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1.  Are patients’ preferences regarding the place of treatment heard and addressed at the point of referral: an exploratory study based on observations of GP-patient consultations 
BMC Family Practice  2013;14:189.
Today, in several north-western European countries, patients are encouraged to choose, actively, a healthcare provider. However, patients often visit the provider that is recommended by their general practitioner (GP). The introduction of patient choice requires GPs to support patients to be involved, actively, in the choice of a healthcare provider. We aim to investigate whether policy on patient choice is reflected in practice, i.e. what the role of the patient is in their choices of healthcare providers at the point of referral and to what extent GPs’ and patients’ healthcare paths influence the role that patients play in the referral decision.
In 2007–2008, we videotaped Dutch GP-patient consultations. For this study, we selected, at random, 72 videotaped consultations between 72 patients and 39 GPs in which the patient was referred to a healthcare provider. These were analysed using an observation protocol developed by the researchers.
The majority of the patients had little or no input into the choice of a healthcare provider at the point of referral by their GP. Their GPs did not support them in actively choosing a provider and the patients often agreed with the provider that the GP proposed. Patients who were referred for diagnostic purposes seem to have had even less input into their choice of a provider than patients who were referred for treatment.
We found that the GP chooses a healthcare provider on behalf of the patient in most consultations, even though policy on patient choice expects from patients that they choose, actively, a provider. On the one hand, this could indicate that the policy needs adjustments. On the other hand, adjustments may be needed to practice. For instance, GPs could help patients to make an active choice of provider. However, certain patients prefer to let their GP decide as their agent. Even then, GPs need to know patients’ preferences, because in a principal-agent relationship, it is necessary that the agent is fully informed about the principal’s preferences.
PMCID: PMC4029442  PMID: 24325155
Choice behaviour; Patient freedom of choice laws; Healthcare providers; Healthcare reform; Communication; General practitioners; Referral; Physicians’ role
2.  Overall scores as an alternative to global ratings in patient experience surveys; a comparison of four methods 
Global ratings of healthcare by patients are a popular way of summarizing patients’ experiences. Summary scores can be used for comparing healthcare provider performance and provider rankings. As an alternative, overall scores from actual patient experiences can be constructed as summary scores. This paper addresses the statistical and practical characteristics of overall scores as an alternative to a global rating in summarizing patient survey results.
Data from a 2010 patient experience survey for approximately 12,000 nursing home residents (7.5% of all Dutch nursing home residents at the time) from 464 nursing homes in the Netherlands (25% of the Dutch nursing homes) was used. Data was collected through specifically designed standardized interview surveys. The respondents’ scores for 15 established quality indicators (or composites) for nursing home care were used to calculate overall scores for each nursing home, using four different strategies. The characteristics of the overall scores were compared against each other and with the respondents’ global rating.
The individual indicators showed stronger associations with each of the four overall strategies than with the global ratings. Furthermore, the dispersion of the overall scores across nursing homes was greater. Differences between overall scores appeared limited.
Overall scores proved more valid than global ratings as a summary of the indicator scores, and also showed more pronounced differences between nursing homes. Because of the limited statistical differences between the strategies, and for practical reasons, a straightforward averaging of quality indicator scores may be preferred as an overall score.
PMCID: PMC3842791  PMID: 24245726
Quality of care; Composite measures; Nursing home; Consumer information
3.  Linking up with the community: a fertile strategy for a university hospital? 
To systematically identify, describe and characterise the collaborative initiatives, which have been established between the Academic Medical Centre/University of Amsterdam and local health care providers in the adjacent community.
The viability of university hospitals is jeopardised. Their narrowed orientation on delivering the most advanced services to the sickest patients challenges their missions in patient care, science and education. By linking up with local health care providers, university hospitals create synergistic relationships that should secure these three academic missions for the future.
We conducted a multiple case study in two stages. Initially, division leaders and the director of integrated care were consulted to identify all existing collaborative initiatives of the Academic Medical Centre. Successively, face-to-face interviews were held with the leaders of these initiatives. During these interviews data were primarily collected through a questionnaire. Notes of the interviewer, and documents (if available) were also collected. The analysis focused on systematically describing and characterising the initiatives using the concept of ‘community-based integrated care’.
Twenty-seven heterogeneous initiatives were identified. Half of these initiatives are targeted to the adjacent community of the Academic Medical Centre, but only four of them are initiated on the basis of community information and involve the community and/or patients. Furthermore, the extent of integration differed per dimension. Functional integration within the initiatives has been relatively low, clinical integration mixed, and professional integration quite advanced.
The results indicate that a considerable number of collaborative initiatives have emerged. Still, these initiatives are loosely ‘community-based’ and hardly focus on the full integration of care services. This suggests that the community linkages of the Academic Medical Centre in Amsterdam could be further developed by gaining the full support of all clinical departments for the strategic approach and by adapting an overall hospital perspective to monitor the progress towards community-based integrated care.
PMCID: PMC1480373  PMID: 16896383
academic medicine; university hospitals; integrated care; community health planning
4.  Health system outcomes and determinants amenable to public health in industrialized countries: a pooled, cross-sectional time series analysis 
BMC Public Health  2005;5:81.
Few studies have tried to assess the combined cross-sectional and temporal contributions of a more comprehensive set of amenable factors to population health outcomes for wealthy countries during the last 30 years of the 20th century. We assessed the overall ecological associations between mortality and factors amenable to public health. These amenable factors included addictive and nutritional lifestyle, air quality, public health spending, healthcare coverage, and immunizations.
We used a pooled cross-sectional, time series analysis with corrected fixed effects regression models in an ecological design involving eighteen member countries of the Organisation for Economic Cooperation and Development during the period 1970 to 1999.
Alcohol, tobacco, and fat consumption, and sometimes, air pollution were significantly associated with higher all-cause mortality and premature death. Immunizations, health care coverage, fruit/vegetable and protein consumption, and collective health expenditure had negative effects on mortality and premature death, even after controlling for the elderly, density of practicing physicians, doctor visits and per capita GDP. However, tobacco, air pollution, and fruit/vegetable intake were sometimes sensitive to adjustments.
Mortality and premature deaths could be improved by focusing on factors that are amenable to public health policies. Tackling these issues should be reflected in the ongoing assessments of health system performance.
PMCID: PMC1185550  PMID: 16076396

Résultats 1-4 (4)