1. Dept Social Medicine Researchers interacting with Policymakers, Managers and Professionals Niek Klazinga Limerick, August 31, 2007

2. Dept Social Medicine What is Health Services / Systems Research? Who wants to know what and why? Examples General conclusions

3. Dept Social Medicine Definition IoM Health Services Research is a multidisciplinary field of inquiry, basic and applied, that examines the use, costs, quality, accessibility, delivery,organization, financing and outcomes of health care to increase the knowledge and understanding of the structure, processes and effects of health services for individuals and populations Field and Lohrs 1995 JECP

4. Dept Social Medicine Health Services Research is the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviours effect access to health care, the quality and cost of health care and ultimately our health and well-being. Lohr, Steiwachs 2002

5. Dept Social Medicine Health Services Research a working model describe health services in terms of structure, process, outcome consider medical practice (health services) as one determinant of health status together with genotype, social and physical environment and behaviour examples  studies of structure (manpower, organization, financing)  studies of structure and process (influence insurance system on use)  studies of structure and outcome (mortality in teaching/non teaching hospitals)  studies of process (appropriateness hospitalization)  studies of process and outcome (compliance and symptoms)  studies of outcome Starfield 1973 NEJM

6. Dept Social Medicine What is Health Services Research? Systematic way of knowledge production Valid knowledge Generalizable knowledge Applicable knowledge Focused on functioning of health care services and health systems

7. Dept Social Medicine Types of questions in HSR Descriptive questions Explorative questions Testing questions Instrumental questions Theoretical interpretative questions

8. Dept Social Medicine Methods in HSR Literature study Interviews, observations, focus groups Questionnaires Case studies Trend analyses / cohorts Pre-post studies Case-control studies Quasi-experimental design RCT

9. Dept Social Medicine OBJECT OF STUDY Organisation Process Intervention Outcomes

10. Dept Social Medicine THEORETICAL PERSPECTIVES Quality of Care Managerial / Administrative Innovation / Change Learning organization Professionalization theory

11. Dept Social Medicine EVALUATION RESEARCH Experimental Economic Managerial Developmental Øvretveit 1998

12. Dept Social Medicine Interaction with policymakers, managers and professionals on: research goals research design data-collection reporting

13. Dept Social Medicine Example Dutch Performance Framework for the Health System 2002 - 2007

14. Dept Social Medicine Table 1.1 Conditions under which performance measurement is possible and problematic is possible and problematic Performance measurementpossible Performance measurement problematic  An organization has products  An organization has obligations and is highly value-oriented  Products are simple  Products are multiple  An organization is product-oriented  An organization is process-oriented  Autonomous production  Co-production: products are generated together with others  Products are isolated  Products are interwoven  Causalities are known  Causalities are unknown  Quality definable in  Quality not definable in performance indicators  Uniform products  Variety of products  Environment is stable  Environment is dynamic Source: Managing performance in the public sector. De Bruijn H. (2002), p. 13

15. Dept Social Medicine Dutch Performance Framework start policy process functions conceptual choices indicator development interaction researchers, policy makers and the health care field

16. Dept Social Medicine Financial perspective Consumer perspective Innovation perspective Internal business processes perspective Health Health Care: prevention, cure, care and welfare Lifestyle Population Health information Management information Lalonde-model Balanced scorecard Genetic layout Environment factors Performance:

17. Dept Social Medicine Internal business processes perspective performance of care financiers quality of health care delivery process availability of choice of insurer and provider concentration of care provision human resources (1) : availability, vacancies, and staff satisfaction substitution of care between professions and between care delivery settings Consumer perspective effectiveness patient safety patient centeredness Innovation perspective allocation of funds for learning and growth diffusion of new technologies information infrastructure human resources (2): innovative working environment, and professionals in training development and diffusion of organisational innovations industry initiated research and development activities in health care Financial perspective health system costs allocative efficiency vertical equity financial accessibility financial viability of financiers and care providers

18. Dept Social Medicine Lessons learned phases of conceptualization, ownership and execution link with health care reforms link with sectoral organization of the department of health link with information policies link with accountability agenda link with international developments

19. Dept Social Medicine

21. System goals (3) Indicatordomains (15) Indicators (125) Keyfindings (120) Summary State Dutch Health Care A B

22. Dept Social Medicine Accessibility Freedom of choice Waiting times Accessibility in line with demand Financial barriers for citizens Concentration of supply Development of health care professions Quality: Effectiveness Safety Consumers and patient satisfaction Accreditation Innovation Financial sustainability Development of macro costs Monitoring the market Productivity Financial position of health care suppliers Main performance fields from a macro perspective

23. Dept Social Medicine Chapter 2. Quality 2.2 Effectiveness of prevention Percentage of (adolescent) smokers Percentage of (adolescent) people with overweight Level of participation in population surveys and screenings Vaccination rate (National Vaccination Programme (RVP), influenza vaccination, hepatitis B) Percentage of patients with diabetes with good glucose control Effectiveness of lifestyle advice in primary care Percentage of schools that offer effective lifestyle programmes Percentage of employers (companies) with an occupational health policy Health protection: consumers’ trust in food safety, emergency treatment of home accidents and an indicator for medical assistance in accidents and disasters Percentage of high-risk youth that is reached by adolescent health care Percentage of deprived areas with an intersectoral approach to health (no information available) Perinatal mortality 2.3 Effectiveness of cure Percentage of cases in which general practitioners do not prescribe medicines they are advised against to prescribe for a particular syndrome Percentage of cases in which general practitioners prescribe medicines that are advised for a specific syndrome Percentage of cases in which general practitioners prescribe according to guidelines Percentage of referrals by general practitioners to medical specialists Percentage of referrals by general practitioners to other primary care workers In-hospital mortality for heart failure In hospital mortality for pneumonia In-hospital mortality for bypass surgery Hospital Standardized Mortality ratio 30-days mortality following acute myocardial infarction 30-days mortality following stroke Asthma mortality per 100,000 people aged 5-39 Breast cancer mortality per 100,000 women Colon cancer mortality per 100,000 people Cervical cancer mortality per 100,000 women Breast cancer 5-year survival rate Colon cancer 5-year survival rate Cervical cancer 5-year survival rate Percentage of (over) 65-year old hip fracture patients with surgery initiated within 48 hours Number of diabetes-related major amputations in 100,000 diabetics aged 18-75

24. Dept Social Medicine 2.4 Effectiveness of long-term care Percentage of people with impairments who indicate that the appliances supplied solve their problems Percentage of people with somatic complaints who return to their own environment after a stay in a nursing home (as an indicator of the scope of temporary stay function of nursing homes) Clients’ experiences with home care, nursing homes and care for the disabled Volume of possibly preventable health care problems (such as falls) in nursing home residents Percentages of patients with decubitus with home care or in nursing homes Judgements of the Health Care Inspectorate on nursing home care Percentage of home care or nursing home patients who are admitted to a hospital at least once a year Number of psychogeriatric patients who live in a small-scale residential care facility 2.5 Effectiveness of care for mental and substance-use conditions Result of prevention measures and target groups that are reached Changes in mental and social functioning of patients Development of the number of suicides and suicide attempts Percentage of the target group that is reached by care professionals Development of the number of discharges in mental health care and substance-use care 2.6 Consumers’ experiences with health care General consumers’ trust: do Dutch people have faith in the health care system, irrespective of their actual use of care? Experiences of consumers: what is opinion of care consumers on the care received? 2.7 Patient safety Percentage of general practitioners and pharmacists that participate in Farmacotherapeutic Consultations Medication monitoring in pharmacies Volume of high-risk surgery in hospitals Incidence of serious adverse effects of blood transfusion Prevalence of decubitus in hospitals Prevalence of decubitus in long-term care facilities 2.8 Quality systems Percentage of institutions that have been certified or accredited Percentage of institutions that have the necessary quality documents Percentage of institutions that use special protocols or guidelines that outline procedures for risky or complex processes Percentage of institutions that use (sub-)systems for feedback of patients and consumers 2.9 Innovations Investments in development and research in the care sector; international comparison Number of biotechnology patents in the Netherlands Utilization and speed of diffusion of minimally non- invasive surgical techniques Use of process innovations, such as ‘integrated care pathways’ and ‘CVA integrated care’ Application of ICT in various health care sectors Development in the ratio of surgical day-treatments to the total number of surgical treatments

25. Dept Social Medicine Chapter 3. Access 3.2 Patient choices in the access to care Actual use of a number of new choices in care: personal care budget and health insurer Wishes of citizens with respect to choices (of health care professional, sources of information and forms of care) 3.3 Accessibility of acute care Percentage of urgent ambulance rides that meets response time targets Number of urgent ambulance rides that exceeds the standard response time (15 minutes) Number of people who are able to reach the nearest emergency department or out-of-hours primary care centre by car within 30 minutes Number of urgent callers to out-of-hours general practitioner centres who are answered by an expert within one minute Number of people waiting for an organ transplant 3.4 Waiting times Percentage of patients who are satisfied with the speed with which they are seen by a general practitioner, specialist or dentist Number of people who wait for care (scope of the waiting list) (Expected) time to treatment (waiting time) Number of people who have to wait for care longer than the Treeknorm 3.5 Accessibility according to need Comparison of care utilization by low and high educated populations, corrected for health inequality Comparison of care utilization by immigrants and the native population, corrected for health inequality Care utilization in deprived areas of large cities and by marginal groups Satisfaction of asylum seekers with medical care 3.6 Financial accessibility Insurance status of the population, including the number of uninsured Costs of care for citizens Volume of co-payments and out-of-pocket payments Tax refunds because of medical expenses Additional care costs of chronically ill patients Use of financial compensation provisions by chronically ill patients Percentage of the family income that is spent on medical expenses by high- versus low- income groups Share of the total healthcare costs in the Netherlands paid by high- and low-income groups separately (income solidarity in health care) 3.7 Geographical accessibility Accessibility of facilities by required travel time and by number of care facilities per municipality or region Number of inpatient and outpatient facilities per region per 10,000 inhabitants 3.8 Personnel Number of vacancies in the health care sector that are hard to fill Rate of sickness absence in health care Current unfilled vacancies Degree to which the current intake of care providers has been tuned to developments in care demand Number of people that is not registered with a general practitioner or dentist 3.9 Professions and training Number of doctors and nurses per 100,000 inhabitants Professional ratios: Number of one type of care provider to another type of care provider (e.g. number of dental hygienists to a dentist) Medical-technical tasks carried out by doctor assistants Number of practice assistants with a higher vocational training Number of experienced graduate physician assistants and nurse practitioners, and number in training Qualification level of care and nursing staff Percentage of Dutch people who provide informal care

26. Dept Social Medicine Chapter 4. Costs 4.2 Macro costs Health care expenditure according to the Health Budget (BKZ) (Ministry of Health, Welfare and Sports) Health care expenditure according to the Health Accounts (Statistics Netherlands) Health care expenditure according to the System of Health Accounts (OECD) Expenditure on the different care sectors Expenditure on BKZ-relevant care by financing source Share of health care expenditure in the Gross Domestic Product Share of health care expenditure in the increase in the Gross Domestic Product Price development in health care Development in care volume Costs of care per capita 4.3 Health care market Variation in insurance premiums (health insurance market) Market concentrations of care providers and insurers (health insurance market/ health care purchase market) Access barriers to the health care market (all sub-markets) Care purchased by insurers (health care purchase market) Vertical integration (all sub-markets) Mobility of insured persons (health insurance market) Risk selection by insurers (health insurance market) Transfer of costs (health insurance market) 4.4 Productivity of health care Development of production volume in six care sectors, divided by the number of employees in fte and corrected for reduction of working hours Recent developments in labour productivity in hospitals compared to recent developments in labour productivity of the Dutch economy as a whole Number of hospital discharges per fte hospital employee 4.5 Financial position of care institutions Profitability Solvency Liquidity Reserves for acceptable costs Level of participation in the Guarantee Fund for the Care Sector

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30. Dept Social Medicine Figure 12b. Breast cancer, 5-year relative survival rates. (data for two years when available) Draft; not for publication

31. Dept Social Medicine Lessons learned 2 major information challenges keeping the links with the policy makers more need for trends and benchmarking better visualization revival BSC revival link to strategy and policy

32. Dept Social Medicine

34. Interaction with policymakers, managers and professionals on: performance agenda and system reform international benchmaking (OECD) patient experiences (CQ-Index/CAHPS) hospital performance (PATH) professional performance (Aire)

35. Dept Social Medicine General conclusions agreement on goals, timing and generalizability agreement on theories and concepts study design should fit the question interaction on data-collection and reporting infrastructure R & D in the health system applying principles knowledge management and learning in the health system