Case-studies of displacement effects in Dutch hospital care.

BACKGROUND: Under a constrained health care budget, cost-increasing technologies may displace funds from existing health services. However, it is unknown what services are displaced and how such displacement takes place in practice. The aim of our study was to investigate how the Dutch hospital sector has dealt with the introduction of cost-increasing health technologies, and to present evidence of the relative importance of three main options to deal with cost-increases in health care: increased spending, increased efficiency, or displacement of other services. METHODS: We conducted six case-studies and interviewed 84 professionals with various roles and responsibilities (practitioners, heads of clinical department, board of directors, insurers, and others) to investigate how they experienced decision making in response to the cost pressure of cost-increasing health technologies. Transcripts were analyzed thematically in Atlas.ti on the basis of an item list. RESULTS: Direct displacement of high-value care due to the introduction of new technologies was not observed; respondents primarily pointed to increased spending and efficiency measures to accommodate the introduction of the cost-increasing technologies. Respondents found it difficult to identify the opportunity costs; partly due to limited transparency in the internal allocation of funds within a hospital. Furthermore, respondents experienced the entry of new technologies and cost-containment as two parallel processes that are generally not causally linked: cost containment was experienced as a permanent issue to level costs and revenues, independent from entry of new technologies. Furthermore, the way of financing was found important in displacement in the Netherlands, especially as there is a separate budget for expensive drugs. This budget pressure was found to be reallocated horizontally across departments, whereas the budget pressure of other services is primarily reallocated vertically within departments or divisions. Respondents noted that hospitals have reacted to budget pressures primarily through a narrowing in the portfolio of their services, and a range of (other) efficiency measures. The board of directors is central in these processes, insurers are involved only to a limited extent. CONCLUSIONS: Our findings indicate that new technologies were generally accommodated by greater efficiency and increased spending, and that hospitals sought savings or efficiency measures in response to cumulative cost pressures rather than in response to single cost-increasing technologies.

The Value of Decision Analytical Modeling in Surgical Research: An Example of Laparoscopic Versus Open Distal Pancreatectomy.

OBJECTIVE: To illustrate how decision modeling may identify relevant uncertainty and can preclude or identify areas of future research in surgery. SUMMARY BACKGROUND DATA: To optimize use of research resources, a tool is needed that assists in identifying relevant uncertainties and the added value of reducing these uncertainties. METHODS: The clinical pathway for laparoscopic distal pancreatectomy (LDP) versus open (ODP) for nonmalignant lesions was modeled in a decision tree. Cost-effectiveness based on complications, hospital stay, costs, quality of life, and survival was analyzed. The effect of existing uncertainty on the cost-effectiveness was addressed, as well as the expected value of eliminating uncertainties. RESULTS: Based on 29 nonrandomized studies (3.701 patients) the model shows that LDP is more cost-effective compared with ODP. Scenarios in which LDP does not outperform ODP for cost-effectiveness seem unrealistic, e.g., a 30-day mortality rate of 1.79 times higher after LDP as compared with ODP, conversion in 62.2%, surgically repair of incisional hernias in 21% after LDP, or an average 2.3 days longer hospital stay after LDP than after ODP. Taking all uncertainty into account, LDP remained more cost-effective. Minimizing these uncertainties did not change the outcome. CONCLUSIONS: The results show how decision analytical modeling can help to identify relevant uncertainty and guide decisions for future research in surgery. Based on the current available evidence, a randomized clinical trial on complications, hospital stay, costs, quality of life, and survival is highly unlikely to change the conclusion that LDP is more cost-effective than ODP.

Group medical consultations in the follow-up of breast cancer: a randomized feasibility study.

PURPOSE: Group medical consultations (GMCs) provide individual medical visits conducted within a group of four to eight peer patients. This study evaluated the feasibility and efficacy of GMCs in the follow-up of breast cancer. METHODS: In this randomized controlled trial, 38 patients participated in a single GMC (intervention group), while the control group (n = 31) received individual outpatient visits. Feasibility is measured in terms of acceptability, demand, practicability and costs, integration and implementation, and efficacy. Between-group differences on the efficacy outcomes distress (SCL-90) and empowerment (CEQ), 1 week and 3 months after the visit, were analyzed using ANCOVAs. RESULTS: GMCs scored high on most areas of feasibility. Patients in GMCs and individual visits were equally satisfied. Patients and professionals reported more discussed themes in GMCs, despite no between-group differences on information needs prior to the visit. Sixty-nine percent of GMC patients experienced peer support. Costs for GMCs were higher compared to individual visits. However, involving a clinical nurse specialist (CNS) instead of a medical specialist reduced costs to the level of individual CNS care. Efficacy outcomes (distress and empowerment) were equal in both groups. CONCLUSION: GMCs in this study were feasible. Further optimization of GMCs in future (cost-)effectiveness trials is possible by increasing the frequency of GMCs, stating criteria for the type of professionals, number of patients involved, and time limits. IMPLICATIONS FOR CANCER SURVIVORS: BCS may benefit from GMCs by receiving more information and additional peer support. GMCs cover all aspects of follow-up and may be a good alternative for individual follow-up.