Godefridus G. van Merode

Does General Practitioner Gatekeeping Curb Health Care Expenditure

Objectives: It is generally assumed that health care systems in which specialist and hospital care is only accessible after referral by a general practitioner (GP) have lower total health care costs. In this study, the following questions were addressed: do health care systems with GPs acting as gatekeepers to specialized care have lower health care expenditure than those with directly accessible specialist care? Does health care expenditure increase more rapidly in countries without a referral system than in those with the GP acting as a gatekeeper? Methods: Multiple regression analyses on total and ambulatory health care expenditure in 18 OECD countries. Results: Analyses showed only one statistically significant effect (P< 0.05) in countries with gatekeeping GPs: ambulatory care expenditure has increased more slowly than in non-gatekeeping systems. No significant effects of gatekeeping were found on the level of ambulatory care costs, or on the level or growth of total health care expenditure. As in earlier studies, the most important factor influencing aggregate health care costs and their growth is gross national product (GNP), followed by the share of public funding. Relationships that exist at a micro level (such as lower costs with a gatekeeping primary care doctor) did not show up in aggregate data at a macro level. Conclusions: Gatekeeping systems appear to be better able to contain ambulatory care expenditure. More research is necessary to understand micro level mechanisms and to distinguish the effects of gatekeeping from other structural aspects of health care systems.

Work Organization, Work Characteristics, and Their Psychological Effects on Nurses in the Netherlands

The aim of the current study was to examine relationships between organizational characteristics, work characteristics, and psychological work reactions in nursing work. We used several theoretical frameworks to select our research variables. In line with the contingency and sociotechnical system approaches, we selected complexity, uncertainty, and decision authority to represent the organizational characteristics. As to the work characteristics, we selected the variables of the Demand–Control–Support model (autonomy, social support, workload), role conflict, and role ambiguity. In order to measure the psychological work reactions, burnout, psychosomatic health complaints, job satisfaction, and intrinsic work motivation were assessed in questionnaires distributed to 1,855 nurses working in general hospitals in the Netherlands. Using correlation and hierarchical multiple regression analysis, the main results showed that high decision authority predicted high social support andhigh autonomy. High decision authority predicted high job satisfaction and high intrinsic work motivation. Finally, high complexity was indirectly predictive for high burnout. Workload operated as a mediator variable in this relationship.

THE DIVERSITY OF WORK: DIFFERENCES, SIMILARITIES AND RELATIONSHIPS CONCERNING CHARACTERISTICS OF THE ORGANISATION, THE WORK AND PSYCHOLOGICAL WORK REACTIONS IN INTENSIVE CARE AND NON-INTENSIVE CARE NURSING

The aim of this study was to examine differences in organisational characteristics, work characteristics and psychological work reactions, and to investigate relationships between these variables in intensive care units (ICUs) and non-ICUs. Questionnaires were distributed to intensive care (n = 184) and non-intensive care nurses (n = 927) working in 15 general hospitals in the Netherlands. MANOVA showed that ICU nurses reported significantly higher uncertainty, higher complexity, and higher decision authority than non-ICU nurses. Emotional exhaustion was significantly lower among ICU nurses. Regarding the pattern of relationships, the LISREL-analyses revealed that the indirect proposed pattern of relationships was invariant across the two samples, which means a validation of our research model.

Applying the quality improvement collaborative method to process redesign: a multiple case study

BackgroundDespite the widespread use of quality improvement collaboratives (QICs), evidence underlying this method is limited. A QIC is a method for testing and implementing evidence-based changes quickly across organisations. To extend the knowledge about conditions under which QICs can be used, we explored in this study the applicability of the QIC method for process redesign.MethodsWe evaluated a Dutch process redesign collaborative of seventeen project teams using a multiple case study design. The goals of this collaborative were to reduce the time between the first visit to the outpatients clinic and the start of treatment and to reduce the in-hospital length of stay by 30% for involved patient groups. Data were gathered using qualitative methods, such as document analysis, questionnaires, semi-structured interviews and participation in collaborative meetings.ResultsApplication of the QIC method to process redesign proved to be difficult. First, project teams did not use the provided standard change ideas, because of their need for customised solutions that fitted with context-specific causes of waiting times and delays. Second, project teams were not capable of testing change ideas within short time frames due to: the need for tailoring changes ideas and the complexity of aligning interests of involved departments; small volumes of involved patient groups; and inadequate information and communication technology (ICT) support. Third, project teams did not experience peer stimulus because they saw few similarities between their projects, rarely shared experiences, and did not demonstrate competitive behaviour. Besides, a number of project teams reported that organisational and external change agent support was limited.ConclusionsThis study showed that the perceived need for tailoring standard change ideas to local contexts and the complexity of aligning interests of involved departments hampered the use of the QIC method for process redesign. We cannot determine whether the QIC method would have been appropriate for process redesign. Peer stimulus was non-optimal as a result of the selection process for participation of project teams by the external change agent. In conclusion, project teams felt that necessary preconditions for successful use of the QIC method were lacking.

Changes in hospital costs after introducing an intermediate care unit: a comparative observational study.

IntroductionThe high cost of critical care resources has resulted in strategies to reduce the costs of ruling out low-risk patients by developing intermediate care units (IMCs). The aim of this study was to compare changes in total hospital costs for intensive care patients before and after the introduction of an IMC at the University Hospital Maastricht.MethodsThe design was a comparative longitudinal study. The setting was a university hospital with a mixed intensive care unit (ICU), an IMC, and general wards. Changes in total hospital costs were measured for patients who were admitted to the ICU before and after the introduction of the IMC. The comparison of interest was the opening of a six-bed mixed IMC.ResultsThe mean total hospital cost per patient increased significantly. Before the introduction of the IMC, the total hospital cost per patient was €12,961 (± €14,530) and afterwards it rose to €16,513 (± €17,718). Multiple regression analysis was used to determine to what extent patient characteristics explained these higher hospital costs using mortality, type of stay, diagnostic categories, length of ICU and ward stay, and the Therapeutic Intervention Scoring System (TISS) as predictors. More surgical patients, greater requirements of therapeutic interventions on the ICU admission day, and longer ICU stay in patients did explain the increase in hospital costs, rather than the introduction of the IMC.ConclusionAfter the introduction of the IMC, the higher mean total hospital costs for patients with a high TISS score and longer ICU stay explained the cost increase.

Towards an organisation-wide process-oriented organisation of care: a literature review

BackgroundMany hospitals have taken actions to make care delivery for specific patient groups more process-oriented, but struggle with the question how to deal with process orientation at hospital level. The aim of this study is to report and discuss the experiences of hospitals with implementing process-oriented organisation designs in order to derive lessons for future transitions and research.MethodsA literature review of English language articles on organisation-wide process-oriented redesigns, published between January 1998 and May 2009, was performed.ResultsOf 329 abstracts identified, 10 articles were included in the study. These articles described process-oriented redesigns of five hospitals. Four hospitals tried to become process-oriented by the implementation of coordination measures, and one by organisational restructuring. The adoption of the coordination mechanism approach was particularly constrained by the functional structure of hospitals. Other factors that hampered the redesigns in general were the limited applicability of and unfamiliarity with process improvement techniques.ConclusionsDue to the limitations of the evidence, it is not known which approach, implementation of coordination measures or organisational restructuring (with additional coordination measures), produces the best results in which situation. Therefore, more research is needed. For this research, the use of qualitative methods in addition to quantitative measures is recommended to contribute to a better understanding of preconditions and contingencies for an effective application of approaches to become process-oriented. Hospitals are advised to take the factors for failure described into account and to take suitable actions to counteract these obstacles on their way to become process-oriented organisations.

The choice of obstetric care by low-risk pregnant women in the Netherlands: Implications for policy and management

In the Netherlands, pregnant women at low risk of complications during pregnancy, have the opportunity to choose freely between giving birth at home or in a hospital maternity unit. This study analyses how various attributes of obstetric care, socio-economic characteristics and attitudes influence the decisions that these women make with regard to obstetric care. The method of discrete-choice experiment was applied in the process of data collection and analysis. The data were collected among low-risk nulliparous pregnant women. The analysis suggests that there are strong preferences among some Dutch women for a home birth. Nevertheless, the absence of a medical pain-relief treatment during home birth, might provide incentives for some women to opt for a birth in a hospital, especially at the end of their pregnancy. If the attractiveness of home birth should be preserved in the Netherlands, specific attention should be paid on the approach to pain during a home birth. Efforts could also be made in offering a domestic atmosphere during hospital births to improve hospital-based obstetric care in view of womens preferences.

Organizational Characteristics as Predictors of Nurses’ Psychological Work Reactions

The current study aims to examine effects of organizational characteristics (decision authority and environmental uncertainty) on nurses’ psychological work reactions (job satisfaction and intrinsic work motivation; burnout and health complaints). In this context, we were primarily interested in the congruence between decision authority and environmental uncertainty. The contingency approach of organizations was used as a leading framework. In order to investigate these relationships, questionnaires were administered to 1188 nurses working in general hospitals in the Netherlands. Because the standardization of tasks is expected to be different between intensive care units (ICUs) and non-ICUs, and consequently, this difference might influence the effects of organizational characteristics on psychological work reactions, the relationships were investigated separately for each type of unit. Correlation and hierarchical regression analysis were used to analyse the data. From the results of these analyses, it appeared that decision authority has a positive effect on intrinsic work motivation in both types of unit. In addition to this additive effect, the congruence between decision authority and environmental uncertainty was confirmed, but only in ICUs. It appeared that high environmental uncertainty would enhance the positive effect of decision authority on intrinsic work motivation. Furthermore, the congruence between decision authority and environmental uncertainty in the prediction of burnout and psychosomatic health complaints was not confirmed: high decision authority appeared not to buffer the negative effect of environmental uncertainty on burnout and health complaints. The results are discussed as well as the limitations of the study. Suggestions for further research are also given.

Willingness and ability of Bulgarian consumers to pay for improved public health care services

An application of the contingent valuation method to the willingness and ability of Bulgarian consumers to pay for public health care services is presented. The study uses data from a household survey conducted in May–June 2000. The willingness and ability to pay for outpatient, inpatient and dental services is investigated. A combination of interval checklist and open-ended questions are used to elicit the willingness-to-pay amounts. The impact of the sociodemographic characteristics on the responses is examined by a generalized Tobit regression. Based on the regression equation, the welfare effects of various fee levels are simulated.

Public attitudes towards patient payments in Bulgarian public health care sector: results of a household survey

This paper analyses the attitudes towards patient payments in the Bulgarian public health care sector. The analysis is based on results of a household survey conducted in the region of Varna (the third largest city in Bulgaria) between May and June 2000. The data are collected through interviews based on a standardised questionnaire and are analysed by non-parametric statistical procedures. The results show that the majority of the respondents accept to pay for public health care services if these services are provided with good quality and quick access. On average, charges for primary and dental care receive higher approval than charges for hospital services. A large percentage of the sample disagrees with charges related to actual service cost or service quality and nearly all respondents consider a ceiling on payments appropriate. According to the majority of the interviewed, the charges should be retained at the place of service provision. The sample shows strong support for an extensive system of exemptions from payments.