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author:("bean, C.A.")
1.  Integrated care, financing and multimorbidity. How to bridge the gaps? 
In many Western countries, including the Netherlands, disease management programs are increasingly being implemented to enhance quality and continuity of care for patients with chronic conditions. Fragmentary funding of these programs, however, hampered the establishment of long-term programs. In 2007, the Dutch minister of health therefore approved the introduction of a bundled-payment approach to stimulate the implementation of disease management. This was initially on an experimental basis for single-disease programs including programs for diabetes patients. In 2010, the bundled-payment concept was approved for nationwide implementation for diabetes, COPD and vascular risk management.
Under this system, insurers pay a single fee to cover a full range of chronic care services for a fixed period. One of the key questions regarding this bundled payment approach is how to deal with patients with multimorbidity. Participation of these patients in multiple single-disease oriented programs may again lead to fragmented care.
The workshop comprises three presentations. The first presentation will provide an overview of disease management initiatives and evidence for their effects on quality of care and health care costs. During this presentation also payment reforms regarding disease management, among which pay-for-performance and bundled payments, will be discussed.
During the second presentation the basic premises of the Dutch bundled payment model for diabetes care will discussed in-depth. Further, the results of a three-year follow-up study evaluating the experiences with bundled payment will be presented. Data from electronic health records, extensive interviews with stakeholders, and patient questionnaires distributed in a random sample of diabetic patients were used to assess the satisfaction of all stakeholders and the quality of delivered care. The third presentation focuses on care programs for patients with multimorbidity. During this presentation the results of a systematic review on care programs for this target group will be summarized. After the presentations a discussion will be held on how to bridge the gap between multimorbidity and the single-disease management approaches funded by bundled payments.
PMCID: PMC3617736
Integrated care; financing; multimorbidity; bundled payment
2.  The association between chronic care management and the quality of thrombosis care 
The oral anticoagulant therapy (OAT), used to prevent thrombosis, is associated with substantial avoidable hospitalization.
Identify the associations between chronic care management and the quality of OAT as suggested by the chronic care model (CCM) of Wagner.
Regression analysis with data of 61 thrombosis clinics and inductive analysis with 63 interviews with health care professionals of 23 thrombosis clinics.
Results show substantial differences between regions in the quality of thrombosis care and the CCM activities. However, the variation in quality of care was not associated with the differences in CCM activities. The inductive analysis indicates that there are problems in the cooperation between caregivers. Several preferred CCM activities (e.g., multidisciplinary protocol) as well as the barriers to implement these activities (e.g., conflicting interests) were put forward by the health care professionals.
It can be concluded that there is variation in quality of thrombosis care between regions. This variation could not be explained by the observed differences in CCM activities. However, fragmentation is a major source of inefficiency according to health care professionals. The paper concludes with suggestions to improve chronic care management for thrombosis.
PMCID: PMC3031809
quality of care; thrombosis; chronic care management; disease management; effectiveness
3.  Mesenchymal stem cells are short-lived and do not migrate beyond the lungs after intravenous infusion 
Mesenchymal stem cells (MSC) are under investigation as a therapy for a variety of disorders. Although animal models show long term regenerative and immunomodulatory effects of MSC, the fate of MSC after infusion remains to be elucidated. In the present study the localization and viability of MSC was examined by isolation and re-culture of intravenously infused MSC. C57BL/6 MSC (500,000) constitutively expressing DsRed-fluorescent protein and radioactively labeled with Cr-51 were infused via the tail vein in wild-type C57BL/6 mice. After 5 min, 1, 24, or 72 h, mice were sacrificed and blood, lungs, liver, spleen, kidneys, and bone marrow removed. One hour after MSC infusion the majority of Cr-51 was found in the lungs, whereas after 24 h Cr-51 was mainly found in the liver. Tissue cultures demonstrated that viable donor MSC were present in the lungs up to 24 h after infusion, after which they disappeared. No viable MSC were found in the other organs examined at any time. The induction of ischemia-reperfusion injury in the liver did not trigger the migration of viable MSC to the liver. These results demonstrate that MSC are short-lived after i.v. infusion and that viable MSC do not pass the lungs. Cell debris may be transported to the liver. Long term immunomodulatory and regenerative effects of infused MSC must therefore be mediated via other cell types.
PMCID: PMC3458305  PMID: 23056000
mesenchymal stem cell; infusion; localization; survival; lung; liver
4.  Intragraft interleukin 2 mRNA expression during acute cellular rejection and left ventricular total wall thickness after heart transplantation 
Heart  2002;87(4):363-367.
Objective: To assess whether diastolic graft function is influenced by intragraft interleukin 2 (IL-2) messenger RNA (mRNA) expression in rejecting cardiac allografts.
Design: 16 recipients of cardiac allografts were monitored during the first three months after transplantation. The presence of IL-2 mRNA in endomyocardial biopsies (n = 123) was measured by reverse transcriptase polymerase chain reaction. To determine heart function, concurrent M mode and two dimensional Doppler echocardiograms were analysed.
Results: Histological signs of acute rejection (International Society for Heart and Lung Transplantation (ISHLT) rejection grade > 2) were strongly associated with IL-2 mRNA expression (IL-2 mRNA was present in 12 of 20 endomyocardial biopsies (60%) with acute rejection and in 24 of 103 endomyocardial biopsies (23%) without acute rejection, p = 0.002). No significant relation was found between either histology or IL-2 mRNA expression alone and the studied echocardiographic parameters. However, stratification of the echocardiographic data into those of patients with and those without acute rejection showed that during acute rejection IL-2 mRNA expression was significantly associated with increased left ventricular total wall thickness (mean change in total wall thickness was +0.22 cm in patients with IL-2 mRNA expression versus −0.18 cm in patients without IL-2 mRNA expression, p = 0.048).
Conclusions: An increase in left ventricular total wall thickness precedes IL-2 positive acute rejection after heart transplantation. Thus, cardiac allograft rejection accompanied by intragraft IL-2 mRNA expression may be indicative of more severe rejection episodes.
PMCID: PMC1767064  PMID: 11907013
transplantation; echocardiography; acute rejection; interleukin-2

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