Abstract Background In 2006, the Health Insurance Act changed Dutch health insurance by implementing managed competition, whereby the health insurance market is strongly regulated by the government. ...The aim of the study is to investigate key stakeholders’ opinions about effects of recent changes in Dutch healthcare policy, focussing upon three important requirements for successful managed competition: risk-adjustment, consumer choice and instruments for managed care. Method Expert interviews with 12 key stakeholders were performed (October/November 2009), transcribed and analyzed in a four-step qualitative process. Results The Dutch risk-adjustment scheme is very advanced but incentives for health insurers to select risks remain. The Health Insurance Act has given insurers new incentives to focus upon consumer needs and preferences, whereby large group contracts have replaced individual consumer choice with collective decision-making. Managed care concepts are slow in developing. Patient organizations and insurers report taking part in such efforts, but other stakeholders do not perceive that progress has been made. Conclusions The pre-requisites for successful managed competition in the Netherlands are not yet entirely in place: risk-adjustment schemes cannot yet counteract all incentives to select risks, consumer preferences are just beginning to influence insurer policies and managed care elements are currently in the development stage.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
To what extent are European rules complied with, and what are the reasons for non-compliance with EU law? According to an intergovernmentalist perspective, implementation problems should occur when ...member states failed to assert their interests in the European decision-making process. Focusing on 26 infringement procedures from the area of labour law, we show that such 'opposition through the backdoor' does occur occasionally. However, we demonstrate that opposition at the end of the EU policy process may also arise without prior opposition at the beginning. Additionally, our findings indicate that non-compliance is often unrelated to opposition, and due to administrative shortcomings, interpretation problems, and issue linkage. This study is based on unique in-depth data stemming from a ground-level analysis of the implementation of six EU Directives in all 15 member states.
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BFBNIB, NUK, PILJ, SAZU, UL, UM, UPUK
This article examines the impact of Europeanization on cooperation between major
interest groups and the state in national policymaking. Its theoretical innovation
centres on two issues: (1) a ...classification of cooperation by management, labour,
and the state in public policy-making and (2) a differentiation of levels of
Europeanization in the Member States. The empirical material highlights the
implementation of six EU Directives in four smaller states: Austria, Denmark,
Luxembourg, and Sweden. A moderate trend towards convergence is discovered, caused
mainly by forced adaptation of the most extreme model of corporatism.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
Karakteristik kecap kedelai sangat ditentukan oleh aktivitas mikroorganisme yang terlibat selama fermentasi khususnya pada fermentasi tahap kedua dengan larutan garam. Kedelai merupakan substrat yang ...tinggi protein, dimana hasil fermentasinya seperti kecap kedelai memiliki rasa yang gurih karena kandungan asam amino bebas dan peptida. Bahan yang dapat meningkatkan pertumbuhan mikroorganisme selama fermentasi seperti ekstrak khamir belum pernah diteliti penggunaannya dalam pembuatan kecap kedelai. Penelitian ini bertujuan mengevaluasi pengaruh penambahan ekstrak khamir pada tahap fermentasi garam terhadap karakteristik kimia moromi kecap kedelai. Moromi adalah hasil fermentasi tahap kedua dan disebut kecap kedelai setengah jadi yang belum dimasak dengan gula dan rempah-rempah untuk menghasilkan kecap asin atau kecap manis. Karakteristik moromi yang diinginkan adalah kadar asam glutamat bebas dan padatan terlarut yang tinggi. Pada penelitian ini koji kering difermentasi dalam larutan garam (1:4= koji:larutan garam) 20% b/v secara spontan. Ekstrak khamir ditambahkan ke dalam larutan garam dengan konsentrasi 0 (M0) sebagai kontrol, 0,05 (M1), 0,15 (M2), dan 0,50 (M3) % b/v. Karakteristik kimia dari moromi dievaluasi pada hari ke- 0, 7, dan kemudian setiap dua minggu sekali hingga hari fermentasi ke-63. Hasil analisis data dengan One-Way ANOVA menunjukkan bahwa karakteristik kimia moromi yang ditambah ekstrak khamir berbeda nyata dengan karakteristik moromi tanpa penambahan ekstrak khamir. Moromi yang ditambah ekstrak khamir 0,50% b/v (M3) memiliki total gula, total asam tertitrasi, dan kadar asam glutamat yang signifikan lebih tinggi dibanding moromi lain (M1 dan M2). Ekstrak khamir dapat dimanfaatkan sebagai nutrisi tambahan bagi mikroorganisme yang berperan dalam proses pembuatan kecap kedelai. Kata kunci: Aktivitas Mikroorganisme; Fermentasi Garam; Ketersediaan Nutrisi; Kualitas Kecap Kedelai
Im Zeitalter immer enger werdender internationaler Vernetzung haben die Themen „Ideentransfer“ und „wechselseitiges Lernen“ auch in Forschungsarbeiten zum internationalen Gesundheitssystemvergleich ...Konjunktur. Sehr schnell wird dabei allerdings oft von einer parallelen institutionellen Entwicklung auf tatsächliche Lernprozesse geschlossen. Dieser Beitrag befasst sich mit dem Gesundheitssystemwandel in drei Ländern, die dem Typ „soziale Krankenversicherung“ zugerechnet werden. Empirische Basis der Untersuchung sind halb-standardisierte, qualitative Experteninterviews, die methodisch geeignet sind, politische Lernprozesse zu untersuchen. Die Analyse geht insbesondere der Frage nach, inwiefern jüngere Veränderungen in den Gesundheitssystemen der drei Länder von grenzüberschreitendem Ideentransfer geprägt waren. Da die drei Länder demselben Modelltypus zugerechnet werden, liegt es nahe zu erwarten, dass diese einem ähnlichen Problemdruck ausgesetzt sind. Der Beitrag zeigt jedoch, dass weder in ihren Problemlösungen alle drei Länder ähnliche Muster aufweisen, noch durchgängig die Erfahrungen aus den „ähnlichen“ Nachbarländern besonders stark herangezogen. Insgesamt erweist sich das Gelingen eines grenzüberschreitenden Ideentransfers als sehr voraussetzungsvoll. Diese Voraussetzungen näher zu beleuchten, ist Ziel dieses Beitrags.
Transthoracic echocardiography is the current standard for assessing aortic regurgitation (AR). AR severity can also be evaluated by flow measurement in the ascending aorta using cardiac magnetic ...resonance (CMR); however, the optimal site for flow measurement and the regurgitant fraction (RF) severity grading criteria that best compares with the transthoracic echocardiographic assessment of AR are not clear. The present study aimed to determine the optimal site and RF grading criteria for AR severity using phase-contrast flow measurements and CMR. A prospective observational study was performed of 107 consecutive patients who were undergoing CMR of the thoracic aorta. Using CMR, the AR severity and aortic dimensions were measured at 3 levels in the aorta (the sinotubular junction, mid-ascending aorta, and distal ascending aorta). The results were compared to the transthoracic echocardiographic grade of AR severity using multiple qualitative and quantitative criteria (grade 0, none; I+, mild; II+, mild to moderate; III+, moderate to severe; and IV+, severe). The mean RF values were significantly greater at the sinotubular junction than at the distal ascending aorta (13 ± 13.3% vs 9.4 ± 12.6%, respectively; p <0.001). The RF values that best defined AR severity using phase-contrast CMR were as follows: grade 0 to I+, <8%; grade II+, 8% to 19%; grade III+, 20 to 29%; and grade IV+, 30%) at the sinotubular or mid-ascending aorta. In conclusion, the quantitative RF values of AR severity using phase-contrast flow are best assessed in the proximal ascending aorta and differ from recognized quantitative echocardiographic criteria.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
We recently found that polyunsaturated lecithin prevents ethanol from causing cirrhosis in the baboon. Because transformation of lipocytes to transitional cells plays a key role in hepatic ...fibrogenesis in vivo, and because this process in alcohol-fed baboons was found to be attenuated by polyunsaturated lecithin, we focused on lipocytes to study the mechanism of the protective effect. Rat lipocytes cultured on plastic undergo spontaneous activation, accompanied by expression of alpha-smooth muscle actin isoform and production of substantial amounts of type I collagen. The latter was further increased on incubation with acetaldehyde. This in vitro model was used here to study how acetaldehyde-mediated collagen production and accumulation can be turned off. Addition of polyunsaturated lecithin (10 mumols/L) was found to prevent the acetaldehyde-induced increase in collagen accumulation by 83% (p less than 0.001). By contrast, a saturated phospholipid (10 mumols/L dilauroyl phosphatidylcholine), a monounsaturated one (10 mumols/L linoleoyl-palmitoyl phosphatidylcholine) or linoleic acid (20 mumols/L bound to albumin) had no such effect. Incorporation of 3Hproline into collagen and the expression of alpha-1 (I) procollagen mRNA were increased by acetaldehyde; the latter was not significantly affected by polyunsaturated lecithin. Polyunsaturated lecithin increased lipocyte collagenase activity by 100% (p less than 0.001), whereas dilauroyl phosphatidylcholine, linoleoyl-palmitoyl phosphatidylcholine and linoleic acid had no such action. We concluded that (a) polyunsaturated lecithin selectively prevents the acetaldehyde-induced increase in collagen accumulation in lipocyte cultures, whereas other phospholipids or linoleate have no such effect; and (b) polyunsaturated lecithin does not modify the acetaldehyde-mediated increase in alpha-1 (I) procollagen mRNA, but it increases collagenase activity, suggesting that the protective effect exerted by polyunsaturated lecithin against alcohol induced fibrosis in vivo is due at least in part to stimulation of collagenase activity, which may prevent excess collagen accumulation by offsetting increased collagen production.
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BFBNIB, FZAB, GIS, IJS, KILJ, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Sequential liver specimens of 18 baboons exposed for up to 6 years to alcohol on a nutritionally adequate diet, as well as those of pair-fed controls, were examined by light microscopy. Whereas ...control animals failed to develop pathologic changes, in all baboons exposed, ethanol produced initial steatosis and subsequently fibrosis. Emphasis was on the pattern of the fiber accumulations as related to lesions of the hepatocytes. Segmented neutrophilic leukocytes were rarely observed, and the picture of frank alcoholic hepatitis was absent, but diffusely increased mononuclear sinusoidal cells and interstitial clusters of such cells with PAS-positive macrophages were abundant. Fibrosis proceeding to septum formation was associated mainly with large-droplet steatosis. Septum formation was initiated by excess layers of reticulin around steatotic hepatocytes or, more frequently, by linking of fiber accumulations around the clusters of mononuclear cells, in both instances with subsequent deposition of collagen fibers. Both processes were prominent in the centrolobular zone, creating a perivenous net-like fibrosis, but septum formation also started within the lobular parenchyma and eventually linked with the barely altered portal tracts. Fifteen alcohol-fed baboons developed septums, with diffuse septal fibrosis in 5; 4 proceeded to septal cirrhosis and 1 each to micronodular and to mixed micromacronodular cirrhosis. Cirrhosis in the baboons thus develops without the conspicuous polymorphonuclear inflammation characteristic of human alcoholic hepatitis. These observations indicate a pathway to cirrhosis over creeping fibrosis that might play a role also in man, instead of (or supplementing) the one proceeding over alcoholic hepatitis.
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