Dutch Hospitals Research Articles

AFFECT-HCM: quality of life and costs in hypertrophic cardiomyopathy

Abstract Background Hypertrophic cardiomyopathy (HCM) is the most common inherited cardiac disease, characterised by increased wall thickness. Pathogenic DNA variants in sarcomeric genes are identified in about half of HCM patients, enabling pre-symptomatic testing in family members. Since the first description of HCM tremendous progress has been made in the evaluation and management of HCM patients. However, little is known on the impact of HCM on quality of life (QoL) and costs. Purpose The AFFECT-HCM study evaluates the QoL, healthcare and societal costs in HCM patients and genotype-positive phenotype-negative (G+/P-) subjects. Methods The AFFECT-HCM is a multi-centre prospective study including genotyped HCM patients aged 18-80 years and G+/P- subjects. The study cohort is divided into three groups based on phenotype: G+/P- (wall thickness <13 mm), non-obstructive HCM (nHCM, maximal left ventricular outflow tract (LVOT) gradient <30 mmHg) and obstructive HCM (oHCM, LVOT gradient ≥30 mmHg). For QoL, the generic five-domain five-level EQ-5D-5L with the attached visual analogue scale and disease-specific Kansas City Cardiomyopathy Questionnaire are used. Healthcare and societal costs are measured via a bottom-up approach using the cost questionnaires iMCQ and iPCQ and expressed with means (the standard in healthcare cost reporting despite non-normality) in 2023 Euro per patient per year (€ PPPY). QoL and costs are compared between phenotypes. Results Results are summarised in the table. Between November 2022 - December 2023, 506 subjects (mean age 55 years, 39% female) were included in three Dutch hospitals. The study included 84 G+/P-, 307 nHCM and 115 oHCM subjects. Questionnaire response rate was 92%. Compared to G+/P- subjects; HCM patients were older (57 vs 46 yrs), more often male (67% vs 32%) and had more cardiovascular risk factors. Compared to nHCM patients, oHCM patients were more often symptomatic (58% vs 34%), more often in NYHA class III (19% vs 2%) and used more HCM-related medications (79% vs 64%). HCM patients, and particularly oHCM patients, reported decreased QoL with lower QoL-related questionnaire scores (Figure). The utilities (EQ-5D-5L) of HCM patients were lower than G+/P- subjects and the Dutch overall average (0.87±0.17), and for oHCM comparable with another study (0.82±0.18). Costs were higher for HCM patients than G+/P- subjects (€14374 vs €5888 PPPY) and higher in oHCM patients compared to nHCM patients (€19672 vs €12419 PPPY). The leading between-group difference is higher productivity losses in oHCM patients. Conclusion HCM is associated with reduced QoL and increased costs, especially in oHCM patients. The primary cost driver are healthcare costs, but the difference between oHCM and nHCM patients is mainly caused by indirect costs due to productivity losses. These data provide novel insights in the BoD of HCM and can aid in assessing cost-effectiveness analyses of new therapies for HCM in the future.Baseline characteristics and resultsQuality of life-related questionnaires

A Personal Health Record for patients with multiple sclerosis: A 2-year evaluation study

Abstract Background Multiple sclerosis (MS) is a chronic disease impacting the central nervous system, affecting 2.8 million people worldwide. Effective self-management is crucial for treating chronic diseases, including MS. Personal health records (PHRs) show promise in supporting self-management, potentially empowering patients and enhancing their engagement in treatment and health. However, implementation challenges persist. Objectives This study aimed to) assess the feasibility and usability of the PHR according to patients and healthcare professionals (HCPs), and 2) evaluate implementation determinants, and exploring preliminary effects on a range of outcomes related to the quality, efficiency, and costs of care, as well as health-related outcomes. Methods A mixed-methods study was conducted in a Dutch hospital. Quantitative data from 80 patients and 12 HCPs were collected via questionnaires at baseline (T0), after one (T1) and 2 years (T2). Focus group interview were conducted at T2 with 7 patients and 4 HCPs. Results Most patients never logged in during the first year and logged in a couple of times during the second year, with 15 minutes per log-in session. The HCPs mainly logged in a couple of times per year, averaging six minutes per session. Patients’ and HCPs’ usability and satisfaction scores were below average and moderate respectively. Various facilitators and barriers were identified, including knowledge gaps, staff capacity issues, and ICT obstacles. No significant differences were found in preliminary effects. Qualitative data highlighted benefits in terms of gaining insight into health data but revealed challenges with log-in issues and information retrieval. Conclusions Implementation challenges hindered PHR adoption. The evolving nature of PHRs requires ongoing evaluation and adaptation to optimize their potential benefits. Utilizing a participatory design approach and a dedicated implementation team could enhance adoption and maximize benefits. Key messages • A personal health record (PHR) for patients with MS was evaluated within the care setting of a Dutch hospital, demonstrating limited usability and moderate satisfaction. • Diverse obstacles impeded the adoption and uptake of the PHR, but potential solutions lie in continuous development with a participatory design approach and dedicated implementation team.

Factors associated with 30-day mortality in patients receiving mechanical circulatory support for cardiogenic shock

Abstract Introduction Mechanical circulatory support (MCS) is often deployed in patients with refractory cardiogenic shock complicating acute myocardial infarction (AMI-CS). Nevertheless, the mortality rate in these patients remains utterly high, around 50%. Purpose The aim of this study was to identify patient characteristics associated with 30-day mortality in patients receiving MCS for AMI-CS. Methods In the Netherlands, all patients undergoing percutaneous coronary intervention (PCI) are prospectively entered in the Netherlands Heart Registration (NHR). Additional data were retrieved for all CS patients between 2017-2021 in 14 Dutch hospitals, including MCS usage. Survivors and non-survivors amongst MCS treated patients were compared to identify patient characteristics associated with 30-day mortality. In addition, multivariate logistic regression analysis on imputed data was performed to quantify these associations in adjustment for confounders. Results MCS was deployed in 516 (23.3%) of all AMI-CS patients. MCS patients had a mean age of 64.2 (± 12.5) years and 74.6% were male. An intra-aortic balloon pump (IABP) was used in 49.0% of the patients. Impella, extracorporeal membrane oxygenation (ECMO) and multiple devices were used in 18.2%, 13.2% and 18.4% respectively. The overall 30-day mortality rate was 55.0%. At baseline, MCS survivors were younger (62.8 vs 65.2, p=0.03), had diabetes less often (18.4 vs. 28.0, p=0.02), and presented with a higher mean arterial pressure (MAP) (77.9 vs. 71.7, p<0.01). An out-of-hospital cardiac arrest (OHCA) preceded in 34.3% of the survivors versus 42.0% of the non-survivors (p=0.09). Survivors also had lower admission levels of lactate (5.0 vs. 7.8, p<0.01), glucose (12.1 vs. 15.2, p<0.01) and creatinine (94 vs. 115, p<0.01). Multivessel disease (MVD) was present less frequently in survivors compared to non-survivors (62.1% vs. 74.2%, p<0.01). In-hospital cardiac arrest (IHCA) occurred less often in survivors both prior to PCI (8.2% vs. 18.0%, p<0.01) and during PCI (22.8% vs. 34.6%, p<0.01). After multivariate logistic regression, higher age (OR 1.04, 95%CI: 1.02-1.05), resuscitation prior to (OR 2.11, 95 %CI: 1.09-4.09) or during PCI (OR 1.58, 95% CI: 1.01-2.47) and the presence of MVD (OR 2.07, 95% CI: 1.32-3.25) were independently associated with 30-day mortality in AMI-CS patients who received MCS. Conclusion In AMI-CS patients who received MCS, older age, the occurrence of an IHCA prior to or during PCI, and the presence of MVD were independently associated with an increased 30-day mortality.Figure 1.Table 1.

Real world economic evaluation of CT-FFR in patients with suspected coronary artery disease

Abstract Background Incorporation of CT-derived fractional flow reserve (CT-FFR) enhances the precision of Coronary CT Angiography (CCTA) to detect hemodynamically significant coronary artery disease (CAD). However, the financial consequences remain unclear. Purpose Our objective is to assess the economic implications of CT-FFR in the Dutch Healthcare system. Methods This retrospective, single-center cost effectiveness analysis includes patient data of a previously published study assessing the impact of routine CT-FFR availability on clinical management. We collected medical resource use for both diagnostic and therapeutic cardiovascular care with a follow-up duration of 1 year. Costs of CT-FFR analysis were set at €1000, its current price for Dutch hospitals. Median total costs at were compared using the Wilcoxon rank sum test, including a sensitivity analysis in which cost estimations (without registered maximum tariffs) were increased or decreased with 10%. Results A total of 360 patients, classified as having low to intermediate risk of CAD, were enrolled in the study – 224 in the CCTA group and 136 in the CT-FFR group. In addition to undergoing more (invasive) diagnostic testing and revascularization procedures over the studied period, patients in the CCTA-group had more outpatient clinic consultations (p<0.001), presented more frequently to the emergency department (p=0.035) and spend more nights in the hospital (p=0.11). Median costs were €3.347 (IQR €1.066 – €4.862) in the CCTA-group and €1.436 (IQR €1.362 - €3.943) in the CT-FFR group (p=0.091). Increasing cost estimation with 10% revealed a median of €3.431 in the CCTA-group versus €1.479 in the CT-FFR group (p=0.078), decreasing with 10% showed median costs of €3.263 in the CCTA-group and €1.392 in the CT-FFR group (p=0.118). In our sample, CT-FFR guided care would have been significantly cheaper than CCTA-guided care at or below a market price of €770. Conclusion Despite the significant reduction in additional diagnostic testing and hospital visits in the CT-FFR group, CT-FFR guided care was not cheaper than CCTA-guided care at its current market price of €1.000. Economic cost-effectiveness would have occurred from a price of €770 per analysis. The large difference between medians suggests that the lack of significance might partially be attributed to insufficient power in this relatively small sample size. Additionally, this study did not account for costs associated with loss of productivity and quality of life. However, less additional diagnostic testing, less revascularization procedures and less hospital consultations and admissions leads to reduction in hospital resource consumption and patient burden, which is an important advantage of CT-FFR as the number of referred patients increases yearly.

Timing of inopressor initiation in patients with acute myocardial infarction complicated by cardiogenic shock

Abstract Introduction Inotropes and vasopressors (inopressors) are commonly used in the treatment of acute myocardial infarction complicated by cardiogenic shock (AMICS). The characteristics of patients subjected to early or late initiation of inopressors are not yet described, and the impact of timing on outcomes remains uncertain. Purpose This retrospective real-world data study aims to identify patient-, treatment-, and outcome characteristics of AMICS patients treated with early- or late initiated inopressors. Methods The Netherlands Heart Registration (NHR) prospectively records baseline, procedural, and outcome data for PCI patients. Between 2017-2021, additional retrospective data on CS patients were collected by fourteen Dutch hospitals. Patients were categorized based on the timing of inopressor initiation, either early (pre PCI) or solely late (at the cathlab or within 24 hours after PCI). Patients presenting with an out of hospital cardiac arrest were excluded. Missing data were imputed through multiple imputation (30x). Multivariable logistic regression analysis was performed to evaluate the association between the timing of inopressor initiation and 30-day mortality, adjusting for univariate significant confounders among variables known at admission. Results A total of 956 consecutive CS patients were included of whom 418 (43.7%) and 538 (57.3%) patients were subjected to early and late initiation of inopressors respectively. The most frequently used drug in both groups was noradrenaline. At baseline, patients in the early initiation group were younger (67.4 vs. 70.0 years, p <0.001), presented with a lower mean arterial pressure (MAP) (72.5 vs. 76.3, p = 0.048) and higher lactate (4.2 vs. 3.6, p = 0.012), and presented with a NSTEMI more often (36.0% vs. 14.2%, p <0.001). They also had a higher prevalence of previous myocardial infarction (33.9% vs. 22.9%, p <0.001) and previous CABG (14.3% vs. 6.2%, p <0.001). Moreover, 30-day mortality rates were higher in the early initiated group (48.6% vs. 37.6%, pLogrank <0.001). After multivariate adjustment for age, admission MAP and lactate, early inopressor initiation remained independently associated with 30-day mortality (OR 1.44, 95%-CI 1.08-1.98) compared to late initiation. Conclusion In this Dutch cohort of CS patients undergoing PCI, baseline- treatment- and outcome characteristics differed between patient categories receiving either early or late initiated inopressors. Patients who were subjected to early initiated inopressors were younger, presented with worse hemodynamics, had a more extensive cardiovascular medical history and higher 30-day mortality rates. The results of this study reemphasize the importance of identifying patients who benefit from inopressors.30-day mortality late vs. earlyTable patient characteristics

Learning by Visualize a Nurse-Led CCOS Using the Functional Resonance Analysis Method.

Quality improvements (QIs) in dynamic and complex health care contexts require resilience and take variability into account in quality improvement. The Functional Resonance Analysis Method (FRAM) helps us understand resilience and gain insight into (un)desirable variability in the complex system of daily practice. We explored how using FRAM in the Deming cycle of a QI project can help professionals and researchers learn from, reflect upon, and improve complex processes. We used FRAM in a Dutch hospital to study a QI: Critical Care Outreach Service (CCOS). The aim was to use FRAM before and after implementation to create a FRAM model and reflect to health care professionals the mismatch between Work As Imagined (WAI) and Work As Done (WAD). The WAI FRAM model was co-created with professionals before the implementation of CCOS. We used descriptions of tasks and processes for ICU nurses and verified them in 30-minute semistructured interviews (N = 2). WAD was created by input of semistructured interviews with key professionals in CCOS (N = 21) and 3 nonparticipant observations of trained CCOS nurses. We validated WAD in 2 dialogue sessions with key professionals (N = 11). Data collection continued until saturation. Juxtaposing the WAI and WAD models showed that WAD contained additional functions and highlighted unexpectedly complex functions. Reflecting on the application of FRAM with health care professionals revealed opportunities and challenges, especially time investment. FRAM helps professionals outline processes and tasks (WAI), learn from, and reflect upon their daily practice (WAD). FRAM models help professionals identify variability proactively to improve practices that enhance resilient performance.

Involving Patients and/or Their Next of Kin in Serious Adverse Event Investigations: A Qualitative Study on Hospital Perspectives.

The involvement of patients or next of kin (P/N) after a serious adverse event (SAE) is evolving. Beyond providing mandatory information, there is growing recognition of the need to incorporate their interests. This study explores practical manifestations of P/N involvement and identifies significant considerations for hospitals. The data collection involved various qualitative research methods: 7 focus groups with 56 professionals from 37 hospitals, an interview with 2 representatives from the Dutch Association of Hospitals, and an interactive reflection seminar with over 60 participants from 34 hospitals. Before the focus groups, a brief questionnaire was sent out to survey participants' practices regarding into SAE investigations. After the study, another questionnaire was distributed to gather suggestions for future improvements and to identify their lessons learned. Thematic analysis was applied to the gathered data to identify key themes. Hospitals are increasingly acknowledging the interests and perspectives of P/N, recognizing their potential contributions to organizational learning and improvement. P/N involvement following SAEs includes active participation in different stages of the investigation process, not just passive information dissemination. Important factors influencing involvement are the provision of (emotional) support, identification of needs, and transparency of the SAE investigation. This study enhances understanding of evolving practices surrounding P/N involvement in the context of SAEs in Dutch hospitals. The findings highlight the importance of promoting meaningful involvement, recognizing the significance of P/N experiences, and fostering a culture of transparency and collaboration. By examining the dynamics of involvement, this research aims to inform policy development and facilitate the implementation of patient-centered approaches to post-SAE care.

Functional connectivity in resting-state networks relates to short-term global cognitive functioning in cardiac arrest survivors.

Long-term cognitive impairment is common in cardiac arrest survivors. Screening to identify patients at risk is recommended. Functional magnetic resonance brain imaging (fMRI) holds potential to contribute to prediction of cognitive outcomes. In this study, we investigated the possible value of early changes in resting-state networks for predicting short and long-term cognitive functioning of cardiac arrest survivors. We performed a prospective multicenter cohort study in cardiac arrest survivors in three Dutch hospitals. Resting-state fMRI scans were acquired within a month after cardiac arrest. We primarily focused on functional connectivity within the default-mode network (DMN) and salience network (SN), and additionally explored functional connectivity in seven other networks. Cognitive outcome was measured using the Montreal Cognitive Assessment (MoCA) during hospital admission and at 3 and 12 months, and by neuropsychological examination (NPE) at 12 months. We tested mixed effects models to evaluate the value of connectivity within the networks for predicting global cognitive outcomes at the three time points, and long-term cognitive outcomes in the memory, attention, and executive functioning domains. We included 80 patients (age 60 ± 11 years, 72 (90%) male). MoCA scores increased significantly between hospital admission and 3 months (ΔMoCAhospital-3M = 2.89, p < 0.01), but not between 3 and 12 months (ΔMoCA3M-12M = 0.38, p = 0.52). Connectivity within the DMN, SN, and dorsal attention network (DAN) was positively related to global cognitive functioning during hospital admission (βDMN = 0.85, p = 0.03; βSN = 1.48, p < 0.01; βDAN = 0.96, p = 0.01), but not at 3 and 12 months. Network connectivity was also unrelated to long-term memory, attention, or executive functioning. Resting-state functional connectivity in the DMN, SN, and DAN measured in the first month after cardiac arrest is related to short-term global, but not long-term global or domain-specific cognitive performance of survivors. These results do not support the value of functional connectivity within these RSNs for prediction of long-term cognitive performance after cardiac arrest.

Tasks and responsibilities of clinical midwives in Dutch hospitals.

The number of Dutch clinical midwives has increased substantially over the last 20 years, but their tasks, responsibilities, and formal positions remain unclear. This study aimed to gain insight into the current tasks and responsibilities of clinical midwives in Dutch hospitals. We also aimed to determine whether these tasks varied among three types of hospitals in the Netherlands: secondary nonteaching hospitals, secondary teaching hospitals, and tertiary hospitals. A cross-sectional national survey in which a questionnaire was sent to 810 clinical midwives from 78 hospitals was conducted. Responses from 412 (51%) clinical midwives from 77 hospitals were included in the analysis. Most respondents (97%) provided care in the delivery wards. They were often involved in the induction of labor (88%), requests for pain relief (87%), cases of meconium-stained fluid (59%), prolonged first-stage labor (56%), and maternal hypertensive disorders (43%). Daily tasks and responsibilities were determined by the type of pathology (60%), caseload in the ward (48%), and years of work experience (28%). The tasks varied according to hospital type, and the majority also conducted non-care-related tasks, such as auditing (83%) and teaching (67%). Dutch clinical midwives play important roles in obstetric care. They provide care for women with a wide range of pathologies they are not always trained for. In addition, they perform non-care-related tasks. Their tasks varied according to hospital type. To ensure that they are both skilled and authorized, compulsory training and formalization of their profession are possible interventions.

Results of the Dutch scalp cooling registry in 7424 patients: analysis of determinants for scalp cooling efficacy.

Chemotherapy-induced alopecia is a common consequence of cancer treatment with a high psychological impact on patients and can be prevented by scalp cooling (SC). With this multi-center patient series, we examined the results for multiple currently used chemotherapy regimens to offer an audit into the real-world determinants of SC efficacy. The Dutch Scalp Cooling Registry collected data on 7424 scalp-cooled patients in 68 Dutch hospitals. Nurses and patients completed questionnaires on patient characteristics, chemotherapy, and SC protocol. Patient-reported primary outcomes at the start of the final SC session included head cover (HC) (eg, wig/scarf) use (yes/no) as a surrogate for patient satisfaction with SC and WHO score for alopecia (0 = no hair loss up to 3 = total alopecia) as a measure of scalp cooling success. Exhaustive logistic regression analysis stratified by chemotherapy regimen was implemented to examine characteristics and interactions associated with the SC result. Overall, over half of patients (n = 4191, 56%) did not wear a HC and 53% (n = 3784/7183) reported minimal hair loss (WHO score 0/1) at the start of their final treatment. Outcomes were drug and dose dependent. Besides the chemotherapy regimen, this study did not identify any patient characteristic or lifestyle factor as a generic determinant influencing SC success. For non-gender specific cancers, gender played no statistically significant role in HC use nor WHO score. Scalp cooling is effective for the majority of patients. The robust model for evaluating the drug and dose-specific determinants of SC efficacy revealed no indications for changes in daily practice, suggesting factors currently being overlooked. As no correlation was identified between the determinants explaining HC use and WHO score outcomes, new methods for evaluation are warranted.

Development and Portability of a Text Mining Algorithm for Capturing Disease Progression in Electronic Health Records of Patients With Stage IV Non-Small Cell Lung Cancer.

The objective was to develop and evaluate the portability of a text mining algorithm for prospectively capturing disease progression in electronic health record (EHR) data of patients with metastatic non-small cell lung cancer (mNSCLC) treated with immunochemotherapy. This study used EHR data from patients with mNSCLC receiving immunochemotherapy (between October 1, 2018, and December 31, 2022) in four Dutch hospitals. A text mining algorithm for capturing disease progression was developed in hospitals 1 and 2 and then transferred to hospitals 3 and 4 to evaluate portability. Performance metrics were calculated by comparing its outcomes with manual chart review. In addition, data were simulated to come available over time to assess performance in real-time applications. Median progression-free survival (PFS) was calculated using the Kaplan-Meier method to compare text mining with manual chart review. During development and portability, the text mining algorithm performed well in capturing disease progression, with all performance scores >90%. When real-time performance was simulated, the performance scores in all four hospitals exceeded 90% from week 15 after the start of follow-up. Although the exact progression dates varied in 46 patients of 157 patients with progressive disease, the number of patients labeled with progression too early (n = 24) and too late (n = 22) was well balanced with discrepancies ranging from -116 to 384 days. Nevertheless, the PFS curves constructed with text mining and manual chart review were highly similar for each hospital. In this study, an accurate text mining algorithm for capturing disease progression in the EHR data of patients with mNSCLC was developed. The algorithm was portable across different hospitals, and the performance over time was good, making this an interesting approach for prospective follow-up of multicenter cohorts.

Effect of Early Levodopa Treatment on Mortality in People with Parkinson's Disease.

The ideal timing for initiating levodopa in newly diagnosed people with Parkinson's disease (PD) is uncertain due to limited data on the long-term effects of levodopa. The aim was to investigate whether early levodopa initiation postpones mortality (primary outcome), the requirement of device-aided therapies, and the incidence of PD-related complications, such as fall-induced injuries. Using nationwide claims data from Dutch hospitals (2012-2020), we grouped newly diagnosed PD individuals as "early initiators" (initiating levodopa within 2 years of diagnosis) or "nonearly initiators." We used the national death registry to assess mortality and health-care claims to assess PD-related complications and device-aided therapies. We used marginal structural models to compare mortality and device-aided therapy rates between groups, and a Poisson regression model to compare PD-related complication rates. Among 29,943 newly diagnosed PD individuals (mean age at diagnosis: 71.6, 38.5% female), there were 24,847 early and 5096 nonearly levodopa initiators. Over a median 4.25 years, 8109 (27.1%) died. The causal risk ratio for mortality was 1.04 (95% confidence interval [CI] 0.92-1.19) for early versus nonearly initiators. The risk ratio of receiving any device-aided therapy was 3.19 (95% CI 2.56-5.80). No association was observed with incidence of PD-related complications (incidence rate ratio: 1.00, 95% CI 0.96-1.05). Early levodopa initiation in PD does neither postpone nor accelerate mortality or PD-related complications, nor does it precipitate earlier occurrence of PD-related complications or mortality. However, we cannot exclude that the results were influenced by residual confounding due to unmeasured risk factors of mortality.

Environmental Outcomes of Reducing Medication Waste by Redispensing Unused Oral Anticancer Drugs

Medications are associated with substantial environmental outcomes, yet frequently end up being unused by patients. Waste-minimizing interventions, such as redispensing of quality-approved oral anticancer drugs remaining unused by patients at home, could reduce the environmental footprint of cancer treatment. To assess the environmental outcomes of redispensing quality-assured oral anticancer drugs and to explore how redispensing could be environmentally optimized. In this quality improvement study, a cradle-to-grave life cycle assessment was performed in the outpatient pharmacy of 4 Dutch hospitals, based on a prospective multicenter trial comprising 1071 patients with a clinical diagnosis of cancer and an active prescription for an oral anticancer drug stored at room temperature from February 1, 2021, to February 1, 2023, with a follow-up of 12 months per patient. Participants received prescribed oral anticancer drugs with additional quality-assurance materials (ie, seal bags and time-temperature indicators), so the pharmacy could redispense quality-assured drugs based on authenticity, appearance, remaining shelf life, and/or adequate storage. The estimated environmental outcomes avoided due to waste reduction (ie, production and transport and incineration of redispensed oral anticancer drugs) corrected for outcomes of process burdens (ie, quality assurance materials), quantified in 3 outcome measures: human health damage (disability-adjusted life-years), ecosystems damage (species × year), and climate change (kg of carbon dioxide equivalent [CO2-eq]) per patient per year. A volunteer sample of 1071 patients (median age, 70 years [IQR, 62-75 years]; 622 men [58.1%]) participated in the intervention. Redispensing oral anticancer drugs was initially associated with an environmental burden, mainly because of the high impact of time-temperature indicators. However, when quality-assurance materials were selectively used for temperature-sensitive oral anticancer drugs (ie, maximum storage temperature of 25 °C), redispensing was environmentally beneficial to human health and ecosystems, providing estimated climate benefits of 1.9 kg (95% CI, 1.4-2.6 kg) of CO2-eq per patient per year. In this quality improvement study, redispensing unused oral anticancer drugs was found to be a suitable strategy to reduce waste and improve environmental sustainability of cancer treatment after process optimization. Redispensing unused oral anticancer drugs could contribute to sustainability of cancer treatment through reduced costs and environmental outcomes.

Comparing Guidelines to Daily Practice When Screening Older Patients for the Risk of Functional Decline in Hospitals: Outcomes of a Functional Resonance Analysis Method (FRAM) Study.

Dutch hospitals are required to screen older patients for functional decline using 4 indicators: malnutrition, delirium, physical impairment, and falls, to recognize frail older patients promptly. The Functional Resonance Analysis Method was employed to deepen the understanding of work according to the protocols (work-as-imagined [WAI]) in contrast to the realities of daily practice (work-as-done [WAD]). Data have been collected from 3 hospitals (2 tertiary and 1 general) and 4 different wards: an internal medicine ward, surgical ward, neurology ward, and a trauma geriatric ward. WAI models were based on national guidelines and hospital protocols. Data on WAD were collected through semistructured interviews with involved nurses (n = 30). Hospital protocols were more extensive than national guidelines for all screening indicators. Additional activities mainly comprised specific preventive interventions or follow-up assessments after adequate measurements. Key barriers identified to work according to protocols included time constraints, ambiguity regarding task ownership, nurses' perceived limitations in applying their clinical expertise due to time constraints, insufficient understanding of freedom-restricted interventions, and the inadequacy of the Delirium Observation Scale Score in patients with neurological and cognitive problems. Performance variability stemmed from timing issues, frequently attributable to time constraints. The most common reasons for deviating from the protocol are related to time constraints, lack of knowledge, and/or patient-related factors. Also, collaboration among relevant disciplines appears important to ensure good health outcomes. Future research endeavors could shed a light on the follow-up procedures of the screening process and roles of other disciplines, such as physiotherapists.

Occurrence and predictors of laboratory abnormalities during outpatient parenteral antimicrobial therapy – A multicenter cohort study to inform laboratory test monitoring

ObjectivesEvidence on the optimal frequency of laboratory testing during outpatient parenteral antimicrobial therapy (OPAT) is lacking. Therefore, we investigated how often and when laboratory abnormalities occur during OPAT and which factors are associated with these abnormalities. MethodsWe performed a multicenter cohort study in four Dutch hospitals among adult patients receiving OPAT and collected routinely obtained laboratory test results. Incidence and incidence rates were calculated for various laboratory abnormalities. Survival analysis was performed to visualize the time to the first occurrence of laboratory abnormalities and Poisson regression analysis to compare the number of abnormalities in the first and second 30 OPAT days among patients receiving OPAT for ≥60 days. Predictors were identified using a multivariable Cox proportional hazard regression model. Results45.1% of 1152 included patients developed laboratory abnormalities, but only 2% led to OPAT discontinuation. Hepatotoxicity was most common (33.9 events/1000 OPAT days), with a time-dependent decrease in the occurrence of the first hepatotoxic event, while hypokalemia was rare (1.7 events/1000 OPAT days). In the subgroup of patients receiving ≥60 days of OPAT, nephrotoxicity was more common in days 31-60. We observed partly toxicity-specific associations between antibiotic type, concomitant medication, baseline laboratory values, patient characteristics, and the occurrence of laboratory abnormalities. ConclusionsWhile laboratory abnormalities are frequently observed during OPAT, they rarely lead to discontinuation of OPAT. Specific patient, treatment and laboratory characteristics were associated with the occurrence of laboratory abnormalities. Based on our results, we recommend a more personalized laboratory monitoring policy with less blood sampling.

Stakeholders' perspectives on capturing societal cost savings from a quality improvement initiative: A qualitative study.

Besides improving the quality of care, quality improvement initiatives often also intend to produce cost savings. An example is prehabilitation, which can reduce complication rates and the length of stay in the hospital. However, the process from utilization reductions to actual societal cost savings remains uncertain in practice. Our aim was to identify barriers and facilitators throughout this process. We used the implementation of prehabilitation in a Dutch hospital as a test case. We held 20 semi-structured interviews between June and November 2023. Eighteen stakeholders were affiliated with the hospital and two with different health insurers. Nine interviews were held face-to-face and 11 via Microsoft Teams. The interviews were recorded and transcribed. The first transcripts were inductively coded by two authors, the subsequent transcripts by one and checked by another. Differences were resolved through discussion. We identified 20 barriers and 23 facilitators across four stages: reducing capacity, reducing departmental expenses, reducing hospital expenses and reducing insurer expenses. All participants expected that the excess capacity will be used for other priorities. This was perceived as highly valuable and as an efficiency gain. Other barriers to capture savings included the fear of losing resilience, flexibility, status and revenue. Misalignment between service contracts among hospitals and insurers can hinder the ability to financially incentivize cost reductions. Additionally, some contract types can hinder the transfer of hospital savings to insurers. Identified facilitators included shared savings agreements, an explicit strategy targeting all stages, and labor shortage, among others. This study systematically describes barriers and facilitators that prevent translating quality improvement initiatives into societal cost savings. Stakeholders expect that any saved capacity will be used for other priorities, including providing care due to the increasing demand. Capturing any cash savings does not occur automatically, emphasizing the need for a strategy targeting all stages.

Non-operative treatment of metacarpal fractures and patient-reported outcomes: a multicentre snapshot study

Abstract Purpose This study aimed to investigate practice variation in non-operative treatment methods and immobilisation duration for metacarpal fractures, and to evaluate patient-reported outcomes. Methods Conducted in 12 Dutch hospitals over three months in 2020, this study included adult patients with non-operatively treated solitary metacarpal fractures. Fractures were classified into intra-articular base, extra-articular base, shaft, neck, and intra-articular head fractures. The treatment methods (functional treatment allowing digit mobilisation or immobilisation) and immobilisation duration were assessed. Patient-reported outcomes were evaluated using the Michigan Hand Outcomes Questionnaire (MHQ) at three months post-trauma. Results Of 389 included patients, shaft fractures were most common (n = 150, 39%), with 93% immobilised, followed by fifth metacarpal neck fractures (n = 93, 24%), with 75% immobilised. Immobilisation rates for fifth metacarpal neck fractures varied between hospitals, ranging from 29% (95% CI 0.10–0.58) to 100% (95% CI 0.78–1.00). The median immobilisation duration for all fractures was 23 days (IQR: 20–28), and hospital setting was independently associated with this duration. Patients with metacarpal shaft fractures immobilised for less than 21 days had higher MHQ scores compared to those immobilised for 21 days or more (median (IQR) 83 (76–100) versus 71 (57–89), p = 0.026). Conclusions The results showed practice variation in the treatment of metacarpal fractures, especially in the treatment of fifth MC neck fractures, with some hospitals following the Dutch guideline that advocates functional treatment while others did not. There are suggestions that prolonged immobilisation of metacarpal shaft fractures may lead to a worse MHQ score. These findings underscore the need for adherence to treatment protocols and emphasize functional treatment to potentially improve patient outcomes and cost-effectiveness.

Efficiency of computerized clinical decision support systems involving anticoagulants: A flashmob study in Dutch hospital pharmacies.

Computerized decision support systems (CDSSs) aim to prevent adverse drug events. However, these systems generate an overload of alerts that are not always clinically relevant. Anticoagulants are frequently involved in these alerts. The aim of this study was to investigate the efficiency of CDSS alerts on anticoagulants in Dutch hospital pharmacies. A multicentre, single-day, cross-sectional study was conducted using a flashmob design in Dutch hospital pharmacies, which have CDSSs that operate on both a national medication surveillance database and on self-developed clinical rules. Hospital pharmacists and pharmacy technicians collected data on the number and type of alerts and time needed for assessing these alerts. The primary outcome was the CDSS efficiency on anticoagulants, defined as the percentage of alerts on anticoagulants that led to an intervention. Secondary outcomes where among other CDSSs efficiency related to any medications and the time expenditure. Descriptive data-analysis was used. Of the 69 hospital pharmacies invited, 42 (61%) participated. The efficiency of CDSS alerts on anticoagulants was 4.0% (interquartile range [IQR] 14.0%) for the national medication surveillance database alerts and 14.3% (IQR 40.0%) for alerts from clinical rules. For any medication, the efficiency was lower: 1.8% (IQR 7.5%) and 13.4% (IQR 21.5%) respectively. The median time for assessing the relevance of all alerts was 2 (IQR 1:21) h/day for pharmacists and 6 (IQR 5:01) h/day for pharmacy technicians. CDSS efficiency is generally low, both for anticoagulants and any medication, while the time investment is high. Optimization of CDSSs is needed.

How do cultural elements shape speak-up behavior beyond the patient safety context? An interprofessional perspective in an obstetrics and gynecology department.

Interprofessional working and learning thrives with speak-up behavior. Efforts to improve speak-up have mainly focused on isolated techniques and training programs within the patient safety scope, yet sustained improvement requires a cultural shift beyond this scope. This research investigates the influence of culture elements on speak-up behavior in interprofessional teams beyond the patient safety context. An exploratory qualitative study design was used in a Dutch hospital's Obstetrics and Gynecology department. A representative sample of stakeholders was purposefully selected, resulting in semi-structured interviews with 13 professionals from different professional backgrounds (nurses, midwifes, managers, medical specialists, and residents). A speak-up pledge was developed by the research team and used to prime participants for discussion. Data analysis involved three-step coding, which led to the development of themes. This study has identified six primary cultural themes that enhance speak-up behavior. These themes encompass the importance of managing a shared vision, the role of functional hierarchy, the significance of robust interpersonal relationships, the formulation of a strategy delineating when to speak up and when to exercise restraint, the promotion of an open-minded professional mindset, and the integration of cultural practices in the context of interprofessional working and learning. Six crucial cultural elements have been pinpointed to boost the practice of speaking up behavior in interprofessional working and learning. Remarkably, hierarchy should not be held responsible as the wrongdoer; instead, can be a great facilitator through respect and appreciation. We propose that employing transformational and humble leadership styles can provide guidance on effectively integrating the identified cultural elements into the workplace and provide an IMOI framework for effective interprofessional speak-up beyond patient safety.

Improving patient care transitions from the intensive care unit to the ward by learning from everyday practice. A multicenter qualitative study

ObjectiveTo explore and describe the everyday practices (Work-As-Done) that hinder and facilitate patient care transitions from the intensive care unit (ICU) to the ward. Research method/designMultiple qualitative case studies in the ICU and various specialized wards of three Dutch hospitals. Adult patients planned to be transferred were purposively sampled on a variety of characteristics along with their relative (if present), and the ICU and ward nurses who were involved in the transition process. Data were collected by using multiple sources (i.e., observations, semi-structured interviews and a qualitative survey) and then systematically analyzed using the thematic analysis approach until saturation was reached. FindingsTwenty-six cases were studied. For each case, the actual transfer was observed. Sixteen patients, five relatives and 36 nurses were interviewed. Two patients completed the survey. Fifteen themes emerged from the data, showing that the quality of transitions is influenced by the extent to which nurses anticipate to patient-specific needs (e.g., providing timely and adequate information, orientation, mental support and aftercare) and to the needs of the counterpart to continue care (e.g., by preparing handovers) besides following standard procedures. Data also show that procedures sometimes interfere with what works best in practice (e.g., communication via a liaison service instead of direct communication between ICU and ward nurses). ConclusionsSubtle, non-technical nursing skills play an important role in comforting patients and in the coordination of care when patients are transferred from the ICU to the ward. Implications for clinical practiceThese Work-As-Done findings and their underlying narratives, that are often overlooked when focusing on quality improvement, can be used as material to reflect on own practice and raise awareness for its impact on patients. They may stimulate healthcare staff in crafting interventions for optimizing the transition process.