Background: Generally, a significant portion of healthcare spending consists of out-of-pocket (OOP) expenses. Patients indicate that, in practice, there are often some OOP expenses, incurred when they receive medical care, which are unexpected for them and should have been taken into account when deciding on a course of action. Patients are often reliant on their GP and may, therefore, expect their GP to provide them with information about the costs of treatment options, taking into consideration their individual insurance plan. This also applies to the Netherlands, where OOP expenses increased rapidly over the years. In the current study, we observed the degree to which matters around patients' insurance and OOP expenses are discussed in the Netherlands, using video recordings of consultations between patients and GPs. Methods: Video recordings were collected from patient-GP consultations in 2015-2016. In 2015, 20 GPs and 392 patients from the eastern part of the Netherlands participated. In 2016, another eight GPs and 102 patients participated, spread throughout the Netherlands. The consultations were coded by three observers using an observation protocol. We achieved an almost perfect inter-rater agreement (Kappa = .82). Results: In total, 475 consultations were analysed. In 9.5% of all the consultations, issues concerning patients' health insurance and OOP expenses were discussed. The reimbursement of the cost of medication was discussed most often and patients' current insurance and co-payments least often. In some consultations, the GP brought up the subject, while in others, the patient initiated the discussion. Conclusions: While GPs may often be in the position to provide patients with information about treatment alternatives, few patients discuss the financial effects of their referral or prescription with their GP. This result complies with existing literature. Policy makers, GPs and insurers should think about how GPs and patients can be facilitated when considering the OOP expenses of treatment. There are several factors why this study, analysing video recordings of routine GP consultations in the Netherlands, is particularly relevant: Dutch GPs play a gatekeeper function; OOP expenses have increased relatively swiftly; and patients have both the right to decide on their treatment, and to choose a provider.
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In most countries, maternal and newborn care is fragmented and focused on identification and treatment of pathology that affects only the minority of women and babies. Recently, a framework for quality maternal and newborn care was developed, which encourages a system-level shift to provide skilled care for all.This care includes preventive and supportive care that works to strengthen women’s capabilities and focuses on promotion of normal reproductive processes while ensuring access to emergency treatment when needed. Midwifery care is pivotal in this framework, which contains several elements that resonate with the main dimensions of primary care. Primary health care is the first level of contact with the health system where most of the population’s curative and preventive health needs can be fulfilled as close as possible to where people live and work. In this paper, we argue that midwifery as described in the framework requires the application of a primary care philosophy for all childbearing women and infants. Evaluation of the implementation of the framework should therefore include tools to monitor the performance of primary midwifery care.
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Kinderen met een lage sociaaleconomische status (SES) hebben een verhoogd risico op een suboptimale start in het leven met hogere kosten voor de gezondheidszorg. Deze studie onderzoekt de effecten van SES op individueel (maandelijks huishoudinkomen) en contextuele SES (huishoudinkomen en buurtdeprivatie), en perinatale morbiditeit op de zorgkosten in het vroege leven (0-3 jaar). Conclusie: Meer buurtdeprivatie was direct gerelateerd aan hogere zorgkosten bij jonge kinderen. Bovendien was een lager huishoudinkomen consistent en onafhankelijk gerelateerd aan hogere zorgkosten. Door de omstandigheden voor lage SES-populaties te optimaliseren, kan de impact van lage SES-omstandigheden op hun zorgkosten positief worden beïnvloed.
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Introduction: Hip and knee osteoarthritis are associated with functional limitations, pain and restrictions in quality of life and the ability to work. Furthermore, with growing prevalence, osteoarthritis is increasingly causing (in)direct costs. Guidelines recommend exercise therapy and education as primary treatment strategies. Available options for treatment based on physical activity promotion and lifestyle change are often insufficiently provided and used. In addition, the quality of current exercise programmes often does not meet the changing care needs of older people with comorbidities and exercise adherence is a challenge beyond personal physiotherapy. The main objective of this study is to investigate the short- and long-term (cost-)effectiveness of the SmArt-E programme in people with hip and/or knee osteoarthritis in terms of pain and physical functioning compared to usual care. Methods: This study is designed as a multicentre randomized controlled trial with a target sample size of 330 patients. The intervention is based on the e-Exercise intervention from the Netherlands, consists of a training and education programme and is conducted as a blended care intervention over 12 months. We use an app to support independent training and the development of self-management skills. The primary and secondary hypotheses are that participants in the SmArt-E intervention will have less pain (numerical rating scale) and better physical functioning (Hip Disability and Osteoarthritis Outcome Score, Knee Injury and Osteoarthritis Outcome Score) compared to participants in the usual care group after 12 and 3 months. Other secondary outcomes are based on domains of the Osteoarthritis Research Society International (OARSI). The study will be accompanied by a process evaluation. Discussion: After a positive evaluation, SmArt-E can be offered in usual care, flexibly addressing different care situations. The desired sustainability and the support of the participants' behavioural change are initiated via the app through audio-visual contact with their physiotherapists. Furthermore, the app supports the repetition and consolidation of learned training and educational content. For people with osteoarthritis, the new form of care with proven effectiveness can lead to a reduction in underuse and misuse of care as well as contribute to a reduction in (in)direct costs.
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This paper explores whether constitutional litigation contributes to sustaining the equity element of the right to health. Equity entails a fair distribution of the burden of healthcare financing across the different socio-economic groups of the population. A shift towards uncontrolled private healthcare provision and financing raises equity challenges by disproportionately benefitting those who are able to afford such services. The extent to which equity is enforced is an indicator of the strength of the right to health. However, do domestic constitutional courts second-guess, based on equity, policy decisions that impact on healthcare financing? Is it the task of constitutional courts to scrutinize such policy decisions? Under what conditions are courts more likely to do so? The paper addresses these questions by focusing on the case of Hungary, where the right to health has been present in the Fundamental Law adopted in 2010 and the Constitutions preceding it. While the Hungarian Constitutional Court has been traditionally cautious to review policy decisions pertaining to healthcare financing, the system has been struggling with equity issues and successive government coalitions have had limited success in tackling these. The paper discusses the role of constitutional litigation in addressing such equity concerns. In doing so, it contributes to the discussion on the role of domestic constitutional courts in the protection of social and economic rights.
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Background A high sedentary time is associated with increased mortality risk. Previous studies indicate that replacement of sedentary time with light- and moderate-to-vigorous physical activity attenuates the risk for adverse outcomes and improves cardiovascular risk factors. Patients with cardiovascular disease are more sedentary compared to the general population, while daily time spent sedentary remains high following contemporary cardiac rehabilitation programmes. This clinical trial investigated the effectiveness of a sedentary behaviour intervention as a personalised secondary prevention strategy (SIT LESS) on changes in sedentary time among patients with coronary artery disease participating in cardiac rehabilitation. Methods Patients were randomised to usual care (n = 104) or SIT LESS (n = 108). Both groups received a comprehensive 12-week centre-based cardiac rehabilitation programme with face-to-face consultations and supervised exercise sessions, whereas SIT LESS participants additionally received a 12-week, nurse-delivered, hybrid behaviour change intervention in combination with a pocket-worn activity tracker connected to a smartphone application to continuously monitor sedentary time. Primary outcome was the change in device-based sedentary time between pre- to post-rehabilitation. Changes in sedentary time characteristics (prevalence of prolonged sedentary bouts and proportion of patients with sedentary time ≥ 9.5 h/day); time spent in light-intensity and moderate-to-vigorous physical activity; step count; quality of life; competencies for self-management; and cardiovascular risk score were assessed as secondary outcomes. Results Patients (77% male) were 63 ± 10 years and primarily diagnosed with myocardial infarction (78%). Sedentary time decreased in SIT LESS (− 1.6 [− 2.1 to − 1.1] hours/day) and controls (− 1.2 [ ─1.7 to − 0.8]), but between group differences did not reach statistical significance (─0.4 [─1.0 to 0.3]) hours/day). The post-rehabilitation proportion of patients with a sedentary time above the upper limit of normal (≥ 9.5 h/day) was significantly lower in SIT LESS versus controls (48% versus 72%, baseline-adjusted odds-ratio 0.4 (0.2–0.8)). No differences were observed in the other predefined secondary outcomes. Conclusions Among patients with coronary artery disease participating in cardiac rehabilitation, SIT LESS did not induce significantly greater reductions in sedentary time compared to controls, but delivery was feasible and a reduced odds of a sedentary time ≥ 9.5 h/day was observed.
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Aim: The aim of this study was to describe the experience with commercially available activity trackers embedded in the physiotherapy treatment of patients with a chronic disease. Methods: In a qualitative study, 29 participants with a chronic disease participated. They wore an activity tracker for two to eight weeks. Data were collected using 23 interviews and discussion with 6 participants. A framework analysis was used to analyze the data. Results: The framework analysis resulted in seven categories: purchase, instruction, characteristics, correct functioning, sharing data, privacy, use, and interest in feedback. The standard goal of the activity trackers was experienced as too high, however the tracker still motivated them to be more active. Participants would have liked more guidance from their physiotherapists because they experienced the trackers as complex. Participants experienced some technical failures, are willing to share data with their physiotherapist and, want to spend a maximum of €50,-. Conclusion: The developed framework gives insight into all important concepts from the experiences reported by patients with a chronic disease and can be used to guide further research and practice. Patients with a chronic disease were positive regarding activity trackers in general. When embedded in physiotherapy, more attention should be paid to the integration in treatment.
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Aim: The aim of this study was to describe the experience with commercially available activity trackers embedded in the physiotherapy treatment of patients with a chronic disease. Methods: In a qualitative study, 29 participants with a chronic disease participated. They wore an activity tracker for two to eight weeks. Data were collected using 23 interviews and discussion with 6 participants. A framework analysis was used to analyze the data. Results: The framework analysis resulted in seven categories: purchase, instruction, characteristics, correct functioning, sharing data, privacy, use, and interest in feedback. The standard goal of the activity trackers was experienced as too high, however the tracker still motivated them to be more active. Participants would have liked more guidance from their physiotherapists because they experienced the trackers as complex. Participants experienced some technical failures, are willing to share data with their physiotherapist and, want to spend a maximum of e50,-. Conclusion: The developed framework gives insight into all important concepts from the experiences reported by patients with a chronic disease and can be used to guide further research and practice. Patients with a chronic disease were positive regarding activity trackers in general. When embedded in physiotherapy, more attention should be paid to the integration in treatment.
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A loss of physical functioning (i.e., a low physical capacity and/or a low physical activity) is a common feature in patients with chronic obstructive pulmonary disease (COPD). To date, the primary care physiotherapy and specialized pulmonary rehabilitation are clearly underused, and limited to patients with a moderate to very severe degree of airflow limitation (GOLD stage 2 or higher). However, improved referral rates are a necessity to lower the burden for patients with COPD and for society. Therefore, a multidisciplinary group of healthcare professionals and scientists proposes a new model for referral of patients with COPD to the right type of exercise-based care, irrespective of the degree of airflow limitation. Indeed, disease instability (recent hospitalization, yes/no), the burden of disease (no/low, mild/moderate or high), physical capacity (low or preserved) and physical activity (low or preserved) need to be used to allocate patients to one of the six distinct patient profiles. Patients with profile 1 or 2 will not be referred for physiotherapy; patients with profiles 3–5 will be referred for primary care physiotherapy; and patients with profile 6 will be referred for screening for specialized pulmonary rehabilitation. The proposed Dutch model has the intention to get the right patient with COPD allocated to the right type of exercise-based care and at the right moment.
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Ondernemen in een veranderende wereld is geschreven voor beleidsmakers, managers, ondernemers, organisatieadviseurs en studenten. Vanuit diverse ontwikkelingen op het gebied van technologische connectiviteit, open innovatie, maatschappelijk verantwoord ondernemen, outsourcing, de herrijzenis van China, samenwerking tussen organisaties, de veranderende consument, de veranderende marketing en authenticiteit, biedt Ondernemen in een veranderende wereld een nieuw perspectief op een veranderende wereld. In dit hoofdstuk wordt ingegaan op Maatschappelijk Verantwoord Ondernemen (MVO). Vaak in één adem genoemd met duurzaamheid. Geen onderneming lijkt zich meer te kunnen veroorloven er niet aan te doen. Waar komt deze ontwikkeling vandaan? Wat moeten we nu precies onder maatschappelijk of duurzaam ondernemen verstaan? En is MVO verenigbaar met meer gangbare financiële ondernemingsdoelstellingen? Vragen die een antwoord, of minstens een aanzet daartoe verdienen.
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