3 research outputs found
Centralising and optimising decentralised stroke care systems: a simulation study on short-term costs and effects
"Strangers in the ER": Quality indicators and third party interference in Dutch emergency care
Rationale, aims, and objectives This paper examines a remarkable dispute between Dutch insurers, hospitals, doctors, and patients about a set of quality indicators. In 2013, private insurers planned to drastically reform Dutch emergency care using quality indicators they had formulated drawing from clinical guidelines, RCTs, and systematic reviews. Insurers' plans caused much debate in the field of emergency care. As quality indicators have come to play a more central role in health care governance, the questions what constitutes good evidence for them, how they ought to be used, and who controls them have become politically and morally charged. This paper is a case study of how a Dutch public knowledge institution, the National Health Care Institute, intervened in this dispute and how they addressed these questions. Method We conducted ethnographic research into the knowledge work of the National Health Care Institute. Research entailed document analysis, participant observation, inâdepth conversations, and formal interviews with 5 keyâinformants. Results The National Health Care Institute problematized not only the evidence supporting insurers' indicators, but alsoâand especiallyâthe scope, purpose, and use of the indicators. Our analysis shows the institute's struggle to reconcile the technical rationality of quality indicators with their social and political implications in practice. The institute deconstructed quality indicators as national standards and, instead, promoted the use of indicators in dialogue with stakeholders and their local and contextual knowledge. Conclusions Even if quality indicators are based on scientific evidence, they are not axiomatically good or useful. Both proponents and critics of Evidenceâbased Medicine always feared uncritical use of evidence by third parties. For nonâmedical parties who have no access to primary care processes, the type of standardized knowledge professed by Evidenceâbased Medicine provides the easiest way to gain insights into âwhat worksâ in clinical practice. This case study reminds us that using standardized knowledge for the management of health care quality requires the involvement of stakeholders for the development and implementation of indicators, and for the interpretation of their results