Purchaser–provider splits in health care—The case of Finland

The purchaser–provider split (PPS) is a service delivery model in which third-party payers are kept organizationally separate from service providers. The operations of the providers are managed by contracts. One of the main aims of PPS is to create competition between providers. Competition and other incentive structures built into the contractual relationship are believed to lead to improvements in service delivery, such as improved cost containment, greater efficiency, organizational flexibility, better quality and improved responsiveness of services to patient needs. PPS was launched in Finland in the early 1990s but was not widely implemented until the early 2000s. Compared to other countries with PPS the development and implementation of PPS in Finland has been unusual. Firstly, purchasing is implemented at the level of municipalities, which means that the size of the Finnish purchasers is extremely small. Elsewhere purchasing is mostly implemented at the regional or national levels. Secondly, PPS is also applied to primary health care and A&E services while in other countries the services mainly include specialized health care and residential care for the elderly. Thirdly, PPS in health and social services is not regulated by any specific legislation, regulative mechanisms or guidelines. Instead it is regulated within the same framework as public procurement in general.     

Unintended consequences of policy change to watchful waiting for asymptomatic inguinal hernias

Introduction

In 2009 the Department of Health instructed McKinsey & Company to provide advice on how commissioners might achieve world class National Health Service productivity. Asymptomatic inguinal hernia repair was identified as a potentially cosmetic procedure, with limited clinical benefit. The Birmingham and Solihull primary care trust cluster introduced a policy of watchful waiting for asymptomatic inguinal hernia, which was implemented across the health economy in December 2010. This retrospective cohort study aimed to examine the effect of a change in clinical commissioning policy concerning elective surgical repair of asymptomatic inguinal hernias.

Methods

A total of 1,032 patients undergoing inguinal hernia repair in the 16 months after the policy change were compared with 978 patients in the 16 months before. The main outcome measure was relative proportion of emergency repair in groups before and after the policy change. Multivariate binary logistic regression was used to adjust the main outcome for age, sex and hernia type.

Results

The period after the policy change was associated with 59% higher odds of emergency repair (3.6% vs 5.5%, adjusted odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.03–2.47). In turn, emergency repair was associated with higher odds of adverse events (4.7% vs 18.5%, adjusted OR: 3.68, 95% CI: 2.04–6.63) and mortality (0.1% vs 5.4%, p<0.001, Fisher’s exact test).

Conclusions

Introduction of a watchful waiting policy for asymptomatic inguinal hernias was associated with a significant increase in need for emergency repair, which was in turn associated with an increased risk of adverse events. Current policies may be placing patients at risk.     

Commissioning of volumetric modulated arc therapy (VMAT) in a dual-vendor environment

Methods and results for commissioning of the complete VMAT delivery chain are presented for the combination of Nucletron’s Oncentra MasterPlan® v3.3 with Elekta’s Mosaiq® v1.6 and SynergyS® linac. VMAT specific linac commissioning included determination of the size of the minimal dynamic leaf gap. Dosimetric validation of the complete treatment chain was performed using a 2D-ionization-chamber-array and showed excellent dosimetric results.     

The effect of commissioning on Portuguese Primary Health Care units’ performance: A four-year national analysis

BackgroundPortugal underwent a paradigmatic Primary Health Care (PHC) reform in 2005. The reform implemented better health information systems, goal-oriented management, pay-for-performance schemes, functional autonomy for the front-line units, and the general adoption of commissioning processes.Since the implementation of the reform, the same set of indicators have been monitored nationally every year. However, from 2014–2016, the five Regional Health Administrations could individually select part of set of indicators to be commissioned.As the same some indicators were used commissioned in some regions, but not in others, a natural experimental setting to observe the impact of commissioning on the results by comparing the performance of commissioned versus non-commissioned indicators emerged and the effects of commissioning on PHC performance could be evaluated.AimOur article aims to clarify the effect of commissioning on the results achieved by PHC units in Portugal following the implementation of the reform.ResultsIn general, the indicator values improved with time in the three types of units that existed after the reform. However, Model B Family Health Units (‘Unidades de Saúde Familiar’ or USFs that use pay-for-performance and are more mature) obtained the highest absolute indicator values, followed by Model A USFs (newer units with a fixed salary) and Personalised Health Care Units (‘Unidades de Cuidados de Saúde Personalizados’ that were created under the model before the reform and offer a fixed salary), respectively.ConclusionThe results show a general increase in indicators in all PHC units. However, the indicators used in the commissioning processes exhibited a greater increase. There was no evidence that the better results exhibited by the commissioned indicators were achieved at the expense of a detrimental effect on non-commissioned indicators.     

Mechanical evaluation of the Bravos afterloader system for HDR brachytherapy

PurposeThe Bravos afterloader system was released by Varian Medical Systems in October of 2018 for high-dose-rate brachytherapy with ¹⁹²Ir sources, containing new features such as the CamScale (a new device for daily quality assurance and system recalibration), channel length verification, and different settings for rigid and flexible applicators. This study mechanically evaluated the Bravos system precision and accuracy for clinically relevant scenarios, using dummy sources.Methods and MaterialsThe system was evaluated after three sets of experiments: (1) The CamScale was used to verify inter- and intra-channel dwelling variability and system calibration; (2) A high-speed camera was used to verify the source simulation cable movement inside a transparent quality assurance device, where dwell positions, dwell times, transit times, speed profiles, and accelerations were measured; (3) The source movement inside clinical applicators was captured with an imaging panel while being exposed to an external kV source. Measured and planned dwell positions and times were compared.ResultsMaximum deviations between planned and measured dwell positions and times for the source cable were 0.4 mm for the CamScale measurements and 0.07 seconds for the high-speed camera measurements. Mean dwell position deviations inside clinical applicators were below 1.2 mm for all applicators except the ring that required an offset correction of 1 mm to achieve a mean deviation of 0.4 mm.ConclusionsFeatures of the Bravos afterloader system provide a robust and precise treatment delivery. All measurements were within manufacturer specifications.     

Members of the British Orthodontic Community are still being abused by the European system.

Abstract

This paper discusses the possibility of new forms of contacting or commissioning emerging between UK Health Authorities (or other parties such as Primary Care Groups and Primary Care Trusts) and established providers of specialist orthodontic services.     

Commissioning and quality assurance of RapidArc radiotherapy delivery system

PURPOSE: The Varian RapidArc is a system for intensity-modulated radiotherapy (IMRT) treatment planning and delivery. RapidArc incorporates capabilities such as variable dose-rate, variable gantry speed, and accurate and fast dynamic multileaf collimators (DMLC), to optimize dose conformality, delivery efficiency, accuracy and reliability. We developed RapidArc system commissioning and quality assurance (QA) procedures. METHODS AND MATERIALS: Tests have been designed that evaluate RapidArc performance in a stepwise manner. First, the accuracy of DMLC position during gantry rotation is examined. Second, the ability to vary and control the dose-rate and gantry speed is evaluated. Third, the combined use of variable DMLC speed and dose-rate is studied. RESULTS: Adapting the picket fence test for RapidArc, we compared the patterns obtained with stationary gantry and in RapidArc mode, and showed that the effect of gantry rotation on leaf accuracy was minimal (相似文献