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Abstract Background Latin America and the Caribbean (LAC) is among the most unequal regions in the world in terms of wealth and household income. Such inequalities have been shown to influence different outcomes during the COVID-19 pandemic, including the disruption of routine health services. The aim of this paper is to examine socioeconomic inequalities in household experiences of healthcare disruption in LAC countries from mid-2020 to late 2021. Methods We used household-level data from the COVID-19 High Frequency Phone Surveys (HFPS), conducted in 14 LAC countries in one round in 2020 and 24 countries in two rounds in 2021. Ordinary least square and Logit multivariate regressions were conducted to examine the correlation between reported healthcare disruptions with household characteristics for 2020 and 2021. Since household income levels were not directly collected in the HPFS, we created an index of inequality and estimated the relative index of inequality. Results When analyzing 2020–2021 together, reported healthcare disruptions were lower if the respondent was employed or did not report lack of food in the last month; if the household had more people aged 65 or older or more rooms to sleep in. When analyzed separately in 2020 and 2021, having more people aged 65 or older or not experiencing food insecurity remained stable factors for lower odds of disruption in both years. In addition, being employed was associated with lower odds of disruption in 2020, while being male or having more rooms to sleep in were associated with lower odds of disruption in 2021. Regarding wealth differences in 2021 (it was not possible to compute it for 2020), households with the lowest wealth were 27.3% more likely to report a care disruption than households with the highest wealth. Conclusions The socioeconomic status of households in LAC was a relevant factor in explaining the disruption of healthcare during the COVID19 pandemic, with a clear social gradient where the wealthier a household, the less likely it was to experience disruption of care. Food security, employment, and gender policies should be integral to preparing for and responding to future shocks such as pandemics. Prioritizing the most affected populations, like the elderly during COVID-19, can enhance the health system effectiveness.

Abstract Background The COVID-19 pandemic severely impacted care for non-COVID patients. Performance indicators to monitor acute care, timely reported and internationally accepted, lacked during the pandemic in OECD countries. This study aims to summarize the performance indicators available in the literature to monitor changes in the quality of acute care in OECD countries during the first year and a half of the pandemic (2020-July 2021) and to assess their trends. Methods Scoping review. Search in Embase and MEDLINE (07-07-2022). Acute care performance indicators and indicators related to acute general surgery were collected and collated following a care pathway approach. Indicators assessing identical clinical measures were grouped under a common indicator title. The trends from each group of indicators were collated (increase/decrease/stable). Results A total of 152 studies were included. 2354 indicators regarding general acute care and 301 indicators related to acute general surgery were included. Indicators focusing on pre-hospital services reported a decreasing trend in the volume of patients: from 225 indicators, 110 (49%) reported a decrease. An increasing trend in pre-hospital treatment times was reported by most of the indicators (n = 41;70%) and a decreasing trend in survival rates of out-of-hospital cardiac arrest (n = 61;75%). Concerning care provided in the emergency department, most of the indicators (n = 752;71%) showed a decreasing trend in admissions across all levels of urgency. Concerning the mortality rate after admission, most of the indicators (n = 23;53%) reported an increasing trend. The subset of indicators assessing acute general surgery showed a decreasing trend in the volume of patients (n = 50;49%), stability in clinical severity at admission (n = 36;53%), and in the volume of surgeries (n = 14;47%). Most of the indicators (n = 28;65%) reported no change in treatment approach and stable mortality rate (n = 11,69%). Conclusion This review signals relevant disruptions across the acute care pathway. A subset of general surgery performance indicators showed stability in most of the phases of the care pathway. These results highlight the relevance of assessing this care pathway more regularly and systematically across different clinical entities to monitor disruptions and to improve the resilience of emergency services during a crisis.

Abstract Background International mobility of health workforce affects the performance of health systems and has major relevance in human resources for health policy and planning. To date, there has been little research exploring the reasons why general practitioners (GPs) migrate. This mixed methods study aimed to investigate the reasons why Spain-trained GPs migrate and develop GP retention and recruitment health policy recommendations relevant to Spanish primary care. Methods The study followed an explanatory sequential mixed methods study design combining surveys with semi-structured interviews and focus groups with GPs who qualified in Spain and were living overseas at the time of the study. The survey data examined the reasons why GPs left Spain and their intention to return and were analysed using quantitative methods. The transcripts from interviews and focus groups centred on GPs’ insights to enhance retention and recruitment in Spain and were analysed thematically. Results The survey had 158 respondents with an estimated 25.4% response rate. Insufficient salary (75.3%), job insecurity and temporality (67.7%), excessive workload (67.7%), poor primary care governance (55.7%), lack of flexibility in the workplace (43.7%) and personal circumstances (43.7%) were the main reasons for leaving Spain. Almost half of the respondents (48.7%) would consider returning to Spanish general practice if their working conditions improved. Interviews and focus groups with respondents (n = 24) pointed towards the need to improve the quality of employment contracts, working conditions, opportunities for professional development, and governance in primary care for effective retention and recruitment. Conclusion Efforts to improve GP retention and recruitment in Spain should focus on salary, job security, flexibility, protected workload, professional development, and governance. We draw ten GP retention and recruitment recommendations expected to inform urgent policy action to tackle existing and predicted GP shortages in Spanish primary care.

Abstract Background In insurance-based healthcare systems, healthcare insurers are interested in engaging citizens in care procurement to contract healthcare services that matter to people. In the Netherlands, an amendment to the Health Insurance Act was set forth in 2021 to formalize and strengthen the engagement of the insured population with healthcare insurers’ procurement cycles. This study explores the role of Dutch healthcare insurers in operationalizing citizen engagement in procurement cycles before changes occur linked to the amendment to the Health Insurance Act. Methods A phenomenological qualitative design was employed in two phases: (1) we consulted academics and policy experts on the role of healthcare insurers regarding citizen engagement; (2) we conducted focus groups with representatives of healthcare insurers to understand how citizens’ engagement is being operationalized. Transcripts of the interviews with experts and detailed notes of focus group meetings were analysed using a qualitative inductive approach. Selected excerpts were analysed on discourse and content and organized by a coding scheme following a rigorous and accelerated data reduction technique. Results We identified four strategies used by healthcare insurers to operationalize citizen engagement: (1) broadening their population health orientation; (2) developing and improving mechanisms for engaging citizens; (3) strengthening features of data governance for effective use of value-driven data; (4) implementing financial and incentive mechanisms among healthcare providers in support of value-based healthcare. However, regulated market mechanisms and low institutional trust in healthcare insurers undermine their transition from merely funding healthcare towards becoming people-centred value-based healthcare purchasers. Conclusion Dutch healthcare insurers seem to be strengthening the community orientation of their functioning while enhancing the end-to-end experience of the insured. The expected practical effects of the amendment to the Health Insurance Act include broadening the role of the council of insurees in decision-making processes and systematically documenting the efforts set forth by healthcare insurers in engaging citizens. Further research is needed to better understand how the regulated competitive market could be hampering the engagement of citizens in healthcare procurement decision-making and value creation from the citizens’ perspective.

Abstract Background Between 2019 and 2021, the first Irish health system performance assessment (HSPA) framework was developed. As routinely collected health data are necessary to continuously populate indicators of an HSPA framework, a purpose-driven assessment of the health information system (HIS) in Ireland and its fitness to support the implementation of an HSPA framework was conducted. This study reports on the status of the Irish HIS through a multimethod assessment based on continuous broad stakeholder involvement. Methods Between May and November 2020, over 50 informants were engaged in individual and group interviews and stakeholder consultation workshops as part of the HIS assessment process. Descriptive themes and high-level data availability heatmaps were derived from interview and workshop data using thematic analysis. Indicator “passports” for the HSPA framework were populated during stakeholder consultation workshops and analysed using univariate descriptive statistics. Results The HIS in Ireland was able to provide administrative, survey and registry-based data for public sector acute care services, focusing on structure, process and output metrics. Significant data availability gaps, most notably from primary care, private hospitals and community care, were reported, with little availability of electronic health record and people-reported data. Data on outcome metrics were mostly missing, as were linkage possibilities across datasets for care pathway monitoring. The COVID-19 pandemic highlighted the national HIS’s shortcomings but also the capacity for rapid development and improvement. Conclusions A tailor-made assessment of the HIS in Ireland, involving a broad set of relevant stakeholders, revealed strengths, weaknesses and areas for improvement in the Irish health data landscape. It also contributed to the development of a national HSPA framework and momentum to further strengthen data infrastructure and governance, while working towards a more data-driven and person-centred healthcare system. This work demonstrates the utility of an inclusive HIS assessment process and is applicable beyond Ireland, where this case study was conducted.

Abstract Background Cancer comprises a high burden on health systems. Performance indicators monitoring cancer outcomes are routinely used in OECD countries. However, the development of process and cancer-pathway based information is essential to guide health care delivery, allowing for better monitoring of changes in the quality of care provided. Assessing the changes in the quality of cancer care during the COVID-19 pandemic requires a structured approach considering the high volume of publications. This study aims to summarize performance indicators used in the literature to evaluate the impact of the COVID-19 pandemic on cancer care (January-June 2020) in OECD countries and to assess changes in the quality of care as reported via selected indicators. Methods Search conducted in MEDLINE and Embase databases. Performance indicators and their trends were collated according to the cancer care pathway. Results This study included 135 articles, from which 1013 indicators were retrieved. Indicators assessing the diagnostic process showed a decreasing trend: from 33 indicators reporting on screening, 30 (91%) signalled a decrease during the pandemic (n = 30 indicators, 91%). A reduction was also observed in the number of diagnostic procedures (n = 64, 58%) and diagnoses (n = 130, 89%). The proportion of diagnoses in the emergency setting and waiting times showed increasing trends (n = 8, 89% and n = 14, 56%, respectively). A decreasing trend in the proportion of earliest stage cancers was reported by 63% of indicators (n = 9), and 70% (n = 43) of indicators showed an increasing trend in the proportion of advanced-stage cancers. Indicators reflecting the treatment process signalled a reduction in the number of procedures: 79%(n = 82) of indicators concerning surgeries, 72%(n = 41) of indicators assessing radiotherapy, and 93%(n = 40) of indicators related to systemic therapies. Modifications in cancer treatment were frequently reported: 64%(n = 195) of indicators revealed changes in treatment. Conclusions This study provides a summary of performance indicators used in the literature to assess the cancer care pathway from January 2020 to June 2020 in OECD countries, and the changes in the quality of care signalled by these indicators. The trends reported inform on potential bottlenecks of the cancer care pathway. Monitoring this information closely could contribute to identifying moments for intervention during crises.

Abstract Background In complex critical neonatal and paediatric clinical practice, little is known about long-term patient outcomes and what follow-up care is most valuable for patients. Emma Children’s Hospital, Amsterdam UMC (Netherlands), implemented a follow-up programme called Follow Me for neonatal and paediatric patient groups, to gain more insight into long-term outcomes and to use such outcomes to implement a learning cycle for clinical practice, improve follow-up care and facilitate research. Three departments initiated re-engineering and change processes. Each introduced multidisciplinary approaches to long-term follow-up, including regular standardised check-ups for defined age groups, based on medical indicators, developmental progress, and psychosocial outcomes in patients and their families. This research evaluates the implementation of the three follow-up programmes, comparing predefined procedures (work-as-imagined) with how the programmes were implemented in practice (work-as-done). Methods This study was conducted in 2019–2020 in the outpatient settings of the neonatal intensive care, paediatric intensive care and paediatric surgery departments of Emma Children’s Hospital. It focused on the organisational structure of the follow-up care. The functional resonance analysis method (FRAM) was applied, using documentary analysis, semi-structured interviews, observations and feedback sessions. Results One work-as-imagined model and four work-as-done models were described. The results showed vast data collection on medical, developmental and psychosocial indicators in all work-as-done models; however, process indicators for programme effectiveness and performance were missing. In practice there was a diverse allocation of roles and responsibilities and their interrelations to create a multidisciplinary team; there was no one-size-fits-all across the different departments. Although control and feedback loops for long-term outcomes were specified with respect to the follow-up groups within the programmes, they were found to overlap and misalign with other internal and external long-term outcome monitoring practices. Conclusion Implementing structured long-term follow-up may provide insights for improving daily practice and follow-up care, with the precondition of standardised measurements. Lessons learned from practice are (1) to address fragmentation in data collection and storage, (2) to incorporate the diverse ways to create a multidisciplinary team in practice, and (3) to include timely actionable indicators on programme effectiveness and performance, alongside medical, developmental and psychosocial indicators.

Objectives Regulatory oversight organisations play an important role in quality stewardship in long-term care (LTC) facilities. Performance indicators are a key tool for any quality-related work. Our aim was to better understand how and what performance indicators are used by regulatory oversight organisations for long-term care facilities oversight and which features are affecting their fitness for use.Design Qualitative descriptive.Setting and participants We explored the use of LTC facility performance indicators by 10 regulatory oversight organisations from England, Ireland, Malta, New Zealand, Norway, Scotland, Singapore, Slovenia, Sweden and the Netherlands. We collected information by means of a questionnaire, 13 follow-up interviews with 20 experts from these organisations and document review.Results Performance indicators are used by participating oversight organisations to choose priority topics for audits, prioritise facilities to be audited and to identify areas within an audited facility, that require more attention. The indicators of most interest to oversight organisations are related to the dimensions of care articulated in the preset requirements on which audits are based. When the purpose of using indicators is to design a risk assessment model, the fitness for use of indicators ultimately depends on their ability to predict non-compliances on subsequent audits. When indicators are used directly by auditors, the ease of access, clear guidance to evaluate the data and the provision of contextual information are used by oversight organisations to increase fitness for use.Conclusions Oversight organisations do not use LTC facility performance indicators to assess quality, but rather to assess the risk of lower quality or of non-compliance with requirements. This risk-related purpose has to be considered when the indicators used in oversight are chosen and when other aspects of fitness for use, such as data analysis and displaying findings, are developed.

Background Governments across the World Health Organization (WHO) European Region have prioritised dashboards for reporting COVID-19 data. The ubiquitous use of dashboards for public reporting is a novel phenomenon. Objective This study explores the development of COVID-19 dashboards during the first year of the pandemic and identifies common barriers, enablers and lessons from the experiences of teams responsible for their development. Methods We applied multiple methods to identify and recruit COVID-19 dashboard teams, using a purposive, quota sampling approach. Semi-structured group interviews were conducted from April to June 2021. Using elaborative coding and thematic analysis, we derived descriptive and explanatory themes from the interview data. A validation workshop was held with study participants in June 2021. Results Eighty informants participated, representing 33 national COVID-19 dashboard teams across the WHO European Region. Most dashboards were launched swiftly during the first months of the pandemic, February to May 2020. The urgency, intense workload, limited human resources, data and privacy constraints and public scrutiny were common challenges in the initial development stage. Themes related to barriers or enablers were identified, pertaining to the pre-pandemic context, pandemic itself, people and processes and software, data and users. Lessons emerged around the themes of simplicity, trust, partnership, software and data and change. Conclusions COVID-19 dashboards were developed in a learning-by-doing approach. The experiences of teams reveal that initial underpreparedness was offset by high-level political endorsement, the professionalism of teams, accelerated data improvements and immediate support with commercial software solutions. To leverage the full potential of dashboards for health data reporting, investments are needed at the team, national and pan-European levels.

Objectives To explore available data sources, secondary uses and key considerations for optimising the actionability of primary care prescribing data to improve quality of care in the Dutch context.Design An exploratory qualitative study was undertaken based on semi-structured interviews. We anchored our investigation around three tracer prescription types: antibiotics; benzodiazepines and opioids. Descriptive and explanatory themes were derived from interview data using thematic analysis.Setting Stakeholders were sampled from across the micro (clinical), meso (organisational) and macro (policy) contexts of the Dutch primary care system.Participants The study involved 28 informants representing general practitioners (GPs), community pharmacists, regional chronic care networks (care groups), academia and research institutes, insurers, professional associations, electronic health record (EHR) vendors and national authorities.Results In the Netherlands, three main sources of data for improving prescribing in primary care are in use: clinical data in the EHRs of GP practices; pharmacy data in community pharmacy databases and claims data of insurers. While the secondary use of pharmacy and claims data is well-established across levels, the use of these data together with EHR data is limited. Important differences in the types of prescribing information needed by micro-meso-macro context are found, though the extent to which current indicators address these varies by prescription type. Five main themes were identified as areas for optimising data use: (1) measuring what matters, (2) increasing data linkages, (3) improving data quality, (4) facilitating data sharing and (5) optimising fit for use analysis.Conclusions To make primary care prescribing data useful for improving quality, consolidated patient-specific data on the indication for a prescription and dispensed medicine, over time, is needed. In the Netherlands, the selection of indicators requires further prioritisation to better signal the appropriateness and long-term use of prescription drugs. Prioritising data linkages is critical towards more actionable use.

Introduction: Data and digital infrastructure drive collaboration and help develop integrated healthcare systems and services. COVID-19 induced changes to collaboration between healthcare organisations, which previously often happened in fragmented and competitive ways. New collaborative practices relied on data and were crucial in managing coordinated responses to the pandemic. In this study, we explored data-driven collaboration between European hospitals and other healthcare organisations in 2021 by identifying common themes, lessons learned and implications going forward. Methods: Study participants were recruited from an existing Europe-wide community of mid-level hospital managers. For data collection, we ran an online survey, conducted multi-case study interviews and organised webinars. Data were analysed using descriptive statistics, thematic analysis and cross-case synthesis. Results: Mid-level hospital managers from 18 European countries reported an increase in data exchange between healthcare organisations during the COVID-19 pandemic. Data-driven collaborative practices were goal-oriented and focused on the optimisation of hospitals’ governance functions, innovation in organisational models and improvements to data infrastructure. This was often made possible by temporarily overcoming system complexities, which would otherwise hinder collaboration and innovation. Sustainability of these developments remains a challenge. Discussion: Mid-level hospital managers form a huge potential of reacting and collaborating when needed, including rapidly setting up novel partnerships and redefining established processes. Major post-COVID unmet medical needs are linked to hospital care provision, including diagnostic and therapeutic backlogs. Tackling these will require rethinking of the position of hospitals within healthcare systems, including their role in care integration. Conclusion: Learning from COVID-19-induced developments in data-driven collaboration between hospitals and other healthcare organisations is important to address systemic barriers, sustain resilience and further build transformative capacity to help build better integrated healthcare systems.

Abstract Background Health workers are at high risk of job burnout. Primary care in China has recently expanded its scope of services to a broader range of public health services in addition to clinical care. This study aims to measure the prevalence of burnout and identify its associated factors among clinical care and public health service providers at primary care facilities. Methods A cross-sectional survey (2018) was conducted among 17,816 clinical care and public health service providers at 701 primary care facilities from six provinces. Burnout was measured by the Chinese version of the Maslach Burnout Inventory-General Scale, and multilevel linear regression analysis was conducted to identify burnout’s association with demographics, as well as occupational and organisational factors. Results Overall, half of the providers (50.09%) suffered from burnout. Both the presence of burnout and the proportion of severe burnout among public health service providers (58.06% and 5.25%) were higher than among clinical care providers (47.55% and 2.26%, respectively). Similar factors were associated with burnout between clinical care and public health service providers. Younger, male, lower-educated providers and providers with intermediate professional title, permanent contract or higher working hours were related to a higher level of burnout. Organisational environment, such as the presence of a performance-based salary system, affected job burnout. Conclusions Job burnout is prevalent among different types of primary care providers in China, indicating the need for actions that encompass the entirety of primary care. We recommend strengthening the synergy between clinical care and public health services and transforming the performance-based salary system into a more quality-based system that includes teamwork incentives.

The COVID-19 pandemic has modified organisation and processes of primary care. In this paper, we aim to summarise experiences of international primary care systems. We explored personal accounts and findings in reporting on the early experiences from primary care during the pandemic, through the online Global Forum on Universal Health Coverage and Primary Health Care. During the early stage of the pandemic, primary care continued as the first point of contact to the health system but was poorly informed by policy makers on how to fulfil its role and ill equipped to provide care while protecting staff and patients against further spread of the infection. In many countries, the creativity and initiatives of local health professionals led to the introduction or extension of the use of telephone, e-mail and virtual consulting, and introduced triaging to separate ‘suspected’ COVID-19 from non-COVID-19 care. There were substantial concerns of collateral damage to the health of the population due to abandoned or postponed routine care. The pandemic presents important lessons to strengthen health systems through better connection between public health, primary care, and secondary care to cope better with future waves of this and other pandemics.

BackgroundPublic web-based COVID-19 dashboards are in use worldwide to communicate pandemic-related information. Actionability of dashboards, as a predictor of their potential use for data-driven decision-making, was assessed in a global study during the early stages of the pandemic. It revealed a widespread lack of features needed to support actionability. In view of the inherently dynamic nature of dashboards and their unprecedented speed of creation, the evolution of dashboards and changes to their actionability merit exploration. ObjectiveWe aimed to explore how COVID-19 dashboards evolved in the Canadian context during 2020 and whether the presence of actionability features changed over time. MethodsWe conducted a descriptive assessment of a pan-Canadian sample of COVID-19 dashboards (N=26), followed by an appraisal of changes to their actionability by a panel of expert scorers (N=8). Scorers assessed the dashboards at two points in time, July and November 2020, using an assessment tool informed by communication theory and health care performance intelligence. Applying the nominal group technique, scorers were grouped in panels of three, and evaluated the presence of the seven defined features of highly actionable dashboards at each time point. ResultsImprovements had been made to the dashboards over time. These predominantly involved data provision (specificity of geographic breakdowns, range of indicators reported, and explanations of data sources or calculations) and advancements enabled by the technologies employed (customization of time trends and interactive or visual chart elements). Further improvements in actionability were noted especially in features involving local-level data provision, time-trend reporting, and indicator management. No improvements were found in communicative elements (clarity of purpose and audience), while the use of storytelling techniques to narrate trends remained largely absent from the dashboards. ConclusionsImprovements to COVID-19 dashboards in the Canadian context during 2020 were seen mostly in data availability and dashboard technology. Further improving the actionability of dashboards for public reporting will require attention to both technical and organizational aspects of dashboard development. Such efforts would include better skill-mixing across disciplines, continued investment in data standards, and clearer mandates for their developers to ensure accountability and the development of purpose-driven dashboards.

Abstract Background Primary health care and its strengthening through performance measurement is essential for sustainably working towards universal health coverage. Existing performance frameworks and indicators to measure primary health care capture system functions like governance, financing and resourcing but to a lesser extent the function of services delivery and its heterogeneous nature. Moreover, most frameworks have weak links with routine information systems and national health priorities, especially in the context of high- and middle-income countries. This paper presents the development of a tool that responds to this context with the aim to create primary health care performance intelligence for the 53 countries of the WHO European Region. Methods The work builds-off of an existing systematic review on primary care and draws on priorities of current European health policies and available (inter)national information systems. Its development included: (i) reviewing and classifying features of primary care; (ii) constructing a set of tracer conditions; and (iii) mapping existing indicators in the framework resulting from (i). The analysis was validated through a series of reviews: in-person meetings with country-nominated focal points and primary care experts; at-distance expert reviews; and, preliminary testing with country informants. Results The resulting framework applies a performance continuum in the classical approach of structures-processes-outcomes spanning 6 domains – primary care structures, model of primary care, care contact, primary care outputs, health system outcomes, and health outcomes – that are further classified by 26 subdomains and 63 features of primary care. A care continuum was developed using a set of 12 tracer conditions. A total of 139 indicators were mapped to the classification, each with an identified data source to safeguard measurability. Individual indicator passports and a glossary of terms were developed to support the standardization of the findings. Conclusion The resulting framework and suite of indicators, coined the Primary Health Care Impact, Performance and Capacity Tool (PHC-IMPACT), has the potential to be applied in Europe, closing the gap on existing data collection, analysis and use of performance intelligence for decision-making towards primary health care strengthening.

Background: In 2017, the European Commission (EC) identified as a policy priority the performance assessment of primary care systems, which relates to a country’s primary care structure, services delivery and outcomes. The EC requested its Expert Panel on Effective Ways of Investing in Health (Expert Panel) to provide an opinion on ways for improving performance assessment of primary care. Objectives: To provide an overview of domains and dimensions to be taken into consideration in assessing primary care and specific indicators to be collected and analysed to improve understanding of primary care performance. Methods: A sub-group of the Expert Panel performed a literature review. The opinion was drafted, improved and approved through working-group discussions, consultations with the EC, the Expert Group on Health Systems Performance Assessment, and a public hearing. Results: Drawing on the main characteristics of primary care, we propose essential elements of a primary care performance assessment system based on specific indicators. We identified ten domains with accompanying dimensions for which comparative key indicators and descriptive indicators are proposed: (1) universal and accessible care, (2) integrated, (3) person-centred, (4) comprehensive and community-oriented care, (5) provided by a team accountable for addressing a vast majority of personal health needs, (6) sustained partnership with patients and informal caregivers, (7) coordination, (8) continuity of care, (9) primary care organization, and (10) human resources. Conclusion: The identified characteristics and criteria for development of a primary care performance assessment system provides a starting point for strengthening the coherence of assessment frameworks across countries and exchanging best practices.

IntroductionPatient-reported experience measures (PREMs) are central to inform on the responsiveness of health systems to citizens' health care needs and expectations. At their current form, PREMs do not reflect the weights that patients assign to varying aspects of the care experience. We aimed to investigate patients' preferences and willingness to pay (WTP) for attributes of the care experience in outpatient settings.MethodsA discrete choice experiment was conducted among a representative sample of the general adult population of Hungary (n = 1000). Choice set attributes and levels were defined based on OECD's standardized PREMs (e.g. a doctor spending enough time in consultation, providing easy to understand explanations, giving opportunity to ask questions, and involving in decision making) and a price attribute. Conditional and mixed logit analyses were conducted. WTP estimates were computed in preference and WTP space.ResultsThe respondents most preferred attribute was that of a doctor spending enough time in consultation, followed by involvement in decision making. Moreover, waiting times had a less important effect on respondents' choice preference compared with aspects of the doctor-patient relationship. Estimates in the WTP space varied from €4.38 (2.85-5.90) for waiting an hour less at a doctor's office to €36.13 (32.07-40.18) for a consultation where a doctor spends enough time with a patient relative to a consultation where a doctor does not.ConclusionsA preference-based PREMs approach provide insight on the value patients assign to different aspects of their care experience. This can inform the decisions of policy-makers and other stakeholders to coordinate efforts and resource allocation in a more targeted manner, by acting on attributes of the care experience that have a greater impact on the implementation of patient-centered care.

BackgroundPatient-reported data are widely used for many purposes by different actors within a health system. However, little is known about the use of such data by health insurers. Our study aims to map the evidence on the use of patient-reported data by health insurers; to explore how collected patient-reported data are utilized; and to elucidate the motives of why patient-reported data are collected by health insurers.MethodsThe study design is that of a scoping review. In total, 11 databases were searched on. Relevant grey literature was identified through online searches, reference mining and recommendations from experts. Forty-two documents were included. We synthesized the evidence on the uses of patient-reported data by insurers following a structure-process-outcome approach; we also mapped the use and function of those data by a health insurer.ResultsHealth insurers use patient-reported data for assurance and improvement of quality of care and value-based health care. The patient-reported data most often collected are those of outcomes, experiences and satisfaction measures; structure indicators are used to a lesser extent and often combined with process indicators. These data are mainly used for the purposes of procurement and purchasing of services, quality assurance, improvement and reporting, and strengthening the involvement of insured people.ConclusionsThe breadth to which insurers use patient-reported data in their business models varies greatly. Some hindering factors to the uptake of such data are the varying and overlapping terminology in use in the field and the limited involvement of insured people in a health insurer's business. Health insurers are advised to be more explicit in regard to the role they want to play within the health system and society at large, and accommodate implications for the use of patient-reported data accordingly.

Background Iran has a widespread diagnostics and clinical support services (DCSS) network that plays a crucial role in providing diagnostic and clinical support services to both inpatient and outpatient care. However, very little is known on the application of quality assurance (QA) policies in DCSS units. This study explores the extent of application of eleven QA strategies in DCSS units within Iranian hospitals and its association with hospital characteristics. Methods A descriptive cross-sectional study was conducted in 2009/2010. Data were collected from 554 DCSS units among 84 hospitals. Results The average reported application rate for the QA strategies ranged from 57%-94% in the DCSS units. Most frequently reported were checking drugs expiration dates (94%), pharmacopoeia availability (92%), equipment calibration (87%) and identifying responsibilities (86%). Least reported was external auditing of the DCSS (57%). The clinical chemistry and microbiology laboratories (84%), pharmacies, blood bank services (83%) reported highest average application rates across all questioned QA strategies. Lowest application rates were reported in human tissue banks (50%). There was no significant difference between the reported application rates in DCSS in the general/specialized, teaching/research, nonteaching/research hospitals with the exception of pharmacies and radiology departments. They reported availability of a written QA plan significantly more often in research hospitals. Nearly all QA strategies were reported to be applied significantly more often in the DCSS of Social Security Organization (SSO) and private-for-profit hospitals than in governmental hospitals. Conclusion There is still room for strengthening the managerial cycle of QA systems and accountability in the DCSS in Iranian hospitals. Getting feedback, change and learning through application of specific QA strategies (eg, external/internal audits) can be improved. Both the effectiveness of QA strategies in practice, and the application of these strategies in outpatient DCSS units require further policy attention.