Low-value chronic prescription of acid reducing medication among Dutch general practitioners: impact of a patient education intervention

BACKGROUND

Dyspepsia is a commonly encountered clinical condition in Dutch general practice, which is often treated through the prescription of acid-reducing medication (ARM). However, recent studies indicate that the majority of chronic ARM users lack an indication for their use and that their long-term use is associated with adverse outcomes. We developed a patient-focussed educational intervention aiming to reduce low-value (chronic) use of ARM.

METHODS

We conducted a randomized controlled study, and evaluated its effect on the low-value chronic prescription of ARM using data from a subset (n = 26) of practices from the Nivel Primary Care Database. The intervention involved distributing an educational waiting room posters and flyers informing both patients and general practitioners (GPs) regarding the appropriate indications for prescription of an ARM for dyspepsia, which also referred to an online decision aid. The interventions' effect was evaluated through calculation of the odds ratio of a patient receiving a low-value chronic ARM prescription over the second half of 2021 and 2022 (i.e. pre-intervention vs. post-intervention).

RESULTS

In both the control and intervention groups, the proportion of patients receiving chronic low-value ARM prescriptions slightly increased. In the control group, it decreased from 50.3% in 2021 to 49.7% in 2022, and in the intervention group it increased from 51.3% in 2021 to 53.1% in 2022. Subsequent statistical analysis revealed no significant difference in low-value chronic prescriptions between the control and intervention groups (Odds ratio: 1.11 [0.84-1.47], p > 0.05).

CONCLUSION

Our educational intervention did not result in a change in the low-value chronic prescription of ARM; approximately half of the patients of the intervention and control still received low-value chronic ARM prescriptions. The absence of effect might be explained by selection bias of participating practices, awareness on the topic of chronic AMR prescriptions and the relative low proportion of low-value chronic ARM prescribing in the intervention as well as the control group compared to an assessment conducted two years prior.

TRIAL REGISTRATION

10/31/2023 NCT06108817.

The implementation of a multidisciplinary, electronic health record embedded care pathway to improve structured data recording and decrease electronic health record burden

INTRODUCTION

Theoretically, the added value of electronic health records (EHRs) is extensive. Reusable data capture in EHRs could lead to major improvements in quality measurement, scientific research, and decision support. To achieve these goals, structured and standardized recording of healthcare data is a prerequisite. However, time spent on EHRs by physicians is already high. This study evaluated the effect of implementing an EHR embedded care pathway with structured data recording on the EHR burden of physicians.

MATERIALS AND METHODS

Before and six months after implementation, consultations were recorded and analyzed with video-analytic software. Main outcome measures were time spent on specific tasks within the EHR, total consultation duration, and usability indicators such as required mouse clicks and keystrokes. Additionally, a validated questionnaire was completed twice to evaluate changes in physician perception of EHR system factors and documentation process factors.

RESULTS

Total EHR time in initial oncology consultations was significantly reduced by 3.7 min, a 27 % decrease. In contrast, although a decrease of 13 % in consultation duration was observed, no significant effect on EHR time was found in follow-up consultations. Additionally, perceptions of physicians regarding the EHR and documentation improved significantly.

DISCUSSION

Our results have shown that it is possible to achieve structured data capture while simultaneously reducing the EHR burden, which is a decisive factor in end-user acceptance of documentation systems. Proper alignment of structured documentation with workflows is critical for success.

CONCLUSION

Implementing an EHR embedded care pathway with structured documentation led to decreased EHR burden.

Trends in low-value GP care during the COVID-19 pandemic: a retrospective cohort study

BACKGROUND

Several studies showed that during the pandemic patients have refrained from visiting their general practitioner (GP). This resulted in medical care being delayed, postponed or completely forgone. The provision of low-value care, i.e. care which offers no net benefit for the patient, also could have been affected. We therefore assessed the impact of the COVID-19 restrictions on three types of low-value GP care: 1) imaging for back or knee problems, 2) antibiotics for otitis media acuta (OMA), and 3) repeated opioid prescriptions, without a prior GP visit.

METHODS

We performed a retrospective cohort study using registration data from GPs part of an academic GP network over the period 2017-2022. The COVID-19 period was defined as the period between April 2020 to December 2021. The periods before (January 2017 to April 2020) and after the COVID-19 period (January 2022 to December 2022) are the pre- and post-restrictions periods. The three clinical practices examined were selected by two practicing GPs from a top 30 of recommendations originating from the Dutch GP guidelines, based on their perceived prevalence and relevance in practice (van Dulmen et al., BMC Primary Care 23:141, 2022). Multilevel Poisson regression models were built to examine changes in the incidence rates (IR) of both registered episodes and episodes receiving low-value treatment.

RESULTS

During the COVID-19 restrictions period, the IRs of episodes of all three types of GP care decreased significantly. The IR of episodes of back or knee pain decreased by 12%, OMA episodes by 54% and opioid prescription rate by 13%. Only the IR of OMA episodes remained significantly lower (22%) during the post-restrictions period. The provision of low-value care also changed. The IR of imaging for back or knee pain and low-value prescription of antibiotics for OMA both decreased significantly during the COVID-restrictions period (by 21% and 78%), but only the low-value prescription rate of antibiotics for OMA remained significantly lower (by 63%) during the post-restrictions period. The IR of inappropriately repeated opioid prescriptions remained unchanged over all three periods.

CONCLUSIONS

This study shows that both the rate of episodes as well as the rate at which low-value care was provided have generally been affected by the COVID-19 restrictions. Furthermore, it shows that the magnitude of the impact of the restrictions varies depending on the type of low-value care. This indicates that deimplementation of low-value care requires tailored (multiple) interventions and may not be achieved through a single disruption or intervention alone.

Low-value wound care: Are nurses and physicians choosing wisely? A mixed methods study

BACKGROUND

Choosing Wisely is an international movement that stimulates conversations about unnecessary care. The campaign created five recommendations including a statement that less wound care is sometimes better.

AIMS

The study aims to evaluate nurses' and physicians' adherence to the Choosing Wisely recommendations for acute wound care in the Netherlands and the barriers and facilitators to improve this.

DESIGN

This is a mixed methods study using a survey and interviews.

METHODS

The survey was completed by 171 nurses and 71 physicians from November 2017 to February 2018. A total of 17 nurses and 6 physicians were interviewed.

RESULTS

Awareness of the five recommendations ranged from 62% to 89% for nurses and 46% to 85% for physicians. However, up to 15% of the nurses and 28% of physicians were aware but did not adhere to the recommendations. Barriers to adhering were a lack of knowledge, the work environment and perceptions of patients' preferences. Repeated attention, cost-consciousness and an open culture facilitated the implementation.

CONCLUSION

Although most nurses and physicians were aware of the recommendations, not all adhered to them. Increasing awareness is not enough for successful implementation. A tailored approach that removes the barriers is necessary, such as increasing knowledge about wounds and changing the work environment.

What are Effective Strategies to Reduce Low-Value Care? An Analysis of 121 Randomized Deimplementation Studies

BACKGROUND

Low-value care is healthcare leading to no or little clinical benefit for the patient. The best (combinations of) interventions to reduce low-value care are unclear.

PURPOSE

To provide an overview of randomized controlled trials (RCTs) evaluating deimplementation strategies, to quantify the effectiveness and describe different combinations of strategies.

METHODS

Analysis of 121 RCTs (1990-2019) evaluating a strategy to reduce low-value care, identified by a systematic review. Deimplementation strategies were described and associations between strategy characteristics and effectiveness explored.

RESULTS

Of 109 trials comparing deimplementation to usual care, 75 (69%) reported a significant reduction of low-value healthcare practices. Seventy-three trials included in a quantitative analysis showed a median relative reduction of 17% (IQR 7%-42%). The effectiveness of deimplementation strategies was not associated with the number and types of interventions applied.

CONCLUSIONS AND IMPLICATIONS

Most deimplementation strategies achieved a considerable reduction of low-value care. We found no signs that a particular type or number of interventions works best for deimplementation. Future deimplementation studies should map relevant contextual factors, such as the workplace culture or economic factors. Interventions should be tailored to these factors and provide details regarding sustainability of the effect.

Evaluation of a remote monitoring app in head and neck cancer follow-up care

BACKGROUND

A remote monitoring app was developed for head and neck cancer (HNC) follow-up during the SARS-CoV-2 pandemic. This mixed-methods study provides insight in the usability and patients' experiences with the app to develop recommendations for future use.

METHODS

Patients were invited to participate if they were treated for HNC, used the app at least once and were in clinical follow-up. A subset was selected for semi-structured interviews through purposive sampling considering gender and age. This study was conducted between September 2021-May 2022 at a Dutch university medical center.

RESULTS

135 of the 216 invited patients completed the questionnaire, resulting in a total mHealth usability score of 4.72 (± 1.13) out of 7. Thirteen semi-structured interviews revealed 12 barriers and 11 facilitators. Most of them occurred at the level of the app itself. For example, patients received no feedback when all their answers were normal. The app made patients feel more responsible over their follow-up, but could not fulfill the need for personal contact with the attending physician. Patients felt that the app could replace some of the outpatient follow-up visits.

CONCLUSIONS

Our app is user-friendly, makes patients feel more in control and remote monitoring can reduce the frequency of outpatient follow-up visits. The barriers that emerged must be resolved before the app can be used in regular HNC follow-up. Future studies should investigate the appropriate ratio of remote monitoring to outpatient follow-up visits and the cost-effectiveness of remote monitoring in oncology care on a larger scale.

Exploring patients' perceptions of low-value care: An interview study

OBJECTIVE

Clinicians consider patients' expectations and demands as a major driver of low-value care. However, little is known about the patients' perspective. We aimed to explore patients' perceptions of low-value care.

METHODS

We performed semi-structured interviews with 24 patients from the Netherlands and explored their ideas of and experiences with low-value care, and their perception of its consequences and solutions. The interviews were analysed using inductive thematic analysis.

RESULTS

Patients considered several types of care to be of low value, such as duplicate care, care that does not fit their preferences, inefficient care, and care that could have been prevented. The main causes of low-value care according to patients are poor clinician-patient communication and adhering to protocols instead of tailoring care to the individual patient. Consequences of low-value care were a burden for the patient, higher healthcare costs, and less room for high-value care.

CONCLUSION

Patients' view of low-value care extends beyond care that is medically ineffective. Their experiences could help to identify opportunities to reduce the (perceived) use of low-value care.

PRACTICE IMPLICATIONS

Future de-implementation studies could benefit from engaging patients. Dutch patients understand the importance of reducing low-value care and could be strong advocates for de-implementation programs.

Development and validation of automated electronic health record data reuse for a multidisciplinary quality dashboard

Objective

To describe the development and validation of automated electronic health record data reuse for a multidisciplinary quality dashboard.

Materials and methods

Comparative study analyzing a manually extracted and an automatically extracted dataset with 262 patients treated for HNC cancer in a tertiary oncology center in the Netherlands in 2020. The primary outcome measures were the percentage of agreement on data elements required for calculating quality indicators and the difference between indicators results calculated using manually collected and indicators that used automatically extracted data.

Results

The results of this study demonstrate high agreement between manual and automatically collected variables, reaching up to 99.0% agreement. However, some variables demonstrate lower levels of agreement, with one variable showing only a 20.0% agreement rate. The indicator results obtained through manual collection and automatic extraction show high agreement in most cases, with discrepancy rates ranging from 0.3% to 3.5%. One indicator is identified as a negative outlier, with a discrepancy rate of nearly 25%.

Conclusions

This study shows that it is possible to use routinely collected structured data to reliably measure the quality of care in real-time, which could render manual data collection for quality measurement obsolete. To achieve reliable data reuse, it is important that relevant data is recorded as structured data during the care process. Furthermore, the results also imply that data validation is conditional to development of a reliable dashboard.

Development of the SPREAD framework to support the scaling of de-implementation strategies: a mixed-methods study

OBJECTIVE

We aimed to increase the understanding of the scaling of de-implementation strategies by identifying the determinants of the process and developing a determinant framework.

DESIGN AND METHODS

This study has a mixed-methods design. First, we performed an integrative review to build a literature-based framework describing the determinants of the scaling of healthcare innovations and interventions. PubMed and EMBASE were searched for relevant studies from 1995 to December 2020. We systematically extracted the determinants of the scaling of interventions and developed a literature-based framework. Subsequently, this framework was discussed in four focus groups with national and international de-implementation experts. The literature-based framework was complemented by the findings of the focus group meetings and adapted for the scaling of de-implementation strategies.

RESULTS

The literature search resulted in 42 articles that discussed the determinants of the scaling of innovations and interventions. No articles described determinants specifically for de-implementation strategies. During the focus groups, all participants agreed on the relevance of the extracted determinants for the scaling of de-implementation strategies. The experts emphasised that while the determinants are relevant for various countries, the implications differ due to different contexts, cultures and histories. The analyses of the focus groups resulted in additional topics and determinants, namely, medical training, professional networks, interests of stakeholders, clinical guidelines and patients' perspectives. The results of the focus group meetings were combined with the literature framework, which together formed the supporting the scaling of de-implementation strategies (SPREAD) framework. The SPREAD framework includes determinants from four domains: (1) scaling plan, (2) external context, (3) de-implementation strategy and (4) adopters.

CONCLUSIONS

The SPREAD framework describes the determinants of the scaling of de-implementation strategies. These determinants are potential targets for various parties to facilitate the scaling of de-implementation strategies. Future research should validate these determinants of the scaling of de-implementation strategies.

Reducing low-value care: what can we learn from eight de-implementation studies in the Netherlands?

Background

Reducing the overuse of care that is proven to be of low value increases the quality and safety of care. We aimed to identify lessons for reducing low-value care by looking at: (1) The effects of eight de-implementation projects. (2) The barriers and facilitators that emerged. (3) The experiences with the different components of the projects.

Methods

We performed a process evaluation of eight multicentre projects aimed at reducing low-value care. We reported the quantitative outcomes of the eight projects on the volume of low-value care and performed a qualitative analysis of the project teams’ experiences and evaluations. A total of 40 hospitals and 198 general practitioners participated.

Results

Five out of eight projects resulted in a reduction of low-value care, ranging from 11.4% to 61.3%. The remaining three projects showed no effect. Six projects monitored balancing measures and observed no negative consequences of their strategy. The most important barriers were a lack of time, an inability to reassure the patient, a desire to meet the patient’s wishes, financial considerations and a discomfort with uncertainty. The most important facilitators were support among clinicians, knowledge of the harms of low-value care and a growing consciousness that more is not always better. Repeated education and feedback for clinicians, patient information material and organisational changes were valued components of the strategy.

Conclusions

Successfully reducing low-value care is possible in spite of the powerful barriers that oppose it. The projects managed to recruit many hospitals and general practices, with five of them achieving significant results without measuring negative consequences. Based on our findings, we offer practical recommendations for successfully reducing low-value care.

Key Factors that Promote Low-Value Care: Views of Experts From the United States, Canada, and the Netherlands

BACKGROUND

Around the world, policies and interventions are used to encourage clinicians to reduce low-value care. In order to facilitate this, we need a better understanding of the factors that lead to low-value care. We aimed to identify the key factors affecting low-value care on a national level. In addition, we highlight differences and similarities in three countries.

METHODS

We performed 18 semi-structured interviews with experts on low-value care from three countries that are actively reducing low-value care: the United States, Canada, and the Netherlands. We interviewed 5 experts from Canada, 6 from the United States, and 7 from the Netherlands. Eight were organizational leaders or policy-makers, 6 as low-value care researchers or project leaders, and 4 were both. The transcribed interviews were analyzed using inductive thematic analysis.

RESULTS

The key factors that promote low-value care are the payment system, the pharmaceutical and medical device industry, fear of malpractice litigation, biased evidence and knowledge, medical education, and a 'more is better' culture. These factors are seen as the most important in the United States, Canada and the Netherlands, although there are several differences between these countries in their payment structure, and industry and malpractice policy.

CONCLUSION

Policy-makers and researchers that aim to reduce low-value care have experienced that clinicians face a mix of interdependent factors regarding the healthcare system and culture that lead them to provide low-value care. Better awareness and understanding of these factors can help policy-makers to facilitate clinicians and medical centers to deliver high-value care.

Quantifying the Electronic Health Record Burden in Head and Neck Cancer Care

Background  Although the main task of health care providers is to provide patient care, studies show that increasing amounts of time are spent on documentation.

Objective  To quantify the time and effort spent on the electronic health record (EHR) in head and neck cancer care.

Methods  Cross-sectional time–motion study. Primary outcomes were the percentages of time spent on the EHR and the three main tasks (chart review, input, placing orders), number of mouse events, and keystrokes per consultation. Secondary outcome measures were perceptions of health care providers regarding EHR documentation and satisfaction.

Results  In total, 44.0% of initial oncological consultation (IOC) duration and 30.7% of follow-up consultation (FUC) duration are spent on EHR tasks. During 80.0% of an IOC and 67.9% of a FUC, the patient and provider were actively communicating. Providers required 593 mouse events and 1,664 keystrokes per IOC and 140 mouse events and 597 keystrokes per FUC, indicating almost 13 mouse clicks and close to 40 keystrokes for every minute of consultation time. Less than a quarter of providers indicated that there is enough time for documentation.

Conclusion  This study quantifies the widespread concern of high documentation burden for health care providers in oncology, which has been related to burnout and a decrease of patient–clinician interaction. Despite excessive time and effort spent on the EHR, health care providers still felt this was insufficient for proper documentation. However, the need for accurate and complete documentation is high, as reuse of information becomes increasingly important. The challenge is to decrease the documentation burden while increasing the quality of EHR data.

Identifying and prioritizing do-not-do recommendations in Dutch primary care

BACKGROUND

Low-value care provides minimal or no benefit for the patient, wastes resources, and can cause harm. Explicit do-not-do recommendations in clinical guidelines are a first step in reducing low-value care. The aim of this study was to identify and prioritize do-not-do recommendations in general practice guidelines with priority for implementation.

METHODS

We used a mixed method design in Dutch primary care. First, we identified do-not-do recommendations through a systematic assessment of 92 Dutch guidelines for general practitioners (GPs), resulting in 385 do-not-do recommendations. Second, we selected 146 recommendations addressing high prevalent conditions. Third, a random sample of 5000 Dutch GPs was invited for an online survey to prioritize recommendations based on the prevalence of the condition and low-value care practice, potential harm, and potential cost reduction on a scale from 1 to 5/6. Total scores could range from 4 to 22. Recommendations with a median score > 12 were included. In total, 440 GPs completed the survey.

RESULTS

The selection process led to 30 prioritised recommendations. These covered drug treatments (n = 12), diagnostics (n = 10), referral to other healthcare professions (n = 5), and non-drug treatment (n = 3).

CONCLUSION

Dutch clinical guidelines include many do-not-do recommendations that are perceived as highly relevant by the GPs. The list of 30 high-priority do-not-do recommendations can be used to raise awareness of low-value care among GPs. As the recommendations are supported with the latest evidence from international studies, primary healthcare professionals and policy makers worldwide can use the list for further validating the list in their local context and designing strategies to reduce low-value care.

Low-value pharmaceutical care among Dutch GPs: a retrospective cohort study

BACKGROUND

Low-value pharmaceutical care exists in general practice. However, the extent among Dutch GPs remains unknown.

AIM

To assess the prevalence of low-value pharmaceutical care among Dutch GPs.

DESIGN AND SETTING

Retrospective cohort study using data from patient records.

METHOD

The prevalence of three types of pharmaceutical care prescribed by GPs between 2016 and 2019 were examined: topical antibiotics for conjunctivitis, benzodiazepines for non-specific lower back pain, and chronic acid-reducing medication (ARM) prescriptions. Multilevel logistic regression analysis was performed to assess prescribing variation and the influence of patient characteristics on receiving a low-value prescription.

RESULTS

Large variation in prevalence as well as practice variation was observed among the types of low-value pharmaceutical GP care examined. Between 53% and 61% of patients received an inappropriate antibiotics prescription for conjunctivitis, around 3% of patients with lower back pain received an inappropriate benzodiazepine prescription, and 88% received an inappropriate chronic ARM prescription during the years examined. The odds of receiving an inappropriate antibiotic or benzodiazepine prescription increased with age (P<0.001), but decreased for chronic inappropriate ARM prescriptions (P<0.001). Sex affected only the odds of receiving a non-indicated chronic ARM, with males being at higher risk (P<0.001). The odds of receiving an inappropriate ARM increased with increasing neighbourhood socioeconomic status (P<0.05). Increasing practice size decreased the odds of inappropriate antibiotic and benzodiazepine prescriptions (P<0.001).

CONCLUSION

The results show that the prevalence of low-value pharmaceutical GP care varies among these three clinical problems. Significant variation in inappropriate prescribing exists between different types of pharmaceutical care - and GP practices.

[How to make vitamin testing by GP's more efficient]

The orders of vitamin tests by general practitioners (GP) has risen dramatically, although the number of indications is constant and limited. This commentary reflects on a study that reduced vitamin B12 testing with 20% and vitamin D testing with 23%. The intervention consisted of feedback for the GPs of the numbers of orders and education including communication skills. A part of the patients received information. The intervention showed also sustainable effects. The study resulted in a national campaign: more than 1000 GP practice employees have been trained through an e-learning that is free available and accredited. More than 4000 leaflets have been disseminated. Also posters, a short movie and benchmark information are available.

The Effect of Noninvasive Telemonitoring for Chronic Heart Failure on Health Care Utilization: Systematic Review

Background

Chronic heart failure accounts for approximately 1%-2% of health care expenditures in most developed countries. These costs are primarily driven by hospitalizations and comorbidities. Telemonitoring has been proposed to reduce the number of hospitalizations and decrease the cost of treatment for patients with heart failure. However, the effects of telemonitoring on health care utilization remain unclear.

Objective

This systematic review aims to study the effect of telemonitoring programs on health care utilization and costs in patients with chronic heart failure. We assess the effect of telemonitoring on hospitalizations, emergency department visits, length of stay, hospital days, nonemergency department visits, and health care costs.

Methods

We searched PubMed, Embase, and Web of Science for randomized controlled trials and nonrandomized studies on noninvasive telemonitoring and health care utilization. We included studies published between January 2010 and August 2020. For each study, we extracted the reported data on the effect of telemonitoring on health care utilization. We used P<.05 and CIs not including 1.00 to determine whether the effect was statistically significant.

Results

We included 16 randomized controlled trials and 13 nonrandomized studies. Inclusion criteria, population characteristics, and outcome measures differed among the included studies. Most studies showed no effect of telemonitoring on health care utilization. The number of hospitalizations was significantly reduced in 38% (9/24) of studies, whereas emergency department visits were reduced in 13% (1/8) of studies. An increase in nonemergency department visits (6/9, 67% of studies) was reported. Health care costs showed ambiguous results, with 3 studies reporting an increase in health care costs, 3 studies reporting a reduction, and 4 studies reporting no significant differences. Health care cost reductions were realized through a reduction in hospitalizations, whereas increases were caused by the high costs of the telemonitoring program or increased health care utilization.

Conclusions

Most telemonitoring programs do not show clear effects on health care utilization measures, except for an increase in nonemergency outpatient department visits. This may be an unwarranted side effect rather than a prerequisite for effective telemonitoring. The consequences of telemonitoring on nonemergency outpatient visits should receive more attention from regulators, payers, and providers. This review further demonstrates the high clinical and methodological heterogeneity of telemonitoring programs. This should be taken into account in future meta-analyses aimed at identifying the effective components of telemonitoring programs.

Using Text Mining Techniques to Identify Health Care Providers With Patient Safety Problems: Exploratory Study

BACKGROUND

Regulatory bodies such as health care inspectorates can identify potential patient safety problems in health care providers by analyzing patient complaints. However, it is challenging to analyze the large number of complaints. Text mining techniques may help identify signals of problems with patient safety at health care providers.

OBJECTIVE

The aim of this study was to explore whether employing text mining techniques on patient complaint databases can help identify potential problems with patient safety at health care providers and automatically predict the severity of patient complaints.

METHODS

We performed an exploratory study on the complaints database of the Dutch Health and Youth Care Inspectorate with more than 22,000 written complaints. Severe complaints are defined as those cases where the inspectorate contact point experts deemed it worthy of a triage by the inspectorate, or complaints that led to direct action by the inspectorate. We investigated a range of supervised machine learning techniques to assign a severity label to complaints that can be used to prioritize which incoming complaints need the most attention. We studied several features based on the complaints' written content, including sentiment analysis, to decide which were helpful for severity prediction. Finally, we showcased how we could combine these severity predictions and automatic keyword analysis on the complaints database and listed health care providers and their organization-specific complaints to determine the average severity of complaints per organization.

RESULTS

A straightforward text classification approach using a bag-of-words feature representation worked best for the severity prediction of complaints. We obtained an accuracy of 87%-93% (2658-2990 of 3319 complaints) on the held-out test set and an F1 score of 45%-51% on the severe complaints. The skewed class distribution led to only reasonable recall (47%-54%) and precision (44%-49%) scores. The use of sentiment analysis for severity prediction was not helpful. By combining the predicted severity outcomes with an automatic keyword analysis, we identified several health care providers that could have patient safety problems.

CONCLUSIONS

Text mining techniques for analyzing complaints by civilians can support inspectorates. They can automatically predict the severity of the complaints, or they can be used for keyword analysis. This can help the inspectorate detect potential patient safety problems, or support prioritizing follow-up supervision activities by sorting complaints based on the severity per organization or per sector.

Identification of Factors Influencing the Adoption of Health Information Technology by Nurses Who Are Digitally Lagging: In-Depth Interview Study

BACKGROUND

The introduction of health information technology (HIT) has drastically changed health care organizations and the way health care professionals work. Some health care professionals have trouble coping efficiently with the demands of HIT and the personal and professional changes it requires. Lagging in digital knowledge and skills hampers health care professionals from adhering to professional standards regarding the use of HIT and may cause professional performance problems, especially in the older professional population. It is important to gain more insight into the reasons and motivations behind the technology issues experienced by these professionals, as well as to explore what could be done to solve them.

OBJECTIVE

Our primary research objective was to identify factors that influence the adoption of HIT in a sample of nurses who describe themselves as digitally lagging behind the majority of their colleagues in their workplaces. Furthermore, we aimed to formulate recommendations for practice and leadership on how to help and guide these nurses through ongoing digital transformations in their health care work settings.

METHODS

In a Dutch university medical center, 10 face-to-face semi-structured interviews were performed with registered nurses (RN). Ammenwerth's FITT-framework (fit between the Individual, Task, and Technology) was used to guide the interview topic list and to formulate themes to explore. Thematic analysis was used to analyze the interview data. The FITT-framework was also used to further interpret and clarify the interview findings.

RESULTS

Analyses of the interview data uncovered 5 main categories and 12 subthemes. The main categories were: (1) experience with digital working, (2) perception and meaning, (3) barriers, (4) facilitators, and (5) future perspectives. All participants used electronic devices and digital systems, including the electronic health record. The latter was experienced by some as user-unfriendly, time-consuming, and not supportive in daily professional practice. Most of the interviewees described digital working as "no fun at all," "working in a fake world," "stressful," and "annoying." There was a lack of general digital knowledge and little or no formal basic digital training or education. A negative attitude toward computer use and a lack of digital skills contributed to feelings of increased incompetency and postponement or avoidance of the use of HIT, both privately and professionally. Learning conditions of digital training and education did not meet personal learning needs and learning styles. A positive impact was seen in the work environment when colleagues and nurse managers were aware and sensitive to the difficulties participants experienced in developing digital skills, and when there was continuous training on the job and peer support from digitally savvy colleagues. The availability of a digital play environment combined with learning on the job and support of knowledgeable peers was experienced as helpful and motivating by participants.

CONCLUSIONS

Nurses who are digitally lagging often have had insufficient and ineffective digital education. This leads to stress, frustration, feelings of incompetency, and postponement or avoidance of HIT use. A digital training approach tailored to the learning needs and styles of these nurses is needed, as well as an on-the-job training structure and adequate peer support. Hospital management and nurse leadership should be informed about the importance of the fit between technology, task, and the individual for adequate adoption of HIT.

Educating Patients by Providing Timely Information Using Smartphone and Tablet Apps: Systematic Review

Background

Patient education is a crucial element within health care. It is a known predictor for increased engagement in shared decision making, improved medication and treatment adherence, higher levels of satisfaction, and even better treatment outcomes. Unfortunately, often patients only remember a very limited amount of medical information. An important reason is that most patients are simply not capable of processing large amounts of new medical information in a short time. Apps for smartphones and tablets have the potential to actively educate patients by providing them with timely information through the use of push notifications.

Objective

The objective of this systematic review is to provide an overview of the effects of using smartphone and tablet apps to educate patients with timely education. Within this review, we focused on patients that receive their care in a hospital setting. We assessed the effects of the interventions on outcomes, such as patients’ knowledge about their illness and treatment, adherence to treatment instructions and to medication usage, and satisfaction with the care they received.

Methods

A comprehensive search of MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Web of Science was conducted. Randomized controlled trials (RCTs) published between January 2015 and November 2019 were eligible for inclusion. Two reviewers independently searched and screened articles, assessed study quality and risk of bias, and extracted the data. Due to the heterogeneity of populations, interventions, and outcomes, a meta-analysis was not deemed appropriate. Instead, a narrative synthesis is presented.

Results

A total of 21 RCTs with 4106 participants were included. Compared to usual care, overall effectiveness of the interventions was demonstrated in 69% of the outcomes. Effectiveness increased to 82% when the intervention had a duration shorter than one month and increased to 78% when the intervention provided at least one push notification per week. The interventions showed the highest effects on satisfaction with information, adherence to treatment instructions and to medication usage, clinical outcomes, and knowledge.

Conclusions

This review demonstrates that educating patients with timely medical information through their smartphones or tablets improves their levels of knowledge, medication or treatment adherence, satisfaction, and clinical outcomes, as well as having a positive effect on health care economics. These effects are most pronounced in interventions with a short duration (ie, less than a month) and with a high frequency of messages to patients (ie, once per week or more). With the knowledge that patient education is a predictor for improved outcomes and the fact that patients have obvious difficulties processing large amounts of new medical information, we suggest incorporating the delivery of timely information through smartphone and tablet apps within current medical practices.

The Effect of an App for Day-to-Day Postoperative Care Education on Patients With Total Knee Replacement: Randomized Controlled Trial

Background

Patients who undergo primary Total Knee Replacement surgery (TKR) are often discharged within 1-3 days after surgery. With this relatively short length of hospital stay, a patient’s self-management is a crucial factor in optimizing the outcome of their treatment. In the case of TKR, self-management primarily involves adequate pain management, followed by physiotherapy exercises and daily self-care activities. Patients are educated on all these topics by hospital staff upon discharge from the hospital but often struggle to comprehend this information due to its quantity, complexity, and the passive mode of communication used to convey it.

Objective

This study primarily aims to determine whether actively educating TKR patients with timely, day-to-day postoperative care information through an app could lead to a decrease in their level of pain compared to those who only receive standard information about their recovery through the app. In addition, physical functioning, quality of life, ability to perform physiotherapy exercises and daily self-care activities, satisfaction with information, perceived involvement by the hospital, and health care consumption were also assessed.

Methods

A multicenter randomized controlled trial was performed in five Dutch hospitals. In total, 213 patients who had undergone elective, primary, unilateral TKR participated. All patients had access to an app for their smartphone and tablet to guide them after discharge. The intervention group could unlock day-to-day information by entering a personal code. The control group only received weekly, basic information. Primary (level of pain) and secondary outcomes (physical functioning, quality of life, ability to perform physiotherapy exercises and activities of daily self-care, satisfaction with information, perceived involvement by the hospital, and health care consumption) were measured using self-reported online questionnaires. All outcomes were measured weekly in the four weeks after discharge, except for physical functioning and quality of life, which were measured at baseline and at four weeks after discharge. Data was analyzed using Student t tests, chi-square tests, and linear mixed models for repeated measures.

Results

In total, 114 patients were enrolled in the intervention group (IG) and 99 in the control group (CG). Four weeks after discharge, patients in the IG performed significantly better than patients in the CG on all dimensions of pain: pain at rest (mean 3.45 vs mean 4.59; P=.001), pain during activity (mean 3.99 vs mean 5.08; P&lt;.001) and pain at night (mean 4.18 vs mean 5.21; P=.003). Additionally, significant differences were demonstrated in favor of the intervention group for all secondary outcomes.

Conclusions

In the four weeks following TKR, the active and day-to-day education of patients via the app significantly decreased their level of pain and improved their physical functioning, quality of life, ability to perform physiotherapy exercises and activities of daily self-care, satisfaction with information, perceived involvement by the hospital, and health care consumption compared to standard patient education. Given the rising number of TKR patients and the increased emphasis on self-management, we suggest using an app with timely postoperative care education as a standard part of care.

Trial Registration

Netherlands Trial Register NTR7182; https://www.trialregister.nl/trial/6992

Patient and Health Care Provider Experiences With a Recently Introduced Patient Portal in an Academic Hospital in the Netherlands: Mixed Methods Study

BACKGROUND

In the Netherlands, the health care system and related information technology landscape are fragmented. Recently, hospitals have started to launch patient portals. It is not clear how these portals are used by patients and their health care providers (HCPs).

OBJECTIVE

The objective of this study was to explore the adoption, use, usability, and usefulness of a recently introduced patient portal in an academic hospital to learn lessons for the implementation of patient portals in a fragmented health care system.

METHODS

A mixed methods study design was used. In the quantitative study arm, characteristics of patients who used the portal were analyzed, in addition to the utilization of the different functionalities of the portal. In the qualitative study arms, think-aloud observations were made to explore usability. Focus group discussions were conducted among patients and HCPs of the dermatology and ophthalmology outpatient departments. Thematic content analysis of qualitative data was carried out and overarching themes were identified using a framework analysis.

RESULTS

One year after the introduction of the portal, 24,514 patients, 13.49% of all patients who visited the hospital, had logged in to the portal. Adoption of the portal was associated with the age group 45 to 75 years, a higher socioeconomic status, and having at least one medical diagnosis. Overarching themes from the qualitative analyses were (1) usability and user-friendliness of the portal, (2) HCP-patient communication through the portal, (3) usefulness of the information that can be accessed through the portal, (4) integration of the portal in care and work processes, and (5) HCP and patient roles and relationships.

CONCLUSIONS

One year after the introduction of the patient portal, patients and HCPs who used the portal recognized the potential of the portal to engage patients in their care processes, facilitate patient-HCP communication, and increase patient convenience. Uncertainties among patients and HCPs about how to use the messaging functionality and limited integration of the portal in care and work processes are likely to have limited portal use and usefulness.

Limit, lean or listen? A typology of low-value care that gives direction in de-implementation

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.

What is the impact on the readmission ratio of taking into account readmissions to other hospitals? A cross-sectional study

OBJECTIVES

Readmissions are used widespread as an indicator of the quality of care within hospitals. Including readmissions to other hospitals might have consequences for hospitals. The aim of our study is to determine the impact of taking into account readmissions to other hospitals on the readmission ratio.

DESIGN AND SETTING

We performed a cross-sectional study and used administrative data from 77 Dutch hospitals (2 333 173 admissions) in 2015 and 2016 (97% of all hospitals). We performed logistic regression analyses to calculate 30-day readmission ratios for each hospital (the number of observed admissions divided by the number of expected readmissions based on the case mix of the hospital, multiplied by 100). We then compared two models: one with readmissions only to the same hospital, and another with readmissions to any hospital in the Netherlands. The models were calculated on the hospital level for all in-patients and, in more detail, on the level of medical specialties.

MAIN OUTCOME MEASURES

Percentage of readmissions to another hospital, readmission ratios same hospital and any hospital and C-statistic of each model in order to determine the discriminative ability.

RESULTS

The overall percentage of readmissions was 10.3%, of which 91.1% were to the same hospital and 8.9% to another hospital. Patients who went to another hospital were younger, more often men and had fewer comorbidities. The readmission ratios for any hospital versus the same hospital were strongly correlated (r=0.91). There were differences between the medical specialties in percentage of readmissions to another hospital and C-statistic.

CONCLUSIONS

The overall impact of taking into account readmissions to other hospitals seems to be limited in the Netherlands. However, it does have consequences for some hospitals. It would be interesting to explore what causes this difference for some hospitals and if it is related to the quality of care.

Re-admission patterns in England and the Netherlands: a comparison based on administrative data of all hospitals

BACKGROUND

Examining variation in patterns of re-admissions between countries can be valuable for mutual learning in order to reduce unnecessary re-admissions. The aim of this study was to compare re-admission rates and reasons for re-admissions between England and the Netherlands.

METHODS

We used data from 85 Dutch hospitals (1 355 947 admissions) and 451 English hospitals (5 260 227 admissions) in 2014 (96% of all Dutch hospitals and 100% of all English NHS hospitals). Re-admission data from England and the Netherlands were compared for all hospital patients and for specific diagnosis groups: pneumonia, urinary tract infection, chronic obstructive pulmonary disease, coronary atherosclerosis, biliary tract disease, hip fracture and acute myocardial infarction. Re-admissions were categorized using a classification system developed on administrative data. The classification distinguishes between potentially preventable re-admissions and other reasons for re-admission.

RESULTS

England had a higher 30-day re-admission rate (adjusted for age and gender) compared to the Netherlands: 11.17% (95% CI 11.14-11.20%) vs. 9.83% (95% CI 9.77-9.88%). The main differences appeared to be in re-admissions for the elderly (England 17.2% vs. the Netherlands 10.0%) and in emergency re-admissions (England 85.3% of all 30-day re-admissions vs. the Netherlands 66.8%). In the Netherlands, however, more emergency re-admissions were classified as potentially preventable compared to England (33.8% vs. 28.8%).

CONCLUSIONS

The differences found between England and the Netherlands indicate opportunities to reduce unnecessary re-admissions. For England this concerns more expanded palliative care, integrated social care and reduction of waiting times. In the Netherlands, the use of treatment plans for daily life could be increased.

To what degree can variations in readmission rates be explained on the level of the hospital? a multilevel study using a large Dutch database

BACKGROUND

It is not clear which part of the variation in hospital readmissions can be attributed to the standard of care hospitals provide. This is in spite of their widespread use as an indicator of a lower quality of care. The aim of this study is to assess the variation in readmissions on the hospital level after adjusting for case-mix factors.

METHODS

We performed multilevel logistic regression analyses with a random intercept for the factor 'hospital' to estimate the variance on the hospital level after adjustment for case-mix variables. We used administrative data from 53 Dutch hospitals from 2010 to 2012 (58% of all Dutch hospitals; 2,577,053 admissions). We calculated models for the top ten diagnosis groups with the highest number of readmissions after an index admission for a surgical procedure. We calculated intraclass correlation coefficients (ICC) per diagnosis group in order to explore the variation in readmissions between hospitals. Furthermore, we determined C-statistics for the models with and without a random effect on the hospital level to determine the discriminative ability.

RESULTS

The ICCs on the hospital level ranged from 0.48 to 2.70% per diagnosis group. The C-statistics of the models with a random effect on the hospital level ranged from 0.58 to 0.65 for the different diagnosis groups. The C-statistics of the models that included the hospital level were higher compared to the models without this level.

CONCLUSIONS

For some diagnosis groups, a small part of the explained variation in readmissions was found on the hospital level, after adjusting for case-mix variables. However, the C-statistics of the prediction models are moderate, so the discriminative ability is limited. Readmission indicators might be useful for identifying areas for improving quality within hospitals on the level of diagnosis or specialty.

Use and Effects of Patient Access to Medical Records in General Practice Through a Personal Health Record in the Netherlands: Protocol for a Mixed-Methods Study

Background

In the Dutch health care system, general practitioners hold a central position. They store information from all health care providers who are involved with their patients in their electronic health records. Web-based access to the summary record in general practice through a personal health record (PHR) may increase patients’ insight into their medical conditions and help them to be involved in their care.

Objective

We describe the protocol that we will use to investigate the utilization of patients’ digital access to the summary of their medical records in general practice through a PHR and its effects on the involvement of patients in their care.

Methods

We will conduct a multilevel mixed-methods study in which the PHR and Web-based access to the summary record will be offered for 6 months to a random sample of 500 polypharmacy patients, 500 parents of children aged <4 years, and 500 adults who do not belong to the former two groups. At the patient level, a controlled before-after study will be conducted using surveys, and concurrently, qualitative data will be collected from focus group discussions, think-aloud observations, and semistructured interviews. At the general practice staff (GP staff) level, focus group discussions will be conducted at baseline and Q-methodology inquiries at the end of the study period. The primary outcomes at the patient level are barriers and facilitators for using the PHR and summary records and changes in taking an active role in decision making and care management and medication adherence. Outcomes at the GP staff level are attitudes before and opinions after the implementation of the intervention. Patient characteristics and changes in outcomes related to patient involvement during the study period will be compared between the users and nonusers of the intervention using chi-square tests and t tests. A thematic content analysis of the qualitative data will be performed, and the results will be used to interpret quantitative findings.

Results

Enrollment was completed in May 2017 and the possibility to view GP records through the PHR was implemented in December 2017. Data analysis is currently underway and the first results are expected to be submitted for publication in autumn 2019.

Conclusions

We expect that the findings of this study will be useful to health care providers and health care organizations that consider introducing the use of PHR and Web-based access to records and to those who have recently started using these.

Trial Registration

Netherlands Trial Registry NTR6395; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6395 (Archived by WebCite at http://www.webcitation.org/71nc8jzwM)

Registered Report Identifier

RR1-10.2196/10193

Prevention of and dealing with poor performance: an interview study about how professional associations aim to support healthcare professionals

Objective

To explore how professional associations of nine healthcare professions aim to support professionals to prevent and deal with poor performance.

Design

Qualitative interview study.

Setting

The Netherlands.

Participants

Representatives of professional associations for dentists, general practitioners, medical specialists, midwives, nurses, pharmacists, physiotherapists, psychologists and psychotherapists.

Interventions

During nine face-to-face semi-structured interviews we asked how associations aim to support professionals in prevention of and dealing with poor performance. Following the first interview, we monitored new initiatives in support over a 2.5-year period, after which we conducted a second interview. Interviews were analysed using thematic analysis.

Main outcome measures

Available policy and support regarding poor performance.

Results

Three themes emerged from our data (i.e. elaborating on professional performance, performance insight and dealing with poor performance) for which we identified a total of 10 categories of support. Support concerned professional codes, guidelines and codes of conduct, quality registers, individual performance assessment, peer consultation, practice evaluation, helpdesk and expert counselling, a protocol for dealing with poor performance, a place for support and to report poor performance, and internal disciplinary procedures.

Conclusions

This study provides an overview of support given to nine healthcare professions by their associations regarding poor performance, and identifies gaps that associations could follow up on, such as clarifying what to do when confronted with a poorly performing colleague, supporting professionals that poorly perform, and developing methods for individual performance assessment to gain performance insight. A next step would be to evaluate the use and effect of different types of support.

How to identify potentially preventable readmissions by classifying them using a national administrative database

Importance

Hospital readmissions are being used increasingly as an indicator of quality of care. However, it remains difficult to identify potentially preventable readmissions.

Objectives

To evaluate the identification of potentially preventable hospital readmissions by using a classification of readmissions based on administrative data.

Design and setting

We classified a random sample of 455 readmissions to a Dutch university hospital in 2014 using administrative data. We compared these results to a classification based on reviewing the medical records of these readmissions to evaluate the accuracy of classification by administrative data.

Main outcome measures

Frequencies of categories of readmissions based on reviewing records versus those based on administrative data. Cohen's kappa for the agreement between both methods. The sensitivity and specificity of the identification of potentially preventable readmissions with classification by administrative data.

Results

Reviewing the medical records of acute readmissions resulted in 28.5% of the records being classified as potentially preventable. With administrative data this was 44.1%. There was slight agreement between both methods: ƙ 0.08 (95% CI: 0.02-0.15, P < 0.05). The sensitivity of the classification of potentially preventable readmissions by administrative data was 63.1% and the specificity was 63.5%.

Conclusions

This explorative study demonstrated differences between categorizing readmissions based on reviewing records compared to using administrative data. Therefore, this tool can only be used in practice with great caution. It is not suitable for penalizing hospitals based on their number of potentially preventable readmissions. However, hospitals might use this classification as a screening tool to identify potentially preventable readmissions more efficiently.

Understanding the impact of supervision on reducing medication risks: an interview study in long-term elderly care

Background

In 2009, the Dutch Health Care Inspectorate (IGZ) observed several serious risks to safety involving medication within elderly care facilities. However, by 2011, high risks had been reduced in almost all the organisations we visited. And yet the IGZ analysed too the alarming increase in the number of incidents arising in the self-reported national indicator of medication safety between 2009 and 2010. The aim of this study was to understand the factors that can explain this contradiction between the increase in self-reported medication incidents and the observation of the IGZ in reducing the risks to medication safety through supervision.

Methods

We interviewed health care professionals of ten care facilities, visited by the IGZ, who were involved in, or responsible for, the improvement of medication safety in their institutions. As outcome measures we used the rate of medication safety risk per facility; the perceptions of the participant with regard to the reports of medication incidents; the level of medication safety of the facility; the measures used to improve medication safety; and the supervision of medication safety.

This was a mixed methods study, qualitative in that we used semi-structured interviews, and quantitative, by calculating risks for the different organisations we visited. The findings from both study methods resulted in a comprehensive view and an in-depth understanding of this contradiction.

Results

The contradiction between the increase in self-reported medication incidents and the observation of reduced risks was explained by three themes: activities designed to improve medication safety, the reporting of medication incidents, and, lastly, the impact of supervision. The focus of the IGZ on issues of medication safety stimulated most elderly care facilities to reduce medication risks. Also, a change in the culture of reporting incidents caused an increase in the number of reported incidents.

Conclusions

Supervision contributed to an improvement in actions geared towards reducing the risks associated with the safety of medication. It also increased a willingness to report such incidents. The more incidents reported are therefore not necessarily a sign of an increase in the risks, but can also be considered as a sign of a safer culture.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2418-6) contains supplementary material, which is available to authorized users.

Identifying and prioritizing lower value services from Dutch specialist guidelines and a comparison with the UK do-not-do list

BACKGROUND

The term 'lower value services' concerns healthcare that is of little or no value to the patient and consequently should not be provided routinely, or not be provided at all. De-adoption of lower value care may occur through explicit recommendations in clinical guidelines. The present study aimed to generate a comprehensive list of lower value services for the Netherlands that assesses the type of care and associated medical conditions. The list was compared with the NICE do-not-do list (United Kingdom). Finally, the feasibility of prioritizing the list was studied to identify conditions where de-adoption is warranted.

METHODS

Dutch clinical guidelines (published from 2010 to 2015) were searched for lower value services. The lower value services identified were categorized by type of care (diagnostics, treatment with and without medication), type of lower value service (not routinely provided or not provided at all), and ICD10 codes (international classification of diseases). The list was prioritized per ICD10 code, based on the number of lower value services per ICD10 code, prevalence, and burden of disease.

RESULTS

A total of 1366 lower value services were found in the 193 Dutch guidelines included in our study. Of the lower value services, 30% covered diagnostics, 29% related to surgical and medical treatment without drugs primarily, and 39% related to drug treatment. The majority (77%) of all lower value services was on care that should not be offered at all, whereas the other 23% recommended on care that should not be offered routinely. ICD10 chapters that included most lower value services were neoplasms and diseases of the nervous system. Dutch guidelines appear to contain more lower value services than UK guidelines. The prioritization processes revealed several conditions, including back pain, chronic obstructive pulmonary disease, and ischemic heart diseases, where lower value services most likely occur and de-adoption is warranted.

CONCLUSIONS

In this study, a comprehensive list of lower value services for Dutch hospital care was developed. A feasible method for prioritizing lower value services was established. Identifying and prioritizing lower value services is the first of several necessary steps in reducing them.

Investigating the Potential Contribution of Patient Rating Sites to Hospital Supervision: Exploratory Results From an Interview Study in the Netherlands

Background

Over the last decades, the patient perspective on health care quality has been unconditionally integrated into quality management. For several years now, patient rating sites have been rapidly gaining attention. These offer a new approach toward hearing the patient’s perspective on the quality of health care.

Objective

The aim of our study was to explore whether and how patient reviews of hospitals, as reported on rating sites, have the potential to contribute to health care inspector’s daily supervision of hospital care.

Methods

Given the unexplored nature of the topic, an interview study among hospital inspectors was designed in the Netherlands. We performed 2 rounds of interviews with 10 senior inspectors, addressing their use and their judgment on the relevance of review data from a rating site.

Results

All 10 Dutch senior hospital inspectors participated in this research. The inspectors initially showed some reluctance to use the major patient rating site in their daily supervision. This was mainly because of objections such as worries about how representative they are, subjectivity, and doubts about the relevance of patient reviews for supervision. However, confrontation with, and assessment of, negative reviews by the inspectors resulted in 23% of the reviews being deemed relevant for risk identification. Most inspectors were cautiously positive about the contribution of the reviews to their risk identification.

Conclusions

Patient rating sites may be of value to the risk-based supervision of hospital care carried out by the Health Care Inspectorate. Health care inspectors do have several objections against the use of patient rating sites for daily supervision. However, when they are presented with texts of negative reviews from a hospital under their supervision, it appears that most inspectors consider it as an additional source of information to detect poor quality of care. Still, it should always be accompanied and verified by other quality and safety indicators. More research on the value and usability of patient rating sites in daily hospital supervision and other health settings is needed.

The disciplined healthcare professional: a qualitative interview study on the impact of the disciplinary process and imposed measures in the Netherlands

OBJECTIVE

It is known that doctors who receive complaints may have feelings of anger, guilt, shame and depression, both in the short and in the long term. This might lead to functional impairment. Less is known about the impact of the disciplinary process and imposed measures. Previous studies of disciplinary proceedings have mainly focused on identifying characteristics of disciplined doctors and on sentencing policies. Therefore, the aim of this study is to explore what impact the disciplinary process and imposed measures have on healthcare professionals.

DESIGN

Semistructured interview study, with purposive sampling and inductive qualitative content analysis.

PARTICIPANTS

16 healthcare professionals (9 medical specialists, 3 general practitioners, 2 physiotherapists and 2 psychologists) that were sanctioned by the disciplinary tribunal.

SETTING

The Netherlands.

RESULTS

Professionals described feelings of misery and insecurity both during the process as in its aftermath. Furthermore, they reported to fear receiving new complaints and provide care more cautiously after the imposed measure. Factors that may enhance psychological and professional impact are the publication of measures online and in newspapers, media coverage, the feeling of treated as guilty before any verdict has been reached, and the long duration of the process.

CONCLUSIONS

This study shows that the disciplinary process and imposed measures can have a profound psychological and professional impact on healthcare professionals. Although a disciplinary measure is meant to have a corrective effect, our results suggest that the impact that is experienced by professionals might hamper optimal rehabilitation afterwards. Therefore, organising emotional support should be considered during the disciplinary process and in the period after the verdict.

Exposure to and experiences with a computerized decision support intervention in primary care: results from a process evaluation

Background

Trials evaluating the effects of interventions usually provide little insight into the factors responsible for (lack of) changes in desired outcomes. A process evaluation alongside a trial can shed light on the mechanisms responsible for the outcomes of a trial. The aim of this study was to investigate exposure to and experiences with a computerized decision support system (CDSS) intervention, in order to gain insight into the intervention’s impact and to provide suggestions for improvement.

Methods

A process evaluation was conducted as part of a large-scale cluster-randomized controlled trial investigating the effects of the CDSS NHGDoc on quality of care. Data on exposure to and experiences with the intervention were collected during the trial period among participants in both the intervention and control group - whenever applicable - by means of the NHGDoc server and an electronic questionnaire. Multiple data were analyzed using descriptive statistics.

Results

Ninety-nine percent (n = 229) of the included practices generated data for the NHGDoc server and 50 % (n = 116) responded to the questionnaire: both general practitioners (GPs; n = 112; 49 %) and practice nurses (PNs; n = 52; 37 %) participated. The actual exposure to the NHGDoc system and specific heart failure module was limited with 52 % of the GPs and 42 % of the PNs reporting to either never or rarely use the system. Overall, users had a positive attitude towards CDSSs. The most perceived barriers to using NHGDoc were a lack of learning capacity of the system, the additional time and work it requires to use the CDSS, irrelevant alerts, too high intensity of alerts and insufficient knowledge regarding the system.

Conclusions

Several types of barriers may have negatively affected the impact of the intervention. Although users are generally positive about CDSSs, a large share of them is insufficiently aware of the functions of NHGDoc and, finds the decision support not always useful or relevant and difficult to integrate into daily practice. In designing CDSS interventions we suggest to more intensely involve the end-users and increase the system’s flexibility and learning capacity. To improve implementation a proper introduction of a CDSS among its target group including adequate training is advocated.

Trial registration

Clinical trials NCT01773057.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-015-0364-0) contains supplementary material, which is available to authorized users.

Implementation of multiple-domain covering computerized decision support systems in primary care: a focus group study on perceived barriers

BACKGROUND

Despite the widespread availability of computerized decision support systems (CDSSs) in various healthcare settings, evidence on their uptake and effectiveness is still limited. Most barrier studies focus on CDSSs that are aimed at a limited number of decision points within selected small-scale academic settings. The aim of this study was to identify the perceived barriers to using large-scale implemented CDSSs covering multiple disease areas in primary care.

METHODS

Three focus group sessions were conducted in which 24 primary care practitioners (PCPs) participated (general practitioners, general practitioners in training and practice nurses), varying from 7 to 9 per session. In each focus group, barriers to using CDSSs were discussed using a semi-structured literature-based topic list. Focus group discussions were audio-taped and transcribed verbatim. Two researchers independently performed thematic content analysis using the software program Atlas.ti 7.0.

RESULTS

Three groups of barriers emerged, related to 1) the users' knowledge of the system, 2) the users' evaluation of features of the system (source and content, format/lay out, and functionality), and 3) the interaction of the system with external factors (patient-related and environmental factors). Commonly perceived barriers were insufficient knowledge of the CDSS, irrelevant alerts, too high intensity of alerts, a lack of flexibility and learning capacity of the CDSS, a negative effect on patient communication, and the additional time and work it requires to use the CDSS.

CONCLUSIONS

Multiple types of barriers may hinder the use of large-scale implemented CDSSs covering multiple disease areas in primary care. Lack of knowledge of the system is an important barrier, emphasizing the importance of a proper introduction of the system to the target group. Furthermore, barriers related to a lack of integration into daily practice seem to be of primary concern, suggesting that increasing the system's flexibility and learning capacity in order to be able to adapt the decision support to meet the varying needs of different users should be the main target of CDSS interventions.

Trends in patient satisfaction in Dutch university medical centers: room for improvement for all

BACKGROUND

Results of patient satisfaction research provide hospitals areas for quality improvement. Although it may take several years to achieve such improvement, not all hospitals analyze changes in patient satisfaction over time structurally. Consequently, they lack information from patients' perspective on effectiveness of improvement programs. This study presents a trend analysis of the patient satisfaction scores in the eight university medical centers in the Netherlands. We focus on the trends, effect size and its consequences for improving patient-centered care.

METHODS

The Core Questionnaire for the assessment of Patient satisfaction (COPS) was used in four large-scale nationwide comparative studies (2003-2009). Data were analyzed at a national level, and for each academic hospital separately. We analyzed the polynomial contrasts in the four measurements by performing an univariate analysis of variance (ANCOVA). The trend lines are presented graphically, with the means, SD, F-statistics and the standardized effect size including confidence intervals expressed by Cohen's d. By analyzing the (logit transformed) percentages of very satisfied patients we examined the change scores.

RESULTS

The dataset consisted of 58,055 inpatients and 79,498 outpatients. Significant positive trends were found on national level and hospital level, especially in outpatient departments. Improvement was especially seen on the dimensions "information" and "discharge and aftercare". Not only university medical centers with a lower score at the start, but surprisingly some best practices and university medical centers with a high initial score improved.

CONCLUSIONS

We conclude that significant trends in patient satisfaction can be identified on a national and a hospital level, in inpatient and outpatient departments. The observed effect size expressed by Cohen's d is rather small. Hospitals have found room for improvement, even hospitals with initial high satisfaction scores. We recommend that hospitals monitor their patient satisfaction scores over time and relate these to quality interventions and organizational changes. Furthermore, we recommend to expand the research to subgroups of unsatisfied patients to improve patient-centered care for all patients.

Using patient experiences on Dutch social media to supervise health care services: exploratory study

Background

Social media has become mainstream and a growing number of people use it to share health care-related experiences, for example on health care rating sites. These users’ experiences and ratings on social media seem to be associated with quality of care. Therefore, information shared by citizens on social media could be of additional value for supervising the quality and safety of health care services by regulatory bodies, thereby stimulating participation by consumers.

Objective

The objective of the study was to identify the added value of social media for two types of supervision by the Dutch Healthcare Inspectorate (DHI), which is the regulatory body charged with supervising the quality and safety of health care services in the Netherlands. These were (1) supervision in response to incidents reported by individuals, and (2) risk-based supervision.

Methods

We performed an exploratory study in cooperation with the DHI and searched different social media sources such as Twitter, Facebook, and healthcare rating sites to find additional information for these incidents and topics, from five different sectors. Supervision experts determined the added value for each individual result found, making use of pre-developed scales.

Results

Searches in social media resulted in relevant information for six of 40 incidents studied and provided relevant additional information in 72 of 116 cases in risk-based supervision of long-term elderly care.

Conclusions

The results showed that social media could be used to include the patient’s perspective in supervision. However, it appeared that the rating site ZorgkaartNederland was the only source that provided information that was of additional value for the DHI, while other sources such as forums and social networks like Twitter and Facebook did not result in additional information. This information could be of importance for health care inspectorates, particularly for its enforcement by risk-based supervision in care of the elderly. Further research is needed to determine the added value for other health care sectors.

Evaluating the uptake and effects of the computerized decision support system NHGDoc on quality of primary care: protocol for a large-scale cluster randomized controlled trial

BACKGROUND

Computerized decision support systems (CDSSs) are increasingly used to improve quality of care. There is evidence for moderate to large effects from randomized controlled trials (RCTs), but evidence on their effectiveness when implemented at a national level is lacking. In the Netherlands, the Dutch College of General Practitioners (NHG) initiated their successful guideline program already 30 years ago. NHGDoc, a CDSS based on these NHG guidelines, covering multiple disease areas for general practice, was developed in 2006 with the aim to improve quality of primary care. In this paper, a protocol is presented to evaluate the uptake and effects of NHGDoc.

METHODS

A cluster RCT will be conducted among 120 general practices in the Netherlands. Eligible general practices will be randomized to receive either the regular NHGDoc decision support modules (control arm) or the regular modules plus an additional module on heart failure (intervention arm). The heart failure module consists of patient-specific alerts concerning the treatment of patients with heart failure. The effect evaluation will focus on performance indicators (e.g., prescription behavior) as well as on patient outcomes (e.g., hospital admissions) relevant in the domain of heart failure. Additionally, a process evaluation will be conducted to gain insight into the barriers and facilitators that affect the uptake and impact of NHGDoc.

DISCUSSION

Results of this study will provide insight in the uptake and impact of a multiple-domain covering CDSS for primary care implemented by a national guideline organization to improve the quality of primary care. Whereas the trial focuses on a specific domain of care-heart failure-conclusions of this study will shed light on the functioning of CDSSs covering multiple disease areas for primary care, particularly as this study also explores the factors contributing to the system's uptake and effectiveness.

TRIAL REGISTRATION

Clinical trials NCT01773057.

Unexpectedly long hospital stays as an indicator of risk of unsafe care: an exploratory study

OBJECTIVES

We developed an outcome indicator based on the finding that complications often prolong the patient's hospital stay. A higher percentage of patients with an unexpectedly long length of stay (UL-LOS) compared to the national average may indicate shortcomings in patient safety. We explored the utility of the UL-LOS indicator.

SETTING

We used data of 61 Dutch hospitals. In total these hospitals had 1 400 000 clinical discharges in 2011.

PARTICIPANTS

The indicator is based on the percentage of patients with a prolonged length of stay of more than 50% of the expected length of stay and calculated among survivors.

INTERVENTIONS

No interventions were made.

OUTCOME MEASURES

The outcome measures were the variability of the indicator across hospitals, the stability over time, the correlation between the UL-LOS and standardised mortality and the influence on the indicator of hospitals that did have problems discharging their patients to other health services such as nursing homes.

RESULTS

In order to compare hospitals properly the expected length of stay was computed based on comparison with benchmark populations. The standardisation was based on patients' age, primary diagnosis and main procedure. The UL-LOS indicator showed considerable variability between the Dutch hospitals: from 8.6% to 20.1% in 2011. The outcomes had relatively small CIs since they were based on large numbers of patients. The stability of the indicator over time was quite high. The indicator had a significant positive correlation with the standardised mortality (r=0.44 (p<0.001)), and no significant correlation with the percentage of patients that was discharged to other facilities than other hospitals and home (r=-0.15 (p>0.05)).

CONCLUSIONS

The UL-LOS indicator is a useful addition to other patient safety indicators by revealing variation between hospitals and areas of possible patient safety improvement.

The influence of corporate structure and quality improvement activities on outcome improvement in residential care homes

OBJECTIVE

To examine the impact of corporate structure and quality improvement (QI) activities on improvements in client-reported and professional indicators between 2007 and 2009.

DESIGN

A cross-sectional study using organizational survey and indicator multilevel modelling to test relationships between corporate structure, QI activities and performance improvements on indicators.

SETTING

In total, 169 residential care homes for the elderly in the Netherlands.

MAIN OUTCOME MEASURES

Change between 2007 and 2009 in client-reported and professional indicators.

RESULTS

A middle-size corporate structure was associated with QI. The QI activity 'multidisciplinary team meetings' was positively correlated with the indicator 'safety environment' for somatic and psycho-geriatric care. The QI activities 'educational material' and 'direct work instructions' were associated negatively with the indicator 'availability of personnel' for somatic clients, but positively for psycho-geriatric clients. QI activities such as 'health plan activities', 'clinical lessons' and 'financial activities' had no relationship to improved performance. For psycho-geriatric clients mainly organizational QI activities were positively associated with QI. The mediating role of the corporate structure for performing QI activities appeared stronger for the change in client-reported than for professional indicators.

CONCLUSION

This study reveals associations between QI activities and corporate structure and changes in indicator performance. A corporate structure was associated with improvement in client-reported indicators, but less on professional indicators, which assumes a central policy at corporate level with impact on client-reported indicators, in contrast to a more local level approach towards activities that result in QI on professional indicators. Tailoring QI activities at the right managerial level may be important to achieve improvement.

A new impetus for guideline development and implementation: construction and evaluation of a toolbox

BACKGROUND

In the last decade, guideline organizations faced a number of problems, including a lack of standardization in guideline development methods and suboptimal guideline implementation. To contribute to the solution of these problems, we produced a toolbox for guideline development, implementation, revision, and evaluation.

METHODS

All relevant guideline organizations in the Netherlands were approached to prioritize the topics. We sent out a questionnaire and discussed the results at an invitational conference. Based on consensus, twelve topics were selected for the development of new tools. Subsequently, working groups were composed for the development of the tools. After development of the tools, their draft versions were pilot tested in 40 guideline projects. Based on the results of the pilot tests, the tools were refined and their final versions were presented.

RESULTS

The vast majority of organizations involved in pilot testing of the tools reported satisfaction with using the tools. Guideline experts involved in pilot testing of the tools proposed a variety of suggestions for the implementation of the tools. The tools are available in Dutch and in English at a web-based platform on guideline development and implementation (http://www.ha-ring.nl).

CONCLUSIONS

A collaborative approach was used for the development and evaluation of a toolbox for development, implementation, revision, and evaluation of guidelines. This approach yielded a potentially powerful toolbox for improving the quality and implementation of Dutch clinical guidelines. Collaboration between guideline organizations within this project led to stronger linkages, which is useful for enhancing coordination of guideline development and implementation and preventing duplication of efforts. Use of the toolbox could improve quality standards in the Netherlands, and might facilitate the development of high-quality guidelines in other countries as well.

Social media and rating sites as tools to understanding quality of care: a scoping review

BACKGROUND

Insight into the quality of health care is important for any stakeholder including patients, professionals, and governments. In light of a patient-centered approach, it is essential to assess the quality of health care from a patient's perspective, which is commonly done with surveys or focus groups. Unfortunately, these "traditional" methods have significant limitations that include social desirability bias, a time lag between experience and measurement, and difficulty reaching large groups of people. Information on social media could be of value to overcoming these limitations, since these new media are easy to use and are used by the majority of the population. Furthermore, an increasing number of people share health care experiences online or rate the quality of their health care provider on physician rating sites. The question is whether this information is relevant to determining or predicting the quality of health care.

OBJECTIVE

The goal of our research was to systematically analyze the relation between information shared on social media and quality of care.

METHODS

We performed a scoping review with the following goals: (1) to map the literature on the association between social media and quality of care, (2) to identify different mechanisms of this relationship, and (3) to determine a more detailed agenda for this relatively new research area. A recognized scoping review methodology was used. We developed a search strategy based on four themes: social media, patient experience, quality, and health care. Four online scientific databases were searched, articles were screened, and data extracted. Results related to the research question were described and categorized according to type of social media. Furthermore, national and international stakeholders were consulted throughout the study, to discuss and interpret results.

RESULTS

Twenty-nine articles were included, of which 21 were concerned with health care rating sites. Several studies indicate a relationship between information on social media and quality of health care. However, some drawbacks exist, especially regarding the use of rating sites. For example, since rating is anonymous, rating values are not risk adjusted and therefore vulnerable to fraud. Also, ratings are often based on only a few reviews and are predominantly positive. Furthermore, people providing feedback on health care via social media are presumably not always representative for the patient population.

CONCLUSIONS

Social media and particularly rating sites are an interesting new source of information about quality of care from the patient's perspective. This new source should be used to complement traditional methods, since measuring quality of care via social media has other, but not less serious, limitations. Future research should explore whether social media are suitable in practice for patients, health insurers, and governments to help them judge the quality performance of professionals and organizations.

A pilot study on record reviewing with a priori patient selection

OBJECTIVES

To investigate whether a priori selection of patient records using unexpectedly long length of stay (UL-LOS) leads to detection of more records with adverse events (AEs) compared to non-UL-LOS.

DESIGN

To investigate the opportunities of the UL-LOS, we looked for AEs in all records of patients with colorectal cancer. Within this group, we compared the number of AEs found in records of patients with a UL-LOS with the number found in records of patients who did not have a UL-LOS.

SETTING

Our study was done at a general hospital in The Netherlands. The hospital is medium sized with approximately 30 000 admissions on an annual basis. The hospital has two major locations in different cities where both primary and secondary care is provided.

PARTICIPANTS

The patient records of 191 patients with colorectal cancer were reviewed.

PRIMARY AND SECONDARY OUTCOME MEASURES

Number of triggers and adverse events were the primary outcome measures.

RESULTS

In the records of patients with colorectal cancer who had a UL-LOS, 51% of the records contained one or more AEs compared with 9% in the reference group of non-UL-LOS patients. By reviewing only the UL-LOS group with at least one trigger, we found in 84% (43 out of 51) of these records at least one adverse event.

CONCLUSIONS

A priori selection of patient records using the UL-LOS indicator appears to be a powerful selection method which could be an effective way for healthcare professionals to identify opportunities to improve patient safety in their day-to-day work.

The hospital standardised mortality ratio: a powerful tool for Dutch hospitals to assess their quality of care?

Aim of the study

To use the hospital standardised mortality ratio (HSMR), as a tool for Dutch hospitals to analyse their death rates by comparing their risk-adjusted mortality with the national average.

Method

The method uses routine administrative databases that are available nationally in The Netherlands—the National Medical Registration dataset for the years 2005–2007. Diagnostic groups that led to 80% of hospital deaths were included in the analysis. The method adjusts for a number of case-mix factors per diagnostic group determined through a logistic regression modelling process.

Results

In The Netherlands, the case-mix factors are primary diagnosis, age, sex, urgency of admission, length of stay, comorbidity (Charlson Index), social deprivation, source of referral and month of admission. The Dutch HSMR model performs well at predicting a patient's risk of death as measured by a c statistic of the receiver operating characteristic curve of 0.91. The ratio of the HSMR of the Dutch hospital with the highest value in 2005–2007 is 2.3 times the HSMR of the hospital with the lowest value.

Discussion

Overall hospital HSMRs and mortality at individual diagnostic group level can be monitored using statistical process control charts to give an early warning of possible problems with quality of care. The use of routine data in a standardised and robust model can be of value as a starting point for improvement of Dutch hospital outcomes. HSMRs have been calculated for several other countries.

Determining the interviewer effect on CQ Index outcomes: a multilevel approach

Background

The CQ Index for the elderly, a quality-of-care questionnaire administered by conducting interviews, is used to assess clients' experiences in Dutch nursing homes and homes for the elderly. This article describes whether inter-interviewer differences influence the perceived quality of healthcare services reported by residents, the size of this interviewer effect and the influence of the interviewer characteristics on CQ Index dimensions for public reporting.

Methods

Data from 4345 questionnaires was used. Correlations were calculated, reliability analyses were performed, and a multilevel analysis was used to calculate the degree of correlation between two interviewers within one health care institution. Five models were constructed and the Intra Class Correlation (ICC) was calculated. Healthcare institutions were given 1-5 stars on every quality dimensions (1 = worst and 5 = best), adjusted for resident and interviewer characteristics. The effect of these characteristics on the assignment of the stars was investigated.

Results

In a multilevel approach, the ICC showed a significant amount of variance on five quality dimensions. Of the interviewer characteristics, only previous interviewing experience, the reason of interviewing and general knowledge of health care had a significant effect on the quality dimensions. Adjusting for interviewer characteristics did not affect the overall star assignment to the institutions regarding 7 of 12 quality dimensions. For the other five dimensions (Shared decision-making, Meals, Professional competency, Autonomy, and Availability of personnel) a minor effect was found.

Conclusions

We have shown that training, the use of experienced interviewers, written instructions, supervision and educational meetings do not automatically prevent interviewer effects. While the results of this study can be used to improve the quality of services provided by these institutions, several CQ index dimensions should be interpreted with caution for external purposes (accountability and transparency).