Inciting maintenance: Tiered institutional work during value-based payment reform in oncology.

Value-based payment aims to shift the focus from traditional volume-driven arrangements to a system that rewards providers for the quality and value of care delivered. Previous research has shown that it is difficult for providers to change their medical and organizational practices to adopt value-based payment, but the role of actors in these reforms has remained underexposed. This paper unravels the motives of non-clinical and clinical professionals to maintain institutionalized payment practices when faced with value-based payment. To illuminate these motives, a case study was conducted in a Dutch hospital alliance that aimed to implement value-based payment to incentivize the transition to novel interventions in a prostate cancer care pathway. Data collection consisted of observations and interviews with actors on multiple levels in the hospital (sales departments, medical specialist enterprises (MSEs) and physicians). On each actor level, motives for maintaining currently prevailing institutional practices were present. Regulative maintenance motives were more common for sales managers whereas cultural-cognitive and normative motives seemed to play an important role for physicians. An overarching motive was that desired transitions to novel interventions proved possible under the currently prevailing institutional logic, dismissing an urgent need for payment reform. Our analysis further revealed that actors engage in diverse institutional maintenance work, and that some actor groups' institutional work carries more weight than others because of the dependency relationships that exist between hospitals, MSEs and physicians. Physicians depend on MSEs and sales departments, who act as gatekeepers and buffers, to decide whether the value-based payment reform is either adopted or abandoned.

The potential of patient-based nurse staffing - a queuing theory application in the neonatal intensive care setting.

Faced by a severe shortage of nurses and increasing demand for care, hospitals need to optimally determine their staffing levels. Ideally, nurses should be staffed to those shifts where they generate the highest positive value for the quality of healthcare. This paper develops an approach that identifies the incremental benefit of staffing an additional nurse depending on the patient mix. Based on the reasoning that timely fulfillment of care demand is essential for the healthcare process and its quality in the critical care setting, we propose to measure the incremental benefit of staffing an additional nurse through reductions in time until care arrives (TUCA). We determine TUCA by relying on queuing theory and parametrize the model with real data collected through an observational study. The study indicates that using the TUCA concept and applying queuing theory at the care event level has the potential to improve quality of care for a given nurse capacity by efficiently trading situations of high versus low workload.

Prioritization of surgical patients during the COVID-19 pandemic and beyond: A qualitative exploration of patients' perspectives.

INTRODUCTION: During the COVID-19 pandemic, prioritizing certain surgical patients became inevitable due to limited surgical capacity. This study aims to identify which factors patients value in priority setting, and to evaluate their perspective on a decision model for surgical prioritization. METHODS: We enacted a qualitative exploratory study and conducted semi-structured interviews with N = 15 patients. Vignettes were used as guidance. The interviews were transcribed and iteratively analyzed using thematic analysis. RESULTS: We unraveled three themes: 1) general attitude towards surgical prioritization: patients showed understanding for the difficult decisions to be made, but demanded greater transparency and objectivity; 2) patient-related factors that some participants considered should, or should not, influence the prioritization: age, physical functioning, cognitive functioning, behavior, waiting time, impact on survival and quality of life, emotional consequences, and resource usage; and 3) patients' perspective on a decision model: usage of such a model for prioritization decisions is favorable if the model is simple, uses trustworthy data, and its output is supervised by physicians. The model could also be used as a communication tool to explain prioritization dilemmas to patients. CONCLUSION: Support for the various factors and use of a decision model varied among patients. Therefore, it seems unrealistic to immediately incorporate these factors in decision models. Instead, this study calls for more research to identify feasible avenues and seek consensus.

Physicians' Perspectives Regarding Private Equity Transactions in Outpatient Health Care-A Scoping Review and Qualitative Analysis.

Private equity (PE) investments in health care have increased drastically over the last decade, and the profit interests of these companies have triggered a vivid discussion among medical professions. However, what are the key underlying perceptions among physicians regarding this trend? Unravelling the argumentative structure of this debate is the purpose of this paper. With physicians being a major stakeholder group in the outpatient health care setting, this paper explores physicians' perspectives regarding increasing PE activities. We systematically searched, selected, and synthesized existing knowledge in a scoping review and complemented the findings through 14 semi-structured interviews with physicians working in the outpatient health care sector in Germany. The results outline a complex network of arguments, concerns, and fears whereby the first intuitive perception of physicians is of critical nature. Arguments cluster around central perceptions of how PE involvement affects the individual autonomy of physicians in their daily work and decision-making, the impact on quality of care, work-life balance considerations, PE investment strategies, lack of medical vs. managerial expertise, and taxation issues. The high number of opinion papers among the literature underlines the actuality of the topic and emphasizes the need for empirical research.

Catholic Ownership, Physician Leadership and Operational Strategies: Evidence from German Hospitals.

Previous research has revealed that Catholic hospitals are more likely follow a strategy of horizontal diversification and maximization of the number of patients treated, whereas Protestant hospitals follow a strategy of horizontal specialization and focus on vertical differentiation. However, there is no empirical evidence pertaining to this mechanism. We conduct an empirical study in a German setting and argue that physician leadership mediates the relationship between ownership and operational strategies. The study includes the construction of a model combining data from a survey and publicly available information derived from the annual quality reports of German hospitals. Our results show that Catholic hospitals opt for leadership structures that ensure operational strategies in line with their general values, i.e., operational strategies of maximizing volume throughout the overall hospital. They prefer part-time positions for chief medical officers, as chief medical officers are identified to foster strategies of maximizing the overall number of patients treated. Hospital owners should be aware that the implementation of part-time and full-time leadership roles can help to support their strategies. Thus, our results provide insights into the relationship between leadership structures at the top of an organization, on the one hand, and strategic choices, on the other.

Integrated Payment, Fragmented Realities? A Discourse Analysis of Integrated Payment in the Netherlands.

The current models used for paying for health and social care are considered a major barrier to integrated care. Despite the implementation of integrated payment schemes proving difficult, such initiatives are still widely pursued. In the Netherlands, this development has led to a payment architecture combining traditional and integrated payment models. To gain insight into the justification for and future viability of integrated payment, this paper's purpose is to explain the current duality by identifying discourses on integrated payment models, determining which discourses predominate, and how they have changed over time and differ among key stakeholders in healthcare. The discourse analysis revealed four discourses, each with its own underlying assumptions and values regarding integrated payment. First, the Quality-of-Care discourse sees integrated payment as instrumental in improving care. Second, the Affordability discourse emphasizes how integrated payment can contribute to the financial sustainability of the healthcare system. Third, the Bureaucratization discourse highlights the administrative burden associated with integrated payment models. Fourth, the Strategic discourse stresses micropolitical and professional issues that come into play when implementing such models. The future viability of integrated payment depends on how issues reflected in the Bureaucratization and Strategic discourses are addressed without losing sight of quality-of-care and affordability, two aspects attracting significant public interest in The Netherlands.

The Effect of Network-Level Payment Models on Care Network Performance: A Scoping Review of the Empirical Literature.

Introduction: Traditional payment models reward volume rather than value. Moving away from reimbursing separate providers to network-level reimbursement is assumed to support structural changes in health care organizations that are necessary to improve patient care. This scoping review evaluates the performance of care networks that have adopted network-level payment models. Methods: A scoping review of the empirical literature was conducted according to the five-step York framework. We identified indicators of performance, categorized them in four categories (quality, utilization, spending and other consequences) and scored whether performance increased, decreased, or remained stable due to the payment model. Results: The 76 included studies investigated network-level capitation, disease-based bundled payments, pay-for-performance and blended global payments. The majority of studies stem from the USA. Studies generally concluded that performance in terms of quality and utilization increased or remained stable. Most payment models were associated with improved spending performance. Overall, our review shows that network-level payment models are moderately successful in improving network performance. Discussion/conclusion: As health care networks are increasingly common, it seems fruitful to continue experimenting with reimbursement models for health care networks. It is also important to broaden the scope to not only scrutinize outcomes, but also the contexts and mechanisms that lead to certain outcomes.

Big Data Health Care Innovations: Performance Dashboarding as a Process of Collective Sensemaking.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/16779.

Have Dutch Hospitals Saved Lives and Reduced Costs? A longitudinal patient-level analysis over the years 2013-2017.

The purpose of this paper is to shed light on the ongoing Dutch health system reforms and identify whether hospital costs and hospital outcomes have changed over time. We present an empirical analysis that is based on granular micro-costing data and focuses on conditions for which mortality is indicative of outcome quality, that is, acute myocardial infarction (AMI), chronic heart failure (CHF), and pneumonia (PNE). We deploy a dataset of more than 80,000 inpatient episodes over 5 years (2013-2017) to estimate regression models that control for variation between patients and hospitals. We have three main findings. First, our results do not indicate significant outcome improvements over the years; that is, there is no time trend for mortality. Second, there is heterogeneity in cost developments: for patients who survive their inpatient stay, our data indicate that costs increase significantly by 0.9% per year for AMI patients, while costs decrease significantly by 1.7% per year for CHF patients and by 1.9% per year for PNE patients. For patients who pass away during their inpatient stay, our data do not indicate significant time trends. Third and finally, our results suggest the existence of substantial cost variation between hospitals.

eHealth Applications to Support Independent Living of Older Persons: Scoping Review of Costs and Benefits Identified in Economic Evaluations.

BACKGROUND: eHealth applications are constantly increasing and are frequently considered to constitute a promising strategy for cost containment in health care, particularly if the applications aim to support older persons. Older persons are, however, not the only major eHealth stakeholder. eHealth suppliers, caregivers, funding bodies, and health authorities are also likely to attribute value to eHealth applications, but they can differ in their value attribution because they are affected differently by eHealth costs and benefits. Therefore, any assessment of the value of eHealth applications requires the consideration of multiple stakeholders in a holistic and integrated manner. Such a holistic and reliable value assessment requires a profound understanding of the application's costs and benefits. The first step in measuring costs and benefits is identifying the relevant costs and benefit categories that the eHealth application affects. OBJECTIVE: The aim of this study is to support the conceptual phase of an economic evaluation by providing an overview of the relevant direct and indirect costs and benefits incorporated in economic evaluations so far. METHODS: We conducted a systematic literature search covering papers published until December 2019 by using the Embase, Medline Ovid, Web of Science, and CINAHL EBSCOhost databases. We included papers on eHealth applications with web-based contact possibilities between clients and health care providers (mobile health apps) and applications for self-management, telehomecare, telemedicine, telemonitoring, telerehabilitation, and active healthy aging technologies for older persons. We included studies that focused on any type of economic evaluation, including costs and benefit measures. RESULTS: We identified 55 papers with economic evaluations. These studies considered a range of different types of costs and benefits. Costs pertained to implementation activities and operational activities related to eHealth applications. Benefits (or consequences) could be categorized according to stakeholder groups, that is, older persons, caregivers, and health care providers. These benefits can further be divided into stakeholder-specific outcomes and resource usage. Some cost and benefit types have received more attention than others. For instance, patient outcomes have been predominantly captured via quality-of-life considerations and various types of physical health status indicators. From the perspective of resource usage, a strong emphasis has been placed on home care visits and hospital usage. CONCLUSIONS: Economic evaluations of eHealth applications are gaining momentum, and studies have shown considerable variation regarding the costs and benefits that they include. We contribute to the body of literature by providing a detailed and up-to-date framework of cost and benefit categories that any interested stakeholder can use as a starting point to conduct an economic evaluation in the context of independent living of older persons.

Do different uses of performance measurement systems in hospitals yield different outcomes?

BACKGROUND: Inspired by the new public management movement, many public sector organizations have implemented business-like performance measurement systems (PMSs) in an effort to improve organizational efficiency and effectiveness. However, a large stream of the accounting literature has remained critical of the use of performance measures in the public sector because of the inherent difficulty in measuring output and the potential adverse effects of performance measurement. Although we acknowledge that PMSs may indeed sometimes yield adverse effects, we highlight in this study that the effects of PMSs depend on the way in which they are used. PURPOSE: The aim of this study was to investigate various uses of PMSs among hospital managers and their effects on hospital outcomes, including process quality, degree of patient-oriented care, operational performance, and work culture. METHODOLOGY: We use a survey sent to 432 Dutch hospital managers (19.2% response rate, 83 usable responses). For our main variables, we rely on previously validated constructs where possible, and we conduct ordinary least squares regressions to explore the relation between PMS use and hospital outcomes. RESULTS: We find that the way in which PMSs are used is associated with hospital outcomes. An exploratory use of PMS has a positive association with patient-oriented care and collective work culture. Furthermore, the operational use of PMSs is positively related to operational performance but negatively related to patient-oriented care. There is no single best PMS use that positively affects all performance dimensions. PRACTICE IMPLICATIONS: The way in which managers use PMSs is related to hospital outcomes. Therefore, hospital managers should critically reflect on how they use PMSs and whether their type of use is in line with the desired hospital outcomes.

Understanding the Uptake of Big Data in Health Care: Protocol for a Multinational Mixed-Methods Study.

BACKGROUND: Despite the high potential of big data, their applications in health care face many organizational, social, financial, and regulatory challenges. The societal dimensions of big data are underrepresented in much medical research. Little is known about integrating big data applications in the corporate routines of hospitals and other care providers. Equally little is understood about embedding big data applications in daily work practices and how they lead to actual improvements for health care actors, such as patients, care professionals, care providers, information technology companies, payers, and the society. OBJECTIVE: This planned study aims to provide an integrated analysis of big data applications, focusing on the interrelations among concrete big data experiments, organizational routines, and relevant systemic and societal dimensions. To understand the similarities and differences between interactions in various contexts, the study covers 12 big data pilot projects in eight European countries, each with its own health care system. Workshops will be held with stakeholders to discuss the findings, our recommendations, and the implementation. Dissemination is supported by visual representations developed to share the knowledge gained. METHODS: This study will utilize a mixed-methods approach that combines performance measurements, interviews, document analysis, and cocreation workshops. Analysis will be structured around the following four key dimensions: performance, embedding, legitimation, and value creation. Data and their interrelations across the dimensions will be synthesized per application and per country. RESULTS: The study was funded in August 2017. Data collection started in April 2018 and will continue until September 2021. The multidisciplinary focus of this study enables us to combine insights from several social sciences (health policy analysis, business administration, innovation studies, organization studies, ethics, and health services research) to advance a holistic understanding of big data value realization. The multinational character enables comparative analysis across the following eight European countries: Austria, France, Germany, Ireland, the Netherlands, Spain, Sweden, and the United Kingdom. Given that national and organizational contexts change over time, it will not be possible to isolate the factors and actors that explain the implementation of big data applications. The visual representations developed for dissemination purposes will help to reduce complexity and clarify the relations between the various dimensions. CONCLUSIONS: This study will develop an integrated approach to big data applications that considers the interrelations among concrete big data experiments, organizational routines, and relevant systemic and societal dimensions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/16779.

Observational study shows that nurses spend more time caring for mechanically ventilated preterm infants than those receiving noninvasive ventilation.

AIM: This study analysed how nursing workloads in a neonatal intensive care unit (NICU) depended on the type of respiratory support provided, and how this relationship varied by the infant's postnatal age and weight. METHODS: We used a prospective study design in a NICU in a tertiary perinatal centre in Germany. This entailed collecting data on nursing activities by observing 41 nurses for 155 hours between June 2015 and November 2015 and measuring the average nursing capacity required for direct care. Regression analysis was used to test for differences in nursing workloads between respiratory support types. RESULTS: Mechanically ventilated infants each required an average of 60% of the time one nurse had available to spend on direct care during the periods observed. In contrast, those receiving noninvasive ventilation only required 34% and special care infants required 13%. After the first 72 hours of life, mechanically ventilated infants required an average nursing capacity of 40%, while infants receiving noninvasive ventilation required 32% and special care infants required 25%. CONCLUSION: Invasive support was associated with higher workloads than noninvasive support. The differences were partially moderated by individual factors, such as the infant's age. The findings should be replicated within a multicentre design.

What drives perceived work intensity in neonatal intensive care units? Empirical evidence from a longitudinal study.

AIM: To investigate the drivers of perceived work intensity among neonatal intensive care unit nurses. BACKGROUND: The consequences of high work intensity have been studied extensively, yet setting-specific drivers have received less attention. DESIGN: Prospective, longitudinal and monocentric study design. METHODS: The study combined data from standardized diary surveys and passive observations of study nurses. Data were collected over a period of 6 months in 2015. We considered two scenarios: (1) the perception of normal work intensity relative to non-normal work intensity; and (2) the perception of high work intensity relative to non-high work intensity. Perceived work intensity was then analysed using mixed-effects probit regression models. RESULTS: We found that when direct and indirect care were provided more frequently than administrative and other duties were performed, the evaluated nurses perceived their work intensity to be higher. We also found that nurses who more frequently provided care for sick and preterm infants were less likely to perceive their work intensity as normal and this effect was stronger among nurses who cared for infants under mechanical ventilation than nurses who cared for infants receiving non-invasive respiratory support. CONCLUSION: In the interest of both nurses and infants and the pursuit of a reduction in perceived work intensity and the provision of better neonatal care, caution must be applied when assigning infants to nurses. Further research is needed to validate these findings using a multicentre study design.

Antiseptic barrier cap effective in reducing central line-associated bloodstream infections: A systematic review and meta-analysis.

BACKGROUND: Microorganisms can intraluminally access a central venous catheter via the catheter hub. The catheter hub should be appropriately disinfected to prevent central line-associated bloodstream infections (CLABSIs). However, compliance with the time-consuming manual disinfection process is low. An alternative is the use of an antiseptic barrier cap, which cleans the catheter hub by continuous passive disinfection. OBJECTIVE: To compare the effects of antiseptic barrier cap use and manual disinfection on the incidence of CLABSIs. DESIGN: Systematic review and meta-analysis. METHODS: We systematically searched Embase, Medline Ovid, Web-of-science, CINAHL EBSCO, Cochrane Library, PubMed Publisher and Google Scholar until May 10, 2016. The primary outcome, reduction in CLABSIs per 1000 catheter-days, expressed as an incidence rate ratio (IRR), was analyzed with a random effects meta-analysis. Studies were included if 1) conducted in a hospital setting, 2) used antiseptic barrier caps on hubs of central lines with access to the bloodstream and 3) reported the number of CLABSIs per 1000 catheter-days when using the barrier cap and when using manual disinfection. RESULTS: A total of 1537 articles were identified as potentially relevant and after exclusion of duplicates, 953 articles were screened based on title and abstract; 18 articles were read full text. Eventually, nine studies were included in the systematic review, and seven of these nine in the random effects meta-analysis. The pooled IRR showed that use of the antiseptic barrier cap was effective in reducing CLABSIs (IRR=0.59, 95% CI=0.45-0.77, P<0.001). CONCLUSIONS: Use of an antiseptic barrier cap is associated with a lower incidence CLABSIs and is an intervention worth adding to central-line maintenance bundles.

Treatment speed and high load in the Emergency Department-does staff quality matter?

Research in the field of operations management and medicine analyzed how workload affects productivity and patient outcomes. However, staff quality has largely been neglected, and if staffing information has indeed been included, then it takes the form of quantitative measures like staff-to-patient ratios. We therefore seek to analyze how education and experience are directly associated with effort. How do responses to workload differ with respect to education and experience? By analyzing a single hospital unit, we are able to establish a link between staff quality and patient outcomes, allowing us to demonstrate empirically that knowledge and experience are highly relevant in staff members' responses to increasing system load. The systematic aligning of staffing with expected system load should therefore consider not only staffing quantity but also staffing quality. Provided with a reliable prediction of system load, this knowledge would allow managers to generate savings since they can assign high-quality staff more effectively.

Modeling and notation of DEA with strong and weak disposable outputs.

Recent articles published in Health Care Management Science have described DEA applications under the assumption of strong and weak disposable outputs. As we confidently assume that these papers include some methodical deficiencies, we aim to illustrate a revised approach.