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Health systems invest in coordination and collaboration between emergency departments (ED) and after-hours primary care providers (AHPCs) to alleviate pressure on the acute care chain. There are substantial gaps in the existing evidence, limited in sample size, follow-up care, and costs. We assess whether acute care collaborations (ACCs) are associated with decreased ED utilization, hospital admission rates, and lower costs per patient journey, compared with stand-alone facilities. The design is a quasi-experimental study using claims data. The study included 610 845 patients in the Netherlands (2017). Patient visits in ACCs were compared to stand-alone EDs and AHPCs. The number of comorbidities was similar in both groups. Multiple logistic and gamma regressions were used to determine whether patient visits to ACCs were negatively associated with ED utilization, hospital admission rates, and costs. Logistic regression analysis did not find an association between patients visiting ACCs and ED utilization compared to patients visiting stand-alone facilities [odds ratio (OR), 1.01; 95% confidence interval (CI), 1.00-1.03]. However, patients in ACCs were associated with an increase in hospital admissions (OR, 1.07; 95% CI, 1.04-1.09). ACCs were associated with higher total costs incurred during the patient journey (OR, 1.02; 95% CI, 1.01-1.03). Collaboration between EDs and AHPCs was not associated with ED utilization, but was associated with increased hospital admission rates, and higher costs. These collaborations do not seem to improve health systems' financial sustainability.

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BACKGROUND: Purchasing systems aim to improve resource allocation in healthcare markets. The Netherlands is characterized by four different purchasing systems: managed competition in the hospital market, a non-competitive single payer system for long-term care (LTC), municipal procurement for home care and social services, and self-procurement via personal budgets. We hypothesize that managed competition and competitive payer reforms boost reallocations of provider market share by means of active purchasing, ie, redistributing funds from high-quality providers to low-quality providers. METHODS: We define a Market Activity Index (MAI) as the sum of funds reallocated between providers annually. Provider expenditures are extracted from provider financial statements between 2006 and 2019. We compare MAI in six healthcare sectors under four different purchasing systems, adjusting for reforms, and market entry/exit. Next, we perform in-depth analyses on the hospital market. Using multivariate linear regressions, we relate reallocations to selective contracting, provider quality, and market characteristics. RESULTS: No difference was found between reallocations in the hospital care market under managed competition and the non-competitive single payer LTC (MAI between 2% and 3%), while MAI was markedly higher under procurement by municipalities and personal budget holders (between 5% and 15%). While competitive reforms temporarily increased MAI, no structural effects were found. Relatively low hospital MAI could not be explained by market characteristics. Furthermore, the extent of selective contracting or hospital quality differences had no significant effects on reallocations of funds. CONCLUSION: Dutch managed competition and competitive purchaser reforms had no discernible effect on reallocations of funds between providers. This casts doubt on the mechanisms advocated by managed competition and active purchasing to improve allocative efficiency.

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STUDY DESIGN: An in-depth interview study including patients, general practitioners, neurologists and neurosurgeons. OBJECTIVE: To gain insight in decision-making in sciatica care, by identifying patients' and physicians' preferences for treatment options, and the differences between and within both groups. SUMMARY OF BACKGROUND DATA: Sciatica is a self-limiting condition, which can be treated both conservatively and surgically. The value of both options has been disputed, and the care pathway is known for a substantial amount of practice variation. Most Dutch patients are taken care of by general practitioners before they are referred to hospital-based neurologists, who might refer to a neurosurgeon, who can perform a surgical intervention. Dutch sciatica care thus follows the principles of stepped care, and a cascade of decisions precedes surgery. Better understanding of the decision-making within this cascade might reveal opportunities to improve shared decision-making and to reduce unwarranted practice variation. METHODS: Interviews with 10 patients and 22 physicians were analysed thematically. RESULTS: While physicians were confident of their clinical diagnosis, patients preferred confirmation trough imaging to exclude other possible explanations. Furthermore, many patients showed reluctance towards the use of (strong) opioids, while all physicians favoured this and underlined the benefits of opioids in the management of sciatica complaints, to buy time and to allow patients to recover naturally. Finally, individual physicians differed strongly in their opinion on benefits and optimal timing of surgical treatment and epidural injections. CONCLUSIONS: Dutch sciatica care is characterised by a cascade of decisions preceding surgery. Preferences differ within and between patients and physicians, which adds to the practice variation. To improve decision-making, physicians and patients should invest not necessarily more in the exchange of options or preferences, but in making sure the other understands the rationale behind them.

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BACKGROUND: Optimal care for Parkinson's disease (PD) requires coordination and collaboration between providers within a complex care network. Individual patients have personalised networks of their own providers, creating a unique informal network of providers who treat ('share') the same patient. These 'patient-sharing networks' differ in density, ie, the number of identical patients they share. Denser patient-sharing networks might reflect better care provision, since providers who share many patients might have made efforts to improve their mutual care delivery. We evaluated whether the density of these patient-sharing networks affects patient outcomes and costs. METHODS: We analysed medical claims data from all PD patients in the Netherlands between 2012 and 2016. We focused on seven professional disciplines that are commonly involved in Parkinson care. We calculated for each patient the density score: the average number of patients that each patient's providers shared. Density scores could range from 1.00 (which might reflect poor collaboration) to 83.00 (which might reflect better collaboration). This score was also calculated at the hospital level by averaging the scores for all patients belonging to a specific hospital. Using logistic and linear regression analyses we estimated the relationship between density scores and health outcomes, healthcare utilization, and healthcare costs. RESULTS: The average density score varied considerably (average 6.7, SD 8.2). Adjusted for confounders, higher density scores were associated with a lower risk of PD-related complications (odds ratio [OR]: 0.901; P<.001) and with lower healthcare costs (coefficients: -0.018, P=.005). Higher density scores were associated with more frequent involvement of neurologists (coefficient 0.068), physiotherapists (coefficient 0.052) and occupational therapists (coefficient 0.048) (P values all <.001). CONCLUSION: Patient sharing networks showed large variations in density, which appears unwanted as denser networks are associated with better outcomes and lower costs.

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OBJECTIVE: To establish a methodological approach to compare two high-need, high-cost (HNHC) patient personas internationally. DATA SOURCES: Linked individual-level administrative data from the inpatient and outpatient sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States. STUDY DESIGN: We outline a methodological approach to identify HNHC patient types for international comparisons that reflect complex, priority populations defined by the National Academy of Medicine. We define two patient profiles using accessible patient-level datasets linked across different domains of care-hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, long-term care, home-health care, and outpatient drugs. The personas include a frail older adult with a hip fracture with subsequent hip replacement and an older person with complex multimorbidity, including heart failure and diabetes. We demonstrate their comparability by examining the characteristics and clinical diagnoses captured across countries. DATA COLLECTION/EXTRACTION METHODS: Data collected by ICCONIC partners. PRINCIPAL FINDINGS: Across 11 countries, the identification of HNHC patient personas was feasible to examine variations in healthcare utilization, spending, and patient outcomes. The ability of countries to examine linked, individual-level data varied, with the Netherlands, Canada, and Germany able to comprehensively examine care across all seven domains, whereas other countries such as England, Switzerland, and New Zealand were more limited. All countries were able to identify a hip fracture persona and a heart failure persona. Patient characteristics were reassuringly similar across countries. CONCLUSION: Although there are cross-country differences in the availability and structure of data sources, countries had the ability to effectively identify comparable HNHC personas for international study. This work serves as the methodological paper for six accompanying papers examining differences in spending, utilization, and outcomes for these personas across countries.

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BACKGROUND: Medicalization has been a topic of discussion and research for over four decades. It is a known concept to researchers from a broad range of disciplines. Medicalization appears to be a concept that speaks to all, suggesting a shared understanding of what it constitutes. However, conceptually, the definition of medicalization has evolved over time. It is unknown how the concept is applied in empirical research, therefore following research question was answered: How is medicalization defined in empirical research and how do the definitions differ from each other? METHODS: We performed a scoping review on the empirical research on medicalization. The 5 steps of a scoping review were followed: (1) Identifying the research question; (2) Identifying relevant studies; (3) Inclusion and exclusion criteria; (4) Charting the data; and (5) Collating, summarizing and reporting the results. The screening of 3027 papers resulted in the inclusion of 50 empirical studies in the review. RESULTS: The application of the concept of medicalization within empirical studies proved quite diverse. The used conceptual definitions could be divided into 10 categories, which differed from each other subtly though importantly. The ten categories could be placed in a framework, containing two axes. The one axe represents a continuum from value neutral definitions to value laden definitions. The other axe represents a continuum from a micro to a macro perspective on medicalization. CONCLUSION: This review shows that empirical research on medicalization is quite heterogeneous in its definition of the concept. This reveals the richness and complexity of medicalization, once more, but also hinders the comparability of studies. Future empirical research should pay more attention to the choice made with regard to the definition of medialization and its applicability to the context of the study.

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BACKGROUND: Studies from different countries have shown that a small number of insured persons (high-cost patients) are responsible for a large portion of health care spending. At the same time, it is assumed that some of these costs could be saved by a better management of this group of people. The aim of this article is to analyze the performance and cost profiles of high-cost patients, to put them in an international comparison, and to derive a better management approach. METHODS: Retrospective observation study based on statutory health insurance data from two statutory health insurances for the year 2013. STUDY POPULATION: top 5 %, as well as top 1 % of the most expensive insured persons. Identification of characteristics of high-cost patients and international comparison with the Netherlands, the USA, Canada, Spain, England and Japan. RESULTS: 5 % of insured persons account for almost half of the total costs and the most expensive 1 % of 22 %. These high-cost patients in Germany are, on average, 20 years older than the general population. Almost every person of the high-cost population was prescribed at least one medication during the study period (99.2 %), and 85.8 % had at least one hospital stay. Hospital care accounts for the biggest part of total costs: 75 % together with drugs. The average per capita costs caused by one of the 5 % most expensive insured persons in the year under review are 20 times higher than that of the other 95 % of insured persons. High-cost patients are generally more multimorbid and have higher mortality rates. The most common diagnoses of these patients are hypertension, lipoprotein metabolism disorder and back pain. CONCLUSION: Similar to other developed countries, Germany faces the challenge to develop and implement adequate intervention approaches addressing the special requirements of high-cost insured persons. This paper provides a first basis. The analogies of high-cost patients in Germany and other countries illustrate the need for transnational research and intervention approaches on this specific issue. More in-depth work is needed to investigate the potentials of Predictive Modelling and integrated care approaches to the management of this group of insured persons.

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AIMS: This study aimed to determine the characteristics of patients with heart failure and high costs (top 1% and top 2-5% highest costs in perspective of the general population) and to explore the longitudinal health care utilization and persistency of high costs. METHODS AND RESULTS: Longitudinal observational study using claims data from 2006 to 2014 in the Netherlands. We identified all patients that received a hospital treatment for chronic heart failure between 1 January 2008 and 31 December 2010. Of each selected patient, all claims from the Dutch curative health system and with a starting date between 1 January 2006 and 31 December 2014 were extracted. Pharmaceutical and hospital claims were used to establish characteristics and indicators for health care utilization. Descriptive analyses and generalized estimating equation models were used to analyse characteristics, longitudinal health care utilization and to identify factors associated with high costs. Our findings revealed that the difference in costs between top 1%, top 2-5%, and bottom 95% patients with heart failure was mainly driven by hospital costs; and the top 1% group experienced a remarkable increase of mental health costs. Top 1% and top 2-5% patients with heart failure differed from lower cost patients in their higher rate of chronic conditions, excessive polypharmacy, hospital admissions, and heart-related surgeries. Heart-related surgeries contributed to the incidental high costs in 54% of top 1% patients, and the costs of the remaining top 1% patients were driven by mental health and pharmaceuticals use and rates of chronic conditions and multimorbidity. Top 1% patients were relatively young. Anaemia, dementia, diseases of arteries, veins and lymphatic vessels, influenza, and kidney failure were significantly associated with high costs. The end-of-life period was predictive of top 1% and top 5% costs. More than 90% of the population incurred at least one top 5% year during follow-up, and 31.8% incurred at least one top 1% year. Fifty-seven per cent incurred multiple top 5% years whereas only 8.6% incurred multiple top 1% years. Top 5% years were more frequently consecutive than top 1% years. CONCLUSIONS: Top 1% utilization occurs predominantly incidentally and among less than a third of patients with heart failure, whereas almost all patients with heart failure experience at least one top 5% year, and more than half experience two or more top 5% years. Both medical and psychiatric/psychosocial needs contribute to high costs in heart failure patients. Comprehensive and integrated efforts are needed to further improve quality of care and reduce unnecessary costs.

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Objective: To reconstruct a sex-specific patient journey for Dutch persons with Parkinson's disease (PD) during the first 5 years after diagnosis. Method: We analyzed a national administrative medical claims database containing data of all patients newly diagnosed with PD between 2012 and 2016 in the Netherlands. We performed time-to-event analysis to identify the moments when patients received care from neurologists, allied healthcare therapists or general practitioners. We also extracted relevant clinical milestones: unexpected hospitalization for PD, pneumonia, orthopedic injuries, nursing home admission, and death. Using these data, we constructed the patient journey stratified for sex. Results: We included claims data of 13,518 men and 8,775 women with newly diagnosed PD in the Netherlands. While we found little difference in neurologist consultations, women visited general practitioners and physiotherapists significantly earlier and more often (all p-values < 0.001). After 5 years, 37.9% (n = 3,326) of women had visited an occupational therapist and 18.5% (n = 1,623) a speech and language therapist at least once. This was 33.1% (n = 4,474) and 23.7% (n = 3,204) for men. Approximately 2 years after diagnosis, PD-related complications (pneumonia, orthopedic injuries, and PD-related hospitalization) occurred for the first time (women: 1.8 years; men: 2.3 years), and after 5 years, 72.9% (n = 6,397) of women, and 68.7% (n = 9,287) of men had experienced at least one. Discussion: Considering the strengths and limitations of our methods, our findings suggest that women experience complications and access most healthcare services sooner after diagnosis and more frequently than men. The identified sex differences extend the debate about phenotypical differences in PD between men and women.

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BACKGROUND: Across countries, a small group of patients accounts for the majority of health care spending. These patients are more likely than other patients to experience problems with quality and safety in their care, suggesting that efforts targeting efficiency and quality among this population might have significant payoffs for health systems. Better understanding of similarities and differences in patient characteristics and health care use in different countries may ultimately inform further efforts to improve care for HNHC patients in these health systems. METHODS: We conducted a cross-sectional descriptive study using one year of patient-level data on high-cost patients in seven high-income OECD member countries. Countries were selected based on availability of detailed information (large enough samples of claims, administrative, and survey data of high-cost patients). We studied concentration of spending among high-cost patients, characteristics of high-cost patients, and per capita spending on high-cost patients. FINDINGS: Cost-concentration of the top 5% of patients varied across countries, from 41% in Japan to 60% in Canada, driven primarily by variation in the top 1% of spenders. In general, high-cost patients were more likely to be female (57.7% on average), had a significant number of multi-morbidities (up to on average 10 major diagnostic categories (ICD chapters), and had a lower socioeconomic status. Characteristics of high-cost patients varied as well: median age ranged from 62 in the Netherlands to 75 in Germany and the difference in socioeconomic status is particularly stark in the US. Lastly, utilization, particularly for inpatient care, varied with an average number of inpatient days ranging from 6.6 nights (US) to 97.7 nights in Japan. INTERPRETATION: In this descriptive study, there is substantial variation in the cost concentration, characteristics, and per capita spending on high-cost patient populations across high-income countries. Differences in the way that health systems are structured likely explains some of this variation, which suggests the potential of cross-system learning opportunities. Our findings highlight the need for further studies including comparable performance metrics and institutional analysis.

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In a system of managed competition, selective contracting and patient choice reward providers for quality improvements through increases in patient numbers and revenue. We research whether these mechanisms function as envisioned by investigating the relationship between quality improvements and patient numbers in assisted reproduction technology in the Netherlands. Success rate improvements primarily reduce volume as fewer secondary treatments are necessary, but this can be compensated by attracting new patients. Using nationwide registry data from 1996 to 2016, we find limited evidence that high-quality clinics attract new patients, and insufficiently as to compensate for the reduction in secondary treatments. The net effect of quality increases appears to be a small decline in revenue. Therefore, we conclude that patient choice and active purchasing reward quality improvements insufficiently. Nevertheless, clinics have improved quality drastically over the last years, showing that financial incentives are perhaps less important factors for quality improvements than factors such as intrinsic motivation and professional autonomy.

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Unsustainable growth in healthcare expenditure demands effective cost-containment policies. We review policy effectiveness using total payer expenditure as primary outcome measure. We included all OECD member states from 1970 onward. After a rigorous quality appraisal, we included 43 original studies and 18 systematic reviews that cover 341 studies. Policies most often evaluated were payment reforms (10 studies), managed care (8 studies) and cost sharing (6 studies). Despite the importance of this topic, for many widely-used policies very limited evidence is available on their effectiveness in containing healthcare costs. We found no evidence for 21 of 41 major groups of cost-containment policies. Furthermore, many evaluations displayed a high risk of bias. Therefore, policies should be more routinely and rigorously evaluated after implementation. The available high-quality evidence suggests that the cost curve may best be bent using a combination of cost sharing, managed care competition, reference pricing, generic substitution and tort reform.

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OBJECTIVES: To investigate the characteristics and healthcare utilisation of high-cost patients and to compare high-cost patients across payers and countries. DESIGN: Systematic review. DATA SOURCES: PubMed and Embase databases were searched until 30 October 2017. ELIGIBILITY CRITERIA AND OUTCOMES: Our final search was built on three themes: 'high-cost', 'patients', and 'cost' and 'cost analysis'. We included articles that reported characteristics and utilisation of the top-X% (eg, top-5% and top-10%) patients of costs of a given population. Analyses were limited to studies that covered a broad range of services, across the continuum of care. Andersen's behavioural model was used to categorise characteristics and determinants into predisposing, enabling and need characteristics. RESULTS: The studies pointed to a high prevalence of multiple (chronic) conditions to explain high-cost patients' utilisation. Besides, we found a high prevalence of mental illness across all studies and a prevalence higher than 30% in US Medicaid and total population studies. Furthermore, we found that high costs were associated with increasing age but that still more than halve of high-cost patients were younger than 65 years. High costs were associated with higher incomes in the USA but with lower incomes elsewhere. Preventable spending was estimated at maximally 10% of spending. The top-10%, top-5% and top-1% high-cost patients accounted for respectively 68%, 55% and 24% of costs within a given year. Spending persistency varied between 24% and 48%. Finally, we found that no more than 30% of high-cost patients are in their last year of life. CONCLUSIONS: High-cost patients make up the sickest and most complex populations, and their high utilisation is primarily explained by high levels of chronic and mental illness. High-cost patients are diverse populations and vary across payer types and countries. Tailored interventions are needed to meet the needs of high-cost patients and to avoid waste of scarce resources.

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BACKGROUND: Overuse of unnecessary care is widespread around the world. This so-called low-value care provides no benefit for the patient, wastes resources and can cause harm. The concept of low-value care is broad and there are different reasons for care to be of low-value. Hence, different strategies might be necessary to reduce it and awareness of this may help in designing a de-implementation strategy. Based on a literature scan and discussions with experts, we identified three types of low-value care. RESULTS: The type ineffective care is proven ineffective, such as antibiotics for a viral infection. Inefficient care is in essence effective, but is of low-value through inefficient provision or inappropriate intensity, such as chronic benzodiazepine use. Unwanted care is in essence appropriate for the clinical condition it targets, but is low-value since it does not fit the patients' preferences, such as a treatment aimed to cure a patient that prefers palliative care. In this paper, we argue that these three types differ in their most promising strategy for de-implementation and that our typology gives direction in choosing whether to limit, lean or listen. CONCLUSION: We developed a typology that provides insight in the different reasons for care to be of low-value. We believe that this typology is helpful in designing a tailor-made strategy for reducing low-value care.

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OBJECTIVE: To determine medical needs, demographic characteristics and healthcare utilisation patterns of the top 1% and top 2%-5% high-cost beneficiaries in the Netherlands. DESIGN: Cross-sectional study using 1 year claims data. We broke down high-cost beneficiaries by demographics, the most cost-incurring condition per beneficiary and expensive treatment use. SETTING: Dutch curative health system, a health system with universal coverage. PARTICIPANTS: 4.5 million beneficiaries of one health insurer. MEASURES: Annual total costs through hospital, intensive care unit use, expensive drugs, other pharmaceuticals, mental care and others; demographics; most cost-incurring and secondary conditions; inpatient stay; number of morbidities; costs per ICD10-chapter (International Statistical Classification of Diseases, 10th revision); and expensive treatment use (including dialysis, transplant surgery, expensive drugs, intensive care unit and diagnosis-related groups >€30 000). RESULTS: The top 1% and top 2%-5% beneficiaries accounted for 23% and 26% of total expenditures, respectively. Among top 1% beneficiaries, hospital care represented 76% of spending, of which, respectively, 9.0% and 9.1% were spent on expensive drugs and ICU care. We found that 54% of top 1% beneficiaries were aged 65 years or younger and that average costs sharply decreased with higher age within the top 1% group. Expensive treatments contributed to high costs in one-third of top 1% beneficiaries and in less than 10% of top 2%-5% beneficiaries. The average number of conditions was 5.5 and 4.0 for top 1% and top 2%-5% beneficiaries, respectively. 53% of top 1% beneficiaries were treated for circulatory disorders but for only 22% of top 1% beneficiaries this was their most cost-incurring condition. CONCLUSIONS: Expensive treatments, most cost-incurring condition and age proved to be informative variables for studying this heterogeneous population. Expensive treatments play a substantial role in high-costs beneficiaries. Interventions need to be aimed at beneficiaries of all ages; a sole focus on the elderly would leave many high-cost beneficiaries unaddressed. Tailored interventions are needed to meet the needs of high-cost beneficiaries and to avoid waste of scarce resources.

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Antimicrobial stewardship is recognized as a key component to stop the current European spread of antimicrobial resistance. It has also become evident that antimicrobial resistance is a problem that cannot be tackled by single institutions or physicians. Prevention of antimicrobial resistance needs rigorous actions at ward level, institution level, national level and at supra-national levels. Countries can learn from each other and possibly transplant best practices across borders to prevent antimicrobial resistance. The aim of this study is to highlight some of the success stories of proven cost-effective interventions, and to describe the actions that have been taken, the outcomes that have been found, and the difficulties that have been met. In some cases we came across substantial scope for real-life cost savings. Although the best approach to effectively hinder the spread of antimicrobial resistance remains unclear and may vary significantly among settings, several EU-wide examples demonstrate that cost-effective antimicrobial stewardship is possible. Such examples can encourage others to implement (the most cost-effective) elements in their system.

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The concept of overdiagnosis is a dominant topic in medical literature and discussions. In research that targets overdiagnosis, medicalisation is often presented as the societal and individual burden of unnecessary medical expansion. In this way, the focus lies on the influence of medicine on society, neglecting the possible influence of society on medicine. In this perspective, we aim to provide a novel insight into the influence of society and the societal context on medicine, in particularly with regard to medicalisation and overdiagnosis.

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Containing health care costs has been a challenge for most OECD member states. We classify 2250 cost containment policies in forty-one groups of policy options. This conceptual framework might act as a toolkit for policymakers that seek to develop strategies for cost control; and for researchers that seek to evaluate them. We found that certain important cost drivers such as wages and capital are being sparsely covered. We distinguish four primary targets to contain costs: volume controls, price controls, budgeting and market oriented policies. Price controls and budgeting, both seen as relatively effective, appear substantially less often in literature than volume controls and market oriented policies. The relative use of each option hardly changed over time, although the health system type did matter. Market oriented policies were more likely to be suggested for countries with public provision of health care, as well as for the US system. In contrast, budgeting policy proposals were more likely to be suggested for countries with market provision systems, such as Canada, Germany and France. Implementation of cost containment policies could lead to convergence of health care systems, except for the US system, if policies are implemented based on the literature.

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BACKGROUND: The majority of curative health care is organized in hospitals. As in most other countries, the current 94 hospital locations in the Netherlands offer almost all treatments, ranging from rather basic to very complex care. Recent studies show that concentration of care can lead to substantial quality improvements for complex conditions and that dispersion of care for chronic conditions may increase quality of care. In previous studies on allocation of hospital infrastructure, the allocation is usually only based on accessibility and/or efficiency of hospital care. In this paper, we explore the possibilities to include a quality function in the objective function, to give global directions to how the 'optimal' hospital infrastructure would be in the Dutch context. METHODS: To create optimal societal value we have used a mathematical mixed integer programming (MIP) model that balances quality, efficiency and accessibility of care for 30 ICD-9 diagnosis groups. Typical aspects that are taken into account are the volume-outcome relationship, the maximum accepted travel times for diagnosis groups that may need emergency treatment and the minimum use of facilities. RESULTS: The optimal number of hospital locations per diagnosis group varies from 12-14 locations for diagnosis groups which have a strong volume-outcome relationship, such as neoplasms, to 150 locations for chronic diagnosis groups such as diabetes and chronic obstructive pulmonary disease (COPD). CONCLUSIONS: In conclusion, our study shows a new approach for allocating hospital infrastructure over a country or certain region that includes quality of care in relation to volume per provider that can be used in various countries or regions. In addition, our model shows that within the Dutch context chronic care may be too concentrated and complex and/or acute care may be too dispersed. Our approach can relatively easily be adopted towards other countries or regions and is very suitable to perform a 'what-if' analysis.

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