Dutch Health Care System Research Articles

Health economics and oral care: an introductory anthology

Healthcare expenditures will continue to increase in the coming years, raising questions regarding the sustainability of the Dutch healthcare system and solidarity, but also about the optimal use of available resources. Given the issues in the oral care sector, attention for economic insights is appropriate there as well. Relevant issues in this regard are the design of the basic and supplementary health insurance schemes for oral care, the market structure and financing of oral care, questions regarding task shifting in oral care, as well as socio-economic inequalities in oral health. A closer cooperative relationship between oral care and the health economy can help in achieving an optimal and sustainable organisation of the Dutch oral care sector. In other words, an organisation contributing in an efficient and fair way to good oral care for all Dutch citizens.

Integrative medicine in Dutch curative and long-term healthcare centres: Mapping the field

IntroductionLittle is known about integration of Complementary and Alternative Medicine (CAM) in the Dutch healthcare system. The aim of the present study was to investigate how Integrative Medicine (IM) is practiced and how CAM is integrated with conventional medicine in curative and long-term healthcare centres in the Netherlands. MethodsA mixed methodology was applied, including a systematic internet search, an online survey and focus groups among healthcare professionals. ResultsMost hospitals (92%) offered some form of CAM to treat anxiety (72%), restlessness (68%), pain (65%), sleeping problems (50%), stress (48%) and fatigue (36%). Mostly offered modalities were relaxation exercises (88%), art therapy (44%) and mindfulness (42%). Similar percentages of CAM use were found in other healthcare centres. Most CAM modalities were implemented without organizational vision, guidelines or protocols. Only 5% of implemented CAM was labelled as IM. Focus groups with health care professionals revealed the need to increase knowledge and to develop a vision for integration of CAM with conventional medicine, as well as to support effectiveness research in this area. ConclusionsThis study is the first in the Netherlands to quantitatively map the extent of CAM integration in conventional health care. The number of CAM interventions offered at conventional health care settings was surprisingly high. However, integration was fragmented. Guidelines, education and research programs are needed to further integration of CAM, preferably organised in a Dutch Consortium for IM.

Does managed competition constrain hospitals' contract prices? Evidence from the Netherlands.

In the Dutch health care system, health insurers negotiate with hospitals about the pricing of hospital products in a managed competition framework. In this paper, we study these contract prices that became for the first time publicly available in 2016. The data show substantive price variation between hospitals for the same products, and within a hospital for the same product across insurers. About 27% of the contract prices for a hospital product are at least 20% higher or lower than the average contract price in the market. For about half of the products, the highest and the lowest contract prices across hospitals differ by a factor of three or more. Moreover, hospital product prices do not follow a consistent ranking across hospitals, suggesting substantial cross-subsidization between hospital products. Potential explanations for the large and seemingly random price variation are: (i) different cost pricing methods used by hospitals, (ii) uncertainty due to frequent changes in the hospital payment system, (iii) price adjustments related to negotiated lumpsum payments and (iv) differences in hospital and insurer market power. Several policy options are discussed to reduce variation and increase transparency of hospital prices.

Compliance with laboratory monitoring guidelines in outpatient HIV care: a qualitative study in the Netherlands

ABSTRACTEvidence-based guidelines in HIV care aim to improve patients’ health outcomes, quality of care, and cost-effectiveness. Laboratory monitoring plays an important role in assessing clinical status of patients and forms an integral part of HIV treatment guidelines. The Dutch HIV monitoring foundation (Stichting HIV Monitoring) previously observed variation between HIV treatment centres in the Netherlands in terms of compliance with guidelines for performing laboratory tests. Drawing on qualitative research methods, this article aims to describe factors that influence guideline compliance for laboratory monitoring in outpatient HIV care in the Netherlands. Twelve semi-structured in-depth interviews were conducted with a convenience sample of physicians from four HIV treatment centres. In general, physicians perceived laboratory guidelines as useful. However, unclear online visual representation of the guidelines, a lack of set reminders for tests, and assessment of patients’ risk behaviour, which differs per patient, were identified as barriers to guideline compliance. The compartmentalisation of the Dutch healthcare system was viewed as hampering guideline compliance. A clinical-decision-support tool could possibly facilitate compliance with laboratory monitoring guidelines. Moreover, better alignment of HIV outpatient care, municipal health services and primary care, in terms of laboratory testing, could optimize efficiency, increase cost-effectiveness, and improve quality of HIV care.

Hoe Elco Brinkman alsnog zijn zin kreeg: neoliberalisme, communitarisme en linkse idealen in de Nederlandse gezondheidszorg

In her seminal book Family Values Melinda Cooper argues that the American welfare state from the 1960s was dismantled because of a combination of three important events: 1) left-wing liberals stopped to embrace and defend the welfare state; they criticized it relentlessly and advocated far reaching radical alternatives, 2) neoliberal thinking became popular when the economic crisis of the 1970s set in and Keynesian remedies failed and 3) neoliberals entered into an ideational coalition with neoconservatives and their combined discourse became dominant over time. In this article Trappenburg uses Cooper’s framework as a heuristic device to describe the evolution of Dutch health care policy from the 1960s and till the 21st century. She finds that the left in the Netherlands was similarly hostile to the existing welfare state, criticizing professionals, care institutions and the existing health care system. The economic crisis of the 1970s led to a growing amount of neoliberal thinking, resulting in 1987 in a state commissioned report that advocated a partial marketization of health care. In the 1990s the neoliberal discourse was combined with conservative elements, introducing communitarian ideas in health care. The present Dutch health care system is a mixture of neoliberal, conservative-communitarian and radical left elements.

The future of healthcare has arrived: who dares take up the challenge?

According to the Euro Health Consumer Index, the Dutch healthcare system is the champion of Europe. Yet we are living for longer, prosperity is increasing and the population is growing. If we do not continue to adjust our healthcare system to these trends, medical expenses in the Netherlands will double to € 174 billion (in 2040). We are also facing job market difficulties in healthcare. We risk a shortfall of 125 thousand employees in 2022. It is therefore time to restructure healthcare. Not tomorrow but today. Healthcare will increasingly be organised around the day-to-day lives of patients—at home or work, with offline and online healthcare seamlessly matching up to each other. The shortage of personnel also demands a different attitude to healthcare provision. As a health insurer we can help to improve healthcare, for instance by giving healthcare providers the financial capacity to organise their care differently. Or by conducting independent research so that conclusions can be drawn on the legal criterion of ‘the state of science and practice’. This is how it was possible, in conjunction with the Dutch Cardiology Centres, the Netherlands Society of Cardiology and FocusCura, to include the ‘Hartwacht’ telemonitoring service in health insurance policies.

Implementation of Patient Engagement in the Netherlands: A Stimulating Environment within a Large Academic Medical Centre.

Patients are the official third party of the Dutch healthcare system, apart from healthcare providers and insurers. Radboud university medical center (Radboudumc) is a regional centre for specialized secondary care in the Netherlands. Here innovation is recognized as a decisive factor when it comes to the implementation of patient engagement. Therefore, all employees are invited to innovate, experiment, fail and implement promising innovations into practice. In this paper, we demonstrate how this stimulating environment led to a rich collection of patient engagement activities in organizational (re-)design and in educational programs for students and employees.

Trust in times of health reform

Trust is seen as an important condition for the smooth functioning of institutions, such as the health care system. In this article we describe the trust relationships between the three main actors in the Dutch health care system: patients/insured, healthcare providers and insurers. We used data from different surveys between 2006 and 2016. 2006 was the year of the introduction of an insurance reform in the Netherlands towards regulated competition.In the triangle of trust relationships between the three actors we found strong and mutual trust relationships between patients and healthcare providers and weak trust relationships between healthcare providers and insurers as well as between insured and insurance organisations. This hampers the intended role of insurers as selective purchasers of health care on the basis of quality and price.

Exploring a transition in Dutch healthcare

PurposeHealthcare systems are facing persistent challenges, such as dealing with an ageing population, related increases in chronic diseases and healthcare costs facilitated by technological progress. The authors argue that the boundaries of optimisation are being reached and a more fundamental change or transition is necessary. The purpose of this paper is to explore the contours of this transition in the Netherlands. The authors do this from the perspective of healthcare organisations that have participated in the “Expedition to Sustainable Healthcare”: a learning programme organised by the Dutch Network for Sustainable Healthcare aimed at creating frontrunners in this transition.Design/methodology/approachThe paper combines conceptual with experimental empirical work. The authors use the transition research frameworks to conceptualise persistent problems and transitional dynamics in the healthcare system. In a longitudinal study, the authors analysed how the participating organisations developed after the expedition.FindingsThe process validated the initial understanding of persistent sustainability challenges. An integral approach to sustainable healthcare is translated as a transformation of culture, structures and practices and the development of capacity for crossing borders and domains, inside and outside of the organisation. To facilitate and stimulate such a process the authors found that problem structuring and collective identification of persistent problems and the unsustainability in the healthcare system is a crucial step towards a shared view and discourse that supports change.Originality/valueA transition in the Dutch healthcare system is just starting to emerge and has barely been subject of research. This paper provides an empirical description of a transition management process in this context. The authors hope to lay a foundation for future work that seeks to explore transitions in healthcare in theory and practice.

Solidarity in the Dutch healthcare system: monitoring trends in willingness to pay

Background Increasing costs of healthcare are putting stress on solidarity principles in social health insurance in European countries. This could pose a threat to equal access to healthcare which can have negative consequences for national health. There have been policy changes to tackle rising costs which alter solidarity in the healthcare system and spark a debate on how resources should be distributed. Institutionalized solidarity principles rely on a broad societal support for equal access to healthcare. A decrease in public support might affect solidarity in healthcare systems. Aim The aim of this research is to monitor solidarity in Dutch society. The focus is on willingness to pay for healthcare costs for others through the years. Methods Questionnaires have been sent out to a random selection of the 12.000 members of Nivel’s Dutch Health Care Consumer Panel, and included, among others, questions about solidarity in healthcare. Data are available from 2013, 2015 and 2017. The response was N = 764 (51%), N = 633 (42%) and N = 668 (45%) respectively. Results In 2017 74% of the respondents stated that they were willing to pay for others, compared to 73% in 2013 and 63% in 2015. If we look at willingness to pay for certain groups the results are similar over time: people show more solidarity towards others when others experience health issues beyond their ‘control’ like a genetic disposition. People show les solidarity when others face health problems due to lifestyle choices like excessive smoking and drinking. Results show time trends, especially for certain groups that have low education or poor health. Conclusions Results show that the willingness to pay for others is high; thus reflecting a high degree of solidarity. However, there is less solidarity for certain groups and attitude is changing over time. Since social health insurance is based on a broad societal support for equal access to healthcare it is paramount to keep monitoring solidarity and see if trends continue. Key messages Willingness to pay for healthcare costs for others is high; showing high degree of solidarity over time. There are trends in willingness to pay which could affect solidarity in healthcare systems.

Role of supplementary health insurance in switching behaviour of consumers in the Netherlands

Background The healthcare systems of several countries have elements of managed competition in which consumers can choose between multiple insurers. The goal of a healthcare system based on managed competition is that it maintains the quality of care while keeping it accessible for all. In order to let the principle of managed competition function properly, all consumers should have equal opportunities to switch insurer. There are indications that some consumers experience barriers to switch, which could have negative consequences for the intended goals of the system. Aim This study aims to explore the role of the supplementary health insurance in the switching behaviour of consumers in the Netherlands. Dutch citizens are obliged to take out a basic insurance and can opt for supplementary insurance. Due to rising costs, policy could be directed at limiting the coverage of the basic insurance causing the supplementary insurance to become more important. Methods Questionnaires have been sent to 1,500 members of the Dutch Health Care Consumer Panel (DHCCP) in February 2017 and 1,854 members of the National Panel of the Chronically Ill and Disabled (NPCD) in April 2017. The response rates were respectively 44% (n = 659) and 86% (n = 1,593). Results In the general population, 6% of the consumers with a supplementary insurance switched insurer, while 16% of the consumers without a supplementary insurance switched. Chronically ill and disabled consumers with a supplementary insurance switched less, namely 5%. Reasons why consumers do not switch are now further analyzed. Conclusions Preliminary results show that consumers with a supplementary insurance switch less often than consumers without a supplementary insurance. Potential reasons for this finding are that consumers with a supplementary insurance are more risk averse and rather avoid the decision to switch. This might imply that the principle of managed competition in the Dutch healthcare system does not work entirely as intended. Key messages: Having a supplementary insurance can hold consumers back to switch from insurer. The supplementary insurance can have implications for how the system of managed competition works.

Building collaboration from scratch: exploring mandated collaboration between healthcare insurers and municipalities

Introduction: Collaboration between public sectors is often understood as a way to manage the complex care challenges society faces [1–4]. However, it is also widely recognized as problematic due to the complexity involved with collaboration across organizational boundaries [5–7]. Paradoxically, intersectoral collaboration is thus seen as both problem and solution for care challenges. Thus far, research into intersectoral collaboration does not detail the micro-dynamics of organizational actors entering into, establishing, maintaining, altering or abandoning collaborative relations. More research is required to better understand the processes that take place when collaborating across sectoral boundaries [8,9] and the frictions involved with the establishment of new roles for the stakeholders involved. In 2015, the Dutch healthcare system was reformed and care tasks that used to be the responsibility of the central government were localized and transferred to healthcare insurers medical care and decentralized to municipalities social care. The government then required municipal actors and healthcare insurers to negotiate about the funding of integration between the social and medical domains [10]. Theory/methods: This paper draws upon a case in which care responsibilities are distributed between healthcare insurers and municipalities. The study methods comprised of participant observation of meetings and in-depth interviews with key informants. Analysing the collaborating stakeholders’ boundary work [11–13], i.e. the discursive practices people deploy in order to organize interaction across boundaries, can provide insight into micro dynamics involved in establishing cross-sector collaboration. Results: The analysis of the stakeholders’ discourse identified three interaction patterns actors deploy to organize this interaction across boundaries: 1 opposing patterns, 2 negotiating patterns, and 3 aligning patterns. Conclusion/discussion: This research elucidates the process of building collaboration about responsibilities in the health and social care fields that stakeholders did not enter voluntarily. The paper demonstrates how the involved actors shift from opposition towards each other to negotiating boundaries and eventually come to a strategic alignment, which includes new forms of opposition towards other stakeholders. Limitations/future research: This is a study of a single case of intersectoral collaboration. Future research could include more and different stakeholders such as healthcare providers.

Substituting hospital care with primary care: The evaluation of a cardiology Primary Care Plus intervention

Introduction: To deal with the pressures on the healthcare system, the healthcare system should focus on high-value health care by pursuing the three aims: improving the health of the population, improving the quality of care as experienced by patients and reducing the increase of healthcare costs. In the Netherlands, several initiatives focus on strengthening the primary care and substituting hospital care with primary care in order to keep the health care system sustainable. This study is concentrated on a cardiology primary care plus PC+ centre where cardiologists provide specialist consultations in a primary care setting. This PC+ intervention aims to improve the health of the population and patients’ experience of care while reducing the healthcare costs by decreasing the number of unnecessary referrals to specialist care in the hospital setting. Methods: This is a practice-based study with a longitudinal observational design. The study population consisted of adult patients with non-acute and low-complexity cardiology-related health complaints, who will be referred to the cardiology PC+ centre intervention group or hospital-based outpatient cardiology care control group. Data of the PC+ centre and the hospital were used to investigate the referral and follow-up patterns of intervention group patients compared to the control group. Furthermore, patients were asked to complete questionnaires at three different time points before consultation, directly after consultation, three months after consultation consisting of items about their demographics, health status SF-12, EQ-5D-5L and EQ-VAS and experience of care. Results: The data of the PC+ centre and the hospital consists of 1838 intervention patients and 2155 control patients. Preliminary results show that 27.9 % n= 513 of the intervention group was referred to hospital care after a consultation at the PC+ centre. Moreover, 437 intervention patients and 328 control patients were included in the questionnaire study. In 25 out of 27 items PC+ results in significantly higher levels of patient satisfaction compared to hospital-based outpatient care. The results of the EQ5D-5L indicate no differences in health status between the groups, taking into account the follow-up period of three months F=0.133; P=0.865. Discussion: PC+ is a new concept in the Dutch healthcare system and evidence about its effects is scarce. The findings of this study will fill a gap in knowledge about the effects of PC+ and in particular whether PC+ is able to pursue the Triple Aim outcomes. Conclusion: Whilethis study showed no effects on the health status of the patients, there are promising results looking at the patients’ experience of care and healthcare utilization. Lessons learned: The implementation, as well as the evaluation, of PC+ initiatives is a dynamic process which requires time and continuous interaction with the stakeholders. Limitations: This study does not yet provide insight in the actual effects of PC+ on healthcare costs. Suggestions for future research: Future research, concentrated on PC+, should continue focusing on the Triple Aim outcomes, with a particular focus on healthcare costs.

How to succeed in population health management by strategic alliances

Background : The quality of the Dutch health care system is found to be one of the best systems in the world. At the same time, it is one of the most expensive systems. Driven from the ambition to create a more sustainable high-quality system, various attempts are made to find efficient strategies to stimulate population health. One of which is population health management (PHM) in which health needs of a specific population are starting point for fundamental changes to the system in order to create value and optimize health outcomes. There is no doubt that PHM only succeeds by cooperation between public health, health and social care. In different areas in The Netherlands strategic alliances originated in which local organisations work together towards population health by PHM. Aims & objectives : From our extensive experience with different alliances, we aim to share lessons learned as it comes to population health management. We will address questions like: ‘What does it take to make such alliances a success?’ and ‘Which factors work counterproductive?’ We talk about leadership, the importance of a sense of urgency and more in general about change management. Target audience : Everyone participating in regional alliances working on creating new systems based on population health management. Health care and social care professionals, and strategic and directing managers working across public health, health and social care. A few of our learnings : One important lesson we’ve learned in the past few years when it comes to population health by means of integrating care is the importance of bridging language differences between different domains like health care and social care. Furthermore, to have a significant impact at system or population level, alliances benefit from a narrow focus. A bundling of coherent actions is needed while we often experience a tendency to carry out single actions towards all kinds of different problems. In addition, we found that placing population needs at the heart of the collaborative process of alliances seems effective in overcoming interest of individually participating organisations. It is therefore that we put great value on exploring population needs instead of jumping into action by starting concrete projects.

From data to meaningful information for population health management

Background: The quality of the Dutch health care system is found to be one of the best systems in the world. At the same time, it is one of the most expensive systems. To create a more sustainable high-quality system, various attempts are made to find efficient strategies to stimulate population health. One of which is population health management PHM. The use of big data is essential to PHM for multiple reasons. First; in order to optimize health outcomes, one has to know which part of the population will benefit most from changes to be made. Population segmentation is needed and target populations should be defined. Second; data on health care processes and outcomes will reveal improvement potential. And third; data are indispensable to be able to monitor progress of the interventions on process and health outcomes. The Robuust foundation initiates alliances that originate in regions with local organisations health and social care and public health working together towards population health by PHM. Robuust facilitates them by offering programme management. These alliances use data to define target populations, for agenda setting in their change programmes, to optimise health care processes and to monitor outcomes. Aims & objectives: Our aim is to provide insight in using data for creating meaningful information and value for collaborating organizations including patients in population health alliances. There are a several possibilities to gain insight in population characteristics. We share our experiences on making regional population intelligence using open-source data and data held by organizations and public health providers, primary care and hospitals. We also share our vision on monitoring and evaluation of the value creating process in different alliances. There is no such thing as a blue print on how one can make the best use of different kinds of data for different purposes. For example; ways to define target populations vary by the extent of your population at the start. We know alliances targeting inhabitants of a neighborhood. But we are also operating in alliances targeting inhabitants of entire regions. Our poster illustrates our experiences on different kinds of data are used and are able to visualize value gain for target populations.

Use and Effects of Patient Access to Medical Records in General Practice Through a Personal Health Record in the Netherlands: Protocol for a Mixed-Methods Study.

BackgroundIn the Dutch health care system, general practitioners hold a central position. They store information from all health care providers who are involved with their patients in their electronic health records. Web-based access to the summary record in general practice through a personal health record (PHR) may increase patients’ insight into their medical conditions and help them to be involved in their care.ObjectiveWe describe the protocol that we will use to investigate the utilization of patients’ digital access to the summary of their medical records in general practice through a PHR and its effects on the involvement of patients in their care.MethodsWe will conduct a multilevel mixed-methods study in which the PHR and Web-based access to the summary record will be offered for 6 months to a random sample of 500 polypharmacy patients, 500 parents of children aged <4 years, and 500 adults who do not belong to the former two groups. At the patient level, a controlled before-after study will be conducted using surveys, and concurrently, qualitative data will be collected from focus group discussions, think-aloud observations, and semistructured interviews. At the general practice staff (GP staff) level, focus group discussions will be conducted at baseline and Q-methodology inquiries at the end of the study period. The primary outcomes at the patient level are barriers and facilitators for using the PHR and summary records and changes in taking an active role in decision making and care management and medication adherence. Outcomes at the GP staff level are attitudes before and opinions after the implementation of the intervention. Patient characteristics and changes in outcomes related to patient involvement during the study period will be compared between the users and nonusers of the intervention using chi-square tests and t tests. A thematic content analysis of the qualitative data will be performed, and the results will be used to interpret quantitative findings.ResultsEnrollment was completed in May 2017 and the possibility to view GP records through the PHR was implemented in December 2017. Data analysis is currently underway and the first results are expected to be submitted for publication in autumn 2019.ConclusionsWe expect that the findings of this study will be useful to health care providers and health care organizations that consider introducing the use of PHR and Web-based access to records and to those who have recently started using these.Trial RegistrationNetherlands Trial Registry NTR6395; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6395 (Archived by WebCite at http://www.webcitation.org/71nc8jzwM)Registered Report IdentifierRR1-10.2196/10193

Economic evaluation of the use of non-vitamin K oral anticoagulants in patients with atrial fibrillation on antiplatelet therapy: a modelling analysis using the healthcare system in the Netherlands.

Non-vitamin K oral anticoagulants (NOACs) have consistently demonstrated superior efficacy in terms of stroke prevention and safety in terms of bleeding over vitamin K antagonist (VKA) in patients with non-valvular atrial fibrillation (AF). The potential use of NOACs in AF patients requiring antiplatelet therapy (APT) has only been assessed in small meta-analyses reporting consistent benefits of NOACs over VKAs. However, the prescription costs of NOACs are higher than those of VKAs. The aim of his study was to estimate the cost-effectiveness (CE) of NOACs compared to VKAs in patients with non-valvular AF also requiring APT with the Dutch healthcare system used as a surrogate of many European healthcare systems. A decision tree was constructed to analyse the CE of NOACs compared to VKAs in patients with non-valvular AF with an indication for APT over a horizon of 1 year. Beside the base-case analysis, univariate probabilistic sensitivity and two sensitivity analyses were performed: first, we assessed the impact of VKA home monitoring; second, we varied the NOACs price assuming patent expiration. Use of NOACs instead of VKA is associated with a health gain of 0.0171 quality-adjusted life years (QALYs) and with an incremental cost of €357, resulting in an incremental cost-effectiveness ratio of €20919, which is almost equal to the generally accepted CE threshold of €20000 used in the Netherlands. The probability that NOACs are cost-effective at a conservative willingness-to-pay threshold of €20000 per QALY was 50%. Introducing home monitoring increased VKAs costs so much that NOACs became the dominant option (less costly and more effective). Price drops associated to patent expiration of NOACs increased its CE. This analysis suggests that the use of NOACs is a cost-effective alternative of VKAs in patients with AF needing APT. Our findings in the Netherlands healthcare system are probably consistent with other European populations.

Evaluation of the COPDnet integrated care model in patients with COPD: the study protocol.

BackgroundProjections on the future suggest a further rise in the prevalence of patients with COPD, and in COPD related morbidity, mortality, and health care costs worldwide. Given the substantial impact on the individual and on society, it is important to establish a care process that maximizes outcomes in relation to the costs and efforts made. In an attempt to bridge this gap, we set out to develop an evidence-based model of integrated care for patients with COPD, named the COPDnet integrated care model.PurposeThe current study protocol sets out to 1) evaluate the feasibility of employing the COPDnet model in present real-life care within the context of the Dutch health care system, 2) explore the potential health status benefits, and 3) analyze the costs of care of this model.Patients and methodsIn this prospective study, feasibility and health status changes will be evaluated with an experimental before and after study design. The costs of the diagnostic trajectory will be calculated according to a standard economic health care evaluation approach. Furthermore, the feasibility and cost of care studies will comprise both quantitative and qualitative data collection. For the studies on the feasibility and change in health status, all new patients qualifying for shared care by primary and secondary care professionals according to the Dutch Standard of Care for COPD, and patients referred by their general practitioners to one of the COPDnet hospitals will be included. To evaluate the feasibility and costs of care, semi-structured interviews will be held with patients, hospital personnel, health care professionals in the affiliated primary care region, and hospital and primary care group managers.ConclusionsThe COPDnet integrated care model for COPD patients has been designed according to the current insights regarding effective care for patients with a chronic condition in general, and for patients with COPD in particular. It will be evaluated for its feasibility, potential health status benefits, and the costs of care of the diagnostic trajectory in secondary care.

Care-related Quality of Life of informal caregivers of the elderly after a hip fracture

BackgroundReforms in the Dutch healthcare system in combination with the aging of the population will lead to a strong increase in the demand for informal care in the Netherlands. A hip fracture is one of the most important causes of hospital admissions among frail elderly and informal caregivers experience stress that may have significantly negative impact on the caregivers’ Quality of Life. The purpose of the study was to determine the nature, intensity and the care-related Quality of Life (CarerQoL) of informal caregivers of elderly patients in the first six months after a hip fracture. In this cross-sectional study, were interviewed the primary informal caregivers of patients with a hip fracture about the informal care provided after one, three or six months following the injury. The CarerQoL of the informal caregivers was measured with the CarerQoL-7D instrument.ResultsIn total, 123 primary informal caregivers were included. The CarerQoL-7D score was on average 83.7 (SD 15.0) after one, three and six months, and there were no major differences between the measurement time points. The average amount of informal care provided per patient per week was 39.5 during the first six months.Partners of patients with a hip fracture provided significantly more hours of informal care (β 34.0; 95% CI: 20.9 – 47.1). Female informal caregivers stated a significantly lower level of CarerQoL (β -7.8; 95% CI: -13.3 – -2.3). Female caregivers were 3.0 times more likely to experience relational problems (aOR 3.02; 95% CI 1.08-8.43). Caregivers provided care at 6 months were associated with physical health problems (aOR 2.54; 95% CI 1.05-6.14).ConclusionsInformal caregivers, especially partners, are faced with providing care of greater intensity to elderly patients during the first six months after a hip fracture. The CarerQoL was not associated with the intensity of the provided informal care. However, this study shows that a considerable group of informal caregivers for elderly patients with a hip fracture experienced relational, physical and mental health problems that stemmed from providing intensive informal care during the first six months.

Optimal treatment of patients with NSTE-ACS in the Dutch health care system.

In the current daily practice of acute coronary syndromes, patients experiencing non-ST-elevation acute coronary syndrome (NSTE-ACS) represent the majority of this population. In these patients it is of utmost importance to estimate both ischaemic and bleeding risk, with subsequent, and preferably tailored pharmacological and, if indicated, invasive treatment. In this paper we describe the several risk scores and evaluate which are most applicable to the Dutch health-care system. Furthermore, we provide an overview of the recommended pharmacological treatment in keeping with the European Society of Cardiology guidelines. An important topic of this paper is how to decide between early or delayed invasive strategies. We describe the recommendations of the European Society of Cardiology and evaluate to which level these should be applied to the Dutch health-care system.