Background: Reducing low-value care (LVC) remains a significant challenge in healthcare systems, despite efforts for de-implementation. To facilitate de-implementation payers may use provider Audit & Feedback (A&F). This study aims to examine trends in LVC following a payer-initiated A&F program, and to explore whether this association varies across hospital payment models. Methods: Multilevel logistic regression was used to examine the trend in LVC in hospitals, its correlation with an A&F intervention, and whether this varied with payment models including fee-for-service (FFS), global budget (GB), cost ceiling (CC) and gradual tariff (GT). To assess this, we used hospital level claims data from a large nationwide Dutch health insurer on 70 hospitals in the period 2017-2022. The primary outcome was the yearly proportion of LVC per hospital. Independent variables were time, market share and payment models. We hypothesized that payer-initiated A&F had a stronger impact in hospitals were the payer had a larger market share, and that the effect would be stronger still for hospitals with financial incentives to reduce production. Results: LVC showed a small, but significant decline over time (odds ratio [OR]: 0.98; 95% confidence level [CI]: 0.98-0.99). LVC tended to be higher in hospitals where the payer had a higher market share (OR: 1.03; 95% CI: 1.00-1.05). The CC model was associated with an increase in LVC (OR: 1.11; 95% CI: 0.99–1.03). The other payment models were associated with a decrease in LVC. The FFS model exhibited the smallest reduction in LVC (OR: 0.98; 95% CI: 0.98-0.99), and the GT model (OR: 1.01; 95% CI: 0.99-1.03) showed similar patterns in LVC. The GB model was associated with the largest reduction in LVC (OR: 0.94; 95% CI: 0.91-0.97). Conclusion: By itself A&F did not clearly contribute to the decline of the proportion of LVC; combined with volumeconstraining financial incentives, it was associated with larger reductions.

Audit Feedback (A F) is a common intervention to enhance clinical guideline adherence, yet uncertainty remains regarding the factors influencing its effectiveness. To examine the effectiveness of A F interventions targeting clinical guideline adherence of hospital-based medical specialists in general and to determine which design characteristics, co-interventions and contextual factors explain variance in A F effectiveness. A systematic review and meta-analysis of randomized controlled trials was conducted following the Cochrane Handbook methodology. The electronic databases MEDLINE, Embase and Web of Science were searched up to January 2024. Two reviewers independently screened articles and selected studies on A F interventions targeting clinical guideline adherence of hospital-based medical specialists. Risk of bias was assessed by two independent reviewers, following the ROB2 tools. Data on design characteristics, co-interventions, contextual factors and outcomes were extracted by one reviewer and checked by a second reviewer. Results were described descriptively and when appropriate meta-analysis and subgroup analyses using random effects modelling was performed. Forty-one studies were included. Studies had a 2-armed (N = 35), 3-armed (N = 5) or 2 × 2 (N = 1) design and compared A F vs. no intervention (N = 15), A F vs. another intervention (N = 8) or A F vs. A F (N = 20). Studies targeted 23 different medical specialties, of which Cardiology (N = 8), General Medicine (N = 7), ICU (N = 6) and Emergency Care (N = 6) were most targeted. Risk of bias was low in six studies, with some risk in 19 studies and high risk in 16 studies. Meta-analysis showed a significant improvement of clinical guideline adherence due to A F, with a pooled OR of 1.30 (95

INTRODUCTION:Comparative effectiveness research (CER) often fails to create quality improvement since implementation of CER results in clinical practice is lacking. Claims-based Audit & Feedback (A&F) provides a resource efficient tool to stimulate implementation, but it is unknown whether medical professionals accept claims-based A&F in the context of CER. Therefore, in this study, we developed claims-based indicators using a cocreation approach and evaluated medical professionals' perception regarding the validity and acceptability of these indicators. METHODS:Between July 2019 and November 2021, we used a cocreation approach with medical experts to develop claims-based indicators for six CER trials. The aim is to use the indicators for group level feedback on implementation of CER results to medical professionals across all healthcare providers in the Netherlands. To build the indicators, we used the most recent available Dutch national healthcare-related claims data of the year 2017. The cocreation process consisted of the following steps: (1) defining the target indicator, (2) selecting relevant claims codes, (3) testing feasibility of the indicators using Dutch claims data, (4) discussing results of feasibility testing and (5) defining the final indicators and reflecting on the acceptability of the indicators for feedback on implementation of CER results by the experts. RESULTS:Claims-based indicators could not perfectly reflect the CER population for any of the six CER trials. However, the cocreation process did lead to a final indicator that medical experts found acceptable in four of six cases. Recommendations of medical experts for improving claims-based indicators included: select patients with minimal over- or underestimation of the CER population, use proxies to identify patients, determine incidence rather than prevalence for chronic conditions and use data linkage with diagnostic test results. CONCLUSION:A cocreation approach was a successful way to develop claims-based indicators on implementation of CER results, which were imperfect, but in some cases still acceptable as feedback to medical experts. Thus, for certain topics, claims data may provide a resource efficient data source for A&F interventions aiming to implement CER trials.

OBJECTIVE:Ventilation tube insertion for paediatric otitis media (POM), including acute otitis media (AOM) and otitis media with effusion (OME), has been signalled in the past for potential unwarranted treatment variation. Quality improvement initiatives, like Audit & Feedback (A&F), often ignore the care pathway when identifying such variation, possibly overestimating variation at a specific care step. To gain more insight into the effect of prior care steps, this study examined (1) the degree of regional variation in each step of the care pathway (general practitioner (GP) contacts, referrals and surgeries) and (2) investigated the effect of adjusting for prior care steps. DESIGN:Observational study using general practice electronic health record data linked to specialist claims data. PARTICIPANTS:272 790 children ≤12 years with and without POM registered in 320 GP practices between 2017 and 2018. PRIMARY AND SECONDARY OUTCOMES:Using multilevel logistic regression, the degree of regional variation in each step of the POM care pathway was assessed by calculating the coefficient of variation (CV).The effect of adjusting for prior care steps was determined by estimating correlations between subsequent care steps and analysing the impact on the CV. RESULTS:Regional variation in POM treatment was larger in each subsequent step in the care pathway (CV POM GP contacts 0.110; referral 0.179; surgery 0.239). In regions with a higher proportion of children with frequent AOM/persistent OME, referral rates were higher (POM: OR: 1.06; 95% CI: 1.02 to 1.11) and surgical rates were higher (for OME only: OR: 1.08; 95% CI: 1.02 to 1.15). Regional variation in referrals and surgery decreased after adjusting for the regional frequent AOM/persistent OME rate (CV referrals POM 0.103 vs 0.128; CV surgery OME 0.047 vs 0.059). CONCLUSIONS:Regional variation is observed in GP contact rates for POM and is larger in referrals and surgeries. Adjusting for the proportion of frequent AOM/persistent OME significantly reduces regional variation in POM treatment. Future A&F should adjust for prior care processes and develop tailored interventions for quality improvement.

OBJECTIVE:To examine the impact of the COVID-19 pandemic on the substitution of surgical procedures in benign gynaecology in the Netherlands. DESIGN:Quantitative longitudinal study evaluating the effects of the COVID-19 pandemic. SETTING:Nationwide healthcare delivery was analysed across six benign gynaecological pathways from 2016 to 2022 using Vektis and Dutch Hospital Data (DHD), accessed via Statistics Netherlands (Centraal Bureau voor de Statistiek). PARTICIPANTS:The study focused on six benign gynaecological pathways classified using Dutch Diagnosis Treatment Combinations (DTCs): heavy menstrual blood loss (G11), uterine fibroids (G15), endometriosis (G17), prolapse (G25), infertility treatment (F11) and first trimester pregnancy complications (Z12). All patients receiving care within these pathways between 1 January 2016 and 31 December 2022 were included. Exclusions applied to all patients under 18 years old and, only within the menstrual disorder pathway, patients over 51 years old to exclude most postmenopausal blood loss cases where no alternative treatment applies. INTERVENTIONS:Cohorts from the initial pandemic year (2020) were compared with four prepandemic cohorts (2016-2019) and late-pandemic (2021) and postpandemic (2022) cohorts. PRIMARY AND SECONDARY OUTCOME MEASURES:The primary outcome was the trend in the total number of patients in surgical and non-surgical procedure groups across cohort periods. Secondary outcomes included trends within individual pathways. RESULTS:The analysis identified a significant reduction in benign gynaecological care during 2020, with an 18.3% (p<0.001) decrease in surgical procedures and a 6% (p=0.02) decrease in non-surgical procedures across all pathways. During the COVID-19 pandemic, surgical care showed the largest significant declines in infertility treatment (-19.3%, p<0.001) and prolapse and heavy menstrual bleeding (both -17.5%, p<0.001), while non-surgical care decreased less markedly, with the largest significant drop in prolapse care (-10.4%, p=0.001). Non-surgical procedures generally returned to pre-pandemic levels, whereas surgical care remained reduced. These differences were conducted using regression models that adjusted for time trends and the COVID-19-related impact. CONCLUSIONS:The COVID-19 pandemic significantly disrupted both surgical and non-surgical procedures within benign gynaecological pathways. Reduced care uptake during the pandemic waves was not recovered but instead forgone. The reduction in surgical procedures did not correspond with increased use of non-surgical alternatives. Future research should prioritise evaluating the long-term impacts of this disruption on patients and society.

Most western countries lack the capacity to maintain institutional care levels for the ageing baby boom generation. To date, the non-medical drivers of the decision to "age in place" versus using expensive institutional long-term care (LTC) have not been comprehensively studied. This study, based on data from the Longitudinal Aging Study Amsterdam, aims to better understand why some individuals, with comparable medical needs, decide or are able to remain living independently longer than others. The sample included a representative cohort of Dutch adults aged 58 and older (n = 1,792), followed from 2005-06 to January 1, 2024. Cox Proportional Hazard models were used to better understand the relationship between potential non-medical barriers and facilitators and the duration of ageing in place. Several factors that facilitate ageing in place were identified. Individuals with comparable medical needs, but who are homeowners, who have a strong social network, or who have been living longer in their neighbourhood were less likely to be granted access to institutional care. This was also the case for those who value independence more or feel in control of their care. In contrast, emotional loneliness or having a partner living separately (typically in a nursing home) were associated with a higher likelihood of being granted institutional care. The actual move to a nursing home was delayed for those who feel that they receive sufficient home help. Developing community-based care approaches that address these factors may improve the ability to age in place.

INTRODUCTION:Many women experience bleeding disorders that may have an anatomical or unexplained origin. Although hysterectomy is the most definitive and common treatment, it is highly invasive and resource-intensive. Less invasive therapies are therefore advised before hysterectomy for women with fibroids or bleeding disorders. This study has two aims related to treating bleeding disorders and uterine fibroids in the Netherlands: (1) to evaluate the regional variations in prevalence and surgical approaches; and (2) to assess the associations between regional rates of hysterectomies and less invasive surgical techniques to analyze whether hysterectomy can be replaced in routine practice. MATERIAL AND METHODS:We completed a register-based study of claims data for bleeding disorders and fibroids in women between 2016 and 2020 using data from Statistics Netherlands for case-mix adjustment. Crude and case-mix adjusted regional hysterectomy rates were examined overall and by surgical approach. Coefficients of variation were used to measure regional variation and regression analyses were used to evaluate the association between hysterectomy and less invasive procedure rates across regions. RESULTS:Overall, 14 186 and 8821 hysterectomies were performed for bleeding disorders and fibroids, respectively. Laparoscopic approaches predominated (bleeding disorders 65%, fibroids 49%), followed by vaginal (bleeding disorders 24%, fibroids 5%) and abdominal (bleeding disorders 11%, fibroids 46%) approaches. Substantial regional differences were noted in both hysterectomy rates and the surgical approaches. For bleeding disorders, regional hysterectomy rates were positively associated with endometrial ablation rates (β = 0.11; P = 0.21) and therapeutic hysteroscopy rates (β = 0.14; P = 0.31). For fibroids, regional hysterectomy rates were positively associated with therapeutic hysteroscopy rates (β = 0.10; P = 0.34) and negatively associated with both embolization rates (β = -0.08; P = 0.08) and myomectomy rates (β = -0.03; P = 0.82). CONCLUSIONS:Regional variation exists in the rates of hysterectomy and minimally invasive techniques. The absence of a significant substitution effect provides no clear evidence that minimally invasive techniques have replaced hysterectomy in clinical practice. However, although the result was not significant, embolization could be an exception based on its stronger negative association.

Abstract Background Rising health care costs are a major concern in most Western countries. The substitution of healthcare stands as a strategic approach aimed at mitigating costs while offering medical services in proximity to patients’ residences. An illustrative instance involves the migration of outpatient hospital care to primary care settings. Notably, the insertion of intrauterine devices (IUDs) can be safely executed within primary care contexts. In order to establish a pragmatic objective for the rate of IUD substitution, we conducted an evaluation of regional disparities in healthcare substitution pertaining to the insertion of intrauterine devices. Furthermore, we investigated disparities in the follow-up ultrasound and reinsertion of IUDs between primary and secondary healthcare environments. Methods All women who underwent IUD insertion in Dutch primary care (by general practitioners and midwives) and secondary care (by hospital physicians) between January 1, 2016, and December 31, 2020 were included. The main outcome measures were the case-mix adjusted IUD insertion rates at the regional level by care setting and the proportions requiring follow-up ultrasound and IUD reinsertion within three months. Results Of the 840,766 IUD placements, 74% were inserted in primary care and 26% in secondary care. The proportion inserted in primary care increased from 70% in 2016 to 77% in 2020. The observed substitution rate ranged from 58 to 82% between regions. Compared with health care professionals in primary care, those in secondary care performed more ultrasounds to verify IUD placement (23% vs. 3%; p-value < 0.01) and more IUD reinsertions within three months (6% vs. 2%; p-value < 0.01). Conclusions IUDs are increasingly being inserted in Dutch primary care, with peak regional IUD insertion care substitution rates at ≥ 80%. IUD insertion care substitution to primary care appears to be associated with significantly fewer women having follow-up ultrasound or IUD reinsertion within three months.

Background: Purchasing systems aim to improve resource allocation in healthcare markets. The Netherlands is characterized by four different purchasing systems: managed competition in the hospital market, a non-competitive single payer system for long-term care (LTC), municipal procurement for home care and social services, and self-procurement via personal budgets. We hypothesize that managed competition and competitive payer reforms boost reallocations of provider market share by means of active purchasing, ie, redistributing funds from high-quality providers to low-quality providers. Methods: We define a Market Activity Index (MAI) as the sum of funds reallocated between providers annually. Provider expenditures are extracted from provider financial statements between 2006 and 2019. We compare MAI in six healthcare sectors under four different purchasing systems, adjusting for reforms, and market entry/exit. Next, we perform in-depth analyses on the hospital market. Using multivariate linear regressions, we relate reallocations to selective contracting, provider quality, and market characteristics. Results: No difference was found between reallocations in the hospital care market under managed competition and the non-competitive single payer LTC (MAI between 2% and 3%), while MAI was markedly higher under procurement by municipalities and personal budget holders (between 5% and 15%). While competitive reforms temporarily increased MAI, no structural effects were found. Relatively low hospital MAI could not be explained by market characteristics. Furthermore, the extent of selective contracting or hospital quality differences had no significant effects on reallocations of funds. Conclusion: Dutch managed competition and competitive purchaser reforms had no discernible effect on reallocations of funds between providers. This casts doubt on the mechanisms advocated by managed competition and active purchasing to improve allocative efficiency.

Non-linear reimbursement contracts in healthcare have been increasingly used to quantify providers’ responses to financial incentives. In the present research, we utilize a large one-off increase in the reimbursement of rehabilitation care to assess to what extent providers are willing to modify their treating behavior to maximize profits. In order to disincentivize the use of short inpatient stays for rehabilitation care, Dutch policy-makers have instated a two-part stepwise tariff-schedule. A lower tariff-schedule is applied for short hospital stays (≤ 14 days), while a higher tariff-schedule is utilized for longer treatments. Switching from one schedule to the other at day 15 of inpatient care leads to a sudden and large increase in tariffs. We show that, for most care-types, patients are seldom treated in an inpatient setting for less than 15 days, while the majority of patients are discharged after the threshold. Therefore, we conclude that the financial incentive at day 15 leads to considerable distortions in treatment. However, instead of discharging all patients at the threshold point where marginal tariffs are maximized, providers tend to continue treatment indicating altruistic behavior. As healthcare payment systems move away from piecewise reimbursement (e.g., fee-for-service arrangements), and services are increasingly ‘lumped’ together into e.g., DRGs and bundled payments, the likelihood of such discontinuities in tariff-schedules radically increases. Our research illustrates how such discontinuities in reimbursements can lead to distortions in the amount of healthcare provided contributing to the debate on optimal healthcare contracting design.

PurposeThe article demonstrates the dangers of gerontocracy and offers solutions.Design/methodology/approachThe article combines desk research, literature review and economic analytical reasoning.FindingsGerontocracy in developed countries is a threat to financial, labour market and political sustainability of care for older people. Without actions today, the problem will become bigger every year, not least because of increased electoral weight of older people. This article proposes to handle gerontocracy in two ways. First is by using the potential of healthy retired people as volunteers, thereby mitigating the intergenerational solidarity challenges. Second is by taxing part of the windfall profits on the housing market, where older generation profited disproportionally.Originality/valueThe added value of the article is twofold. First, it signals a serious problem in affluent societies that is largely ignored, both in the academic world and in politics. Second, it offers original solutions that mitigate the problem.

Research into the quality of cancer screening programs often lacks the perspective of clinicians, missing insights into the performance of individual hospitals. This retrospective cohort study aimed to identify guideline deviation (specifically, overtreatment and undertreatment) related to the cervical cancer screening program in Dutch hospitals by deterministically linking nationwide insurance data with pathology data for cervical intraepithelial neoplasia (CIN). We then constructed quality indicators using the Dutch CIN guideline and National Health Care Institute recommendations to assess compliance with CIN management, treatment outcomes, and follow-up, using an empirical Bayes shrinkage model to correct for case-mix variation and hospitals with few observations. Data were linked for 115,899 of 125,751 (92%) eligible women. Overtreatment was observed in the seeand-treat approach (immediate treatment) for women with low-grade referral cytology (4%; hospital range, 0%- 25%), CIN <= 1 treatment specimens (26%; hospital range, 10%-55%), and follow-up cervix cytology >= 2 months before the guideline recommendation after treatment for CIN 2 (2%; hospital range, 0%-9%) or CIN 3 (5%; hospital range, 0%-19%). By contrast, undertreatment was observed for treatment within 3 months after a CIN 3 biopsy result (90%; hospital range 59%-100%) and follow-up >= 2 months beyond the guideline recommendation after treatments for CIN 2 (21%, hospital range 7%-48%) and CIN 3 (20%, hospital range 7%-90%). In conclusion, we found evidence of CIN overtreatment and undertreatment in all measured domains at the hospital level. Guideline adherence could be improved by implementing the developed indicators in an audit and feedback instrument for use by healthcare professionals in routine practice.

Introduction: Heavy menstrual bleeding (HMB) affects a quarter of all women, with half having no structural cause. Dutch guidelines recommend a stepped care approach to the management of such idiopathic HMB, starting with medication or a levonorgestrel-releasing intrauterine device (LNG-IUD), before progressing to endometrial ablation, and ultimately, hysterectomy. However, practice variation between hospitals could lead to suboptimal health outcomes and increased healthcare costs for some women.Objectives: To evaluate adherence to stepped care for women with idiopathic HMB and to identify practice variation among Dutch hospitals.Study design: This population-based cross-sectional study used Dutch insurance claims data from primary and secondary care for all women with idiopathic HMB referred to a gynecologist between January 2019 and December 2020. We calculated the average number of treatments in the 3 years before each treatment step at each hospital, making adjustments for age, socioeconomic status, and ethnicity. Variation in medical practice was measured by the coefficient of variation (CV).Results: We studied 20,715 women treated with LNG-IUDs (56%), endometrial ablation (36%), laparoscopic hysterectomy (13%), or vaginal hysterectomy (4%) in 93 hospitals. Before endometrial ablation, on average 47% used medication (hospital range 27%-71%; CV 0.17) and 16% used an LNG-IUD (hospital range 8%-29%, CV 0.32). Before hysterectomy, 52% (hospital range 28%-65%, CV 0.16) used medication, 21% (hospital range 6%- 38%, CV 0.35) used an LNG-IUD, and 23% underwent endometrial ablation (hospital range 0%-59%, CV 0.55). On average, women underwent 0.63 (hospital range 0.36-1.00, adjusted rate 0.40-0.98, CV 0.17) and 0.96 (hospital range 0.56-1.45, adjusted rate 0.56-1.44, CV 0.18) treatments before endometrial ablation and hys-terectomy, respectively.Conclusions: Considerable practice variation exists among Dutch hospitals in the stepped care approach to idiopathic HMB. Improving adherence to this approach could improve quality of care and reduce costs.

BackgroundUnwarranted practice variation refers to regional differences in treatments that are not driven by patients' medical needs or preferences. Although it is the subject of numerous studies, most research focuses on variation at the end stage of treatment, i.e. the stage of the treating specialist, disregarding variation stemming from other sources (e.g. patient preferences, general practitioner referral patterns). In the present paper, we introduce a method that allows us to measure regional variation at different stages of the patient journey leading up to treatment.MethodsA series of logit regressions estimating the probability of (1) initial visit with the physician and (2) treatment correcting for patient needs and patient preferences. Calculating the coefficient of variation (CVU) at each stage of the patient journey.ResultsOur findings show large regional variations in the probability of receiving an initial visit, The CVU, or the measure of dispersion, in the regional probability of an initial visit with a specialist was significantly larger (0.87-0.96) than at the point of treatment both conditional (0.14-0.25) and unconditional on an initial visit (0.65-0.74), suggesting that practice variation was present before the patient reached the specialist.ConclusionsWe present a new approach to attribute practice variation to different stages in the patient journey. We demonstrate our method using the clinically-relevant segment of varicose veins treatments. Our findings demonstrate that irrespective of the gatekeeping role of general practitioners (GPs), a large share of practice variation in the treatment of varicose veins is attributable to regional variation in primary care referrals. Contrary to expectation, specialists' decisions meaningfully diminish rather than increase the amount of regional variation.

Abstract Background One of the most significant challenges of implementing a multi-provider bundled payment contract is to determine an appropriate, casemix-adjusted total bundle price. The most frequently used approach is to leverage historic care utilization based on claims data. However, those claims data may not accurately reflect appropriate care (e.g. due to supplier induced demand and moral hazard effects). This study aims to examine variation in claims-based costs of post-discharge primary care physical therapy (PT) utilization after total knee and hip arthroplasties (TKA/THA) for osteoarthritis patients. Methods This retrospective cohort study used multilevel linear regression analyses to predict the factors that explain the variation in the utilization of post-discharge PT after TKA or THA for osteoarthritis patients, based on the historic (2015–2018) claims data of a large Dutch health insurer. The factors were structured as predisposing, enabling or need factors according to the behavioral model of Andersen. Results The 15,309 TKA and 14,325 THA patients included in this study received an average of 20.7 (SD 11.3) and 16.7 (SD 10.1) post-discharge PT sessions, respectively. Results showed that the enabling factor ‘presence of supplementary insurance’ was the strongest predictor for post-discharge PT utilization in both groups (TKA: β = 7.46, SE = 0.498, p-value< 0.001; THA: β = 5.72, SE = 0.515, p-value< 0.001). There were also some statistically significant predisposing and need factors, but their effects were smaller. Conclusions This study shows that if enabling factors (such as supplementary insurance coverage or co-payments) are not taken into account in risk-adjustment of the bundle price, they may cause historic claims-based pricing methods to over- or underestimate appropriate post-discharge primary care PT use, which would result in a bundle price that is either too high or too low. Not adjusting bundle prices for all relevant casemix factors is a risk because it can hamper the successful implementation of bundled payment contracts and the desired changes in care delivery it aims to support.

Abrupt jumps in reimbursement tariffs have been shown to lead to unintended effects in physicians' behavior. A sudden change in tariffs at a pre-defined point in the treatment can incentivize health care providers to prolong treatment to reach the higher tariff, and then to discharge patients once the higher tariff is reached. The Dutch reimbursement schedule in hospital rehabilitation care follows a two-threshold stepwise-function based on treatment duration. We investigated the prevalence of strategic discharges around the first threshold and assessed whether their share varies by provider type. Our findings suggest moderate response to incentives by traditional care providers (general and academic hospitals, rehabilitation centers and multicategorical providers), and strong response by profit-oriented independent treatment centers. When examining the variation in response based on the financial position of the organization, we found a higher probability of manipulation among providers in financial distress. Our findings provide multiple insights and possible indicators to identify provider types that may be more prone to strategic behavior.

Abstract Background In patient choice, patients are expected to select the provider that best fits their preferences. In this study, we assess to what extent the hospital choice of patients in practice corresponds with their preferred choice. Methods Dutch patients with breast cancer (n = 631) and cataract (n = 1109) were recruited. We employed a discrete choice experiment (DCE) per condition to measure stated preferences and predict the distribution of patients across four hospitals. Each DCE included five attributes: patient experiences, a clinical outcome indicator, waiting time, travel distance and whether the hospital had been recommended (e.g., by the General Practitioner (GP)). Revealed choices were derived from claims data. Results Hospital quality was valued as most important in the DCE; the largest marginal rates of substitution (willingness to wait) were observed for the clinical outcome indicator (breast cancer: 38.6 days (95% confidence interval (95%CI): 32.9–44.2); cataract: 210.5 days (95%CI: 140.8–280.2)). In practice, it was of lesser importance. In revealed choices, travel distance became the most important attribute; it accounted for 85.5% (breast cancer) and 95.5% (cataract) of the log-likelihood. The predicted distribution of patients differed from that observed in practice in terms of absolute value and, for breast cancer, also in relative order. Similar results were observed in population weighted analyses. Discussion Study findings show that patients highly valued quality information in the choice for a hospital. However, in practice these preferences did not prevail. Our findings suggest that GPs played a major role and that patients mostly ended up selecting the nearest hospital.

Adult body height appears to be significantly associated with marital outcomes: taller men across contexts have been found to be more likely to be married, and more likely to be married at younger ages. We are interested in exploring both outcomes individually and simultaneously, while using an unique, individual-level dataset of Dutch men and their brothers born between 1841 and 1900. To do so, we exploit survival models and cure models. While survival models yield a single estimate for the hazard (or age at) marriage, cure models yield two: one for the likelihood of marriage, and one for the hazard of first marriage. Cure models thus account for selection into marriage, while survival models do not. We find that, in the survival analyses, being in the shortest 20 % of heights is associated with later ages of marriage, relative to being average height. However, when we account for selection into marriage with cure models, we find that height is no longer associated with age at marriage. Instead, we see that height is associated with the likelihood of being married, with being in the bottom 20 % of heights associated with a 56.1 % decreased likelihood of being married, relative to being average height. We therefore conclude that height may be a gatekeeper for access to marriage, but it appears that other factors - likely related to the ability to set up an independent household - are more important in determining the timing of marriage for our research population.

Hospital quality indicators provide valuable insights for quality improvement, empower patients to choose providers, and have become a cornerstone of value-based payment. As outcome indicators are cumbersome and expensive to measure, many health systems have relied on proxy indicators, such as structure and process indicators. In this paper, we assess the extent to which publicly reported structure and process indicators are correlated with outcome indicators, to determine if these provide useful signals to inform the public about the outcomes. Quality indicators for three conditions (breast and colorectal cancer, and hip replacement surgery) for Dutch hospitals (2011-2018) were collected. Structure and process indicators were compared to condition-specific outcome indicators and in-hospital mortality ratios in a between-hospital comparison (cross-sectional and between-effects models) and in within-hospital comparison (fixed-effects models). Systematic association could not be observed for any of the models. Both positive and negative signs were observed where negative associations were to be expected. Despite sufficient statistical power, the share of significant correlations was small [mean share: 13.2% (cross-sectional); 26.3% (between-effects); 13.2% (fixed-effects)]. These findings persisted in stratified analyses by type of hospital and in models using a multivariate approach. We conclude that, in the context of compulsory public reporting, structure and process indicators are not correlated with outcome indicators, neither in between-hospital comparisons nor in within-hospital comparisons. While structure and process indicators remain valuable for internal quality improvement, they are unsuitable as signals for informing the public about hospital differences in health outcomes.