"Strangers in the ER"

Quality indicators and third party interference in Dutch emergency care

F.B. Moes, E.S. Houwaart, D. Delnoij, K. Horstman

Research output: Contribution to journalArticleScientificpeer-review

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Abstract

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, in‐depth conversations, and formal interviews with 5 key‐informants.
Results
The National Health Care Institute problematized not only the evidence supporting insurers' indicators, but also—and especially—the 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 Evidence‐based Medicine always feared uncritical use of evidence by third parties. For non‐medical parties who have no access to primary care processes, the type of standardized knowledge professed by Evidence‐based Medicine provides the easiest way to gain insights into “what works” 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.
Original languageEnglish
Pages (from-to)390-397
JournalJournal of Evaluation in Clinical Practice
Volume25
Issue number3
DOIs
Publication statusPublished - 2019

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Insurance Carriers
Emergency Medical Services
Delivery of Health Care
Medicine
Observation
Interviews

Keywords

  • HEALTH-INSURANCE
  • MEDICINE
  • PERFORMANCE
  • SOCIOLOGY
  • emergency care
  • evidence-based medicine
  • health insurance
  • health services research
  • quality indicators

Cite this

Moes, F.B. ; Houwaart, E.S. ; Delnoij, D. ; Horstman, K. / "Strangers in the ER" : Quality indicators and third party interference in Dutch emergency care. In: Journal of Evaluation in Clinical Practice. 2019 ; Vol. 25, No. 3. pp. 390-397.
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abstract = "Rationale, aims, and objectivesThis 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.MethodWe conducted ethnographic research into the knowledge work of the National Health Care Institute. Research entailed document analysis, participant observation, in‐depth conversations, and formal interviews with 5 key‐informants.ResultsThe National Health Care Institute problematized not only the evidence supporting insurers' indicators, but also—and especially—the 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.ConclusionsEven if quality indicators are based on scientific evidence, they are not axiomatically good or useful. Both proponents and critics of Evidence‐based Medicine always feared uncritical use of evidence by third parties. For non‐medical parties who have no access to primary care processes, the type of standardized knowledge professed by Evidence‐based Medicine provides the easiest way to gain insights into “what works” 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.",
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year = "2019",
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"Strangers in the ER" : Quality indicators and third party interference in Dutch emergency care. / Moes, F.B.; Houwaart, E.S.; Delnoij, D.; Horstman, K.

In: Journal of Evaluation in Clinical Practice, Vol. 25, No. 3, 2019, p. 390-397.

Research output: Contribution to journalArticleScientificpeer-review

TY - JOUR

T1 - "Strangers in the ER"

T2 - Quality indicators and third party interference in Dutch emergency care

AU - Moes, F.B.

AU - Houwaart, E.S.

AU - Delnoij, D.

AU - Horstman, K.

PY - 2019

Y1 - 2019

N2 - Rationale, aims, and objectivesThis 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.MethodWe conducted ethnographic research into the knowledge work of the National Health Care Institute. Research entailed document analysis, participant observation, in‐depth conversations, and formal interviews with 5 key‐informants.ResultsThe National Health Care Institute problematized not only the evidence supporting insurers' indicators, but also—and especially—the 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.ConclusionsEven if quality indicators are based on scientific evidence, they are not axiomatically good or useful. Both proponents and critics of Evidence‐based Medicine always feared uncritical use of evidence by third parties. For non‐medical parties who have no access to primary care processes, the type of standardized knowledge professed by Evidence‐based Medicine provides the easiest way to gain insights into “what works” 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.

AB - Rationale, aims, and objectivesThis 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.MethodWe conducted ethnographic research into the knowledge work of the National Health Care Institute. Research entailed document analysis, participant observation, in‐depth conversations, and formal interviews with 5 key‐informants.ResultsThe National Health Care Institute problematized not only the evidence supporting insurers' indicators, but also—and especially—the 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.ConclusionsEven if quality indicators are based on scientific evidence, they are not axiomatically good or useful. Both proponents and critics of Evidence‐based Medicine always feared uncritical use of evidence by third parties. For non‐medical parties who have no access to primary care processes, the type of standardized knowledge professed by Evidence‐based Medicine provides the easiest way to gain insights into “what works” 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.

KW - HEALTH-INSURANCE

KW - MEDICINE

KW - PERFORMANCE

KW - SOCIOLOGY

KW - emergency care

KW - evidence-based medicine

KW - health insurance

KW - health services research

KW - quality indicators

U2 - 10.1111/jep.12900

DO - 10.1111/jep.12900

M3 - Article

VL - 25

SP - 390

EP - 397

JO - Journal of Evaluation in Clinical Practice

JF - Journal of Evaluation in Clinical Practice

SN - 1356-1294

IS - 3

ER -