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Background Reducing the overuse of care that is proven to be of low value increases the quality and safety of care. We aimed to identify lessons for reducing low-value care by looking at: (1) The effects of eight de-implementation projects. (2) The barriers and facilitators that emerged. (3) The experiences with the different components of the projects.Methods We performed a process evaluation of eight multicentre projects aimed at reducing low-value care. We reported the quantitative outcomes of the eight projects on the volume of low-value care and performed a qualitative analysis of the project teams’ experiences and evaluations. A total of 40 hospitals and 198 general practitioners participated.Results Five out of eight projects resulted in a reduction of low-value care, ranging from 11.4% to 61.3%. The remaining three projects showed no effect. Six projects monitored balancing measures and observed no negative consequences of their strategy. The most important barriers were a lack of time, an inability to reassure the patient, a desire to meet the patient’s wishes, financial considerations and a discomfort with uncertainty. The most important facilitators were support among clinicians, knowledge of the harms of low-value care and a growing consciousness that more is not always better. Repeated education and feedback for clinicians, patient information material and organisational changes were valued components of the strategy.Conclusions Successfully reducing low-value care is possible in spite of the powerful barriers that oppose it. The projects managed to recruit many hospitals and general practices, with five of them achieving significant results without measuring negative consequences. Based on our findings, we offer practical recommendations for successfully reducing low-value care.

Background. Cholecystectomy does not relieve abdominal symptoms in up to 40% of patients. With 700,000 cholecystectomies performed in the US, annually, about 280,000 patients are left with symptoms, making this a serious problem. We performed a systematic review to determine the different etiologies of long-term postcholecystectomy symptoms with the aim to provide guidance for clinicians treating these patients. Methods. A systematic search of the literature was performed using MEDLINE, EMBASE, and Web of Science. Articles describing at least one possible etiology of long-term symptoms after a laparoscopic cholecystectomy were included in this review. Long-term symptoms were defined as abdominal symptoms that were present at least four weeks after cholecystectomy, either persistent or incident. The etiologies of persistent and incident symptoms after LC and the mechanism or hypothesis behind the etiologies are provided. If available, the prevalence of the discussed etiology is provided. Results. The search strategy identified 3320 articles of which 130 articles were included. Etiologies for persistent symptoms were residual and newly formed gallstones (41 studies, prevalence ranged from 0.2 to 23%), coexistent diseases (64 studies, prevalence 1-65%), and psychological distress (13 studies, no prevalence provided). Etiologies for incident symptoms were surgical complications (21 studies, prevalence 1-3%) and physiological changes (39 studies, prevalence 16-58%). Sphincter of Oddi dysfunction (SOD) was reported as an etiology for both persistent and incident symptoms (21 studies, prevalence 3-40%). Conclusion. Long-term postcholecystectomy symptoms vary amongst patients, arise from different etiologies, and require specific diagnostic and treatment strategies. Most symptoms after cholecystectomy seem to be caused by coexistent diseases and physiological changes due to cholecystectomy. The outcome of this research is summarized in a decision tree to give clinical guidance on the treatment of patients with symptoms after cholecystectomy.

This article provides a snapshot of primary prevention activities in hospitals in 20 European high-income countries, based on inputs from experts of the Observatory's Health Systems and Policies Monitor (HSPM) network using a structured questionnaire. We found that in the vast majority of countries (15), there are no systematic national policies on primary prevention in hospitals. Five countries (Cyprus, Finland, Ireland, Romania and the United Kingdom) reported systematic primary prevention activities in hospitals, although in one of them (Cyprus) this was due to the fact that small hospitals in rural areas or less populated districts host providers of primary care. In two of the five countries with systematic national policies on primary prevention, there are no incentives (financial or otherwise) to provide these interventions. The remaining three countries (Finland, Romania and the United Kingdom) report the existence of incentives, but only two of them (Romania and the United Kingdom) provide financial incentives in the form of additional funding. Only two of the 20 countries (Ireland and the United Kingdom) make explicit use of the Making Every Contact Count (MECC) approach. Overall, it can be concluded that there is little focus on primary prevention in hospitals in Europe, which may be seen as a missed opportunity., Competing Interests: Declaration of competing interest The authors have no financial interests and no conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier B.V.)

Various countries have implemented a choice-based health insurance system. For such systems to function as intended, it is crucial that all citizens have the opportunity to make well-informed decisions with regard to their health insurance policy. There is, however, ample research evidence to suggest that many citizens may lack the required skills to do so, thus increasing the likelihood of suboptimal insurance choices and incurring unexpected costs. The current study explored what barriers citizens in the Netherlands, with low health insurance literacy (HIL), face when selecting a health insurance policy, and what their specific needs and preferences are regarding information and support. Semi-structured interviews (online or telephone) were performed between January 2023 and April 2023 among sixteen with a low level of HIL. The data were analyzed using thematic analysis methods. Our results show that not all citizens with low HIL are sufficiently motivated to actively look for alternative health insurance options every year. This is partly due to the feeling that it is a task imposed upon them by the government, and because choosing a health insurance policy is perceived as too complicated and not sufficiently worthwhile. There is a need among citizens with low HIL for clear and practical information about health insurance policies, especially from the government and health insurers. In addition to this need, we recommend enhancing awareness regarding the consequences of neglecting to explore such health insurance options. Moreover, more personal attention for the process of selecting a health insurance policy should be offered to vulnerable groups such as those who possess insufficient digital skills., Competing Interests: Declarations. Ethics approval and consent to participate: The data are analysed anonymously, and processed according to the panel’s privacy policy, which complies with the General Data Protection Regulation (GDPR). According to Dutch legislation, neither obtaining informed consent, nor approval by a medical ethics committee, is obligatory for carrying out research using the panel. Source: https://english.ccmo.nl/investigators/legal-framework-for-medical-scientific-research/your-research-is-it-subject-to-the-wmo-or-not . Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

BackgroundThe Organisation for Economic Co-operation and Development (OECD) Patient-Reported Indicator Surveys (PaRIS) initiative aims to support countries in improving care for people living with chronic conditions by collecting information on how people experience the quality and performance of primary and (generalist) ambulatory care services. This paper presents the development of the conceptual framework that underpins the rationale for and the instrumentation of the PaRIS survey., Methods: The guidance of an international expert taskforce and the OECD Health Care Quality Indicators framework (2015) provided initial specifications for the framework. Relevant conceptual models and frameworks were then identified from searches in bibliographic databases (Medline, EMBASE and the Health Management Information Consortium). A draft framework was developed through narrative review. The final version was codeveloped following the participation of an international Patient advisory Panel, an international Technical Advisory Community and online international workshops with patient representatives., Results: 85 conceptual models and frameworks were identified through searches. The final framework maps relationships between the following domains (and subdomains): patient-reported outcomes (symptoms, functioning, self-reported health status, health-related quality of life); patient-reported experiences of care (access, comprehensiveness, continuity, coordination, patient safety, person centeredness, self-management support, trust, overall perceived quality of care); health and care capabilities; health behaviours (physical activity, diet, tobacco and alcohol consumption), sociodemographic characteristics and self-reported chronic conditions; delivery system characteristics (clinic, main healthcare professional); health system, policy and context., Discussion: The PaRIS conceptual framework has been developed through a systematic, accountable and inclusive process. It serves as the basis for the development of the indicators and survey instruments as well as for the generation of specific hypotheses to guide the analysis and interpretation of the findings., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In the management of epidemics, like COVID-19, trade-offs have to be made between reducing mortality and morbidity and minimizing socioeconomic and political consequences. Traditionally, epidemic management (EM) has been guided and executed attentively by experts and policymakers. It can, however, still be controversial in the public sphere. In the last decades, public engagement (PE) has been successfully applied in various aspects of healthcare. This leads to the question if PE could be implemented in EM decision-making., Methods: From June to October 2020, seven deliberative discussion focus groups were executed with 35 Dutch citizens between 19 and 84 years old. Their views on PE in COVID-19 management were explored. The deliberative approach allows for the education of participants on the topic before the discussion. The benefits, barriers, timing and possible forms of PE in EM were discussed., Results: Almost all participants supported PE in EM, as they thought that integrating their experiences and ideas would benefit the quality of EM, and increase awareness and acceptance of measures. A fitting mode for PE was consultation, as it was deemed important to provide the public with possibilities to share ideas and feedback; however, final authority remained with experts. The publics could particularly provide input about communication campaigns and control measures. PE could be executed after the first acute phase of the epidemic and during evaluations., Conclusions: This paper describes the construction of an empirically informed framework about the values and conditions for PE in EM from the perspective of the public. Participants expressed support to engage certain population groups and considered it valuable for the quality and effectiveness of EM; however, they expressed doubts about the feasibility of PE and the capabilities of citizens. In future studies, these results should be confirmed by a broader audience., Patient or Public Contribution: No patients or members of the public were involved in the construction and execution of this study. This study was very exploratory, to gain a first insight into the views of the public in the Netherlands, and will be used to develop engagement practices accordingly. At this stage, the involvement of the public was not yet appropriate., (© 2022 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

An important criterion for the proper functioning of a managed competition healthcare system, such as operates in the Netherlands, is that all citizens can make well-informed decisions regarding their health insurance policy. In order to achieve this, citizens need certain health insurance literacy skills. It is not known how far citizens in the Netherlands have these skills. The aim of this study is to provide a reliable instrument that measures the health insurance literacy of citizens in the Netherlands. It would be based upon an existing instrument developed in the US. We translated the US Health Insurance Literacy Measure (HILM) into Dutch. Furthermore, we established the psychometric properties of the Dutch version (HILM-NL), and we validated the HILM-NL in a general population sample by sending surveys to members of the Nivel Dutch Health Care Consumer Panel (DHCCP) in February and March 2020. The response rates were respectively 54% (n = 806) and 56% (n = 595). No insurmountable difficulties with equivalence were encountered throughout the translation process. The HILM-NL showed an acceptable level of internal consistency, good test-retest reliability, and a good construct validity. The HILM-NL is a reliable instrument for measuring health insurance literacy among citizens in the Netherlands. With this instrument, it is better possible both to assess how these citizens choose and use a health insurance policy, and also the difficulties they face. It enables citizens in the Netherlands to be supported better in making well-informed decisions on health insurance., Competing Interests: The authors have declared that no competing interests exist.

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries. We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff. We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care., (Copyright © 2021. Published by Elsevier B.V.)

Countries with social health insurance (SHI) systems display some common defining characteristics - pluralism of actors and strong medical associations - that, in dealing with crisis times, may allow for common learnings. This paper analyses health system responses during the COVID-19 pandemic in eight countries representative of SHI systems in Europe (Austria, Belgium, France, Germany, Luxembourg, the Netherlands, Slovenia and Switzerland). Data collection and analysis builds on the methodology and content in the COVID-19 Health System Response Monitor (HSRM) up to November 2020. We find that SHI funds were, in general, neither foreseen as major stakeholders in crisis management, nor were they represented in crisis management teams. Further, responsibilities in some countries shifted from SHI funds to federal governments. The overall organisation and governance of SHI systems shaped how countries responded to the challenges of the pandemic. For instance, coordinated ambulatory care often helped avoid overburdening hospitals. Decentralisation among local authorities may however represent challenges with the coordination of policies, i.e. coordination costs. At the same time, bottom-up self-organisation of ambulatory care providers is supported by decentralised structures. Providers also increasingly used teleconsultations, which may remain part of standard practice. It is recommended to involve SHI funds actively in crisis management and in preparing for future crisis to increase health system resilience., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background: Oral health, coupled with rising awareness on the impact that limited dental care coverage has on oral health and general health and well-being, has received increased attention over the past few years. The purpose of the study was to compare the statutory coverage and access to dental care for adult services in 11 European countries using a vignette approach., Methods: We used three patient vignettes to highlight the differences of the dimensions of coverage and access to dental care (coverage, cost-sharing and accessibility). The three vignettes describe typical care pathways for patients with the most common oral health conditions (caries, periodontal disease, edentulism). The vignettes were completed by health services researchers knowledgeable on dental care, dentists, or teams consisting of a health systems expert working together with dental specialists., Results: Completed vignettes were received from 11 countries: Bulgaria, Estonia, France, Germany, Republic of Ireland (Ireland), Lithuania, the Netherlands, Poland, Portugal, Slovakia and Sweden. While emergency dental care, tooth extraction and restorative care for acute pain due to carious lesions are covered in most responding countries, root canal treatment, periodontal care and prosthetic restoration often require cost-sharing or are entirely excluded from the benefit basket. Regular dental visits are also limited to one visit per year in many countries. Beyond financial barriers due to out-of-pocket payments, patients may experience very different physical barriers to accessing dental care. The limited availability of contracted dentists (especially in rural areas) and the unequal distribution and lack of specialised dentists are major access barriers to public dental care., Conclusions: According to the results, statutory coverage of dental care varies across European countries, while access barriers are largely similar. Many dental services require substantial cost-sharing in most countries, leading to high out-of-pocket spending. Socioeconomic status is thus a main determinant for access to dental care, but other factors such as geography, age and comorbidities can also inhibit access and affect outcomes. Moreover, coverage in most oral health systems is targeted at treatment and less at preventative oral health care., (© 2022. The Author(s).)

Background: Several healthcare systems have elements of managed competition in which citizens can choose between multiple insurers. In order for this principle to function properly, all citizens should have equal opportunities to switch insurer. Studies, conducted around 2015, have shown that the supplementary insurance policy is perceived by citizens as a barrier to switching, which could have negative consequences for the intended goals of the system.. We aim to explore whether a supplementary insurance policy still has a restraining role on the opportunity to switch among citizens in the Netherlands from 2015 to 2020. Furthermore, we will examine if the extensiveness of the supplementary insurance policy relates to the switching behaviour of citizens. This element has not been addressed in previous studies., Methods: We obtained information on the role of the supplementary health insurance policy in the switching behaviour of citizens by sending questionnaires, yearly in February from 2015-2020, to 1,500 members of the Dutch Health Care Consumer Panel (DHCCP) each year. As such, we were able to examine whether having a supplementary insurance policy plays a role in the decision of Dutch citizens to switch insurer. The response rates were consecutively from 2015 to 2020: 60% (n = 896), 47% (n = 703), 44% (n = 659), 50% (n = 751), 48% (n = 715), and 54% (n = 806)., Results: Citizens with a supplementary insurance policy switch less often than citizens without one. The extensiveness of the supplementary insurance policy is significantly associated with the decision of citizens to switch insurer; the more extensive citizens are insured, the less often they switch. Additionally, our results show that every year a small group of citizens does not switch insurer because they are concerned that they will not be accepted for a supplementary insurance policy., Conclusions: Our results indicate that having a supplementary insurance policy holds citizens back from using their opportunity to switch. This contributes to the idea that having a supplementary insurance policy could be experienced by citizens as a barrier to switch. This raises questions about the extent to which the principle of managed competition in the Dutch healthcare system works as intended., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background: Although fatigue among the dialysis population is known as a severe and debilitating health problem, this symptom is often under recognized and undertreated., Objective: This qualitative study aimed to gain a better understanding of how dialysis nurses and renal health professionals perceive and address dialysis patient's fatigue in renal care practice., Design: We conducted a qualitative descriptive study to explore how nurses and renal health professionals perceive and address dialysis patients' fatigue in their daily health care practices. A constructivist grounded theory approach guided analysis and conceptualisation of findings., Setting(s): This study took place at 13 academic and regional settings across the Netherlands. The study was approved by the Medical Ethics Committee (2015.049), on behalf of VU University medical center in Amsterdam., Participants: Twenty-one renal health professionals of various disciplines took part in interviews: ten dialysis nurses, four nephrologists, two physician assistants, five medical social workers., Methods: Semi-structured interviews were conducted in order to gain in-depth insight into the perspectives of dialysis nurses and renal health professionals. An inductive thematic analysis provided insight into health professionals' stances toward dialysis patients' fatigue in light of their daily care context and practices., Results: Two main themes emerged; 1) 'Fatigue in the background': Shows there is strong focus on medical-technical aspects of the disease. All health professionals perceive fatigue as an intangible symptom that is difficult to address, and falls outside their scope of responsibility and competence. Communication about fatigue among professionals and with patients is limited, pushing fatigue further into the background. 2) 'Vulnerabilities in the background': Especially nurses and social workers signal the accumulating vulnerabilities of dialysis patients and associate these with fatigue (old age, multimorbidities, financial and social problems). Although the need for psychological support is acknowledged, multiple vulnerabilities increase the complexity and intensity of care, and further strengthens the medical-technical focus of care and treatment., Conclusions: There is a need to enable renal health professionals to communicate about the complex nature of fatigue in renal patients and stimulate interdisciplinary exchange and shared responsibility. Dialysis nurses have frequent contact with patients during dialysis treatment and are the first to notice when patients' fatigue increases and their overall condition deteriorates. They can play an important role to go beyond the technological imperative of care and understand the lived experiences of patients within their social contexts., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Community pharmacy is shifting its focus from traditional, product-focused roles to the provision of cognitive pharmaceutical services (CPS). Previous research has indicated that community pharmacists predominantly want to devote their capacity to CPS. Ideally, services provided also address users' needs. The general public's preferences regarding the services provided by community pharmacists are currently less understood., Aim: This study investigates the general public's preferences and perceived importance of CPS versus convenience in community pharmacy practice., Method: An online survey of 1.500 members of the Dutch Health Care Consumer Panel containing questions regarding preferences for CPS and convenience was distributed. Descriptive statistics and linear regression analysis were performed to investigate the relationship between preferences and participant characteristics., Results: 516 panel members completed all questions regarding preferences and importance of the availability of services. The majority preferred convenience (68.2%) and a smaller proportion preferred CPS (27.7%). However, participants considered it important from a societal viewpoint that CPS is provided (45.0%). Participants who preferred CPS over convenience were generally older (p < 0.001) and used more medicines (p < 0.001)., Conclusion: Convenience of community pharmacy services is most preferred by the general public. However, CPS is perceived as important, especially for elderly who use more medicines. Elderly patients who use more medicines more often rate CPS as more important than convenience. These findings suggest that community pharmacists should ensure that pharmacy logistics are organized efficiently before focusing on the provision of CPS., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: For better supporting the science-governance interface, the potential of health assessments appears underrated., Aims: To identify what various types of health assessment have in common; how they differ; which assessment(s) to apply for which purpose; and what needs and options there are for future joint development., Methods: This review is based on five types of health assessment: monitoring/surveillance/reporting, assessment of health impact, of health technology, of health systems performance, health-related economic assessment. The approach is exploratory and includes: applying an agreed set of comparative criteria; circulating and supplementing synoptic tables; and interpreting the results., Results: Two of the assessments deal with the question 'Where do we stand?', two others with variants of 'What if' questions. Economic Assessment can take place in combination with any of the others. The assessments involve both overall 'procedures' and a variety of 'methods' which inescapably reflect some subjective assumptions and decisions, e.g. on issue framing. Resources and assistance exist for all these assessments. The paper indicates which type of assessment is appropriate for what purpose., Conclusions: Although scientific soundness of health assessments is not trivial to secure, existing types of health assessment can be interpreted as a useful 'toolkit' for supporting governance. If current traces of 'silo' thinking can be overcome, the attainability of a more unified culture of health assessments increases and such assessments might more widely be recognized as a prime, 'tried and tested' way to voice Public Health knowledge and to support rational governance and policy-making., (© The Author 2017. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.)

This analysis of the Dutch health system reviews recent developments in organization and governance, health financing, healthcare provision, health reforms and health system performance. Without doubt, two major reforms implemented since the mid-2000s are among the main issues today. The newly implemented long-term care reform will have to realize a transition from publicly provided care to more self-reliance on the part of the citizens and a larger role for municipalities in its organization. A particular point of attention is how the new governance arrangements and responsibilities in long-term care will work together. The 2006 reform replaced the division between public and private insurance by one universal social health insurance and introduced managed competition as a driving mechanism in the healthcare system. Although the reform was initiated almost a decade ago, its stepwise implementation continues to bring changes in the healthcare system in general and in the role of actors in particular. In terms of performance, essential healthcare services are within easy reach and waiting times have been decreasing. The basic health insurance package and compensations for lower incomes protect citizens against catastrophic spending. Out-of-pocket payments are low from an international perspective. Moreover, the Dutch rate the quality of the health system and their health as good. International comparisons show that the Netherlands has low antibiotic use, a low number of avoidable hospitalizations and a relatively low avoidable mortality. National studies show that healthcare has made major contributions to the health of the Dutch population as reflected in increasing life expectancy. Furthermore, some indicators such as the prescription of generics and length of stay reveal improvements in efficiency over the past years. Nevertheless, the Netherlands still has one of the highest per capita health expenditures in Europe, although growth has slowed considerably after reverting to more traditional sector agreements on spending., (World Health Organization 2016 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies).)

In demand-led health care systems, consumers are expected to play an informed, active role in health care decisions by making use of health information. The ability to seek and use this information depends on specific knowledge, skills, and self-confidence. In this study, the authors validated a translated instrument to measure patient activation (Dutch PAM-13) in a general sample of Dutch health care consumers. Furthermore, the authors examined the relative contribution of patient activation and functional health literacy to the seeking and use of health information in The Netherlands. The mean patient activation score in the Dutch sample was higher for younger health care consumers and for those with a higher education, higher income, and better self-reported general and mental health status. More activated consumers were more likely to seek and use health information. Patient activation proved to be a stronger predictor for seeking and using health information than functional health literacy.

Objective: In several countries, patients are encouraged to choose health care providers. Simultaneously, there is a tendency towards the concentration of health care, which might lessen the choice. Our aim was to assess the impact of patients' distances from their providers on their information-seeking, which is one element of choice., Methods: Two thousand members of the Dutch Health Care Consumer Panel were sent a questionnaire that included a question on whether they would search for information about hospitals to inform their choice. Distances from providers were obtained from a database that includes the distances between all postcodes in the Netherlands. To assess the influence of distance on information-seeking, logistic regression analyses were conducted., Results: There was a good response (75%). Older, less educated respondents were less inclined to seek information when their nearest alternative was located further away (OR 0.85; 95% CI: 0.79-0.92), and younger, more educated respondents were more inclined to search in this situation (OR 1.11; 95% CI: 1.01-1.22)., Conclusions: As fewer older, less educated patients would search for information to guide their choice, they might not opt for the best hospital. Additionally, the need for providers to compete for the patronage of these patients might be lessened.

As the major federal agency responsible for improving the delivery and effectiveness of substance abuse and mental health services to the American public, the Substance Abuse and Mental Health Services Administration (SAMHSA) is aware that its programs deal with especially sensitive issues. As a national leader in advancing effective services to persons with addictive and mental disorders, SAMHSA has stewardship over important interventions affecting personal, community, institutional, and social values. Inherent in SAMHSA's mission and goals is a commitment to protect and promote the human, civil, and legal rights and moral freedoms of those individuals and groups who participate in SAMHSA-funded activities and to demonstrate that Agency policies and procedures are congruent with publicly acceptable ethical principles and standards of conduct. A foundation of mutual trust between SAMHSA officials and participants as well as sensitivity to issues of public accountability will hasten and strengthen progress toward this shared vision.