Orchestration versus bookkeeping:How stakeholder pressures drive a healthcare purchaser’s institutional logics

BACKGROUND: Healthcare purchasers such as health insurers and governmental bodies are expected to strategically manage chronic care chains. In doing so, purchasers can contribute to the goal of improving task division and collaboration between chronic care providers as has been recommended by numerous studies. However, healthcare purchasing research indicates that, in most countries, purchasers still struggle to fulfil a proactive, strategic approach. Consequently, a typical pattern occurs in which care improvement initiatives are instigated, but not transformed into regular care. By acknowledging that healthcare purchasers are embedded in a care chain of stakeholders who have different, sometimes conflicting, interests and, by taking an institutional logics lens, we seek to explain why achieving strategic purchasing and sustainable improvement is so elusive. METHOD AND FINDINGS: We present a longitudinal case study in which we follow a health insurer and care providers aiming to improve the care of patients with Chronic Obstructive Pulmonary Disease (COPD) in a region of the Netherlands. Taking a theoretical lens of institutional logics, our aim was to answer ‘how stakeholder pressures influence a purchaser’s use of institutional logics when pursuing the right care at the right place’. The insurer by default predominantly expressed a bookkeeper’s logic, reflecting a focus on controlling short-term care costs by managing individual providers. Over time, a contrasting orchestrator’s logic emerged in an attempt to achieve chain-wide improvement, striving for better health outcomes and lower long-term costs. We established five types of stakeholder pressure to explain the shift in logic adoption: relationship pressures, cost pressures, medical demands, public health demands and uncertainty. Linking the changes in logic over time with stakeholder pressures showed that, firstly, the different pressures interact in influencing the purchaser. Secondly, we saw that the lack of intra-organisational alignment affects how the purchaser deals with the different stakeholder pressures. CONCLUSIONS: By highlighting the purchaser’s difficult position in the care chain and the consequences of their own internal responses, we now better understand why the intended orchestrator’s logic and thereby a strategic approach to purchasing chronic care proves unsustainable within the Dutch healthcare system of managed competition

Isolation of the Two Monoferric Human Transferrins by Preparative Isoelectric Focussing

Peer Reviewe

“I Am Here to Assist You Today”: The Role of Entity, Interactivity and Experiential Perceptions in Chatbot Persuasion

Online users are increasingly exposed to chatbots as one form of AI-enabled media technologies, employed for persuasive purposes, e.g., making product/service recommendations. However, the persuasive potential of chatbots has not yet been fully explored. Using an online experiment (N = 242), we investigate the extent to which communicating with a stand-alone chatbot influences affective and behavioral responses compared to interactive Web sites. Several underlying mechanisms are studied, showing that enjoyment is the key mechanism explaining the positive effect of chatbots (vs. Web sites) on recommendation adherence and attitudes. Contrary to expectations, perceived anthropomorphism seems not to be particularly relevant in this comparison

Modelling Eco-Driving Support System for Microscopic Traffic Simulation

Microscopic traffic simulation is an ideal tool for investigating the network level impacts of eco-driving in different networks and traffic conditions, under varying penetration rates and driver compliance rates. The reliability of the traffic simulation results however rely on the accurate representation of the simulation of the driver support system and the response of the driver to the eco-driving advice, as well as on a realistic modelling and calibration of the driver’s behaviour. The state-of-the-art microscopic traffic simulation models however exclude detailed modelling of the driver response to eco-driver support systems. This paper fills in this research gap by presenting a framework for extending state-of-the-art traffic simulation models with sub models for drivers’ compliance to advice from an advisory eco-driving support systems. The developed simulation framework includes among others a model of driver’s compliance with the advice given by the system, a gear shifting model and a simplified model for estimating vehicles maximum possible acceleration. Data from field operational tests with a full advisory eco-driving system developed within the ecoDriver project was used to calibrate the developed compliance models. A set of verification simulations used to illustrate the effect of the combination of the ecoDriver system and drivers’ compliance to the advices are also presented

Intensive out-of-hospital coaching for frequently hospitalized COPD patients::a before-after feasibility study

Background. This study assesses whether out-of-hospital coaching of re-hospitalized, severe COPD patients by specialized respiratory nurses is feasible in terms of cost-effectiveness, implementation, and recipient acceptability. The coaching was aimed at improving patients’ health management abilities, motivation for healthy behavior, strengthening the professional and informal care network, stimulating physiotherapy treatment and exercise training, improving knowledge on symptom recognition and medication use, and providing safety and support. Methods. Cost-effectiveness of 6 months of out-of-hospital coaching was assessed based on a before-after intervention design, with real-life data and one-year follow-up. A total of 170 patients were included. Primary (questionnaires, meeting reports) and secondary data (insurance reimbursement data) were collected in one province in the Netherlands. The implementing and recipient acceptability was assessed based on the number of successfully delivered coaching sessions, questionnaire response rate, Patient Reported Experience Measure, and interviews with coaches. Results. Post-intervention, the COPD-related hospitalization rate was reduced by 24%, and patients improved in terms of health status, anxiety, and nutritional status. Patients with a high mental burden and a poor score for health impairment and wellbeing at the start of the intervention showed the greatest reduction in hospitalizations. The coaching service was successfully implemented and considered acceptable by recipients, based on patient and coach satisfaction and clinical use of patient-reported measures.Conclusion. The study demonstrates the value of coaching patients out-of-hospital, with a strong link to primary care, but with support of hospital expertise, thereby adding to previous studies on disease- or self-management support in either primary or secondary care settings. Patients benefit from personal attention, practical advice, exercise training, and motivational meetings, thereby improving health status and reducing the likelihood of re-hospitalization and its associated costs

Exploring molecular biology in sequence space: the road to next-generation single-molecule biophysics

Next-generation sequencing techniques have led to a new quantitative dimension in the biological sciences. In particular, integrating sequencing techniques with biophysical tools allows sequence-dependent mechanistic studies. Using the millions of DNA clusters that are generated during sequencing to perform high-throughput binding affinity and kinetics measurements enabled the construction of energy landscapes in sequence space, uncovering relationships between sequence, structure, and function. Here, we review the approaches to perform ensemble fluorescence experiments on next-generation sequencing chips for variations of DNA, RNA, and protein sequences. As the next step, we anticipate that these fluorescence experiments will be pushed to the single-molecule level, which can directly uncover kinetics and molecular heterogeneity in an unprecedented high-throughput fashion. Molecular biophysics in sequence space, both at the ensemble and single-molecule level, leads to new mechanistic insights. The wide spectrum of applications in biology and medicine ranges from the fundamental understanding of evolutionary pathways to the development of new therapeutics.Biological and Soft Matter Physic

Visualizing China’s Belt and Road Initiative on RT (Russia Today): from infrastructural project to human development

This paper comprises original research on China’s use of bilateral media cooperation to mediate its Belt and Road Initiative (BRI). Building upon the literature on strategic narratives, aesthetic power and the Silk Road as a foreign policy concept, we present a detailed case study of the visual imagery of the “Silk Road” documentary collaboration between China’s and Russia’s state-owned international broadcasters, China Radio International and RT (formerly Russia Today). We employ a visual methodology to interrogate the formation and projection of multimodal (visual, textual and oral) narratives about China’s infrastructural activities along this metaphorical new “Silk Road”. We examine how the Silk Road series gives sense to China’s BRI, the relative weighting of Chinese and Russian strategic narratives about the BRI, and how power is distributed in this Chinese-Russian media partnership. Our analysis reveals that in re-packaging visual imagery that applies nostalgia to the history of core places and technologizes their future, the series projects a pre-curated Chinese visual narrative that emplots the BRI as human and cultural development. Russian regional strategic narratives are marginalized. China is applying its aesthetic power to Russian journalists and politicians; RT obtains some commercial benefits, but the Russian state’s aesthetic power is ceded to China