Hans Okkels Birk

Patient reactions to hospital choice in Norway, Denmark, and Sweden.

This article is a comparative study of three Scandinavian countries--Norway, Denmark, and Sweden--all of which have provided the individual patient with extensive rights to choose the hospital where he/she wishes to receive treatment. In the paper, we present an analysis of the utilization of the opportunity to choose between hospitals in these three countries. The analysis addresses two questions: (i) How many patients are exercising the right to choose between hospitals in these countries and who is making use of this opportunity? (ii) How can we explain the observed utilization pattern? The results of the study reveal clear similarities between the three countries and suggest that few patients have actually chosen their hospital. However, a gradual increase can be observed over the years. Few formal, legislative, or economic barriers exist for patients. Instead, limited knowledge amongst patients regarding reforms, combined with insufficient support from GPs and limited information, can explain why few patients choose to receive care outside of their local region.

Integrated care: a Danish perspective

Despite three decades of reform Denmark’s health sector is still struggling to provide coordinated care for an ageing population with a high burden of chronic disease. Andreas Rudkjøbing and colleagues describe recent initiatives to improve continuity of care

Which factors decided general practitioners’ choice of hospital on behalf of their patients in an area with free choice of public hospital? A questionnaire study

BackgroundParts of New Public Management-reforms of the public sector depend on introduction of market-like mechanisms to manage the sector, like free choice of hospital. However, patients may delegate the choice of hospital to agents like general practitioners (GPs). We have investigated which factors Danish GPs reported as decisive for their choice of hospital on behalf of patients, and their utilisation of formal and informal data sources when they chose a hospital on behalf of patients.MethodsRetrospective questionnaire study of all of the 474 GPs practising in three counties which constituted a single uptake area. Patients were free to choose a hospital in another county in the country. The GPs were asked about responsibility for choice of the latest three patients referred by the GP to hospital; which of 16 factors influenced the choice of hospital; which of 15 sources of information about clinical quality at various hospitals/departments were considered relevant, and how often were six sources of information about waiting time utilised.ResultsFifty-one percent (240 GPs) filled in and returned the questionnaire. One hundred and eighty-three GPs (76%) reported that they perceived that they chose the hospital on behalf of the latest referred patient. Short distance to hospital was the most common reason for choice of hospital.The most frequently used source of information about quality at hospital departments was anecdotal reports from patients referred previously, and the most important source of information about waiting time was the hospitals’ letters of confirmation of referrals.ConclusionsIn an area with free choice of public hospital most GPs perceived that they chose the hospital on behalf of patients. Short distance to hospital was the factor which most often decided the GPs’ choice of hospital on behalf of patients. GPs attached little weight to official information on quality and service (waiting time) at hospitals or departments, focusing instead on informal sources like feedback from patients and colleagues and their experience with cooperation with the department or hospital.

Analytical perspectives on performance­based management: an outline of theoretical assumptions in the existing literature

Performance-based management (PBM) has become a dominant form of governance in health care and there is a need for careful assessment of its function and effects. This article contains a cross-disciplinary literature synthesis of current studies of PBM. Literature was retrieved by database searches and categorized according to analytical differences and similarities concerning (1) purpose and (2) governance mechanism of PBM. The literature could be grouped into three approaches to the study of PBM, which we termed: the ‘functionalist’, the ‘interpretive’ and the ‘post-modern’ perspective. In the functionalist perspective, PBM is perceived as a management tool aimed at improving health care services by means of market-based mechanisms. In the interpretive perspective, the adoption of PBM is understood as consequence of institutional and individual agents striving for public legitimacy. In the post-modern perspective, PBM is analysed as a form of governance, which has become so ingrained in Western culture that health care professionals internalize and understand their own behaviour and goals according to the values expressed in these governance systems. The recognition of differences in analytical perspectives allows appreciation of otherwise implicit assumptions and potential implications of PBM. Reflections on such differences are important to ensure vigilant appropriation of shifting management tools in health quality governance.

Evaluation of a policy to strengthen case management and quality of diabetes care in general practice in Denmark

OBJECTIVES To evaluate the utilization of a policy for strengthening general practitioners case management and quality of care of diabetes patients in Denmark incentivized by a novel payment mode. We also want to elucidate any geographical variation or variation on the basis of practice features such as solo- or group practice, size of practice and age of the GP. METHODS On the basis registers encompassing reimbursement data from GPs and practice specific information about geographical location (region), type of practice (solo- or group-practice), size of practice (number of patients listed) and age of the GP were are able to determine differences in use of the policy in relation to the practice-specific information. RESULTS At the end of the study period (2007-2012) approximately 30% of practices have enrolled extending services to approximately 10% of the diabetes population. There is regional--as well as organizational differences between GPs who have enrolled and the national averages with enrolees being younger, from larger practices and with more patients listed. CONCLUSIONS Our study documents an organizationally and regionally varied and limited utilization with the overall incentive structure defined in the policy not strong enough to move the majority of GPs to change their way of delivering and financing care for patients with diabetes within a period of more than 5 years.

Mortality in joggers : Healthy jogger effect might explain differences in mortality

Editor—As chairman of the expert planning group set up by the Medical Research Council and Wellcome Trust, I can reassure readers of the article by Kaye and Martin that all the issues they raise about the proposed population study in the United Kingdom involving genetic information have been fully recognised.1 The study will not and cannot be started until arrangements acceptable to all concerned are in place. These arrangements are currently being actively developed and entail consultation with lay and professional advisers. The two main reasons behind the high degree of public concern and debate about the study in Iceland were the initial proposal for an “opt out” approach to consent for collection of some of the data and the decision to license the databases exclusively to a commercial company. Neither of these has ever been considered as a possibility in the British study. Consent to take part will be on an “opt in” basis only after full verbal and written explanations and guarantees on confidentiality. The availability of fully anonymised material to others in order to pursue the full scientific and therapeutic potential of the study will be tightly controlled. The study will be overseen and regulated by a publicly accountable and independent body responsible for reviewing all its procedures and activities. In addition, full ethical approval will of course also have to be obtained. The United Kingdom has well developed, high quality expertise in both genetics and population based research, and its diverse population and healthcare system are additional advantages. Others have emphasised the importance for future health care of deriving the full benefit from recent and future developments in genetics.2 While the appropriate regulatory procedures are being put in place we should not lose sight of the willingness of many people in this country to take part in research, including work likely to benefit others perhaps more than themselves. We must ensure that they can express this readiness through their contribution to important studies such as the one the Medical Research Council and Wellcome Trust are setting up.