Explaining Unexplained Variation: Capturing my journey across Long-Term Care and statistics

Health care systems, based on a framework of social cohesion, usually strive towards equity of access, financed by the state. Against this background, it is important to align the access to health care resources to the need for such care in order to enable an equitable distribution. One way to achieve equity in access is to eliminate practice variation (variation in practice styles—usually across regions— that cannot be explained by differences in patient populations such as need or illness, certain risk factors, or patient preferences). There are several potential explanations for practice variation regarding: (a) patient or demand-side factors (other than need or illness), (b) physician or supply-side factors and (c) situational factors. As practice variation in LTC is a relatively new area of research, with many countries looking at ways to organise the allocation and use of LTC as efficiently and equitably as possible to contain the ever increasing costs, we wanted to contribute to the literature by sharing our insights on practice variation in access to and the use of LTC and the gap between these two. The system in place in the Netherlands has provided an interesting case-study, as the country has, in comparison to other OECD countries, the largest share of BP spent on LTC. The main aim of this dissertation was therefore to provide additional insights into the equity in access to and the use of the Dutch LTC; and also into the influence of different supply and demand factors that policy makers can use to move towards a more efficient and equitable system. This dissertation consists of five scientific papers: The first aspect we studied, in chapter 2, was the local variation in the probability of being granted long-term institutional care and the intensity of care granted to individuals who had applied for long-term care (LTC). We also investigated whether the variation observed was related to differences in the availability of care facilities locally. The second study, in chapter 3, focussed on practice variation in publicly financed home care and on whether and how patient experiences were associated with this variation. Practice variation across regions in the use of insured institutional LTC was the focus of the third study, in chapter 4. In addition, we analysed how a co-payment measure could be used to reduce unwarranted variation across regions and incomeclasses. The fourth aspect, which we studied in chapter 5 was the role of informal care in explaining the gap between need for and the use of formal home care. A patients’ needs were characterized according to the care granted. The fifth paper, in chapter 6, addressed the effects of the LTC reform in the Netherlands in 2015. We studied this by examining regional differences in rejection rates of applications for insured institutional LTC. Furthermore, we investigated how local factors (supply) affect the differences in rejection rates across regions. Overall, this dissertation shows how supply, demand and situational factors of the Dutch LTC process influence equity in access to and the use of various types of LTC. We observe that contrary to most studies on practice variation in health care our findings are that demand factors may be a better determinant of practice variation than supply factors. All in all, the insights of this dissertation can be used by countries seeking to reform their LTC system to consider the effects of the implementation of different policy measures on equal and efficient access to and the use of LTC. Moreover, our findings can be used as a starting point to uncover more factors associated with practice variation and the non-use of LTC.