Frits van Merode

Optimal Organization of Health Care in Diabetic Foot Disease: Introduction to the Eurodiale Study

This article describes the rationale and protocol of a large data collection study in patients with new diabetic foot ulcers by the Eurodiale study group, a consortium of centers of expertise in the field of diabetic foot disease within Europe. This study is a multicenter, observational, prospective data collection study. Its main aim is to determine the major factors determining clinical outcome and outcome in terms of health-related quality of life and health care consumption. Between September 1, 2003, and October 1, 2004, in 14 European centers, all consecutive patients with diabetes and a new foot ulcer were included in the study and followed until the end point or for a maximum of 1 year. End points were healing of the foot, major amputation, or death. Data were collected on patient, foot, and ulcer characteristics and on diagnostic and management procedures. Furthermore, data were collected on health care organization, quality of life, and resource use. A total of 1232 patients were included in the study. Sixty-three percent of the patients were referred by their general practitioner or were self-referrals. Twenty-seven percent of the patients were admitted at the time of inclusion; 1088 patients were followed until the end point. “Optimal Organization of Health Care in Diabetic Foot Disease” is one of the first large multicenter studies in the field of diabetic foot disease on clinical presentation, clinical outcome, quality of life, resource utilization, and health care organization and their interrelationships. These data will provide us with new insights that enable us to improve care for these patients and guide the development of new studies in this area. The results of this study are the subject of a separate presentation.

Cost-utility of a disease management program for patients with asthma

OBJECTIVES The long-term cost-utility of a disease management program (DMP) for adults with asthma was assessed compared to usual care. METHODS A DMP for patients with asthma has been developed and implemented in the region of Maastricht (The Netherlands). By integrating care, the program aims to continuously improve quality of care within existing budgets. A clinical trial was performed over a period of 15 months to collect data on costs and effects of the program and usual care. These data were used to inform a probabilistic decision-analytic model to estimate the 5-year impact of the program beyond follow-up. A societal perspective was adopted, with outcomes assessed in terms of costs per quality-adjusted life-year (QALY). RESULTS The DMP is associated with a gain in QALYs compared to usual care (2.7+/-.2 versus 3.4+/-.8), at lower costs (3,302+/-314 euro versus 2,973+/-304 euro), thus leading to dominance. The probability that disease management is the more cost-effective strategy is 76 percent at a societal willingness to pay (WTP) for an additional QALY of 0 euro, reaching 95 percent probability at a WTP of 1,000 euro per additional QALY. CONCLUSIONS Organizing health care according to the principles of disease management for adults with asthma has a high probability of being cost-effective and is associated with a gain in QALYs at lower costs.

Principal agent relationships and the efficiency of hospitals

The efficiency of hospitals is an important political issue and has been the subject of a number of studies. Most studies find evidence for inefficiency but provide no theoretical explanations for differences in efficiency. This study used principal agent theory to explain differences in efficiency between hospitals. Two agency issues are examined: (1) quality of care in the relationship between hospital and patient, and (2) internal organisation, i.e. the relationship between the hospital and its main departments. It was found that efficiency and quality go together. This implies that the potential harmful information asymmetry between hospitals and patients does not appear to be a major problem, because increasing efficiency does not seem to reduce quality. Further, we find no relationship between the efficiency of departments and the efficiency of the entire hospital. The interest of hospital departments is currently not in line with the interests of the entire hospital.

Are we measuring what matters in health technology assessment of disease management? Systematic literature review

OBJECTIVES An overview was produced of indicators currently used to assess disease management programs and, based on these findings, provide a framework regarding sets of indicators that should be used when taking the aims and types of disease management programs into account. METHODS A systematic literature review was performed. RESULTS Thirty-six studies met the inclusion criteria. It appeared that a link between aims of disease management and evaluated structure, process, as well as outcome indicators does not exist in a substantial part of published studies on disease management of diabetes and asthma/chronic obstructive pulmonary disease, especially when efficiency of care is concerned. Furthermore, structure indicators are largely missing from the evaluations, although these are of major importance for the interpretation of outcomes for purposes of decision-making. Efficiency of disease management is mainly evaluated by means of process indicators; the use of outcome indicators is less common. Within a framework, structure, process, and outcome indicators for effectiveness and efficiency are recommended for each type of disease management program. CONCLUSIONS The link between aims of disease management and evaluated structure, process, and outcome indicators does not exist in a substantial part of published studies on disease management. The added value of this study mainly lies in the development of a framework to guide the choice of indicators for health technology assessment of disease management.

Appraising the financial reform in Bulgarian public health care sector: the health insurance act of 1998

The public health care services in Bulgaria were deteriorating, especially during the decade of transitional process. The method of health care finance was a major reason for the poor performance of the Bulgarian public health care sector. Bulgarian policy-makers decided that an insurance-based financial mechanism could help to rescue the failing public health care services. This paper explores the social benefits and the feasibility of the insurance-based finance in the Bulgarian public health care sector. The discussion in the paper implies that, in the current conditions of economic recession, the insurance-based health care finance can not be socially beneficial for Bulgaria. Moreover, the insurance implementation seams to be unfeasible due to a lack of sufficient financial resources.

Integrated health care from an economic point of view

In many countries, health care reforms are being made with the purpose of stimulating actors to make economically sound decisions. Recent attempts in The Netherlands encompass the development and introduction of integrated health care arrangements. Since these arrangements are directly tailored to care demand, it is generally expected that integrated health care will enhance efficiency. This paper analyses whether a shift towards integrated health care actually represents a Pareto‐optimal change. An analysis of the consequences shows that care demanders, providers and informal care givers, to some extent and under certain conditions, can be expected to benefit from the introduction of integrated health care. Under long‐term considerations, the introduction of integrated care may be categorised as a potential Pareto‐improvement.

Integrated care management: applying control theory to networks.

Delivery of integrated care by interorganizational networks attracts much attention in Europe. Such care is required to meet the demands of multi-problem patients. Many efforts are made to establish networks. Often, established networks do not deliver integrated care. Managers must understand the background of this problem, in order to deal with it. The issue addressed here concerns behaviour control in networks of autonomous care-providing organizations. So far, publications have focused on behaviour control in single organisations. Based on empirical data we argue that, due to an essential distinction between networks and single organizations, behaviour control in the former should be approached differently. In addition, we discuss the implications of our findings for the management of integrated care delivery.

Hospital efficiency and transaction costs: A stochastic frontier approach

The make-or-buy decision of organizations is an important issue in the transaction cost theory, but is usually not analyzed from an efficiency perspective. Hospitals frequently have to decide whether to outsource or not. The main question we address is: Is the make-or-buy decision affected by the efficiency of hospitals? A one-stage stochastic cost frontier equation is estimated for Dutch hospitals. The make-or-buy decisions of ten different hospital services are used as explanatory variables to explain efficiency of hospitals. It is found that for most services the make-or-buy decision is not related to efficiency. Kitchen services are an important exception to this. Large hospitals tend to outsource less, which is supported by efficiency reasons. For most hospital services, outsourcing does not significantly affect the efficiency of hospitals. The focus on the make-or-buy decision may therefore be less important than often assumed.

Analyzing the dynamics in multilateral negotiations

The purpose of this article is to examine phase-differences in the patterns of actors involved in decision making. Two phases are distinguished, the negotiating phase, and the decision-making phase. During the first phase the agents primary goal is to influence the policy position of other agents, whereas during the second phase the agents goal is to find a solution (especially if there is a credible threat of a worse outcome). Convincing others is easier in a bilateral setting than in a multilateral one, and thus the decision-making phase is expected to result in an increase in multilateral interactions. To reveal the participation pattern of agents, we discuss methods for quantitative analyses of complex negotiations. A dynamic analysis of participation in multilateral negotiations gives insight into the continuity and change of participation during a negotiating process. The process of determining prices for specialized medical care in The Netherlands is used as a case study. The quantitative methods seem to be useful for analyzing such a complex case. Following our hypothesis, in the case study multilateral contacts are shown to be more frequent over time as compared to bilateral negotiations.