Living Lab for Sustainable Care involved in the NZa’s National Impact Analysis on Concentration of Services for Congenital Heart Disease

Last week, the Dutch Healthcare Authority (NZa) published an impact analysis about concentration of care for patients with congenital heart disease (in Dutch often referred to as ‘kinderhartchirurgie’) in Dutch Academic Medical Centers. As part of this analysis, Anne van den Bulck and Arianne Elissen (Creating Value-Based Healthcare) conducted a Delphi-study among stakeholders to identify important impact indicators for assessing the effects of concentration on patients, professionals, organizations, and regions.

For almost thirty years, there is an ongoing debate on the concentration of interventions for patients with congenital heart disease. In 2021, the Dutch Minister of Health, Welfare and Sports (VWS) decided to concentrate this care in two of the four Dutch academic medical centers that currently provide it. This decision caused considerable unrest among stakeholders involved as well as in society. Therefore, the Minister has asked the Dutch Healthcare Authority (NZa) to conduct an impact-analysis, to gain insight into the effects this concentration would have on the involved patients, healthcare professionals, academic medical centers, and regions.

Involvement of Maastricht University

As part of this impact-analysis, the NZa invited Dr. Anne van den Bulck and Dr. Arianne Elissen (CAPHRI’s research line Creating Value-Based Healthcare, Living Lab for Sustainable Care) to guide and conduct a ‘rapid’ Delphi-study. The aim of this Delphi-study was to identify what indicators are relevant to take into account when determining the impact of concentrating care for congenital heart disease.

The NZa invited three groups of experts to participate in the study. Experts were representatives of all seven Dutch academic medical centers, patient representatives (such as the Heart Foundation), and representatives from academic professional associations (such as the associations for intensive care (NVIC) and pediatrics (NVK)). With a framework provided by the NZa, Anne and Arianne set up a questionnaire. Experts evaluated an extensive list of 101 potential impact indicators, including 57 indicators proposed by the NZa and 44 indicators additionally proposed by the experts. All impact indicators were assessed on their relevance for determining the impact of concentrating care for congenital heart disease. Experts also discussed why they did or did not find certain impact indicators relevant.

The Delphi-study findings and their use

In total, 46 out of the 101 indicators were assessed as relevant by at least one of the expert groups. Examples of relevantly assessed impact indicators include the availability of professionals and professional expertise, patients’ access to care, and quality of care. The relevant impact indicators formed the basis for the next steps of the NZa’s impact-analysis, in which they stepped into daily practice to determine the degree in which the impacts occur. For example, what is the potential impact on patients’ access to care if one specific medical center would close?

Last week, the NZa published their report describing the findings of the impact-analysis. The Delphi-study conducted by Anne and Arianne is included as Appendix 4. In their report, the NZa acknowledges the importance of concentrating high-complex care with low volumes in care, such interventions for congenital heart disease. However, the NZa concludes that concentrating the care for congenital heart disease will have excessive, irreversible consequences due to shifts in personnel, facilities, center-specific expertise or the center’s regional function. It is therefore recommended to first set up clusters of centers based on strong collaboration. In the meantime, an integrative perspective should be developed on the future of academic medical centers in general, which can guide decision-making on concentration issues.


Anne van den Bulck and Arianne Elissen

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