Abstract
Rationale, aims, and objectivesThis paper examines a remarkable dispute between Dutch insurers, hospitals, doctors, and patients about a set of quality indicators. In 2013, private insurers planned to drastically reform Dutch emergency care using quality indicators they had formulated drawing from clinical guidelines, RCTs, and systematic reviews. Insurers' plans caused much debate in the field of emergency care. As quality indicators have come to play a more central role in health care governance, the questions what constitutes good evidence for them, how they ought to be used, and who controls them have become politically and morally charged. This paper is a case study of how a Dutch public knowledge institution, the National Health Care Institute, intervened in this dispute and how they addressed these questions.MethodWe conducted ethnographic research into the knowledge work of the National Health Care Institute. Research entailed document analysis, participant observation, in‐depth conversations, and formal interviews with 5 key‐informants.ResultsThe National Health Care Institute problematized not only the evidence supporting insurers' indicators, but also—and especially—the scope, purpose, and use of the indicators. Our analysis shows the institute's struggle to reconcile the technical rationality of quality indicators with their social and political implications in practice. The institute deconstructed quality indicators as national standards and, instead, promoted the use of indicators in dialogue with stakeholders and their local and contextual knowledge.ConclusionsEven if quality indicators are based on scientific evidence, they are not axiomatically good or useful. Both proponents and critics of Evidence‐based Medicine always feared uncritical use of evidence by third parties. For non‐medical parties who have no access to primary care processes, the type of standardized knowledge professed by Evidence‐based Medicine provides the easiest way to gain insights into “what works” in clinical practice. This case study reminds us that using standardized knowledge for the management of health care quality requires the involvement of stakeholders for the development and implementation of indicators, and for the interpretation of their results.
Highlights
In response to growing demands to achieve cost control, safety, and transparency, quality indicators have become increasingly important in the governance of health care
Our analysis shows the institute's struggle to reconcile the technical rationality of quality indicators with their social and political implications in practice
Even if quality indicators are based on scientific evidence, they are not axiomatically good or useful
Summary
In response to growing demands to achieve cost control, safety, and transparency, quality indicators (or “performance measures”) have become increasingly important in the governance of health care. Quality indicators provide a means for care providers, decision makers, and purchasers to measure, compare, and improve the quality of care.[1,2,3] Experts agree, both in Dutch context,[4,5] and internationally,[6,7,8] that indicators are ideally based on a clinical guideline, or—in absence of a guideline—on the best available scientific evidence with regard to quality of care. As quality indicators have come to play a more central role in health care governance, the questions what constitutes good evidence for these parameters, how indicators ought (and ought not) to be used, and who controls them have become politically and morally charged. The Association of Dutch Health Insurers had formulated these indicators drawing from clinical guidelines, RCTs, and systematic reviews from the field of emergency care. The indicators substantiated insurers' argument that the centralization of complex emergency care in few specialized hospitals would lead to better and cheaper care
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