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1.  Is the Readmission Rate a Valid Quality Indicator? A Review of the Evidence 
PLoS ONE  2014;9(11):e112282.
Hospital readmission rates are increasingly used for both quality improvement and cost control. However, the validity of readmission rates as a measure of quality of hospital care is not evident. We aimed to give an overview of the different methodological aspects in the definition and measurement of readmission rates that need to be considered when interpreting readmission rates as a reflection of quality of care.
We conducted a systematic literature review, using the bibliographic databases Embase, Medline OvidSP, Web-of-Science, Cochrane central and PubMed for the period of January 2001 to May 2013.
The search resulted in 102 included papers. We found that definition of the context in which readmissions are used as a quality indicator is crucial. This context includes the patient group and the specific aspects of care of which the quality is aimed to be assessed. Methodological flaws like unreliable data and insufficient case-mix correction may confound the comparison of readmission rates between hospitals. Another problem occurs when the basic distinction between planned and unplanned readmissions cannot be made. Finally, the multi-faceted nature of quality of care and the correlation between readmissions and other outcomes limit the indicator's validity.
Although readmission rates are a promising quality indicator, several methodological concerns identified in this study need to be addressed, especially when the indicator is intended for accountability or pay for performance. We recommend investing resources in accurate data registration, improved indicator description, and bundling outcome measures to provide a more complete picture of hospital care.
PMCID: PMC4224424  PMID: 25379675
2.  The strength of primary care in Europe: an international comparative study 
The British Journal of General Practice  2013;63(616):e742-e750.
A suitable definition of primary care to capture the variety of prevailing international organisation and service-delivery models is lacking.
Evaluation of strength of primary care in Europe.
Design and setting
International comparative cross-sectional study performed in 2009–2010, involving 27 EU member states, plus Iceland, Norway, Switzerland, and Turkey.
Outcome measures covered three dimensions of primary care structure: primary care governance, economic conditions of primary care, and primary care workforce development; and four dimensions of primary care service-delivery process: accessibility, comprehensiveness, continuity, and coordination of primary care. The primary care dimensions were operationalised by a total of 77 indicators for which data were collected in 31 countries. Data sources included national and international literature, governmental publications, statistical databases, and experts’ consultations.
Countries with relatively strong primary care are Belgium, Denmark, Estonia, Finland, Lithuania, the Netherlands, Portugal, Slovenia, Spain, and the UK. Countries either have many primary care policies and regulations in place, combined with good financial coverage and resources, and adequate primary care workforce conditions, or have consistently only few of these primary care structures in place. There is no correlation between the access, continuity, coordination, and comprehensiveness of primary care of countries.
Variation is shown in the strength of primary care across Europe, indicating a discrepancy in the responsibility given to primary care in national and international policy initiatives and the needed investments in primary care to solve, for example, future shortages of workforce. Countries are consistent in their primary care focus on all important structure dimensions. Countries need to improve their primary care information infrastructure to facilitate primary care performance management.
PMCID: PMC3809427  PMID: 24267857
benchmarking, Europe; delivery of health care; general practice; primary health care
3.  Development and impact of the Iranian hospital performance measurement program 
Iran developed a national hospital performance measurement program (HPMP) which has been implemented annually throughout its hospitals since 1997. However, little is known yet about its development and the impact of the program on hospital performance.
This study aims to describe the development and process of implementation of the HPMP, and to explore the impact on hospital performance by looking at the trends of performance scores of all different types of Iranian hospitals.
This was a mixed method study consisting of longitudinal data and qualitative document analysis. Hospital performance data over the period of 2002 to 2008 was analysed.
Iran instituted a comprehensive HPMP and implemented it in all hospitals since 1997. The program followed a phased development to stimulate performance and quality improvement in hospitals. Overall, the program has had a positive impact on the performance of general and specialized hospitals. The performance of general hospitals did not appear to be associated with their size or affiliated university ranking. However, the rate of performance improvement of general teaching and private hospitals was significantly lower than the average improvement rate of all general hospitals. There was no relationship between teaching status of the specialized hospitals and their level of performance. However, the performance of the governmental specialized hospitals showed a substantial decline over time. Moreover, among specialized hospitals, the bigger sized and those affiliated with higher ranked universities, reported better performance.
Overall, the development and implementation of an obligatory HPMP in Iran has improved the level of performance in general and specialized hospitals. However, there is room for further performance improvement especially in the general teaching, private, and governmental specialized hospitals. Reconsidering the ownership type, funding mechanisms and responsibility for the HPMP may have an impact on the absolute level of performance and improvement capacity of hospitals. In addition, the role and composition of survey teams, mechanism of implementation according to the characteristics of hospitals, and updating standards are important factors to promote performance improvement and hospital accreditation requirements.
PMCID: PMC4263047  PMID: 25269656
Hospital performance; Performance measurement; Accreditation; External evaluation; Quality assurance; Quality improvement; Iran
4.  Implementation of Patient Safety and Patient-Centeredness Strategies in Iranian Hospitals 
PLoS ONE  2014;9(9):e108831.
To examine the extent of implementation for patient safety (PS) and patient-centeredness (PC) strategies and their association with hospital characteristics (type, ownership, teaching status, annual evaluation grade) in Iran.
A cross-sectional study through an adapted version of the MARQuIS questionnaire, eliciting information from hospital and nursing managers in 84 Iranian hospitals on the implementation of PS and PC strategies in 2009–2010.
The majority of hospitals reported to have implemented 84% of the PS and 72% of the PC strategies. In general, implementation of PS strategies was unrelated to the type of hospital, with the exception of health promotion reports, which were more common in the Social Security Organization (SSO), and MRSA testing, which was reported more often in nonprofit hospitals. MRSA testing was also more common among teaching hospitals compared to non-teaching hospitals. The higher grade hospitals reported PS strategies significantly more frequently than lower grade hospitals. Overall, there was no significant difference in the reported implementation of PC strategies across general and specialized hospitals; except for the provision of information in different languages and recording of patient’s diet which were reported significantly more often by general than specialized hospitals. Moreover, patient hotel services were more common in private compared to public hospitals.
Despite substantial reporting of PS and PC strategies, there is still room for strengthening standard setting on safety, patient services and patient-centered information strategies in Iranian hospitals. To assure effective implementation of PS and PC strategies, enforcing standards, creating a PS and PC culture, increasing organizational responsiveness, and partnering with patients and their families need more attention.
PMCID: PMC4182570  PMID: 25268797
5.  Using Quality Measures for Quality Improvement: The Perspective of Hospital Staff 
PLoS ONE  2014;9(1):e86014.
Research objective
This study examines the perspectives of a range of key hospital staff on the use, importance, scientific background, availability of data, feasibility of data collection, cost benefit aspects and availability of professional personnel for measurement of quality indicators among Iranian hospitals. The study aims to facilitate the use of quality indicators to improve quality of care in hospitals.
Study design
A cross-sectional study was conducted over the period 2009 to 2010. Staff at Iranian hospitals completed a self-administered questionnaire eliciting their views on organizational, clinical process, and outcome (clinical effectiveness, patient safety and patient centeredness) indicators.
Population studied
93 hospital frontline staff including hospital/nursing managers, medical doctors, nurses, and quality improvement/medical records officers in 48 general and specialized hospitals in Iran.
Principal findings
On average, only 69% of respondents reported using quality indicators in practice at their affiliated hospitals. Respondents varied significantly in their reported use of organizational, clinical process and outcome quality indicators. Overall, clinical process and effectiveness indicators were reported to be least used. The reported use of indicators corresponded with their perceived level of importance. Quality indicators were reported to be used among clinical staff significantly more than among managerial staff. In total, 74% of the respondents reported to use obligatory indicators, while this was 68% for voluntary indicators (p<0.05).
There is a general awareness of the importance and usability of quality indicators among hospital staff in Iran, but their use is currently mostly directed towards external accountability purposes. To increase the formative use of quality indicators, creation of a common culture and feeling of shared ownership, alongside an increased uptake of clinical process and effectiveness indicators is needed to support internal quality improvement processes at hospital level.
PMCID: PMC3900447  PMID: 24465842
6.  The Dutch health care performance report: seven years of health care performance assessment in the Netherlands 
In 2006, the first edition of a monitoring tool for the performance of the Dutch health care system was released: the Dutch Health Care Performance Report (DHCPR). The Netherlands was among the first countries in the world developing such a comprehensive tool for reporting performance on quality, access, and affordability of health care. The tool contains 125 performance indicators; the choice for specific indicators resulted from a dialogue between researchers and policy makers. In the ‘policy cycle’, the DHCPR can rationally be placed between evaluation (accountability) and agenda-setting (for strategic decision making). In this paper, we reflect on important lessons learned after seven years of health care system performance assessment. These lessons entail the importance of a good conceptual framework for health system performance assessment, the importance of repeated measurement, the strength of combining multiple perspectives (e.g., patient, professional, objective, subjective) on the same issue, the importance of a central role for the patients’ perspective in performance assessment, how to deal with the absence of data in relevant domains, the value of international benchmarking and the continuous exchange between researchers and policy makers.
PMCID: PMC3896735  PMID: 24405849
Health care; Health system performance assessment; Performance indicators
7.  International developments in revenues and incomes of general practitioners from 2000 to 2010 
The remuneration system of General Practitioners (GPs) has changed in several countries in the past decade. The aim of our study was: to establish the effect of these changes on the revenues and income of GPs in the first decade of the 21st century.
Annual GP revenue and practice costs were collected from national institutes in the eight countries included in our study (Belgium, Denmark, Finland, France, Germany, The Netherlands, Sweden, The United Kingdom (UK)) from 2000–2010. The data were corrected for inflation and purchasing power. Data on the remuneration systems and changes herein were collected from the European Observatory Health Systems Reviews and country experts.
Comprehensive changes in the remuneration system of GPs were associated with considerable changes in GP income. Incremental changes mainly coincided with a gradual increase in income after correction for inflation. Average GP income was higher in countries with a strong primary care structure.
The gap between the countries where GPs have a lower income (Belgium, Sweden, France and Finland) and the countries where GPs have a higher income (Netherlands, Germany and the UK) continues to exist over time and appeared to be related to dimensions of primary care, such as governance and access. New payment forms, such as integrated care payment systems, and new health care professionals that are working for GPs, increasingly blur the line between practice costs and income, making it more and more important to clearly define expenditures on GPs, to remain sight on the actual income of GPs.
PMCID: PMC4015771  PMID: 24152337
General practice; Income; International comparative research
8.  QUALICOPC, a multi-country study evaluating quality, costs and equity in primary care 
BMC Family Practice  2011;12:115.
The QUALICOPC (Quality and Costs of Primary Care in Europe) study aims to evaluate the performance of primary care systems in Europe in terms of quality, equity and costs. The study will provide an answer to the question what strong primary care systems entail and which effects primary care systems have on the performance of health care systems. QUALICOPC is funded by the European Commission under the "Seventh Framework Programme". In this article the background and design of the QUALICOPC study is described.
QUALICOPC started in 2010 and will run until 2013. Data will be collected in 31 European countries (27 EU countries, Iceland, Norway, Switzerland and Turkey) and in Australia, Israel and New Zealand. This study uses a three level approach of data collection: the system, practice and patient. Surveys will be held among general practitioners (GPs) and their patients, providing evidence at the process and outcome level of primary care. These surveys aim to gain insight in the professional behaviour of GPs and the expectations and actions of their patients. An important aspect of this study is that each patient's questionnaire can be linked to their own GP's questionnaire. To gather data at the structure or national level, the study will use existing data sources such as the System of Health Accounts and the Primary Health Care Activity Monitor Europe (PHAMEU) database. Analyses of the data will be performed using multilevel models.
By its design, in which different data sources are combined for comprehensive analyses, QUALICOPC will advance the state of the art in primary care research and contribute to the discussion on the merit of strengthening primary care systems and to evidence based health policy development.
PMCID: PMC3206822  PMID: 22014310
9.  Home care in Europe: a systematic literature review 
Health and social services provided at home are becoming increasingly important. Hence, there is a need for information on home care in Europe. The objective of this literature review was to respond to this need by systematically describing what has been reported on home care in Europe in the scientific literature over the past decade.
A systematic literature search was performed for papers on home care published in English, using the following data bases: Cinahl, the Cochrane Library, Embase, Medline, PsycINFO, Sociological Abstracts, Social Services Abstracts, and Social Care Online. Studies were only included if they complied with the definition of home care, were published between January 1998 and October 2009, and dealt with at least one of the 31 specified countries. Clinical interventions, instrument developments, local projects and reviews were excluded. The data extracted included: the characteristics of the study and aspects of home care 'policy & regulation', 'financing', 'organisation & service delivery', and 'clients & informal carers'.
Seventy-four out of 5,133 potentially relevant studies met the inclusion criteria, providing information on 18 countries. Many focused on the characteristics of home care recipients and on the organisation of home care. Geographical inequalities, market forces, quality and integration of services were also among the issues frequently discussed.
Home care systems appeared to differ both between and within countries. The papers included, however, provided only a limited picture of home care. Many studies only focused on one aspect of the home care system and international comparative studies were rare. Furthermore, little information emerged on home care financing and on home care in general in Eastern Europe. This review clearly shows the need for more scientific publications on home care, especially studies comparing countries. A comprehensive and more complete insight into the state of home care in Europe requires the gathering of information using a uniform framework and methodology.
PMCID: PMC3170599  PMID: 21878111
home care; European Union; care systems; international comparison
10.  A snapshot of the organization and provision of primary care in Turkey 
This WHO study aimed to support Turkey in its efforts to strengthen the primary care (PC) system by implementing the WHO Primary Care Evaluation Tool (PCET). This article provides an overview of the organization and provision of primary care in Turkey.
The WHO Primary Care Evaluation Tool was implemented in two provinces (Bolu and Eskişehir) in Turkey in 2007/08. The Tool consists of three parts: a national questionnaire concerning the organisation and financing of primary care; a questionnaire for family doctors; and a questionnaire for patients who visit a family health centre.
Primary care has just recently become an official health policy priority with the introduction of a family medicine scheme. Although the supply of family doctors (FDs) has improved, they are geographically uneven distributed, and nationwide shortages of primary care staff remain. Coordination of care could be improved and quality control mechanisms were lacking. However, patients were very satisfied with the treatment by FDs.
The study provides an overview of the current state of PC in Turkey for two provinces with newly introduced family medicine, by using a structured approach to evaluate the essential functions of PC, including governance, financing, resource generation, as well as the characteristics of a "good" service delivery system (as being accessible, comprehensive, coordinated and continuous).
PMCID: PMC3095534  PMID: 21542904
11.  The european primary care monitor: structure, process and outcome indicators 
BMC Family Practice  2010;11:81.
Scientific research has provided evidence on benefits of well developed primary care systems. The relevance of some of this research for the European situation is limited.
There is currently a lack of up to date comprehensive and comparable information on variation in development of primary care, and a lack of knowledge of structures and strategies conducive to strengthening primary care in Europe. The EC funded project Primary Health Care Activity Monitor for Europe (PHAMEU) aims to fill this gap by developing a Primary Care Monitoring System (PC Monitor) for application in 31 European countries. This article describes the development of the indicators of the PC Monitor, which will make it possible to create an alternative model for holistic analyses of primary care.
A systematic review of the primary care literature published between 2003 and July 2008 was carried out. This resulted in an overview of: (1) the dimensions of primary care and their relevance to outcomes at (primary) health system level; (2) essential features per dimension; (3) applied indicators to measure the features of primary care dimensions. The indicators were evaluated by the project team against criteria of relevance, precision, flexibility, and discriminating power. The resulting indicator set was evaluated on its suitability for Europe-wide comparison of primary care systems by a panel of primary care experts from various European countries (representing a variety of primary care systems).
The developed PC Monitor approaches primary care in Europe as a multidimensional concept. It describes the key dimensions of primary care systems at three levels: structure, process, and outcome level. On structure level, it includes indicators for governance, economic conditions, and workforce development. On process level, indicators describe access, comprehensiveness, continuity, and coordination of primary care services. On outcome level, indicators reflect the quality, and efficiency of primary care.
A standardized instrument for describing and comparing primary care systems has been developed based on scientific evidence and consensus among an international panel of experts, which will be tested to all configurations of primary care in Europe, intended for producing comparable information. Widespread use of the instrument has the potential to improve the understanding of primary care delivery in different national contexts and thus to create opportunities for better decision making.
PMCID: PMC2975652  PMID: 20979612
12.  The breadth of primary care: a systematic literature review of its core dimensions 
Even though there is general agreement that primary care is the linchpin of effective health care delivery, to date no efforts have been made to systematically review the scientific evidence supporting this supposition. The aim of this study was to examine the breadth of primary care by identifying its core dimensions and to assess the evidence for their interrelations and their relevance to outcomes at (primary) health system level.
A systematic review of the primary care literature was carried out, restricted to English language journals reporting original research or systematic reviews. Studies published between 2003 and July 2008 were searched in MEDLINE, Embase, Cochrane Library, CINAHL, King's Fund Database, IDEAS Database, and EconLit.
Eighty-five studies were identified. This review was able to provide insight in the complexity of primary care as a multidimensional system, by identifying ten core dimensions that constitute a primary care system. The structure of a primary care system consists of three dimensions: 1. governance; 2. economic conditions; and 3. workforce development. The primary care process is determined by four dimensions: 4. access; 5. continuity of care; 6. coordination of care; and 7. comprehensiveness of care. The outcome of a primary care system includes three dimensions: 8. quality of care; 9. efficiency care; and 10. equity in health. There is a considerable evidence base showing that primary care contributes through its dimensions to overall health system performance and health.
A primary care system can be defined and approached as a multidimensional system contributing to overall health system performance and health.
PMCID: PMC2848652  PMID: 20226084

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