributes of health care interventions in the context of disinvestment. METHODS A participatory value evaluation (PVE) was conducted in April and May 2020. In this PVE, 1143 Dutch citizens were asked to save at least €100 million by selecting health care interventions for disinvestment from a list of eight unlabeled health care interventions, described solely with attributes. A portfolio choice model was used to analyze participants' choices. RESULTS Participants preferred to disinvest health care interventions resulting in smaller gains in quality of life and life expectancy that are provided to older patient groups. Portfolios (i.e. combinations of health care interventions) resulting in smaller savings were preferred for disinvestment over portfolios with larger savings. CONCLUSION The disinvestment of health care interventions resulting in smaller health gains and that are targeted at older patient groups is likely to receive most public support. By incorporating this information in the selection of candidate interventions for disinvestment and the communication on disinvestment decisions, policymakers may increase public support for disinvestment.
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Affiliation(s)
- A H Rotteveel
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
- Julius Centre for Primary care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
- Erasmus School for Health Policy & Management, Erasmus University, Rotterdam, The Netherlands
| | - M S Lambooij
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - E A B Over
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - J I Hernández
- Faculty of Technology, Policy and Management, Delft University of Technology, Delft, The Netherlands
| | - A W M Suijkerbuijk
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - A T de Blaeij
- Centre for Safety of Substances and Products, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - G A de Wit
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
- Julius Centre for Primary care, UMC Utrecht, Utrecht University, Utrecht, The Netherlands
| | - N Mouter
- Faculty of Technology, Policy and Management, Delft University of Technology, Delft, The Netherlands
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Strand L, Sandman L, Tinghög G, Nedlund AC. Withdrawing or withholding treatments in health care rationing: an interview study on ethical views and implications. BMC Med Ethics 2022; 23:63. [PMID: 35751123 PMCID: PMC9233323 DOI: 10.1186/s12910-022-00805-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/17/2022] [Indexed: 11/10/2022] Open
Abstract
Background When rationing health care, a commonly held view among ethicists is that there is no ethical difference between withdrawing or withholding medical treatments. In reality, this view does not generally seem to be supported by practicians nor in legislation practices, by for example adding a ‘grandfather clause’ when rejecting a new treatment for lacking cost-effectiveness. Due to this discrepancy, our objective was to explore physicians’ and patient organization representatives’ experiences- and perceptions of withdrawing and withholding treatments in rationing situations of relative scarcity. Methods Fourteen semi-structured interviews were conducted in Sweden with physicians and patient organization representatives, thematic analysis was used. Results Participants commonly express internally inconsistent views regarding if withdrawing or withholding medical treatments should be deemed as ethically equivalent. Participants express that in terms of patients’ need for treatment (e.g., the treatment’s effectiveness and the patient’s medical condition) withholding and withdrawing should be deemed ethically equivalent. However, in terms of prognostic differences, and the patient-physician relation and communication, there is a clear discrepancy which carry a moral significance and ultimately makes withdrawing psychologically difficult for both physicians and patients, and politically difficult for policy makers. Conclusions We conclude that the distinction between withdrawing and withholding treatment as unified concepts is a simplification of a more complex situation, where different factors related differently to these two concepts. Following this, possible policy solutions are discussed for how to resolve this experienced moral difference by practitioners and ease withdrawing treatments due to health care rationing. Such solutions could be to have agreements between the physician and patient about potential future treatment withdrawals, to evaluate the treatment’s effect, and to provide guidelines on a national level.
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Affiliation(s)
- Liam Strand
- Swedish National Centre for Priorities in Health, Department of Health, Medicine, and Caring Sciences, Linköping University, Sandbäcksgatan 7, 581 83, Linköping, Sweden.
| | - Lars Sandman
- Swedish National Centre for Priorities in Health, Department of Health, Medicine, and Caring Sciences, Linköping University, Sandbäcksgatan 7, 581 83, Linköping, Sweden
| | - Gustav Tinghög
- Swedish National Centre for Priorities in Health, Department of Health, Medicine, and Caring Sciences, Linköping University, Sandbäcksgatan 7, 581 83, Linköping, Sweden.,Department of Management and Engineering, Linköping University, Linköping, Sweden
| | - Ann-Charlotte Nedlund
- Swedish National Centre for Priorities in Health, Department of Health, Medicine, and Caring Sciences, Linköping University, Sandbäcksgatan 7, 581 83, Linköping, Sweden
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Rotteveel AH, Lambooij MS, van Exel J, de Wit GA. To what extent do citizens support the disinvestment of healthcare interventions? An exploration of the support for four viewpoints on active disinvestment in the Netherlands. Soc Sci Med 2021; 293:114662. [PMID: 34953417 DOI: 10.1016/j.socscimed.2021.114662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 11/19/2021] [Accepted: 12/15/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Active disinvestment of healthcare interventions (i.e. discontinuing reimbursement by means of a policy decision) has received limited public support in the past. Previous research has identified four viewpoints on active disinvestment among citizens in the Netherlands. However, it remained unclear how strong these viewpoints are supported by society, and by whom. Therefore, the current study aimed to 1) measure the support for these four viewpoints and 2) assess whether support is associated with background characteristics of citizens. METHOD In an online survey, a representative sample of adult citizens in the Netherlands (n = 1794) was asked to rate their agreement with short narratives of the four viewpoints on a 7-point Likert scale. The survey also included questions on sociodemographic characteristics, health status, healthcare utilization, and opinions about responsibility and costs in the healthcare context. Logistic regression models were estimated for each viewpoint to assess the association between viewpoint support and these characteristics. RESULTS The support for the different viewpoints varied between 46.8% and 57.7% of the sample. Viewpoint support was associated with participants' age, gender, educational level, financial situation, healthcare utilization, opinion on the responsibility of the government for the health of citizens, and opinion on whether the increase in healthcare expenditure and health insurance premiums is considered a problem. CONCLUSION Resistance to active disinvestment may partially be explained by the consequences of disinvestment citizens anticipate experiencing themselves. Citizens considering the increase in healthcare expenditure a larger problem were more supportive of disinvestment than those considering it less of a problem.
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Affiliation(s)
- Adriënne H Rotteveel
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands; Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Mattijs S Lambooij
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - G Ardine de Wit
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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