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\"Michael Jackson is one of the most influential cultural figures to come out of the 20th century and his legacy continues into the 21st century. His significance is widely acknowledged when it comes to music, music videos, dance, choreography and fashion, but his considerable influence on contemporary art is an untold story. Since Andy Warhol first used his image in 1982, Jackson has become the most depicted cultural figure in visual art by an extraordinary array of leading contemporary artists. For the first time, Michael Jackson: On the Wall will bring together the works of over forty of these artists, drawn from public and private collections around the world, including new works made especially for the exhibition.\"--Publisher's description.

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.

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.

Background Living in a deprived neighborhood is associated with poorer health, due to factors such as lower socio-economic status and an adverse lifestyle. There is little insight into whether living in deprived neighborhood is associated with adverse maternity care outcomes and maternity health care costs. We expect women in a deprived neighborhood to experience a more complicated pregnancy, with more secondary obstetric care (as opposed to primary midwifery care) and higher maternity care costs. This study aimed to answer the following research question: to what extent are moment of referral from primary to secondary care, mode of delivery, (extreme or very) preterm delivery and maternity care costs associated with neighborhood deprivation? Methods This retrospective cohort study used a national Dutch database with healthcare claims processed by health insurers. All pregnancies that started in 2018 were included. The moment of referral from primary to secondary care, mode of delivery, (extreme or very) preterm delivery and maternity care costs were compared between women in deprived and non-deprived neighborhoods. We reported descriptive statistics, and results of ordinal logistic, multinomial and linear regressions to assess whether differences between the two groups exist. Results Women in deprived neighborhoods had higher odds of being referred from primary to secondary care during pregnancy (adjusted OR 1.49, 95%CI 1.41–1.57) and to start their pregnancy in secondary care (adjusted OR 1.55, 95%CI 1.44–1.66). Furthermore, women in deprived neighborhoods had lower odds of assisted delivery than women in non-deprived neighborhoods (adjusted OR 0.73, 95%CI 0.66–0.80), and they had higher odds of a cesarean section (adjusted OR 1.19, 95%CI 1.13–1.25). On average, women in a deprived neighborhood had higher maternity care costs worth 156 euros (95%CI 104–208). Conclusion This study showed that living in a deprived neighborhood is associated with more intensive maternal care and higher maternal care costs in the Netherlands. These findings support the needs for greater attention to socio-economic factors in maternity care in the Netherlands.

Background Patients having forgone healthcare because of the costs involved has become more prevalent in recent years. Certain patient characteristics, such as income, are known to be associated with a stronger demand-response to cost-sharing. In this study, we first assess the relative importance of patient characteristics with regard to having forgone healthcare due to cost-sharing payments, and then employ qualitative methods in order to understand these findings better. Methods Survey data was collected from a Dutch panel of regular users of healthcare. Logistic regression models and dominance analyses were performed to assess the relative importance of patient characteristics, i.e., personal characteristics, health, educational level, sense of mastery and financial situation. Semi-structured interviews ( n  = 5) were conducted with those who had forgone healthcare. The verbatim transcribed interviews were thematically analyzed. Results Of the 7,339 respondents who completed the questionnaire, 1,048 respondents (14.3%) had forgone healthcare because of the deductible requirement. The regression model indicated that having a higher income reduced the odds of having forgone recommended healthcare due to the deductible (odds ratios of higher income categories relative to the lowest income category (reference): 0.29–0.49). However, dominance analyses revealed that financial leeway was more important than income: financial leeway contributed the most (34.8%) to the model’s overall McFadden’s pseudo-R2 (i.e., 0.123), followed by income (25.6%). Similar results were observed in stratified models and in population weighted models. Qualitative analyses distinguished four main themes that affected the patient’s decision whether to use healthcare: financial barriers, structural barriers related to the complex design of cost-sharing programs, individual considerations of the patient, and the perceived lack of control regarding treatment choices within a given treatment trajectory. Furthermore, “ having forgone healthcare” seemed to have a negative connotation. Conclusion Our findings show that financial leeway is more important than income with respect to having forgone recommended healthcare due to cost-sharing payments, and that other factors such as the perceived necessity of healthcare also matter. Our findings imply that solely adapting cost-sharing programs to income levels will only get one so far. Our study underlines the need for a broader perspective in the design of cost-sharing programs.

BackgroundThere is an increasing number of quality indicators being reported publicly with aim to improve the transparency on hospital care quality. However, they are little used by patients. Knowledge on patients’ preferences regarding quality may help to optimise the information presented to them.ObjectiveTo measure the preferences of patients with breast and colon cancers regarding publicly reported quality indicators of Dutch hospital care.MethodsFrom the existing set of clinical quality indicators, participants of patient group discussions first assessed an indicator’s suitability as choice information and then identified the most relevant ones. We used the final selection as attributes in two discrete choice experiments (DCEs). Questionnaires included choice vignettes as well as a direct ranking exercise, and were distributed among patient communities. Data were analysed using mixed logit models.ResultsBased on the patient group discussions, 6 of 52 indicators (breast cancer) and 5 of 21 indicators (colon cancer) were selected as attributes. The questionnaire was completed by 84 (breast cancer) and 145 respondents (colon cancer). In the patient group discussions and in the DCEs, respondents valued outcome indicators as most important: those reflecting tumour residual (breast cancer) and failure to rescue (colon cancer). Probability analyses revealed a larger range in percentage change of choice probabilities for breast cancer (10.9%–69.9%) relative to colon cancer (7.9%–20.9%). Subgroup analyses showed few differences in preferences across ages and educational levels. DCE findings partly matched with those of direct ranking.ConclusionStudy findings show that patients focused on a subset of indicators when making their choice of hospital and that they valued outcome indicators the most. In addition, patients with breast cancer were more responsive to quality information than patients with colon cancer.

Electronic nicotine delivery systems (ENDS) are rapidly increasing in popularity. However, little is known about sociodemographic differences in use of ENDS. This study aims to assess the sociodemographic characteristics associated with ENDS ever-use and use as a cessation tool in the European Union. We analyzed data from the 2012 Eurobarometer wave 77.1, with 25 922 respondents aged 15 years or above from all 27 member states. We estimated the prevalence of ever-use and use as a cessation tool, and performed binary logistic regression to analyze associations with sociodemographic characteristics. Overall, 7.2% reported having ever used ENDS. Of all smokers who ever tried to quit, 7.0% used ENDS. Ever-use was inversely associated with being older than 34 years (odds ratio [OR] = 0.63, 95% confidence interval [CI] = 0.51-0.76 for 35-44 years, and OR = 0.34, 95% CI = 0.25-0.46 for at least 65 years), and positively associated with being higher educated (OR = 1.50, 95% CI = 1.22-1.84) or a student (OR = 2.34, 95% CI = 1.77-3.08). ENDS were more often used to quit smoking by students (OR = 2.05, 95% CI = 1.10-3.82), and were less likely to be used by those aged 65 or older (OR = 0.30, 95% CI = 0.15-0.61). No significant differences were found according to sex, social class, marital status or type of community. In 2012, ever-use of ENDS was low in the European population in general. However, younger people or those with a high education used ENDS more frequently. These results indicate a need for more appropriate product information targeted at these groups. This study shows that in the European Union in 2012, regular use of ENDS was rare, especially among nonsmokers. Only age and education were strongly associated with ENDS use. The increased prevalence of ever-use among the younger age groups is relevant, as in this age group smoking habits are established. The higher ever-use of ENDS among younger and higher educated people found in this study indicates a need to target appropriate product information, stressing that ENDS use does not imply zero harm.

Background Cost-sharing programs are often too complex to be easily understood by the average insured individual. Consequently, it is often difficult to determine the amount of expenses in advance. This may preclude well-informed decisions of insured individuals to adhere to medical treatment advised by the treating physician. Preliminary research has showed that the uncertainty in these cost-sharing payments are affected by four design characteristics, i.e. 1) type of payments (copayments, coinsurances or deductibles), 2) rate of payments, 3) annual caps on cost-sharing and 4) moment that these payments must be made (directly at point of care or billed afterwards by the insurer). Methods An online discrete choice experiment was used to assess the extent to which design characteristics of cost-sharing programs affect the decision of individuals to adhere to recommended care (prescribed medications, ordered diagnostic tests and referrals to medical specialist care). Analyses were performed using mixed multinomial logits. Results The questionnaire was completed by 7921 members of a patient organization. Analyses showed that 1) cost-sharing programs that offer clear information in advance on actual expenses that are billed afterwards, stimulate adherence to care recommended by the treating physician; 2) the relative importance of the design characteristics differed between respondents who reported to have forgone health care due to cost-sharing and those who did not; 3) price-awareness among respondents was limited; 4) the utility derived from attributes and respondents’ characteristics were positively correlated; 5) an optimized cost-sharing program revealed an adherence of more than 72.9% among those who reported to have forgone health care. Conclusions The analyses revealed that less complex cost-sharing programs stimulate adherence to recommended care. If these programs are redesigned accordingly, individuals who had reported to have forgone a health service recommended by their treating physician due to cost-sharing, would be more likely to use this service. Such redesigned programs provide a policy option to reduce adverse health effects of cost-sharing in these groups. Considering the upcoming shift from volume-based to value-based health care provision, insights into the characteristics of a cost-sharing program that stimulates the use of recommended care may help to design value-based insurance plans.

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.

We analyze the effect of economic conditions early in life on individual mortality rate later in life, using business cycle conditions early in life as an exogenous indicator. Individual records from Dutch registers of birth, marriage, and death, covering a window of unprecedented size (1912–2000) are merged with historical data on macroeconomic and health indicators. We correct for secular changes over time and other mortality determinants. We nonparametrically compare those born in a recession to those born in the preceding boom, and we estimate duration models where the individual's mortality rate depends on current conditions, conditions early in life, age individual characteristics, including individual socioeconomic indicators, and interaction terms. The results indicate a significant negative effect of economic conditions early in life on individual mortality rates at all ages.