Before interpreting the results of our series of studies, some methodological considerations
need to be made. The cross-sectional design of the questionnaire studies in 2010 and
2013 conducted among HCPs and patients excludes causal interpretations of the associations
between the study variables. Furthermore, the results of our questionnaire studies
are based on self-reported data, which may have led to bias, e.g. through factors
related to social desirability. The strength of our studies was the use of a mixed
methods design in which we conducted qualitative and quantitative studies at multiple
stages of the implementation process, thus enabling triangulation. Moreover, we were
able to provide insight into the implementation of the CS from the perspectives of
both HCPs and patients, and we included large samples of patients and HCPs covering
the full range of professions involved in diabetes care.
NAD as best practice
Looking back over the past decade, we can conclude that the focus on the implementation
of the CS, through the NAD, has had positive results. Moreover, the experiences with
the NAD have also provided us with a great deal of information necessary to take further
steps in implementing Care Standards for other chronic diseases both in the Netherlands
and elsewhere. Accompanying the implementation of the CS with a government funded
NAD may have been an example of a best practice. Although the CS was available before
the start of the NAD, little effort had been put in facilitating its implementation
in practice. The NAD has given the CS the attention it needed to become widely known
and used among professionals and has facilitated its easy accessibility. As a result
of these efforts, the CS has become more prominent and embedded in daily health care
practice. The findings of our studies largely support the approach of the NAD, since
professionals’ appreciation and use of the CS increased in the period 2010–2013. Moreover,
the implementation of several elements of the CS significantly improved, with even
more positive results in the NAD pilot regions. This indicates that in daily practice
professionals have become more aware of the position and benefits of both the CS and
the guidelines issued by their individual professional groups.
CS as flywheel
It is also clear that in the Netherlands the CS has provided momentum for the realization
of various processes relating to the wider implementation of standards to improve
the care for people with other chronic diseases. Multidisciplinary collaboration,
registration, and use of quality indicators for the purpose of benchmarking, and substitution
of care originally provided by family physicians and specialists to practice nurses
and diabetes nurses, are a direct spin-off of the focus on and activities related
to the implementation of the CS. The CS has created awareness of the importance of
these aspects of care for chronic diseases. It seems plausible that these processes
would also have come about without the focus on and efforts put into the implementation
of the CS, but they would probably have taken much more time and effort. Moreover,
the introduction of the Individual Care Plan and the increased focus on self-management
means that the patient is now playing a more pivotal role in the treatment of their
disease 25],26]. However, the question is whether changing the structure of care through the CS amongst
others, also changes the care processes itself, since previous research on the effects
of population-based disease management programs among Dutch care groups showed little
impact of these programs on patients’ health 27].
Lessons learned from the implementation of the CS
Currently there are eight Care Standards covering diabetes, COPD, obesity, vascular
risk management, cardiovascular diseases/TIA, hereditary breast- and ovarian cancer
and Asthma among children and adults. Furthermore, two standards are under authorization,
two are in development, six are planned and proposals for two more are being explored.
The CS for diabetes was the first to be completed. Experiences with the implementation
of this CS can be used to aid the adoption and implementation of Care Standards for
other chronic diseases in the future. The currently finished standards are published,
but their implementation is not accompanied by an approach such as the NAD and appears
to receive less attention than the CS for diabetes. Yet, the CS for obesity and CVRM
are available for use within the bundled payment approach.
The series of studies on the implementation of the CS has taught us several key lessons.
They show that implementation takes time and effort. Developing and publishing a CS
does not automatically mean that it will be used in practice. Partly due to the function
of the CS as a purchasing instrument within the Dutch bundled payment approach for
integrated chronic care, many policymakers assumed that the implementation would occur
automatically. However, implementation means more than the adoption and diffusion
of innovations 28],29]. Research into the implementation of innovations teaches us that successful implementation
of interventions requires systematic planning during the development phase and that
the interventions should made workable and integrated in everyday health care practice
30],31]. However, in practice, the implementation of innovations often seems subordinate
to the development of the product itself.
Organizations currently involved in developing the Care Standards for other chronic
diseases could benefit from the existing knowledge and expertise related to the implementation
of the CS for diabetes and the facilitating approach used in the NAD pilot regions.
Previous research into the dissemination and implementation of quality interventions,
i.e. quality improvement efforts, has recognized the tendency of innovators to re-invent
the wheel instead of efficiently making use of existing knowledge and insights 32],33]. One explanation for this seeming reluctance to use existing expertise in the implementation
of the CS is that organizations and professionals involved in the development of the
Care Standards for other diseases were not involved in the implementation process
of the CS for diabetes. As a result they did not obtain ownership of the CS and a
low level of ownership is expected to hamper the implementation of innovations 34].
Future directions
Despite the multidisciplinary character of the care described in the CS, the CS itself
is disease-specific, while multimorbidity is common among (elderly) diabetes patients
35]–38]. Therefore health care needs to move towards an integrated multidisciplinary approach
of chronic diseases worldwide in which the patient with one or more chronic diseases
is playing a more pivotal role. Although the etiology, management and prognosis of
other chronic diseases are different, the organisation and quality of care need to
meet the same criteria as the care for diabetes as disease management strategies are
similar in most chronic diseases. Despite the international differences in health
care systems, there is international consensus on the goals of treatment for diabetes
and the same type and quality of care needs to be provided to patients with one or
more chronic disease 6]. The Care Standards and the bundled payment approach are useful instruments in organising
integrated care and stimulating multidisciplinary collaboration. Furthermore, preventive
activities targeting chronic diseases need to become embedded in primary care and
close collaboration with the public domain needs to be established within such an
integrated multidisciplinary approach. In 2012, prevention was added to the CS by
means of an addendum. The importance of the availability of prevention and care close
to patients at a local level is underpinned by the positive results and experiences
with the CS for diabetes in the NAD pilot regions 19],23]. Achieving local collaboration between prevention, care and other relevant parties
involved is expected to be difficult and depends on several local preconditions, such
as the intentions of current municipal administrators, embedment into existing policies,
political support and funding 23]. However, the force of action in multiple environmental settings and levels, compounded
by the collective ability to accelerate and strengthen each other’s impact, can profoundly
improve the nation’s health 39]. Moreover, the community approach to chronic disease prevention has a high degree
of generalizability, cost-effectiveness, ability to diffuse information successfully
through use of community networks, and potential for influencing environmental, regulatory
and institutional policies that shape health 40].
Finally, the CS is currently mainly supply driven rather than tailored to the needs
of patients 41], while we see an international and national need to abandon the one-size-fits-all
approach and move towards personalized care 42],43]. To meet this need in the Netherlands, a group of experts and scientists is currently
– in collaboration with the NDF- working on the development of so called ‘patient
profiles’, a new tool which can help HCPs to provide personalized care tailored to
the needs of patients with diabetes. Within these profiles treatment-, personal- and
environmental factors are taken into account when tailoring the care and treatment.
The Netherlands is the first country worldwide that will start with evidence-based
application of patient profiles 44].