Dutch healthcare reform: did it result in performance improvement of health plans? A comparison of consumer experiences over time

<p>Abstract</p> <p>Background</p> <p>Many countries have introduced elements of managed competition in their healthcare system with the aim to accomplish more efficient and demand-driven health care. Simultaneously, generating and reporting of comparative healthcare information has become an important quality-improvement instrument. We examined whether the introduction of managed competition in the Dutch healthcare system along with public reporting of quality information was associated with performance improvement in health plans.</p> <p>Methods</p> <p>Experiences of consumers with their health plan were measured in four consecutive years (2005-2008) using the CQI^®health plan instrument 'Experiences with Healthcare and Health Insurer'. Data were available of 13,819 respondents (response = 45%) of 30 health plans in 2005, of 8,266 respondents (response = 39%) of 32 health plans in 2006, of 8,088 respondents (response = 34%) of 32 health plans in 2007, and of 7,183 respondents (response = 31%) of 32 health plans in 2008. We performed multilevel regression analyses with three levels: respondent, health plan and year of measurement. Per year and per quality aspect, we estimated health plan means while adjusting for consumers' age, education and self-reported health status. We tested for linear and quadratic time effects using chi-squares.</p> <p>Results</p> <p>The overall performance of health plans increased significantly from 2005 to 2008 on four quality aspects. For three other aspects, we found that the overall performance first declined and then increased from 2006 to 2008, but the performance in 2008 was not better than in 2005. The overall performance of health plans did not improve more often for quality aspects that were identified as important areas of improvement in the first year of measurement. On six out of seven aspects, the performance of health plans that scored below average in 2005 increased more than the performance of health plans that scored average and/or above average in that year.</p> <p>Conclusion</p> <p>We found mixed results concerning the effects of managed competition on the performance of health plans. To determine whether managed competition in the healthcare system leads to quality improvement in health plans, it is important to examine whether and for what reasons health plans initiate improvement efforts.</p

A case-control study of sporadic Creutzfeldt-Jakob disease in Switzerland: analysis of potential risk factors with regard to an increased CJD incidence in the years 2001-2004

BACKGROUND: In 2001, the observed annual mortality from Creutzfeldt-Jakob disease (CJD) in Switzerland increased from less than 1.5 to 2.6 per million inhabitants. An underlying cause could not be identified. METHODS: To analyse potential risk factors for sCJD in Switzerland, close relatives of 69 sCJD-patients and 224 frequency age-matched controls were interviewed in a case-control study using a standardised questionnaire. 135 potential risk factors including socio-demographics, medical history, occupation and diet were analysed by logistic regression adjusting for age, sex and education. RESULTS: sCJD patients were more likely to have travelled abroad, worked at an animal laboratory, undergone invasive dental treatment, orthopaedic surgery, ophthalmologic surgery after 1980, regular GP visits, taken medication regularly, and consumed kidney. No differences between patients and controls were found for residency, family history, and exposure to environmental and other dietary factors. CONCLUSION: Although some factors were significantly more frequent among sCJD-cases, this study did not reveal specific explanations for the increased incidence of deaths due to sporadic CJD observed in Switzerland since 2001. Results have to be interpreted with caution due to multiple testing and possible recall bias in association with a long incubation period. The most plausible reason for the increase in Swiss sCJD cases after 2000 is an improved case ascertainment. Therefore, underreporting of cases might well have occurred before the year 2001, and the "real" yearly incidence of sCJD might not be lower than, but rather above 2 per million inhabitants

Gravitační mapy litosférické struktury pod Indickým oceánem

Litosférická struktura pod Indickým oceánem je pravděpodobně nejsložitější, ale zároveň nejméně pochopená mezi světovými oceány. Výsledky tomografických, geochemických, magnetických a jiných průzkumů svědčí o jeho komplexní geologické historii. Seismické průzkumy byly primárním zdrojem informací o litosférické struktuře pod Indickým oceánem, ale tyto experimenty jsou soustředěny hlavně na místech s vysokým geofyzikálním zájmem. Údaje o mořské gravitaci získané zpracováním měření družicové výškoměry naopak poskytují podrobný obraz reliéfu celého mořského dna, čímž se dále rozšiřují znalosti o jeho tvorbě, tektonismu a vulkanismu. V této studii používáme údaje o gravitační, bathymetrické, mořské sedimentu a litosférické hustotě pro sestavení gravitačních map Bouguer a pláště. Poté použijeme obě gravitační mapy k interpretaci litosférické struktury pod Indickým oceánem. Bouguerova gravitační mapa odhaluje hlavní tektonické a sopečné rysy, které jsou prostorově korelovány s odchylkami tloušťky kůry. Mapa gravitačního pláště vykazuje hlavně tepelný podpis litosférického pláště. Gravitační minima v této gravitační mapě značí výrazně aktivní oceánské divergentní tektonické okraje podél středových, jihovýchodních a jihozápadních indických hřebenů, včetně také Carlsbergského hřebene. Gravitační minima se rozprostírá podél Rudého moře - Adenského zálivu a východoafrických trhlin, což potvrzuje spojení mezi středo oceánskými hřebeny šíření (v Indickém oceánu) a kontinentálními trhlinami (ve východní Africe). Kombinovaná interpretace Bouguerových a plášťových gravitačních map potvrzuje kolizní původ horských pásem podél kontinentálních trhlin ve východní Africe. Důkaz o jižním rozšíření východoafrického riftového systému a jeho spojení s jihozápadním indickým hřbetem v mapě gravitačního pláště chybí. Podobně se neprojevuje pokračující rozpad složené indo-australské desky. Chybějící tepelný podpis v gravitační mapě pláště na těchto dvou místech je vysvětlen skutečností, že jižní hranice Nubian-Somálska (tj. Lwandleova deska) a Indo-australská hranice (tj. Capricornova deska) jsou rozptýlené zóny konvergence, charakterizované nízkou deformací a seismicitou v důsledku velmi pomalých rychlostí relativních pohybů ubytovaných přes tyto hranice. Chybí také jasný projev tepelného podpisu horkých míst uvnitř destičky v mapě gravitace pláště. Toto zjištění souhlasí s důkazy z přímých měření tepelného toku, které nenaznačují přítomnost významné pozitivní teplotní anomálie ve srovnání s oceánskou litosférou podobného věku.The lithospheric structure beneath the Indian Ocean is probably the most complicated, but at the same time, the least understood among world’s oceans. Results of tomographic, geochemical, magnetic and other surveys provide the evidence of its complex geological history. Seismic surveys have been a primary source of information about the lithospheric structure beneath the Indian Ocean, but these experiments are mainly concentrated at locations of a high geophysical interest. Marine gravity data obtained from processing the satellite altimetry measurements, on the other hand, deliver a detailed image of the whole seafloor relief, advancing further the knowledge about its formation, tectonism and volcanism. In this study, we use gravitational, bathymetric, marine sediment and lithospheric density structure data to compile the Bouguer and mantle gravity maps. We then use both gravity maps to interpret the lithospheric structure beneath the Indian Ocean. The Bouguer gravity map reveals major tectonic and volcanic features that are spatially correlated with crustal thickness variations. The mantle gravity map exhibits mainly a thermal signature of the lithospheric mantle. Gravity lows in this gravity map mark distinctively active oceanic divergent tectonic margins along the Central, Southeast and Southwest Indian Ridges including also the Carlsberg Ridge. Gravity lows extend along the Red Sea–Gulf of Aden and East African Rift Systems, confirming a connection between mid-oceanic spreading ridges (in the Indian Ocean) and continental rift systems (in East Africa). The combined interpretation of the Bouguer and mantle gravity maps confirms a non-collisional origin of mountain ranges along continental rift systems in East Africa. The evidence of a southern extension of the East African Rift System and its link with the Southwest Indian Ridge in the mantle gravity map is absent. Similarly, the ongoing breakup of the composite Indo-Australian plate is not manifested. A missing thermal signature in the mantle gravity map at these two locations is explained by the fact that the southern Nubian-Somalian plate boundary (i.e., the Lwandle plate) and the Indo-Australian plate boundary (i.e., the Capricorn plate) are diffuse zones of convergence, characterized by low deformation and seismicity due to very slow rates of relative motions accommodated across these boundaries. The clear manifestation of the thermal signature of intraplate hot spots in the mantle gravity map is also absent. This finding agrees with the evidence from direct heat flow measurements that do not indicate the presence of a significant positive temperature anomaly compared to the oceanic lithosphere of a similar age