Dutch Health Care System Research Articles

Cost-effectiveness of Implementing a Genotype-Guided De-Escalation Strategy in Patients with Acute Coronary Syndrome.

A genotype-guided P2Y12-inhibitor de-escalation strategy, switching acute coronary syndrome (ACS) patients without a CYP2C19 loss-of-function allele from ticagrelor or prasugrel to clopidogrel, has shown to reduce bleeding risk without affecting effectivity of therapy by increasing ischemic risk. We estimated the cost-effectiveness of this personalized approach compared to standard dual antiplatelet therapy (DAPT; aspirin plus ticagrelor/prasugrel) in the Netherlands. We developed a one-year decision tree based on results of the FORCE-ACS registry, comparing a cohort of ACS patients who underwent genotyping with a cohort of ACS patients treated with standard DAPT. This was followed by a lifelong Markov model to compare lifetime costs, and quality-adjusted life years (QALYs) for a fictional cohort of 1000 patients. The cost-effectiveness analysis was performed from the perspective of the Dutch healthcare system. A genotype-guided de-escalation strategy led to anincrease of 55.30 QALYs and saved €698,286 compared to standard DAPT based on a lifetime horizon. Probabilistic sensitivity analysis showed that the genotype-guided strategy was cost-saving in 93% and increased QALYs in 86% of simulations. The intervention remained cost-effective in the scenario where prices for all P2Y12-inhibitors were equalized. The genotype-guided strategy remained dominant in various other scenario and sensitivity analyses. A genotype-guided de-escalation strategy in patients with ACS was both cost-saving and yielded higher QALYs compared to standard DAPT, highlighting its potential for implementation in clinical practice. Trial registration: ClinicalTrials.gov identifier: NCT03823547.

Real world economic evaluation of CT-FFR in patients with suspected coronary artery disease

Abstract Background Incorporation of CT-derived fractional flow reserve (CT-FFR) enhances the precision of Coronary CT Angiography (CCTA) to detect hemodynamically significant coronary artery disease (CAD). However, the financial consequences remain unclear. Purpose Our objective is to assess the economic implications of CT-FFR in the Dutch Healthcare system. Methods This retrospective, single-center cost effectiveness analysis includes patient data of a previously published study assessing the impact of routine CT-FFR availability on clinical management. We collected medical resource use for both diagnostic and therapeutic cardiovascular care with a follow-up duration of 1 year. Costs of CT-FFR analysis were set at €1000, its current price for Dutch hospitals. Median total costs at were compared using the Wilcoxon rank sum test, including a sensitivity analysis in which cost estimations (without registered maximum tariffs) were increased or decreased with 10%. Results A total of 360 patients, classified as having low to intermediate risk of CAD, were enrolled in the study – 224 in the CCTA group and 136 in the CT-FFR group. In addition to undergoing more (invasive) diagnostic testing and revascularization procedures over the studied period, patients in the CCTA-group had more outpatient clinic consultations (p<0.001), presented more frequently to the emergency department (p=0.035) and spend more nights in the hospital (p=0.11). Median costs were €3.347 (IQR €1.066 – €4.862) in the CCTA-group and €1.436 (IQR €1.362 - €3.943) in the CT-FFR group (p=0.091). Increasing cost estimation with 10% revealed a median of €3.431 in the CCTA-group versus €1.479 in the CT-FFR group (p=0.078), decreasing with 10% showed median costs of €3.263 in the CCTA-group and €1.392 in the CT-FFR group (p=0.118). In our sample, CT-FFR guided care would have been significantly cheaper than CCTA-guided care at or below a market price of €770. Conclusion Despite the significant reduction in additional diagnostic testing and hospital visits in the CT-FFR group, CT-FFR guided care was not cheaper than CCTA-guided care at its current market price of €1.000. Economic cost-effectiveness would have occurred from a price of €770 per analysis. The large difference between medians suggests that the lack of significance might partially be attributed to insufficient power in this relatively small sample size. Additionally, this study did not account for costs associated with loss of productivity and quality of life. However, less additional diagnostic testing, less revascularization procedures and less hospital consultations and admissions leads to reduction in hospital resource consumption and patient burden, which is an important advantage of CT-FFR as the number of referred patients increases yearly.

Case studies on the impact of ex-post legislative evaluations in Dutch healthcare: a within and cross-case analysis

ABSTRACT Globally, ex-post legislative evaluations are becoming increasingly important for understanding how laws function in practice and identifying their limitations and their effects upon stakeholders. This study delves into the impact of ex-post legislative evaluations within the Dutch healthcare system. Building upon insights from previous literature, we aim to refine existing ideas within the field through empirical data. Utilising the realist evaluation method, we examine three distinct case studies followed by a cross-case analysis. Our research underscores that the impact of these evaluations extends beyond policy and politics to the broader societal arena. Our findings also point towards opportunities for strengthening the impact of ex-post legislative evaluations within this broader societal arena. Specifically, we identify strategic phases within the evaluation process through which we aim to maximise impact. Finally, the study emphasises the importance of context awareness, the strategic utilisation of research quality as well as interactional factors for enhancing impact.

Can’t Contracting Be Relational?; Comment on "Alignment in the Hospital-Physician Relationship: A Qualitative Multiple Case Study of Medical Specialist Enterprises in the Netherlands"

Ubels and van Raaij provide a valuable account of the operation of novel hospital/medical specialist enterprise contracts in a Dutch healthcare system shaped by market reform. However, their analytical distinction between the separate domains of contractual and relational governance frames the contractual domain more narrowly than does the relational contract theory widely deployed in socio-legal studies. The authors’ conclusion that contract plays little or no part in governing relations between hospitals and MSEs leads them to underplay a wider realm of contractual practices that develop in the shadow of the written contract. Apparent non-use of contracts in favour of shared planning, compromise and extralegal solutions only takes the form it does because of the potential application of the available legal framework. Larger qualitative field studies involving a more extensive combination of interviews and observations may be needed to gain fuller insights into the relational dimensions of the contracting process.

Navigating conflicting expectations in addressing healthcare scarcity: a q-methodology study on the Dutch National Health Care Institute.

In many European countries, semi-autonomous agencies have been created in health policy to safeguard general public interests. In executing their tasks, these agencies need to deal with conflicting expectations. Particularly avoiding the risk of regulatory capture and aligning with parent ministries are frequently studied challenges, even more so when complex issues such as scarcity are at stake. In this paper, we use q-methodology to provide a thorough overview of the debate regarding the role of an important agency in the Dutch healthcare system; the National Health Care Institute (Zorginstituut Nederland). We conducted 41 q-interviews with agency employees, evaluators, regulatees, ministry employees, health policy experts, members of its advisory committees, and peer agencies. We identify three viewpoints on what the agency should focus on. These are on societally relevant issues, strict package management, and efficient organisation of care. In doing so, our study shows how agencies are pulled in different directions by conflicting expectations. We show that this can be problematic because it complicates a clear role of the agency that allows addressing such issues. We thereby contribute to theories on agencies' complex relations with their external environment such as regulatory capture, tripartism, reflexive regulation, legal boundaries, and stewardship theory.

Should Patients Be Allowed to Pay Out of Pocket? The Ethical Dilemma of Access to Expensive Anti-cancer Treatments in Universal Healthcare Systems: A Dutch Case Study.

With the increasing prices of newly approved anti-cancer treatments contributing to rising healthcare costs, healthcare systems are facing complex economic and ethical dilemmas. Especially in countries with universal access and mandatory health insurance, including many European countries, the organizing of funding or reimbursement of expensive new treatments can be challenging. When expensive anti-cancer treatments are deemed safe and effective, but are not (yet) reimbursed, ethical dilemmas arise. In countries with universal healthcare systems, such as the Netherlands, this gives rise to a rather new ethical dilemma: should patients be allowed to pay out of pocket, using private funds, for medical treatments? On the one hand, to allow patients to pay for treatments out of pocket would be in line with the medical-ethical principles of beneficence and autonomy. On the other hand, allowing patients to pay out of pocket for anti-cancer treatments may lead to unequal access to medical treatments and could be considered unfair to patients who are less well-off. Thus, it could undermine the values of equality and solidarity, on which the Dutch healthcare system is built. Furthermore, out-of-pocket payments could potentially lead to financial hardship and distress for patients, which would conflict with the principle of non-maleficence. Does this mean that patients can rightfully be denied access to approved but not (yet) reimbursed anti-cancer treatments? In this article, we will use the Dutch healthcare system, which is based on equal access and solidarity, as a case study to draw attention to this-currently relatively unknown and unresolved-dilemma and to clarify the values at stake. This article contributes to current discussions about the societal problem of rising healthcare costs by informing policymakers, healthcare professionals, and ethicists about the ethical dilemma of out-of-pocket payments in universal healthcare systems, and aims to support health authorities, policymakers and health professionals in developing policy for whether to allow out-of-pocket payment-based access to newly approved but (too) expensive anti-cancer treatments.

Promoting the implementation of a computer-tailored physical activity intervention: development and feasibility testing of an implementation intervention

BackgroundAlthough there are many proven effective physical activity (PA) interventions for older adults, implementation in a real world setting is often limited. This study describes the systematic development of a multifaceted implementation intervention targeting the implementation of an evidence-based computer-tailored PA intervention and evaluates its use and feasibility.MethodsThe implementation intervention was developed following the Intervention Mapping (IM) protocol, supplemented with insights from implementation science literature. The implementation intervention targets the municipal healthcare policy advisors, as an important implementation stakeholder in Dutch healthcare system. The feasibility of the implementation intervention was studied among these stakeholders using a pretest–posttest design within 8 municipal healthcare settings. Quantitative questionnaires were used to assess task performance (i.e. achievement of performance objectives), and utilization of implementation strategies (as part of the intervention). Furthermore, changes in implementation determinants were studied by gathering quantitative data before, during and after applying the implementation intervention within a one-year period. Additionally, semi-structured interviews with stakeholders assessed their considerations regarding the feasibility of the implementation intervention.ResultsA multi-faceted implementation intervention was developed in which implementation strategies (e.g. funding, educational materials, meetings, building a coalition) were selected to target the most relevant identified implementation determinants. Most implementation strategies were used as intended. Execution of performance objectives for adoption and implementation was relatively high (75–100%). Maintenance objectives were executed to a lesser degree (13–63%). No positive changes in implementation determinants were found. None of the stakeholders decided to continue implementation of the PA intervention further, mainly due to the unforeseen amount of labour and the disappointing reach of end-users.ConclusionThe current study highlights the importance of a thorough feasibility study in addition to the use of IM. Although feasibility results may have demonstrated that stakeholders broadly accepted the implementation intervention, implementation determinants did not change favorably, and stakeholders had no plans to continue the PA intervention. Yet, choices made during the development of the implementation intervention (i.e. the operationalization of Implementation Mapping) might not have been optimal. The current study describes important lessons learned when developing an implementation intervention, and provides recommendations for developers of future implementation interventions.

Whole genome sequencing as a ticket to cancer treatment in the Netherlands: Are inequalities in access to molecular diagnostics unfair?

Whole genome sequencing (WGS) of a tumour may sometimes reveal additional potential targets for medical treatment. Practice variation in the use of WGS is therefore a source of unequal access to targeted therapies and, as a consequence, of disparities in health outcomes. Moreover, this may even be more significant if patients seek access to WGS by paying a relatively limited amount of money out of pocket, and sometimes effectively buy themselves a ticket to (very) expensive publicly funded treatments. Should resulting unequal access to WGS be considered unfair? Drawing from current practice in the Dutch healthcare system, known as egalitarian, we argue that differences in employment of WGS between hospitals are the consequence of the fact that medical innovation and its subsequent uptake inevitably takes time. Consequently, temporal inequalities in access can be deemed acceptable, or at least tolerated, because and insofar as, ultimately, all patients benefit. However, we argue against allowing a practice of out-of-pocket payments for WGS in publicly funded healthcare systems, for four reasons: because allowing private spending favours patients with higher socio-economic status significantly more than practice variation between hospitals does, may lead to displacement of publicly funded health care, does not help to ultimately benefit all, and may undermine the solidaristic ethos essential for egalitarian healthcare systems.

Illustrating the Financial Consequences of Outcome-Based Payment Models From a Payers Perspective: The Case of Autologous Gene Therapy Atidarsagene Autotemcel (Libmeldy®)

ObjectivesTo illustrate the financial consequences of implementing different managed entry agreements (managed entry agreements for the Dutch healthcare system for autologous gene therapy atidarsagene autotemcel [Libmeldy]), while also providing a first systematic guidance on how to construct managed entry agreements to aid future reimbursement decision making and create patient access to high-cost, one-off potentially curative therapies. MethodsThree payment models were compared: (1) an arbitrary 60% price discount, (2) an outcome-based spread payment with discounts, and (3) an outcome-based spread payment linked to a willingness to pay model with discounts. Financial consequences were estimated for full responders (A), patients responding according to the predicted clinical pathway presented in health technology assessment reports (B), and unstable responders (C). The associated costs for an average patient during the time frame of the payment agreement, the total budget impact, and associated benefits expressed in quality-adjusted life-years of the patient population were calculated. ResultsWhen patients responded according to the predicted clinical pathway presented in health technology assessment reports (scenario B), implementing outcome-based reimbursement models (models 2 and 3) had lower associated budget impacts while gaining similar benefits compared with the discount (scenario 1, €8.9 million to €6.6 million vs €9.2 million). In the case of unstable responders (scenario C), costs for payers are lower in the outcome-based scenarios (€4.1 million and €3.0 million, scenario 2C and 3C, respectively) compared with implementing the discount (€9.2 million, scenario 1C). ConclusionsOutcome-based models can mitigate the financial risk of reimbursing atidarsagene autotemcel. This can be considerably beneficial over simple discounts when clinical performance was similar to or worse than predicted.

Cost-utility analysis of TAVI compared with surgery in patients with severe aortic stenosis at low risk of surgical mortality in the Netherlands

BackgroundThere is growing evidence to support the benefits of transcatheter aortic valve implantation (TAVI) over surgical aortic valve replacement (SAVR) in patients with symptomatic severe aortic stenosis (sSAS) who are at high- or intermediate-risk of surgical mortality. The PARTNER 3 trial showed clinical benefits with SAPIEN 3 TAVI compared with SAVR in patients at low risk of surgical mortality. Whether TAVI is also cost-effective compared with SAVR for low-risk patients in the Dutch healthcare system remains uncertain. This article presents an analysis using PARTNER 3 outcomes and costs data from the Netherlands to inform a cost-utility model and examine cost implications of TAVI over SAVR in a Dutch low-risk population.MethodsA two-stage cost-utility analysis was performed using a published and validated health economic model based on adverse events with both TAVI and SAVR interventions from a published randomized low risk trial dataset, and a Markov model that captured lifetime healthcare costs and patient outcomes post-intervention. The model was adapted using Netherlands-specific cost data to assess the cost-effectiveness of TAVI and SAVR. Uncertainty was addressed using deterministic and probabilistic sensitivity analyses.ResultsTAVI generated 0.89 additional quality-adjusted life years (QALYs) at a €4742 increase in costs per patient compared with SAVR over a lifetime time horizon, representing an incremental cost-effectiveness ratio (ICER) of €5346 per QALY gained. Sensitivity analyses confirm robust results, with TAVI remaining cost-effective across several sensitivity analyses.ConclusionsBased on the model results, compared with SAVR, TAVI with SAPIEN 3 appears cost-effective for the treatment of Dutch patients with sSAS who are at low risk of surgical mortality. Qualitative data suggest broader societal benefits are likely and these findings could be used to optimize appropriate intervention selection for this patient population.

“Till Corona Sets Us Apart”: Emerging Vaccination Risks among Serbian Parents in the Netherlands

Abstract In developed European Union (EU) countries, migrants are thought to be less likely to have their children fully vaccinated. To investigate this idea, this study examines parental perceptions of child vaccination during the Covid-19 pandemic. It is based on semi-structured interviews with 42 Serbian migrants in the Netherlands, conducted in the summer of 2020. The aim was to determine if the pandemic changed these parents’ attitudes towards the Dutch healthcare system and vaccination in general. The paper’s theoretical framework juxtaposes a “risk society” approach with a governmentality approach. The majority of the parents surveyed had had their children vaccinated according to the Dutch national vaccination programme. However, the study shows that many Serbian migrants had negative attitudes towards the then forthcoming SARS-CoV-2 vaccine. I therefore conclude that new vaccines, such as the Covid-19 vaccine, act as risk technologies which create a new “risk environment” rather than being perceived as preventive health measures.

Cancer centre information and support services and patient needs: participatory action research study

ObjectivesClear information and supportive care are necessary for oncology patients and their relatives to manage the disease (trajectory). Centres for information and support aim to address their needs by offering...

An Exploration of Dutch Dermatologists' Experience and Satisfaction With Teledermatology: Sociotechnical and Complex Adaptive System Perspective.

Despite the global upscale of teledermatology during the COVID-19 pandemic, persistent barriers, such as the poor anamnesis and photo quality, hinder its effective use in practice. Understanding Dutch dermatologists' experiences and satisfaction with using the teledermatology system in the Dutch health care system is needed. A holistic evaluation may provide valuable insight to understand how barriers interrelate which is deemed necessary for the innovation of teledermatology in practice. Guided by a complex adaptive system perspective, this study aims to understand Dutch dermatologists' experience and satisfaction with their training, support communication, interaction, and usage of a teledermatology platform of a Dutch digital hospital during the COVID-19 pandemic, uncovering insights to improve teledermatology services for the future. A web-based questionnaire was sent in December 2021 to Dutch dermatologists who (1) had an active teledermatology platform account, and (2) responded to a teledermatology consultation between October 1, 2019, and September 30, 2021. The questionnaire consisted of the validated Store-and-Forward Telemedicine Service User-satisfaction Questionnaire (SAF-TSUQ) questionnaire, and new questions regarding; demographics of teledermatologists, the use of teledermatology during the COVID-19 pandemic, the performance of teledermatology by general practitioners (GP), and the role of dermatologists in the teledermatology process. The open-ended questions were analyzed by a grounded theory approach guided by a sociotechnical model and complemented by a complex adaptive system perspective. A panel discussion with 3 dermatologists was performed to provide additional insight into the responses to the questionnaire. We obtained responses from 25 out of the 249 (10%) invited dermatologists. Overall, dermatologists had a positive experience with teledermatology. Interestingly, teledermatology use frequency remained unaffected by the COVID-19 pandemic. However, the insufficient quality and incompleteness of the clinical content (photos and anamneses information) of the teledermatology consultation impacted the efficiency of the teledermatology workflow. Dermatologists expressed the need for improvement to avoid time-consuming processes or physical referrals. The panel discussion enriched and confirmed the responses, suggesting solutions like mandatory fields for the GPs for a complete anamnesis. Dutch Dermatologists view teledermatology as a valuable tool to provide access to dermatology care. However, improvements regarding the quality and completeness of the provided clinical content are necessary for the effectiveness and efficiency of the complex teledermatology system in Dutch health care. This could increase both the dermatologists' satisfaction and the quality of teledermatology services. Managing trade-offs, such as time investments versus image quality, is crucial for teledermatology implementation and should be assessed from a complexity perspective to understand trade-offs and prevent unintended consequences.

Embedding artificial intelligence in healthcare: An ethnographic exploration of an AI-based mHealth app through the lens of legitimacy.

Skin cancer, a significant global health problem, imposes financial and workload burdens on the Dutch healthcare system. Artificial intelligence (AI) for diagnostic augmentation has gained momentum in dermatology, but despite significant research on adoption, acceptance, and implementation, we lack a holistic understanding of why technologies (do not) become embedded in the healthcare system. This study utilizes the concept of legitimacy, omnipresent but underexplored in health technology studies, to examine assumptions guiding the integration of an AI mHealth app for skin lesion cancer risk assessment in the Dutch healthcare system. We conducted a 3-year ethnographic case study, using participant observation, interviews, focus groups, and document analysis to explore app integration within the Dutch healthcare system. Participants included doctors, policymakers, app users, developers, insurers, and researchers. Our analysis focused on moments of legitimacy breakdown, contrasting company narratives and healthcare-based assumptions with practices and affectively-charged experiences of professionals and app users. Three major kinds of legitimacy breakdowns impacted the embedding of this app: first, lack of institutional legitimacy led to informal workarounds by the company at the institutional level; second, quantification privilege impacted app influence in interactions with doctors; and third, interactive limits between users and the app contradicted expectations around ease of use and work burden alleviation. Our results demonstrate that legitimacy is a useful lens for understanding the embedding of health technology while taking into account institutional complexity. A legitimacy lens is helpful for decision-makers and researchers because it can clarify and anticipate pain points for the integration of AI into healthcare systems.

Towards population-based payment models in multiple-payer systems: the case of the Netherlands

Introduction: The Dutch private multi-payer system is predominately paying providers on a fee-for-service basis, not incentivising efforts towards integrated care and prevention. Up to now, alternative payment models have not taken flight. Recent small-scale experiments in the Netherlands show substantial potential benefits of population-based payment models. Taking the Netherlands as an example, this study aims to analyse how such population-based payment schemes may be taken up more fiercely in systems running on the principles of managed competition. 
 Methods: PubMed and Medline were searched for international studies reporting on effects of introducing population-based payments compared to a control group. Quantitative results for both quality of care and healthcare utilisation were summarized and articles were qualitatively assessed to identify facilitators and barriers for implementation. Next, results of this review were presented to a panel of nine Dutch experts in the field of health policy to (1) validate and supplement findings from the literature review and (2) identify and determine processes to overcome barriers and enable further uptake of such payment schemes in managed competition systems.
 Key findings: The literature search yielded 24 studies reporting on 10 international cases. Cases showed predominantly positive effects for both healthcare utilisation and quality of care. Identified challenges related to measuring quality, linking indicators to financial incentives, having an inappropriate data infrastructure to facilitate monitoring, and possible long-term financial instability for providers. Initiators of reforms and the degree of involvement of national policies and legislation differed, but the decentralised nature of healthcare systems in which these reforms were implemented seems to offer opportunities for small-scale experiments rather than radically reforming the entire healthcare system. The expert panel found that the Dutch system aligns with such a bottom-up approach. Payers and providers can initiate population-based payment systems to fit local needs, but should determine clear preconditions that focus on quality of care. Quality indicators tied to financial incentives, such as shared savings, might minimise risks of undertreatment. Upfront investments are needed to facilitate necessary data infrastructure and reforms might be encouraged through nationally set default options towards integrated payment systems, potentially reducing administrative burdens. Strong leadership, trust, and mutual understanding are paramount to overcome silos to integrate services across providers. 
 Conclusions: Several international examples of population-based payment reforms in multiple-payer systems have shown promising results in the last couple of years, but implementation is often accompanied by various challenges. Successful experiments were often initiated bottom-up: payers and providers both have an active role in initiating such reforms, defining goals, and experimenting in local populations. Governmental bodies should have a facilitating rather than a directive role. 
 Implications: Whilst this paper used the Dutch healthcare system as their primary example, similar mechanisms and processes can act as a guide for the implementation of population-based payments in other multiple-payer settings. Policymakers in other multi-payer managed competition systems may therefore benefit from these insights to overcome barriers while transforming their healthcare systems through population-based payment schemes.
 

Sustainable prevention infrastructure in the healthcare system: Developments in The Netherlands

Introduction: There is increasing attention to (disease) prevention within healthcare. However, in OECD countries only around 1% of health expenditure is spent on prevention. In the Netherlands different parties are responsible for organizing prevention. As a consequence, embedding preventive activities into the Dutch healthcare system lags behind. Especially for people with health risks, such as overweight children or frail older people. In order to move towards sustainable organized prevention, it is necessary that organizations start working together. In recent years several policy interventions have been introduced to stimulate cross-sector collaboration and the transition towards sustainable prevention infrastructure in the healthcare system. The aim of this study is to learn more form this transition.
 Who is it for? Researchers, policymakers, collaborative prevention networks.
 Methods: This longitudinal qualitative study was conducted among collaborative networks working together on integrating prevention, care and welfare to build a prevention infrastructure. Interviews were held with representatives of municipalities, health insurers, municipality health services and program managers. Two to five interviews per network were conducted during a five year study period. In total 88 semi-structured interviews were held. Networks were followed over time to gain insight into experiences with cross-sectoral collaboration. And to explore the changes in perceived barriers and facilitators associated with collaborating on implementing a prevention infrastructure.
 Key findings: Barriers for implementing a prevention infrastructure are unknown (cost-)effectiveness and differences in organization culture between municipalities and health insurers. Growing awareness of the urgency of prevention and acknowledgement of mutual responsibilities can be seen as a facilitator. As well as national policy interventions concerning a regional prevention infrastructure and a intervention-oriented approach. Preconditions for cross-sector collaboration became more specific over time, commitment and trust provide the basis, followed by low-threshold contact and having a shared goal. Clearness about legal responsibilities is important for stakeholders in order to work together to organize prevention. The discussion on appropriate funding played a major role over the years.
 Conclusions/Learning: This study shows that collaboration regarding prevention is becoming more and more common. The relationship between key stakeholders, like municipalities and health insurers, is generally more strengthened than five years ago. They have better understanding of each other’s interests and expectations. In addition, they started to consider prevention more as their mutual responsibility in recent years. It was found to be important for the government to regularly collect from stakeholders what they need, in order to continuously improve national public health policy. 
 Next steps: Policies regarding prevention infrastructure continues to evolve, in order to further stimulate collaboration between stakeholder. Developments in this area will continue to be monitored in the coming years.
 Keywords: Prevention, health policy, healthcare system, cross-sector collaboration, longitudinal qualitative research, collaborative networks.

Uncovering communication strategies used in language-discordant consultations with people who are migrants: Qualitative interviews with healthcare providers.

Global migration has led to a sharp increase in the number of language-discordant consultations (LDCs) in healthcare. Evidence on how healthcare providers (HCPs) meet migrant patients' needs while mitigating language barriers is lacking. Using purposive and snowball sampling, we recruited twenty-seven Dutch HCPs (Mage = 45.07, SD = 11.46) and conducted semi-structured interviews to collect qualitative, open-ended data for identifying the communication strategies used with migrant patients in LDCs. We analysed the transcripts using deductive and inductive approaches (e.g., constant comparative method from Grounded Theory). Final pattern codes (i.e., key themes) were discussed among the research team until mutual agreement had been achieved. Five key themes emerged from the analyses: HCPs often 'got-by' with (1) instrumental and (2) affective communication strategies used in language-concordant consultations to start medical consultations. When some instrumental communication strategies were deemed ineffective (e.g., lingua franca, gesturing, etc.) to bridge language barriers, HCPs turned to (3) incorporating digital tools (e.g., Google Translate). When HCPs were unable to communicate with migrant patients at all, (4) informal, ad-hoc and professional interpreters were involved. Finally, HCPs often (5) involved additional support to engage migrant patients to engage in treatment-related behaviours. Our results highlight the importance of raising awareness among HCPs about using various combinations of different strategies. The development of a guideline indicating the optimal combination of communication strategies for different medical consultation goals may be useful in reshaping the current communication behaviour of HCPs in LDCs. HCPs were the study population involved in this qualitative study. Refugee health advisors, general practitioners and linguistic specialists (i.e., members of the Right2Health consortium) with experience with the Dutch healthcare system were involved throughout the development of this research. This includes a review of the research question, participant information sheet and interview topic guide as well as providing interpretations of the data and feedback to this manuscript.

HSD73 Establishing a Learning Healthcare System for Metastatic Prostate Cancer in the Dutch Healthcare System: Preconditions and Potential Benefits of Real-World Data Utilization

HSD73 Establishing a Learning Healthcare System for Metastatic Prostate Cancer in the Dutch Healthcare System: Preconditions and Potential Benefits of Real-World Data Utilization

A normal day in the life of a neonatal nurse practitioner: experience report

This experience report provides an expert opinion on the daily routine and responsibilities of a neonatal nurse practitioner within the framework of the nurse practitioner role in the Netherlands. The aim is to enhance understanding of the unique contributions made by nurse practitioners in delivering high-quality care to newborns and their families in the Dutch healthcare system, by showcasing the diverse clinical, educational, and research activities involved. Therefore, it highlights the specific scope of practice for nurse practitioners in neonatology, the collaborative approach between healthcare professionals and parents, and the importance of family-centered care, offering valuable insights into the multifaceted nature on the role of the practitioner nurse, emphasizing the adherence to national guidelines and protocols.

Current uptake and barriers to wider use of the International Ovarian Tumor Analysis (IOTA) models in Dutch gynaecological practice

ObjectiveCorrect referral of women with an ovarian tumor to an oncology department remains challenging. The International Ovarian Tumor Analysis (IOTA) consortium has developed models with higher diagnostic accuracy than the alternative Risk of Malignancy Index (RMI). This study explores the uptake of the IOTA models in Dutch hospitals and factors that impede or promote implementation. Optimal implementation is crucial to improve pre-operative classification of ovarian tumors, which may lead to better patient referral to the appropriate level of care. Study DesignIn February 2021, an electronic questionnaire consisting of 37 questions was sent to all 72 hospitals in the Netherlands. One pre-selected gynaecologist per hospital was asked to respond on behalf of the department. ResultsThe study had a response rate of 93% (67/72 hospitals). All respondents (100%) were familiar with the IOTA models with 94% using them in practice. The logistic regression 2 (LR2)-model, Simple ultrasound-based rules (SR) and Assessment of Different NEoplasias in the adneXa (ADNEX) model were used in respectively 40%, 67% and 73% of these hospitals. Respondents rated the models overall with an 8.2 (SD 1.8), 8.3 (SD 1.6) and 8.9 (SD 1.3) respectively for LR2, SR and ADNEX on a scale from 1 to 10. Moreover, 89% indicated to have confidence in the results of the IOTA models. The most important factors to improve further implementation are more training (43%), research on sensitivity, specificity and cost-effectiveness in the Dutch health care system (27%), easier usability (24%) and more consultation time (19%). ConclusionThe IOTA ultrasound models are adopted in the majority of Dutch hospitals with the ADNEX model being used the most. While Dutch gynecologists have a strong familiarity and confidence in the models, the uptake varies in reality. Areas that warrant improvement in the Dutch context are more uniformity, education and more research. These findings can be helpful for other countries considering adopting the IOTA models.