An econometric approach to aggregating multiple cardiovascular outcomes in German hospitals

Objective Development of an aggregate quality index to evaluate hospital performance in cardiovascular events treatment. Methods We applied a two-stage regression approach using an accelerated failure time model based on variance weights to estimate hospital quality over four cardiovascular interventions: elective coronary bypass graft, elective cardiac resynchronization therapy, and emergency treatment for acute myocardial infarction. Mortality and readmissions were used as outcomes. For the estimation we used data from a statutory health insurer in Germany from 2005 to 2016. Results The precision-based weights calculated in the first stage were higher for mortality than for readmissions. In general, teaching hospitals performed better in our ranking of hospital quality compared to non-teaching hospitals, as did private not-for-profit hospitals compared to hospitals with public or private for-profit ownership. Discussion The proposed approach is a new method to aggregate single hospital quality outcomes using objective, precision-based weights. Likelihood-based accelerated failure time models make use of existing data more efficiently compared to widely used models relying on dichotomized data. The main advantage of the variance-based weights approach is that the extent to which an indicator contributes to the aggregate index depends on the amount of its variance

How to pay primary care physicians for SARS-CoV-2 vaccinations: An analysis of 43 EU and OECD countries.

Vaccinations are crucial to fighting SARS-CoV-2, and high coverage rates can in most countries probably only be achieved with the involvement of primary care physicians (PCPs). We aimed to explore how SARS-CoV-2 vaccination payment schemes in 43 countries differ with regard to the (i) type of payment scheme, (ii) amount paid, (iii) degree of bundling, and (iv) use of pay-for-performance elements. We collected information on payments and health system characteristics, such as PCP income and employment status, in all EU and OECD countries over time. We regressed the payment amount on the income of PCPs for countries with activity-dependent schemes using a linear regression (OLS), and we interpreted the residuals of this regression as a vaccination payment index. The majority of countries (30/43) had chosen payment schemes that reward PCPs for the activity they perform. Seventeen countries paid less per vaccination than the income-adjusted average, whereas 13 countries paid more. Twelve countries used pay-for-performance elements

Improving health care from the bottom up: Factors for the successful implementation of kaizen in acute care hospitals

Background Kaizen—a management technique increasingly employed in health care—enables employees, regardless of their hierarchy level, to contribute to the improvement of their organization. The approach puts special emphasis on frontline employees because it represents one of their main opportunities to participate directly in decision making. In this study, we aimed to (1) understand the experiences of nurses in two hospitals that had recently implemented kaizen, and (2) identify factors affecting the implementation of the technique. Methods By means of purposeful sampling, we selected 30 nurses from different units in two private acute care hospitals in Switzerland in May 2018. We used the Organizational Transformation Model to conduct semi-structured interviews and perform qualitative content analysis. Lastly, originating from Herzberg’s motivation theory, we suggest two types of factor influencing the implementation of kaizen—hygiene factors that may prevent nurses from getting demotivated, and motivational factors that may boost their motivation. Results Nurses generally experienced kaizen as a positive practice that enabled them to discuss work-related activities in a more comprehensive manner. In some cases, however, a lack of visible improvement in the workplace lowered nurses’ motivation to make suggestions. Nurses’ attitudes towards kaizen differed across both hospitals depending on the available managerial support, resources such as infrastructure and staffing levels. Conclusions From our findings, we derived several coping strategies to help health practitioners implement kaizen for the benefit of their organization and employees: Strong managerial support, appropriate use of kaizen tools, and a greater sense of team cohesion, among other factors, can influence how effectively hospital teams implement kaizen. To reap the benefits of kaizen, hospital managers should promote the exchange of opinions across hierarchy levels, allocate the necessary resources in terms of personnel and infrastructure, and show nurses how the technique can help them improve their workplace

Antibiotici efficaci per il sistema sanitario Svizzero: oggi e in futuro

Gli antibiotici hanno svolto un ruolo indispensabile nella medicina clinica, nella sanità pubblica, nella zootecnia e nella medicina veterinaria fin dai primi decenni del XX° secolo. La loro notevole efficacia nel trattamento delle infezioni batteriche e nella riduzione dei rischi negli interventi chirurgici, in chemioterapia e in altre procedure mediche li ha consacrati come pietra miliare della medicina moderna. Tuttavia, il loro ampio successo e la loro accessibilità economica hanno portato a un loro uso eccessivo, spesso superiore alle necessità cliniche. Ciò ha accelerato lo sviluppo naturale della cosiddetta “resistenza agli antibiotici” nei batteri che hanno la capacità di adattarsi facilmente all’ambiente in cui si trovano. Poiché la progressiva resistenza intacca l'efficacia degli antibiotici, le infezioni batteriche possono diventare difficili o addirittura impossibili da trattare, soprattutto quando i batteri sviluppano una resistenza a più antibiotici. Il crescente numero di decessi sottolinea la gravità di questo trend. Nonostante l'impellente necessità di nuovi antibiotici e di una disponibilità affidabile di quelli esistenti, la cruda realtà, sia in Svizzera che a livello internazionale, è una preoccupante stagnazione nel rinnovamento dell'arsenale antibiotico. Ciò è dovuto alla scarsa attività di ricerca e sviluppo (R&S), alla riluttanza dei produttori a immettere antibiotici non soltanto nei pochi Paesi ad alto reddito, alla carenza dovuta a catene di approvvigionamento neglette e, in Svizzera, al frequente ritiro di antibiotici dal suo, relativamente piccolo, mercato. Per affrontare queste molteplici sfide, il piano d'azione nazionale “Strategia svizzera contro la resistenza agli antibiotici” (StAR) ha delineato diverse iniziative in otto campi d'azione, tra cui uno che chiama il governo e le parti interessate a “promuovere la disponibilità di antibiotici di prima scelta e lo sviluppo di nuovi antibiotici” (Capitolo 2). In questo Libro Bianco, la Tavola Rotonda Svizzera sugli Antibiotici presenta una proposta per aumentare la disponibilità di nuovi antibiotici in Svizzera, in particolare quelli necessari per trattare le infezioni multiresistenti. Per raggiungere questo obiettivo, è indispensabile che la remunerazione degli antibiotici in Svizzera rappresenti una quota equa del reddito che i produttori devono generare a livello globale per coprire i costi di ricerca, sviluppo, produzione, mantenimento nel mercato e per generare un profitto ragionevole. Questa sostenibilità finanziaria è essenziale per incoraggiare gli investimenti dell'industria negli antibiotici, un settore che molte grandi aziende hanno abbandonato negli ultimi decenni a causa del rischio più elevato di perdite finanziarie nel settore delle malattie infettive. Per rinvigorire l'innovazione nel campo degli antibiotici, sono necessari incentivi economici e regolamentari lungo l'intero ciclo di vita del farmaco (Capitolo 3). La nostra proposta si concentra sui cosiddetti incentivi pull, che entrano in vigore dopo che un nuovo antibiotico ha ottenuto l'autorizzazione all'immissione in commercio. Il Capitolo 4 illustra il nostro approccio allo sviluppo di questa proposta. Il Capitolo 5 fornisce una descrizione dettagliata di quattro modelli di incentivi pull, seguita dalla loro valutazione nel Capitolo 6. Ciò ha permesso di identificare il modello ad abbonamento come il più adatto per l'implementazione in Svizzera. Infine, nel Capitolo 7, proponiamo un rimedio a una limitazione chiave del modello di voucher trasferibili per l'estensione dell'esclusività (TEEV) ed esploriamo il modello a prevalenza come potenziale soluzione provvisoria nel caso in cui l'implementazione del modello ad abbonamento richieda più tempo del previsto. Nel corso del nostro lavoro, siamo rimasti concentrati sul mandato della StAR di “promuovere la disponibilità di antibiotici di prima scelta”. Il preoccupante aumento delle carenze e dei ritiri dal mercato ci ha spinto a valutare i modelli di incentivo pull per il loro potenziale di mitigazione di questi problemi. Abbiamo messo in evidenza che il modello ad abbonamento proposto contribuisce a questo obiettivo, pur riconoscendo che è necessaria una serie di misure aggiuntive

System Dynamics and Intervention Design

In this article, we transform thoughts from classical strategy and insights from modern complexity science into a novel concept of intervention. In doing so, we pursue two goals: First, to improve the prediction of outcomes, and second, to refine the design of interventions. For the first purpose, we outline approaches to modeling the natural behavior of systems and the effect of interventions. For the second purpose, we propose an idea for the design of interventions. We call the concepts that relate to modeling system behaviors system dynamics, and those that relate to predicting outcomes of interventions intervention dynamics, and we call the concepts that relate to the design of interventions intervention design

Why the US spends more treating high-need high-cost patients: a comparative study of pricing and utilization of care in six high-income countries.

One of the most pressing challenges facing most health care systems is rising costs. As the population ages and the demand for health care services grows, there is a growing need to understand the drivers of these costs across systems. This paper attempts to address this gap by examining utilization and spending of the course of a year for two specific high-need high-cost patient types: a frail older person with a hip fracture and an older person with congestive heart failure and diabetes. Data on utilization and expenditure is collected across five health care settings (hospital, post-acute rehabilitation, primary care, outpatient specialty and drugs), in six countries (Canada (Ontario), France, Germany, Spain (Aragon), Sweden and the United States (fee for service Medicare) and used to construct treatment episode Purchasing Power Parities (PPPs) that compare prices using baskets of goods from the different care settings. The treatment episode PPPs suggest other countries have more similar volumes of care to the US as compared to other standardization approaches, suggesting that US prices account for more of the differential in US health care expenditures. The US also differs with regards to the share of expenditures across care settings, with post-acute rehab and outpatient speciality expenditures accounting for a larger share of the total relative to comparators

Coverage with evidence development for medical devices in Europe: Can practice meet theory?

Health economists have written extensively on the design and implementation of coverage with evidence development (CED) schemes and have proposed theoretical frameworks based on cost-effectiveness modeling and value of information analysis. CED may aid decision-makers when there is uncertainty about the (cost-)effectiveness of a new health technology at the time of reimbursement. Medical devices are potential candidates for CED schemes, as regulatory regimes do not usually require the same level of efficacy and safety data normally needed for pharmaceuticals. The purpose of this research is to assess whether the actual practice of CED for medical devices in Europe meets the theoretical principles proposed by health economists and whether theory and practice can be more closely aligned. Based on decision-makers' perceptions of the challenges associated with CED schemes, plus examples from the schemes themselves, we discuss a series of proposals for assessing the desirability of schemes, their design, implementation, and evaluation. These proposals, while reflecting the practical challenges with developing CED programs, embody many of the principles suggested by economists and should support decision-makers in dealing with uncertainty about the real-world performance of devices

Do existing real-world data sources generate suitable evidence for the HTA of medical devices in Europe? Mapping and critical appraisal.

Aim Technological and computational advancements offer new tools for the collection and analysis of real-world data (RWD). Considering the substantial effort and resources devoted to collecting RWD, a greater return would be achieved if real-world evidence (RWE) was effectively used to support Health Technology Assessment (HTA) and decision making on medical technologies. A useful question is: To what extent are RWD suitable for generating RWE? Methods We mapped existing RWD sources in Europe for three case studies: hip and knee arthroplasty, transcatheter aortic valve implantation (TAVI) and mitral valve repair (TMVR), and robotic surgery procedures. We provided a comprehensive assessment of their content and appropriateness for conducting the HTA of medical devices. The identification of RWD sources was performed combining a systematic search on PubMed with gray literature scoping, covering fifteen European countries. Results We identified seventy-one RWD sources on arthroplasties; ninety-five on TAVI and TMVR; and seventy-seven on robotic procedures. The number, content, and integrity of the sources varied dramatically across countries. Most sources included at least one health outcome (97.5%), with mortality and rehospitalization/reoperation the most common; 80% of sources included resource outcomes, with length of stay the most common, and comparators were available in almost 70% of sources. Conclusions RWD sources bear the potential for the HTA of medical devices. The main challenges are data accessibility, a lack of standardization of health and economic outcomes, and inadequate comparators. These findings are crucial to enabling the incorporation of RWD into decision making and represent a readily available tool for getting acquainted with existing information sources

Quo Vadis HTA for medical devices in Central and Eastern Europe? Recommendations to address methodological challenges

Objectives: Methodological challenges in the evaluation of medical devices (MDs) may be different for early and late technology adopter countries, as well as the potential health technology assessment (HTA) solutions to tackle them. This study aims to provide guidance to Central and Eastern European (CEE) countries on how to address key challenges of HTA for MDs with special focus on the transferability of scientific evidence. Methods: As part of the COMED Horizon 2020 project, a comprehensive list of issues related to MD HTA were identified based on a targeted literature review. Health technology assessment issues which pose a greater challenge or require different solutions in late technology adopter countries were selected. Draught recommendations to address these issues were developed and discussed in a focus group. The recommendations were then validated with a wider group of experts, including HTA and reimbursement decision makers from CEE countries in May and June 2020. Results: A consolidated list of 11 recommendations were developed in 3 major areas: (1) clinical value assessment, focusing on the use of joint EU work, relying on real-world evidence, use of coverage with evidence development schemes, transferring evidence from foreign countries and addressing the challenges of learning curve and centre effect; (2) economic value assessment, covering cost calculation of complex medical devices and transferability of economic evaluations of MDs; (3) HTA processes, related to the frequent product modifications and various indications of MDs. Conclusions: Central and Eastern European countries with limited resources for conducting HTA, can benefit from HTA methods and evidence generated in early technology adopter countries. Considering the appropriate reuse of international HTA materials, late technology adopter countries can still implement HTA, even for MDs, which have a more limited evidence base compared with pharmaceuticals