Effectiveness and Policy Determinants of Sugar-Sweetened Beverage Taxes

Sugar consumption is on the rise globally with detrimental (oral) health effects. There is ample evidence that sugar-sweetened beverage (SSB) taxes can efficiently reduce sugar consumption. However, evidence alone is seldom enough to implement a policy. In this article, we present a narrative synthesis of evidence, based on real-world SSB tax evaluations, and we combine this with lessons from policy development case studies. This article is structured according to the Health Policy Analysis Triangle, which identifies a policy's content and process and important contextual factors. SSB tax policy content needs to be coupled to existing problems and public sentiment, which depend on more aspects than aspects related to (oral) health alone. Whether or not to include artificially sweetened beverages, therefore, is not solely a matter of showing the evidence of their oral health impact but also dependent on the stated aim of a tax and public sentiment toward tax policies in general. SSB taxes also need to be in line with existing tax and decision-making rules. Earmarking revenue for specific (health promotion) purposes may therefore be less straightforward as it might appear. The policy process of creating context-sensitive SSB tax policy content is not easy either. Advocacy coalitions need to be formed early in the process, and stamina, expertise, and flexibility are required to get a SSB tax adopted in a specific community. This requires a meticulously considered SSB tax structure implementation process. Oral health professionals who want to lead the way in advocating for SSB taxes should realize that evidence-based arguments on potential effectiveness alone will not be enough to realize change. The oral health community can learn important lessons from other "doctor-activists" such as pulmonologists, who have successfully advocated for higher tobacco taxes by being visible in the public debate with clear messaging and robust policy proposals.

Public reporting of performance measures in long-term care in Canada: does it make a difference?

Background

Evidence of the impact of public reporting of healthcare performance on quality improvement is not yet sufficient to draw conclusions with certainty, despite the important policy implications. This study explored the impact of implementing public reporting of performance indicators of long-term care facilities in Canada. The objective was to analyse whether improvements can be observed in performance measures after publication.

Methods

We considered 16 performance indicators in long-term care in Canada, 8 of which are publicly reported at a facility level, while the other 8 are privately reported. We analysed data from the Continuing Care Reporting System managed by the Canadian Institute for Health Information and based on information collection with RAI-MDS 2.0 © between the fiscal years 2011 and 2018. A multilevel model was developed to analyse time trends, before and after publication, which started in 2015. The analysis was also stratified by key sample characteristics, such as the facilities' jurisdiction, size, urban or rural location and performance prior to publication.

Results

Data from 1087 long-term care facilities were included. Among the 8 publicly reported indicators, the trend in the period after publication did not change significantly in 5 cases, improved in 2 cases and worsened in 1 case. Among the 8 privately reported indicators, no change was observed in 7, and worsening in 1 indicator. The stratification of the data suggests that for those indicators that were already improving prior to public reporting, there was either no change in trend or there was a decrease in the rate of improvement after publication. For those indicators that showed a worsening trend prior to public reporting, the contrary was observed.

Conclusions

Our findings suggest public reporting of performance data can support change. The trends of performance indicators prior to publication appear to have an impact on whether further change will occur after publication.

Key messages

Public reporting is likely one of the factors affecting change in performance in long-term care facilities. Public reporting of performance measures in long-term care facilities may support improvements in particular in cases where improvement was not observed before publication.

Using routine data to benchmark quality and outcomes of diabetes care in the EU HEALTHPROS project

Background

The EU-funded Marie Curie project HEALTHPROS aims to foster a new generation of “Healthcare Performance Intelligence Professionals” through a cohesive stream of 13 doctoral projects (www.healthpros-h2020.eu). Over 48 months, researchers will investigate key levers of healthcare improvement in 7 different countries, using methods drawn from the diverse fields of biostatistics, medical informatics and health services research.

Objectives

To describe barriers and enablers in the conduction of two doctoral projects aimed at exploring the impact of personal risk factors and organizational arrangements on lower extremity amputations in diabetes, through the use of large-scale databases from England, Scotland, Denmark and Germany.

Results

The research plan included a systematic review, structured comparison of data sources, predictive modelling and software development for automated international comparisons. Barriers encountered by researchers were: knowledge and access to data sources from different countries, dealing with data protection rules and the ability to carry out international comparisons when individual records are not easily allowed to leave national boundaries. Enabling factors included: a targeted educational process for risk modelling in diabetes and a multidisciplinary support team to help doctoral students overcoming the above barriers across different sites. Further clinical insight and contextual knowledge of data systems in place at different locations were needed in addition to the statistical, epidemiological and technical skills initially foreseen by the program.

Conclusions

The success of studies within a general educational program on health systems performance may depend from the continued support of a multidisciplinary team helping students in their educational process as well as with the practicalities of their research. International comparisons using routine data may require prioritisation to meet the tight timelines of doctoral theses.

Key messages

Academic programs for international comparisons in health care may be hampered by different type of barriers including technical aspects, legal regulations and a range of contextual factors. The establishment of multidisciplinary support teams may be essential for training doctoral students aiming to conduct international comparisons using routine data.

Lower extremity amputation rates in people with diabetes as an indicator of health systems performance. A critical appraisal of the data collection 2000-2011 by the Organization for Economic Cooperation and Development (OECD)

AIMS

Critical appraisal of secondary data made available by the OECD for the time frame 2000-2011.

METHODS

Comparison of trends and variation of amputations in people with diabetes across OECD countries. Generalized estimating equations to test the statistical significance of the annual change adjusting for major potential confounders.

RESULTS

A total of 26 OECD countries contributed to the OECD data collection for at least 1 year in the reference time frame, showing a decline in rates of over 40 %, from a mean of 13.2 (median 9.4, range 5.1-28.1) to 7.8 amputations per 100,000 in the general population (9.9, 1.0-18.4). The multivariate model showed an average decrease equal to -0.27 per 100,000 per year (p = 0.015), adjusted by structural characteristics of health systems, showing lower amputation rates for health systems financed by public taxation (-4.55 per 100,000 compared to insurance based, p = 0.002) and non-ICD coding mechanisms (-7.04 per 100,000 compared to ICD-derived, p = 0.001). Twelve-year decrease was stronger among insurance-based financing systems (tax based: -0.16 per 100,000, p = 0.064; insurance based: -0.36 per 100,000; p = 0.046).

CONCLUSIONS

In OECD countries, amputation rates in diabetes continuously decreased over 12 years. Still, in 2011, one amputation every 7 min could be directly attributed to diabetes. Although interesting, these results should be taken with extreme caution, until common definitions are improved and data quality issues, e.g., a different ability in capturing diabetes diagnoses, are fully resolved.

The involvement of medical doctors in hospital governance and implications for quality management: a quick scan in 19 and an in depth study in 7 OECD countries

Background

Hospital governance is broadening its orientation from cost and production controls towards ‘improving performance on clinical outcomes’. Given this new focus one might assume that doctors are drawn into hospital management across OECD countries. Hospital performance in terms of patient health, quality of care and efficiency outcomes is supposed to benefit from their involvement. However, international comparative evidence supporting this idea is limited. Just a few studies indicate that there may be a positive relationship between medical doctors being part of hospital boards, and overall hospital performance. More importantly, the assumed relationship between these so-called doctor managers and hospital performance has remained a ‘black-box’ thus far. However, there is an increasing literature on the implementation of quality management systems in hospitals and their relation with improved performance. It seems therefore fair to assume that the relation between the involvement of doctors in hospital management and improved hospital performance is partly mediated via quality management systems. The threefold aim of this paper is to 1) perform a quick scan of the current situation with regard to doctor managers in hospital management in 19 OECD countries, 2) explore the phenomenon of doctor managers in depth in 7 OECD countries, and 3) investigate whether doctor involvement in hospital management is associated with more advanced implementation of quality management systems.

Methods

This study draws both on a quick scan amongst country coordinators in OECD’s Health Care Quality Indicator program, and on the DUQuE project which focused on the implementation of quality management systems in European hospitals.

Results

This paper reports two main findings. First, medical doctors fulfil a broad scope of managerial roles at departmental and hospital level but only partly accompanied by formal decision making responsibilities. Second, doctor managers having more formal decision making responsibilities in strategic hospital management areas is positively associated with the level of implementation of quality management systems.

Conclusions

Our findings suggest that doctors are increasingly involved in hospital management in OECD countries, and that this may lead to better implemented quality management systems, when doctors take up managerial roles and are involved in strategic management decision making.

Towards actionable international comparisons of health system performance: expert revision of the OECD framework and quality indicators

OBJECTIVE

To review and update the conceptual framework, indicator content and research priorities of the Organisation for Economic Cooperation and Development's (OECD) Health Care Quality Indicators (HCQI) project, after a decade of collaborative work.

DESIGN

A structured assessment was carried out using a modified Delphi approach, followed by a consensus meeting, to assess the suite of HCQI for international comparisons, agree on revisions to the original framework and set priorities for research and development.

SETTING

International group of countries participating to OECD projects.

PARTICIPANTS

Members of the OECD HCQI expert group.

RESULTS

A reference matrix, based on a revised performance framework, was used to map and assess all seventy HCQI routinely calculated by the OECD expert group. A total of 21 indicators were agreed to be excluded, due to the following concerns: (i) relevance, (ii) international comparability, particularly where heterogeneous coding practices might induce bias, (iii) feasibility, when the number of countries able to report was limited and the added value did not justify sustained effort and (iv) actionability, for indicators that were unlikely to improve on the basis of targeted policy interventions.

CONCLUSIONS

The revised OECD framework for HCQI represents a new milestone of a long-standing international collaboration among a group of countries committed to building common ground for performance measurement. The expert group believes that the continuation of this work is paramount to provide decision makers with a validated toolbox to directly act on quality improvement strategies.

The influence of corporate structure and quality improvement activities on outcome improvement in residential care homes

OBJECTIVE

To examine the impact of corporate structure and quality improvement (QI) activities on improvements in client-reported and professional indicators between 2007 and 2009.

DESIGN

A cross-sectional study using organizational survey and indicator multilevel modelling to test relationships between corporate structure, QI activities and performance improvements on indicators.

SETTING

In total, 169 residential care homes for the elderly in the Netherlands.

MAIN OUTCOME MEASURES

Change between 2007 and 2009 in client-reported and professional indicators.

RESULTS

A middle-size corporate structure was associated with QI. The QI activity 'multidisciplinary team meetings' was positively correlated with the indicator 'safety environment' for somatic and psycho-geriatric care. The QI activities 'educational material' and 'direct work instructions' were associated negatively with the indicator 'availability of personnel' for somatic clients, but positively for psycho-geriatric clients. QI activities such as 'health plan activities', 'clinical lessons' and 'financial activities' had no relationship to improved performance. For psycho-geriatric clients mainly organizational QI activities were positively associated with QI. The mediating role of the corporate structure for performing QI activities appeared stronger for the change in client-reported than for professional indicators.

CONCLUSION

This study reveals associations between QI activities and corporate structure and changes in indicator performance. A corporate structure was associated with improvement in client-reported indicators, but less on professional indicators, which assumes a central policy at corporate level with impact on client-reported indicators, in contrast to a more local level approach towards activities that result in QI on professional indicators. Tailoring QI activities at the right managerial level may be important to achieve improvement.

The use of on-site visits to assess compliance and implementation of quality management at hospital level

OBJECTIVE

Stakeholders of hospitals often lack standardized tools to assess compliance with quality management strategies and the implementation of clinical quality activities in hospitals. Such assessment tools, if easy to use, could be helpful to hospitals, health-care purchasers and health-care inspectorates. The aim of our study was to determine the psychometric properties of two newly developed tools for measuring compliance with process-oriented quality management strategies and the extent of implementation of clinical quality strategies at the hospital level.

DESIGN

We developed and tested two measurement instruments that could be used during on-site visits by trained external surveyors to calculate a Quality Management Compliance Index (QMCI) and a Clinical Quality Implementation Index (CQII). We used psychometric methods and the cross-sectional data to explore the factor structure, reliability and validity of each of these instruments.

SETTING AND PARTICIPANTS

The sample consisted of 74 acute care hospitals selected at random from each of 7 European countries.

MAIN OUTCOME MEASURES

The psychometric properties of the two indices (QMCI and CQII).

RESULTS

Overall, the indices demonstrated favourable psychometric performance based on factor analysis, item correlations, internal consistency and hypothesis testing. Cronbach's alpha was acceptable for the scales of the QMCI (α: 0.74-0.78) and the CQII (α: 0.82-0.93). Inter-scale correlations revealed that the scales were positively correlated, but distinct. All scales added sufficient new information to each main index to be retained.

CONCLUSION

This study has produced two reliable instruments that can be used during on-site visits to assess compliance with quality management strategies and implementation of quality management activities by hospitals in Europe and perhaps other jurisdictions.

Development and validation of an index to assess hospital quality management systems

Objective

The aim of this study was to develop and validate an index to assess the implementation of quality management systems (QMSs) in European countries.

Design

Questionnaire development was facilitated through expert opinion, literature review and earlier empirical research. A cross-sectional online survey utilizing the questionnaire was undertaken between May 2011 and February 2012. We used psychometric methods to explore the factor structure, reliability and validity of the instrument.

Setting and participants

As part of the Deepening our Understanding of Quality improvement in Europe (DUQuE) project, we invited a random sample of 188 hospitals in 7 countries. The quality managers of these hospitals were the main respondents.

Main Outcome Measure

The extent of implementation of QMSs.

Results

Factor analysis yielded nine scales, which were combined to build the Quality Management Systems Index. Cronbach's reliability coefficients were satisfactory (ranging from 0.72 to 0.82) for eight scales and low for one scale (0.48). Corrected item-total correlations provided adequate evidence of factor homogeneity. Inter-scale correlations showed that every factor was related, but also distinct, and added to the index. Construct validity testing showed that the index was related to recent measures of quality. Participating hospitals attained a mean value of 19.7 (standard deviation of 4.7) on the index that theoretically ranged from 0 to 27.

Conclusion

Assessing QMSs across Europe has the potential to help policy-makers and other stakeholders to compare hospitals and focus on the most important areas for improvement.

Is having quality as an item on the executive board agenda associated with the implementation of quality management systems in European hospitals: a quantitative analysis

Objective

To assess whether there is a relationship between having quality as an item on the board's agenda, perceived external pressure (PEP) and the implementation of quality management in European hospitals.

Design

A quantitative, mixed method, cross-sectional study in seven European countries in 2011 surveying CEOs and quality managers and data from onsite audits.

Participants

One hundred and fifty-five CEOs and 155 quality managers.

Setting

One hundred and fifty-five randomly selected acute care hospitals in seven European countries (Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey).

Main outcome measure(s)

Three constructs reflecting quality management based on questionnaire and audit data: (i) Quality Management System Index, (ii) Quality Management Compliance Index and (iii) Clinical Quality Implementation Index. The main predictor was whether quality performance was on the executive board's agenda.

Results

Discussing quality performance at executive board meetings more often was associated with a higher quality management system score (regression coefficient b = 2.53; SE = 1.16; P = 0.030). We found a trend in the associations of discussing quality performance with quality compliance and clinical quality implementation. PEP did not modify these relationships.

Conclusions

Having quality as an item on the executive board's agenda allows them to review and discuss quality performance more often in order to improve their hospital's quality management. Generally, and as this study found, having quality on the executive board's agenda matters.

Evaluating the effectiveness of an educational and feedback intervention aimed at improving consideration of sex differences in guideline development

OBJECTIVES

To investigate the effect of an educational and feedback intervention to enhance consideration of sex differences in clinical guideline development.

DESIGN

Preintervention and postintervention questionnaires in intervention and control groups. Content analysis of intervention guidelines and former versions.

SETTING

Guideline consultants, working-group members and guideline documents of two Dutch guideline-developing organisations.

MAIN OUTCOME MEASURES

Attitudes of guideline developers concerning the importance of considering sex differences and the number of the sex-specific statements in the contents of guideline documents.

RESULTS

The attitude of the intervention group did not change significantly relative to the control group. Consideration of sex-related factors within the guidelines increased relative to available previous versions.

CONCLUSION

Education and expert feedback may increase consideration of sex differences in guidelines. Further efforts are needed to implement and test these interventions.

Three methods of multi-source feedback compared: a plea for narrative comments and coworkers' perspectives

BACKGROUND

Doctor performance assessments based on multi-source feedback (MSF) are increasingly central in professional self-regulation. Research has shown that simple MSF is often unproductive. It has been suggested that MSF should be delivered by a facilitator and combined with a portfolio.

AIMS

To compare three methods of MSF for consultants in the Netherlands and evaluate the feasibility, topics addressed and perceived impact upon clinical practice.

METHOD

In 2007, 38 facilitators and 109 consultants participated in the study. The performance assessment system was composed of (i) one of the three MSF methods, namely, Violato's Physician Achievement Review (PAR), the method developed by Ramsey et al. for the American Board of Internal Medicine (ABIM), or the Dutch Appraisal and Assessment Instrument (AAI), (ii) portfolio, (iii) assessment interview with a facilitator and (iv) personal development plan. The evaluation consisted of a postal survey for facilitators and consultants. Generalized estimating equations were used to assess the association between MSF method used and perceived impact.

RESULTS

It takes on average 8 hours to conduct one assessment. The CanMEDS roles 'collaborator', 'communicator' and 'manager' were discussed in, respectively, 79, 74 and 71% of the assessment interviews. The 'health advocate role' was the subject of conversation in 35% of the interviews. Consultants are more satisfied with feedback that contains narrative comments. The perceived impact of MSF that includes coworkers' perspectives significantly exceeds the perceived impact of methods not including this perspective.

CONCLUSIONS

Performance assessments based on MSF combined with a portfolio and a facilitator-led interview seem to be feasible in hospital settings. The perceived impact of MSF increases when it contains coworkers' perspectives.

Differentiating between hospitals according to the "maturity" of quality improvement systems: a new classification scheme in a sample of European hospitals

Aim:

This study, part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project focusing on cross-border patients in Europe, investigated quality policies and improvement in healthcare systems across the European Union (EU). The aim was to develop a classification scheme for the level of quality improvement (maturity) in EU hospitals, in order to evaluate hospitals according to the maturity of their quality improvement activities.

Methods:

A web-based questionnaire survey designed to measure quality improvement in EU hospitals was used as the basis for the classification scheme. Items included for the development of an evaluation tool—the maturity index—were considered important contributors to quality improvement. The four-stage quality cycle (plan, do, check and act) was used to determine the level of maturity of the various items. Psychometric properties of the classification scheme were assessed, and validation analyses were performed.

Results:

A total of 389 hospitals participated in a questionnaire survey; response rates varied by country. For a final sample of 349 hospitals, it was possible to construct a quality improvement maturity index which consisted of seven domains and 113 items. The results of independent analyses sustained the validity of the index, which was useful in differentiating between hospitals in the research sample according to the maturity of their quality improvement system (defined as the total of all quality improvement activities).

Discussion:

Further research is recommended to develop an instrument which for use in the future as a practical tool to evaluate the maturity of hospital quality improvement systems.

Application of quality improvement strategies in 389 European hospitals: results of the MARQuIS project

CONTEXT

This study was part of the Methods of Assessing Response to Quality Improvement Strategies (MARQuIS) research project investigating the impact of quality improvement strategies on hospital care in various countries of the European Union (EU), in relation to specific needs of cross-border patients.

AIM

This paper describes how EU hospitals have applied seven quality improvement strategies previously defined by the MARQuIS study: organisational quality management programmes; systems for obtaining patients' views; patient safety systems; audit and internal assessment of clinical standards; clinical and practice guidelines; performance indicators; and external assessment.

METHODS

A web-based questionnaire was used to survey acute care hospitals in eight EU countries. The reported findings were later validated via on-site survey and site visits in a sample of the participating hospitals. Data collection took place from April to August 2006.

RESULTS

389 hospitals participated in the survey; response rates varied per country. All seven quality improvement strategies were widely used in European countries. Activities related to external assessment were the most broadly applied across Europe, and activities related to patient involvement were the least widely implemented. No one country implemented all quality strategies at all hospitals. There were no differences between participating hospitals in western and eastern European countries regarding the application of quality improvement strategies.

CONCLUSIONS

Implementation varied per country and per quality improvement strategy, leaving considerable scope for progress in quality improvements. The results may contribute to benchmarking activities in European countries, and point to further areas of research to explore the relationship between the application of quality improvement strategies and actual hospital performance.

Attention to sex-related factors in the development of clinical practice guidelines

BACKGROUND

Clinical practice guidelines describe optimal strategies for disease prevention, diagnosis, or treatment. Increasing evidence indicates that sex-related factors may have an impact on these strategies. We examined the way in which two Dutch guideline organizations address evidence on sex factors in their guideline development methodologies. We then determined whether attention to these factors could be improved and, if so, how this could be done.

METHODS

We selected seven recent guidelines on four conditions: hypertension, depression, osteoporosis, and rheumatoid arthritis. We studied information obtained from interviews with members of the guideline committees and analyzed the content of the guideline documents themselves. Our findings were discussed at an expert meeting.

RESULTS

We found that all the guideline committees concerned applied an internationally accepted framework for guideline development. The proportion of male members ranged from 67% to 100%. None of the guidelines included a question (or subquestion) focusing on sex-related factors. In the literature searches no sex-specific search terms were used. Critical appraisals did not include any systematic focus on sex-related factors or effects. The number of sex-specific recommendations (relative to the total number of recommendations) ranged from 0 of 82 and 0 of 148 in the guidelines on depression to 16 of 84 in one of the guidelines on osteoporosis.

CONCLUSIONS

We found that when developing guidelines, none of the committees systematically focused on sex-related factors that might be relevant to the way in which evidence is identified, appraised, or described. A number of recommendations were made with the aim to facilitate greater attention to sex-related factors in the current methods of guideline development.

The effect of national guidelines on the implementation of outpatient preoperative evaluation clinics in Dutch hospitals

BACKGROUND AND OBJECTIVES

Preoperative evaluation performed by anaesthesiologists primarily aims to estimate the risk of perioperative complications and to create opportunities to optimize the patients' condition before surgery. In this study an inventory was made of the current practice of preoperative evaluation in Dutch hospitals. It was estimated how many hospitals had implemented an outpatient preoperative evaluation clinic in 2004. Subsequently, current practice was compared with the results of a previous inventory (2000). It was also evaluated to what extent the guidelines of the Dutch Health Council and the Netherlands Society of Anaesthesiology were followed.

METHODS

The study consisted of two phases. First, a literature research was performed and pilot interviews were constructed. The interviews were conducted face-to-face with anaesthesiologists in a sample of Dutch hospitals. Based on the results, written questionnaires were constructed. In the second phase these questionnaires were sent to all general and academic hospitals in the Netherlands.

RESULTS

In 2004, 74% of the hospitals had an outpatient preoperative evaluation clinic, compared with 50% in 2000. The percentage of hospitals with an outpatient preoperative evaluation clinic available for all elective patients increased from 20% to 52%.

CONCLUSIONS

The Dutch guidelines on preoperative evaluation seem to have influenced current practice. An increase in the number of outpatient preoperative evaluation clinics was seen after the guidelines were published. The implementation of an outpatient preoperative clinic seems to warrant that anaesthesiologists are carrying out the activities prescribed by the guidelines. Most hospitals without a clinic aim to implement one in the future.

Evidence‐based re‐engineering: re‐engineering the evidence

PURPOSE

Business process redesign (BPR) is used to implement organizational transformations towards more customer-focused and cost-effective care. Ideally, these innovations should be carefully described and evaluated so that "best practices" can be re-applied. To investigate this, available evidence was collected on patient care redesign projects.

DESIGN/METHODOLOGY/APPROACH

The Ebsco Business Source Premier, Embase and Medline databases were searched. Studies on innovations related to re-engineering patient care that used before-after design as minimum prerequisites were selected. General characteristics, logistic parameters and other outcome measures to determine the objectives and results and interventions used were looked at.

FINDINGS

A total of 86 studies that conformed to the criteria were found: a minority mentioned measurable parameters in their objectives. In the majority of studies, multiple interventions were combined within single studies, making it impossible to compare the effects of individual interventions. Only three randomized controlled trials were found. Furthermore, inconsistencies were noted between the study objectives and the reported results. Many more issues were reported in the results than were mentioned in the study aims. It would appear that publications were hard to find owing to a lack of specific MeSH headings. Nearly 7,500 abstracts were scanned and from these it was concluded that clear and univocal research methods, terms and reporting guidelines are advisable and must be developed in order to learn and benefit from BPR innovations in health care organizations.

ORIGINALITY/VALUE

This appears to be the first time available evidence about redesign projects in hospitals has been systematically collected and assessed.

Local health systems in 21st century: who cares?-An exploratory study on health system governance in Amsterdam

BACKGROUND

There is a growing awareness that there should be a public health perspective to health system governance. Its intrinsic population health orientation provides the ultimate ground for determining the health needs and governing collaborative care arrangements within which these needs can be met. Notwithstanding differences across countries, population health concerns are not central to European health reforms. Governments currently withdraw leaving governance roles to care providers and/or financiers. Thereby, incentives that trigger the uptake of a public health perspective are often ignored.

METHODS

In this study we addressed this issue in the city of Amsterdam. Using a qualitative study design, we explored whether there is a public health perspective to the governance practices of the municipality and the major sickness fund in Amsterdam. And if so, what the scope of this perspective is. And if not, why not.

RESULTS

Findings indicate that the municipality has a public health perspective to local health system governance, but its scope is limited. The municipality facilitates rather than governs health care provision in Amsterdam. Furthermore, the sickness fund runs major financial risks when adapting a public health perspective. It covers an insured population that partly overlaps the Amsterdam population. Returns on investments in population health are therefore uncertain, as competitors would also profit from the sickness fund's investments.

CONCLUSION

The local health system in Amsterdam is not consistently aligned to the health needs of the Amsterdam population. The Amsterdam case is not unique and general consequences for local health system governance are discussed.

[Historical health posters as expressions of public health dilemmas]

Historical health posters as expressions of public health dilemmas. The University of Amsterdam's historical collection of health and safety posters (1914-1960) from various countries deals primarily with workplace safety, infectious diseases and the early detection of cancer. Distinct underlying socio-medical dilemmas emerge in four areas: the industrial-political issues behind promoting responsible behaviour in the workplace; class issues in public tuberculosis education; public morality in anti-venereal propaganda, and dealing with fear and hope in the management of cancer. The main goal of the historical posters was to establish a general awareness of both health and individual responsibility. Yet this collection illustrates how socio-medical, political and cultural contextual factors strongly influenced the message and style of the posters.

[Dutch medical specialists as authors of scientific publications in English on clinical drug research (1997/'03)]

OBJECTIVE

To determine the number and type of medical specialists in Dutch hospitals that were authors of scientific papers published in English in the field of clinical drug research in the period 1997/'03.

DESIGN

Descriptive.

METHOD

PubMed was searched for articles on clinical drug research published in February 1997-January 2003. (Co)authors were included if they were registered in the Geneeskundig Adresboek 2002-2003 (Medical Address Book 2002-2003) as a medical specialist working in a hospital. Hospitals were categorized as academic, non-academic teaching, general or non-affiliated. Journals were categorized by the type of published research: fundamental or biomedical, disease-specific, or specialty-specific.

RESULTS

A total of 1776 articles in 426 journals were retrieved with at least 1 medical specialist listed as a (co)author. 1728 medical specialists were identified as authors, which represents 11% of the 16.065 registered medical specialists in The Netherlands. Most authors were involved in the nonsurgical specialties, primarily internist subspecialties, followed by paediatrics, cardiology, and neurology. The authors were employed in nearly all Dutch hospitals. The 1728 specialists had a total of 4952 authorships; 57% of the authors and 70% of the authorships came from academic hospitals. The average impact factor, the number of articles and the number ofauthorships were greatest in the disease-specific journal category. In the period 1997/'03 the number of authorships from non-academic teaching hospitals and general hospitals decreased, while the number of authorships from academic hospitals increased, particularly with regard to the number of co-authorships.

Implementing global knowledge in local practice: a WHO lung health initiative in Nepal

Clinical practice guidelines are used widely to improve the quality of primary health care in different health systems, including those of low-income countries. Often developed at international level and adapted to national contexts to increase the feasibility of effective uptake, guideline initiatives aim to transfer global scientific knowledge into local practice. The WHO's Practical Approach to Lung Health (PAL) is an example of such an initiative and is currently being developed to improve the quality of care for youths and adults with respiratory diseases. We assessed ex-ante the feasibility of successful implementation of PAL in a pilot programme in rural Nepal, studying three components: the quality of the innovation (i.e. the guidelines), the effectiveness of the implementation strategy (i.e. training) and the receptiveness of the social system of health staff at all levels (i.e. social and organizational characteristics). We assessed the guideline innovation with the AGREE instrument for guidelines, the intended implementation strategy by critical comparison with literature on effective strategies, and the social system with both a stakeholder analysis and a descriptive analysis of the health care system at district level. This ex-ante assessment of an adaptive local implementation of international WHO guidelines showed that in July 2002 the 'implementability' of the package was challenged on the three components studied. To increase the chances of successful implementation, the national guideline development process should be improved and the implementation strategy needs to be upgraded. In order to successfully transfer global knowledge into local practice, we need to develop additional multifactorial sustained interventions that tackle other culture-specific and health system-specific barriers as well. The primary health workers are key informants for these barriers.

How safe is the safety paradigm?

This paper reviews safety initiatives in the health systems of the UK, Canada, Australia, and the US. Initiatives to tackle safety shortcomings involve public-private collaborations. Patient safety agencies (to institute learning, action and safety culture), adverse event reporting and, to a lesser extent, safety related performance indicators are currently used to design safer health systems. Their benefits are mixed, but there is little debate as to their possible side effects. Foreseeable adverse effects of multiple safety organisations stem from them being too many, too vague, too narrowly focused, threatened by the medical practice environment, and too optimistic. Safety related performance indicators are most developed in the US but suffer from inadequacies of administrative data, underreporting, variable indicator definitions, "extended" use, and low sensitivity of the diagnosis coding system, and arguable preventability of the prescribed conditions. A critical appraisal of the implications of these deficiencies is important to assure the safety of current health system safety initiatives and to establish evidence based safety. It is necessary to embed health system safety (as well as patient safety) in the societal culture, structures, and policies which promote effective, user centred, high performance care while allowing for healthy innovation.

How safe is the safety paradigm?

This paper reviews safety initiatives in the health systems of the UK, Canada, Australia, and the US. Initiatives to tackle safety shortcomings involve public-private collaborations. Patient safety agencies (to institute learning, action and safety culture), adverse event reporting and, to a lesser extent, safety related performance indicators are currently used to design safer health systems. Their benefits are mixed, but there is little debate as to their possible side effects. Foreseeable adverse effects of multiple safety organisations stem from them being too many, too vague, too narrowly focused, threatened by the medical practice environment, and too optimistic. Safety related performance indicators are most developed in the US but suffer from inadequacies of administrative data, underreporting, variable indicator definitions, "extended" use, and low sensitivity of the diagnosis coding system, and arguable preventability of the prescribed conditions. A critical appraisal of the implications of these deficiencies is important to assure the safety of current health system safety initiatives and to establish evidence based safety. It is necessary to embed health system safety (as well as patient safety) in the societal culture, structures, and policies which promote effective, user centred, high performance care while allowing for healthy innovation.

An implementation study of two evidence-based exercise and health education programmes for older adults with osteoarthritis of the knee and hip

Implementation studies are recommended to assess the feasibility and effectiveness in real-life of programmes which have been tested in randomized controlled trials (RCTs). We report on an implementation study of two evidence-based exercise and health education programmes for older adults with osteoarthritis (OA) of the knee or hip. Three types of primary health-care providers (n = 18) delivered the OA Knee programme (n = 20) and the OA Hip programme (n = 20), supported by programme manuals and implementation guidelines, in four regions. The outcome measures were pain and mobility. The Knee programme had OA knowledge and self-efficacy as additional outcome measures. Differences in outcome measures and background variables of participants were assessed between the RCTs and the implementation study. Positive effects (P < 0.05) were found for OA knowledge, pain and self-efficacy in the Knee programme (n = 157), and for pain in the Hip programme (n = 132). No effect was found for mobility. Effect sizes of the RCTs and the present study were comparable. Background variables did not explain the variance in the outcome measures. The outcomes of the previous RCTs and the implementation study were comparable, and indicated the ecological validity of the two programmes. The implications for nationwide dissemination and implementation in The Netherlands are discussed.

[Prevention demands a more ambitious approach. Response to the cabinet policy document 'Live healthier for longer 2004-2007; also a matter of healthy behavior']

In the cabinet policy document 'Live healthily for longer 2004-2007; also a matter of healthy behaviour' the Dutch Secretary of State for Health, Welfare and Sport assumes that many health problems are linked to behaviours such as smoking and lack of physical activity. He places the prime responsibility for that with the citizens and also with local councils, trade and industry, care providers and schools. However conscious behavioural choices by individual citizens form only a small part of the cause-effect chain that leads to ill health. It is incorrect to ascribe the differences in unhealthy behaviour to freely made behavioural choices. Moreover it begs the question as to whether the proposed measures will be effective. Over and above all this, the finances that are available to strengthen preventative measures are completely inadequate. The central government should be encouraging the health care sector to devise a more central position for prevention and ensuring that effective opportunities for prevention are used as much as possible. After all, it is expected of the central government that it will look after the collective interests and protect and promote the health of the population. The necessary improvements can only be achieved through a much more ambitious approach than that presented by the cabinet.

Developing a national performance indicator framework for the Dutch health system

OBJECTIVE

To report on the first phase of the development of a national performance indicator framework for the Dutch health system.

METHODS

In January 2002, we initiated an informed interactive process with the intended users-policymakers at the Ministry of Health, Welfare and Sport-and academics to develop both the conceptual framework and its content. Decisions were based on consensus after discussing strategic goals of the health system, information needs of policy makers at the Ministry of Health, Welfare and Sport, and studying existing theory and international experiences with national performance indicator frameworks. We identified objectives and criteria for a framework at the national level, constructed a conceptual model, and selected indicator areas.

RESULTS

As a starting point we chose a balanced scorecard reflecting four perspectives towards health system management information at the national level. These perspectives are consumer orientation, finances, delivery of high quality care, and the ability to learn and grow. We then linked the Lalonde model for population health to a balanced scorecard model. The constructed model makes the relationship between population health and health system management apparent, and facilitates the presentation of performance information from various perspectives. The model reflects the strategic goals of the Dutch health system, i.e. contributing to the production of health by providing necessary health care of good quality that is accessible for all Dutch citizens while simultaneously informing policy makers about the performance of the entire health system in all sectors (care, cure, prevention, and social services). The selected indicator areas for health system management information (20 in total) reflect the policy and management functions of the government and the defined public goals of the health system. The model was formally adopted by the Ministry of Health, Welfare and Sport in February 2003, and since then individual indicator areas have been operationalized by 30 representatives of various departments at the Ministry with continuous external research support.

CONCLUSION

The merit of linking the balanced scorecard inspired model to public health data is that it facilitates the visualization of the contribution of the health system to the improvement of population health. The method of an intensive interactive indicator development process between policy makers and researchers has so far proven successful.

Conceptual frameworks for health systems performance: a quest for effectiveness, quality, and improvement

ISSUES

Countries and international organizations have recently renewed their interest in how health systems perform. This has led to the development of performance indicators for monitoring, assessing, and managing health systems to achieve effectiveness, equity, efficiency, and quality. Although the indicators populate conceptual frameworks, it is often not very clear just what the underlying concepts might be or how effectiveness is conceptualized and measured. Furthermore, there is a gap in the knowledge of how the resultant performance data are used to stimulate improvement and to ensure health care quality.

ADDRESSING THE ISSUES

This paper therefore explores, individually, the conceptual bases, effectiveness and its indicators, as well as the quality improvement dynamics of the performance frameworks of the UK, Canada, Australia, US, World Health Organization, and Organisation for Economic Co-operation and Development.

RESULTS

We see that they all conceive health and health system performance in one or more supportive frameworks, but differ in concepts and operations. Effectiveness often implies, nationally, the achievement of high quality outcomes of care, or internationally, the efficient achievement of system objectives, or both. Its indicators are therefore mainly outcome and, less so, process measures. The frameworks are linked to a combination of tools and initiatives to stimulate and manage performance and quality improvement.

CONCLUSIONS

These dynamics may ensure the proper environment for these conceptual frameworks where, alongside objectives such as equity and efficiency, effectiveness (therefore, quality) becomes the core of health systems performance.

[Cardiovascular risk factors for Surinamese in the Netherlands: a literature review]

OBJECTIVE

To obtain an overview of the prevalence of cardiovascular risk factors in Surinamese (Hindustani and Creoles) individuals in the Netherlands and the implications of this for secondary prevention.

DESIGN

Literature study.

METHOD

A Medline literature search was carried out for the period 1985-2001 with the keywords 'cardiovascular risk factor' or 'cardiovascular risk factors', and 'Surinamese'. In addition to this, so-called grey literature was searched and the reference lists of articles found were also checked. A total of 7 studies were selected.

RESULTS

Smoking is less frequent among Surinamese individuals in the Netherlands compared to the indigenous population, especially in women. The prevalence of both hypertension and diabetes is higher among the Surinamese. Data on dyslipidaemia are almost absent; it is only known that hypercholesterolaemia is less prevalent among the Surinamese. Ethnicity is not included in the risk cards used in the secondary treatment of cardiovascular diseases.

CONCLUSION

The lack of research with respect to the cardiovascular risk profile of Surinamese (Hindustani and Creoles) in the Netherlands indicates an unfavourable profile compared to the indigenous Dutch population. This difference justifies further research into the differentiation of prevention and treatment according to ethnic origin.

How disturbing is it to be approached for a genetic cascade screening programme for familial hypercholesterolaemia? Psychological impact and screenees' views

OBJECTIVES

To assess the screenees' views on, and the psychological impact of, a family-based genetic screening programme for familial hypercholesterolaemia (FH) and to evaluate non-participation.

METHODS

Self-administered questionnaires were filled out at the time of screening and after communication of the test result. Non-participants were interviewed by phone.

RESULTS

Of the people approached for screening, 2% did not participated. These 2% were not interested, had already been clinically diagnosed, or were afraid of insurance consequences. 677 screenees participated, of whom 215 (32%) tested FH positive. Less than 5% of the screenees were critical of the approach and the information provided. 20% of the screenees expressed feelings of social pressure. Effects on mood were minimal to absent, as were general 'quality of life' effects.

CONCLUSIONS

Screening for FH is highly acceptable to screenees, although social pressure is prevalent. Only a small percentage of people being approached did not participate.

Supporting Dutch medical specialists with the implementation of visitatie recommendations: a descriptive evaluation of a 2-year project

OBJECTIVE

To improve the quality of patient care by supporting the implementation of practice-specific visitatie (external peer review) recommendations.

DESIGN

A descriptive evaluation of an intervention strategy (Quality Consultation). Data collection through participatory observation, telephone interviews, and a postal survey.

SETTING

Twenty-five specialist group practices (67 specialists) from the specialty societies of surgeons, paediatricians, and gynaecologists, supported in their implementation efforts by two experienced management consultants.

INTERVENTION

Approximately 20 h of management consultancy. The Quality Consultation took a site-specific multifaceted implementation approach; its tool kit consisted of various management and quality improvement support methods.

MAIN MEASURES

Choice of recommendations supported; type of interventions offered; degree of implementation; appreciation of implementation results and process; and impact of management consultants as assessed by participants.

RESULTS

The level of participation was high and evaluation of the consultants and the impact of their support positive. Most implementation projects were related to strategic issues or the functioning of the specialist group. Every specialist group was offered multiple interventions, both participatory and non-participatory. The degree of implementation was rated 4.0 on a 5-point scale; the scores for the implementation result and process were 6.6 on a 10-point scale.

CONCLUSIONS

Visitatie seems to inherently enforce the development of management of medical specialist care. This might also be true for other external peer review models. The development of effective specialist groups deserves high priority in order to implement visitatie recommendations successfully. Management consultants can be instrumental in this process.

Cost-effectiveness of a family and DNA based screening programme on familial hypercholesterolaemia in The Netherlands

AIMS

To estimate the cost-effectiveness of the current screening programme on Familial Hypercholesterolaemia (FH) in relatives of diagnosed FH-patients in The Netherlands.

METHODS AND RESULTS

Data from 2229 screened FH-relatives, including age, sex, risk factor status and screening outcome, were combined with the Framingham risk function and national disease-specific cost data to arrive at a model-based comparison of survival and costs, with and without the screening programme. Cost-effectiveness ratios were computed for various treatment strategies, with no screening as reference. Costs per life year gained varied between 25.5- and 32-thousand Euros, depending upon the precise treatment strategy after a positive screen. The costs for screening (tracing the FH-positive individuals) were much lower than the follow-up costs (treatment), of which 80% were costs for statins. Consequently, the costs per life year gained of alternative screening programmes are about the same.

CONCLUSION

The cost-effectiveness ratio of FH screening is within the range requiring explicit political consideration in The Netherlands. As the costs of statin treatment are the single most important determinant of costs, policy decisions reduce to decisions on the acceptability of statin treatment for this risk group. Pending major changes in statin price, clear guidelines should be developed on how screen positive individuals should be treated, since not all of them have an elevated cholesterol level.

Urgency coding as a dynamic tool in management of waiting lists for psychogeriatric nursing home care in The Netherlands

Criteria are used to prioritise patients on waiting lists for health care services. This is also true for waiting lists for admission to psychogeriatric nursing homes. A patient's position on these latter waiting lists is determined by (changes in) urgency and waiting time. The present article focuses on the process and outcome of an urgency coding system in a fair selection of patients. It discusses the use of urgency codes in the daily practice of waiting list management and the related waiting times. Patients and their informal caregivers were followed from entry on the waiting list to admission to a nursing home. Caregivers were interviewed during the waiting period and after their relative's admission to a nursing home, and the formal urgency codes on the waiting list were monitored. Seventy-eight of the initial 93 patients were admitted to a nursing home. High urgency codes were commonly assigned and the waiting times were shorter for patients with higher urgency codes. Negative consequences of an urgency coding system, e.g. patients with less urgency not being admitted at all and patients not being admitted to the nursing home of their choice, could not be demonstrated. Patients without higher urgency codes were admitted after a mean waiting time of 28 weeks. It may be questioned whether this long waiting time is problematic, because satisfaction of the caregivers with regard to waiting times was not influenced by the actual waiting times. An urgency coding system enables health care professionals to react to changes in the situation of both patients and caregivers by adjusting urgency codes to influence the length of time until nursing home admission.

Community-based integrated care: myth or must?

ISSUE

In spite of the many efforts that have been made to rationalize and improve the functioning and the quality of health care delivery in industrialized countries, too limited a degree of success has been achieved so far. This paper argues that this limited success originates from a lack of coherence among the various strategies and instruments developed to rationalize and improve the delivery of health care.

ADDRESSING THE ISSUE

This fact can be shown by reducing the complexity of today's health care into three levels of decision making: the primary process of patient care, the organizational context, and the financing and policy context of health care systems. Distinct rationales exist on each of these three levels of decision making as actors have their own perspectives, cultures, disciplines, and traditions concerning the delivery of health care. These differences can often result in ambiguity of goals, conflicting interests between decision makers, bureaucracy, poor information transfer, and limited use of the available scientific knowledge on all three levels. In such a context, rationalization and quality-improvement efforts are frustrated and will have limited effectiveness. Therefore, the various rationalization strategies and instruments on all three levels of decision making should be embedded in our health care systems in a synergistic way.

DEMONSTRATING THE PROPOSED SOLUTION

Community-based integrated care is a promising approach to addressing this issue successfully. How this concept might function as a unifying concept for quality improvement will be illustrated by relevant developments in the Academic Medical Center, University of Amsterdam in The Netherlands.

Burden of delayed admission to psychogeriatric nursing homes on patients and their informal caregivers

OBJECTIVE

To assess the deleterious effects of waiting for admission to a nursing home on the state of health of patients and their informal caregivers, and on the burden of caring.

DESIGN AND PARTICIPANTS

Prospective longitudinal study consisting of interviews with informal caregivers during the period on the waiting list and after admission of the patient to a nursing home. Analysis of patients' files on diagnosis, date of registration on the waiting list, and date of admission to nursing home.

SETTING

Ninety three patients registered on waiting lists for admission to a psychogeriatric nursing home in two regions of Amsterdam.

RESULTS

Seventy eight of the 93 patients were admitted to a nursing home. The burden on the caregivers declined after admission of the patient but depressive symptoms did not. After 6 months a subgroup of 19 caregivers whose relatives were still waiting to be admitted were interviewed. The health of these patients remained stable during this waiting period and only problems in activities of daily living increased. The burden on these 19 informal caregivers and their state of health remained stable during the waiting period.

CONCLUSIONS

A decline in the state of health and a rise in the burden on caregivers during the waiting period did not occur. However, a decrease in the burden and an improvement in mental health could have started earlier if patients had been admitted earlier.

A policy analysis of the introduction and dissemination of external peer review (visitatie) as a means of professional self-regulation amongst medical specialists in The Netherlands in the period 1985-2000

By examining the introduction and dissemination of external peer review through site-visits (visitatie) amongst Dutch medical specialists, this paper sets out to deepen our insight into the dynamics of professional self-regulation and health care policy making. We explore how visitatie has been used in the political process between medical specialists and the state, serving as a strategy in protecting the autonomy of physicians. In the late eighties and early nineties, factors both internal as well as external to the medical profession all together determined the start and spread of visitatie. The conflict between state and doctors over the specialists' income, the introduction of the market oriented policies, new visions on quality assurance, the debate on the future of medical specialistic care and a new legal framework on quality assurance, challenged the medical community to find ways to reconfirm the public's trust in the self-regulating mechanism of the profession. One answer is found in carrying out 300-400 visitaties annually. During the past years, many stakeholders have perceived visitatie as a credible instrument in assuring quality patient care. The dynamics of professionalization and measurable impact of visitatie will determine whether or not it is here to stay.

Medical audit: threat or opportunity for the medical profession. A comparative study of medical audit among medical specialists in general hospitals in The Netherlands and England, 1970-1999

Medical audit has been introduced among hospital specialists in both the Netherlands and England. In the Netherlands following some local experiments, medical audit was promoted nationally as early as 1976 by the medical profession itself and became a mandatory activity under the Hospital Licensing Act of 1984. In England it was the government who promoted medical audit as a compulsory activity for medical specialists, in particular since 1989. In this article the development and introduction of medical audit in the two health care systems is described and its impact on the clinical autonomy of medical specialists gauged. It is concluded that in both countries external pressures seem to have been crucial in the 'compulsory' introduction of medical audit. Although there are differences in the organisation and culture of the medical profession in the two countries, in both countries medical audit turned out to be an instrument 'controlled' by the profession itself. The question whether medical audit is instrumental in preserving clinical autonomy has also been addressed. Our conclusion is that in its present form medical audit in the two countries has not been a threat to the clinical autonomy of the medical profession. At the same time it is clear that the study of one quality instrument is insufficient to draw conclusions about the development of clinical autonomy, let alone autonomy in general. Moreover, it remains to be seen how medical audit can survive alongside quality improvement mechanisms such as accreditation, certification, performance indicators and formal quality systems (ISO, EFQM) where hospital management executes more control. The history of medical audit in the Netherlands and England over the past 30 years does illustrate, however, the capability of the profession to maintain autonomy through re-negotiated mechanisms for self-control.

Burden of delayed admission to psychogeriatric nursing homes on patients and their informal caregivers

OBJECTIVE

To assess the deleterious effects of waiting for admission to a nursing home on the state of health of patients and their informal caregivers, and on the burden of caring.

DESIGN AND PARTICIPANTS

Prospective longitudinal study consisting of interviews with informal caregivers during the period on the waiting list and after admission of the patient to a nursing home. Analysis of patients' files on diagnosis, date of registration on the waiting list, and date of admission to nursing home.

SETTING

Ninety three patients registered on waiting lists for admission to a psychogeriatric nursing home in two regions of Amsterdam.

RESULTS

Seventy eight of the 93 patients were admitted to a nursing home. The burden on the caregivers declined after admission of the patient but depressive symptoms did not. After 6 months a subgroup of 19 caregivers whose relatives were still waiting to be admitted were interviewed. The health of these patients remained stable during this waiting period and only problems in activities of daily living increased. The burden on these 19 informal caregivers and their state of health remained stable during the waiting period.

CONCLUSIONS

A decline in the state of health and a rise in the burden on caregivers during the waiting period did not occur. However, a decrease in the burden and an improvement in mental health could have started earlier if patients had been admitted earlier.

Caring for relatives with dementia--caregiver experiences of relatives of patients on the waiting list for admission to a psychogeriatric nursing home in The Netherlands

AIMS

Institutionalising a relative is a difficult decision and often relatives have to feel heavily burdened before they take such a step. Then the following delay because of waiting lists can be too much. This paper examines the experiences of caregivers of demented patients at the moment of registration on the waiting list for nursing-home care.

METHODS

Interviews were carried out with 93 informal caregivers and analysis was made of the files of patients who were registered on the waiting list for nursing-home admission in Amsterdam in 1997 and 1998. Data collection included the Interview for Deterioration in Daily living activities in Dementia, The Revised Memory and Behaviour Problem Checklist, the Social Support List-Interaction, and three subscales of the Caregiver Reaction Assessment (CRA) scale.

RESULTS

At the moment of admission to the waiting list, half of the respondents were rather heavily burdened or worse. Less severe dementia, lower age of the patient and providing more hours of informal care especially accounted for more negative experiences of caregivers. The self-esteem derived from caregiving was higher for caregivers with lower income and for those who perceived the quality of the relationship with the demented person as better.

CONCLUSIONS

The high burden levels at the moment the decision to institutionalise the patient is taken put a heavy claim on the energy needed to continue to care during the ensuing waiting period. More social support and formal home care may reduce the level of burden of caregiving.

EFQM approach and the Dutch Quality Award

Different approaches to improve quality are used in organizations delivering health care. Donabedian introduced structure, process and outcome, from which other approaches like self-assessment, accreditation, visitation, International Standards Organisation (ISO) and European Foundation for Quality Management (EFQM) can be aligned. The EFQM model is one such approach that has been adopted and adapted by the Dutch Institute for Quality Management. This article describes the background and progress relating to the use of the EFQM business excellence model within Dutch health care organizations. In addition the process for applying for the European Quality Award and the Dutch Quality Award are described in detail. Finally, the reader is enlightened regarding the work of the European ExPeRT research group who are promoting the use of quality models within health care.

[Inventory and comparison of guidelines for antibiotic utilization in Dutch hospitals]

In 1976 the Dutch Health Council advised hospitals to formulate guidelines for use of antibiotics. These guidelines and their use should improve the quality of care in terms of medical effectiveness and cost-effectiveness. In 1988 the Peer Review Council held a survey among all (140) Dutch hospitals to collect data about these guidelines. Thirty-seven sets of guidelines used in 71 hospitals were obtained. We analysed these sets of guidelines as to the following general aspects: the status of the guidelines in the hospitals, the problem-oriented approach, the topics dealt with in the guidelines and the authors of the guidelines. Four specific aspects related to rational use of antibiotics were analysed as well: the use of cephalosporin, the use of different antibiotics for prophylaxis and therapy and the cost-effectiveness of antibiotic treatment in relation to urosepsis. Results of these analyses show that guidelines are too often formulated in a noncommittal way and that there is a need for a more functional registration system to link information about the clinical working diagnoses, the bacteria isolated and the sensitivity to the antibiotics used. These linkages are essential for feedback to clinicians, microbiologists and pharmacists and a prerequisite for management of the quality of care with respect to use of antibiotics.