Patients and nurses determine variation in adherence to guidelines at Dutch hospitals more than internists or settings.

AIMS: To measure adherence to recently developed diabetes guidelines at Dutch hospital outpatient clinics and distinguish determinants for variations in care on hospital, internist and patient levels. METHODS: Thirteen general hospitals with 58 internists recruited 1950 diabetic patients. Data were extracted from medical files (n = 1915) and from patient questionnaires (n = 1465). Multilevel logistic regression analysis was performed to explain differences in adherence rates to the guidelines. RESULTS: Adherence to process measures was high, except for the examination of feet, calculation of the body mass index and patient education activities (the mean of 12 process measures was 64%). Adherence to intermediate outcome indicators was moderate. The mean percentage of patients with HbA(1c) < 7.0% was 23%. Adherence variation on a hospital level was very small (0.6-7.9%), on an internist level moderate (0.4-18.8%) and on a patient level high (74.4-98.8%). Adherence to all process measures and most of the intermediate outcome indicators was highest in the patients seen by a diabetes specialist nurse. DISCUSSION: More focus on patient involvement in diabetic care and the contribution of diabetes specialist nurses may be important factors in improving the quality of diabetes care.

Cost-effectiveness of glycemic control and ophthalmological care in diabetic retinopathy.

AIMS: Glycemic control and ophthalmological care are known to significantly diminish the risk of visual impairment and blindness by diabetic retinopathy (DRP). The (cost-)effectiveness of both strategies was studied to highlight their benefits for patients and care providers. METHODS: A computer analysis was developed, following the progression of DRP and the effectiveness of metabolic control and ophthalmological care continuously and individually in cohorts of type I and type II DM patients with divergent degrees of compliance. Costs relate to present medical charges in the Netherlands. RESULTS: Intensive glycemic control shortens the duration of blindness in a type I DM patient by 0.76 years, intensive ophthalmological care by 0.53 years. One year sight gain may cost 1126 euros by providing ophthalmological care and 50479 euros by glycemic control. The duration of blindness drops in a type II DM patient by 0.48 and 0.13 years, respectively, whereas the effectiveness decreases as the age of onset of DM rises. CONCLUSIONS: The vast majority of diabetic patients benefits from both intensive glycemic control and intensive ophthalmological care, but these cost-effective interventions which are not only complementary, but also substitute each other, require lasting, full compliance by all parties concerned.

Lifetime health effects and costs of diabetes treatment.

BACKGROUND: This article presents cost-effectiveness analyses of the major diabetes interventions as formulated in the revised Dutch guidelines for diabetes type 2 patients in primary and secondary care. The analyses consider two types of care: diabetes control and the treatment of complications, each at current care level and according to the guidelines. METHODS: A validated probabilistic diabetes model describes diabetes and its complications over a lifetime in the Dutch population, computing quality-adjusted life years and medical costs. Effectiveness data and costs of diabetes interventions are from observational current care studies and intensive care experiments. Lifetime consequences of in total sixteen intervention mixes are compared with a baseline glycaemic control of 10% HBA1C. RESULTS: The interventions may reduce the cumulative incidence of blindness, lower-extremity amputation, and end-stage renal disease by >70% in primary care and >60% in secondary care. All primary care guidelines together add 0.8 quality-adjusted life years per lifetime. CONCLUSION: In case of few resources, treating complications according to guidelines yields the most health benefits. Current care of diabetes complications is inefficient. If there are sufficient resources, countries may implement all guidelines, also on diabetes control, and improve efficiency in diabetes care.

Medical audit: threat or opportunity for the medical profession. A comparative study of medical audit among medical specialists in general hospitals in The Netherlands and England, 1970-1999.

Medical audit has been introduced among hospital specialists in both the Netherlands and England. In the Netherlands following some local experiments, medical audit was promoted nationally as early as 1976 by the medical profession itself and became a mandatory activity under the Hospital Licensing Act of 1984. In England it was the government who promoted medical audit as a compulsory activity for medical specialists, in particular since 1989. In this article the development and introduction of medical audit in the two health care systems is described and its impact on the clinical autonomy of medical specialists gauged. It is concluded that in both countries external pressures seem to have been crucial in the 'compulsory' introduction of medical audit. Although there are differences in the organisation and culture of the medical profession in the two countries, in both countries medical audit turned out to be an instrument 'controlled' by the profession itself. The question whether medical audit is instrumental in preserving clinical autonomy has also been addressed. Our conclusion is that in its present form medical audit in the two countries has not been a threat to the clinical autonomy of the medical profession. At the same time it is clear that the study of one quality instrument is insufficient to draw conclusions about the development of clinical autonomy, let alone autonomy in general. Moreover, it remains to be seen how medical audit can survive alongside quality improvement mechanisms such as accreditation, certification, performance indicators and formal quality systems (ISO, EFQM) where hospital management executes more control. The history of medical audit in the Netherlands and England over the past 30 years does illustrate, however, the capability of the profession to maintain autonomy through re-negotiated mechanisms for self-control.

Diabetes nephropathy in the Netherlands: a cost effectiveness analysis of national clinical guidelines.

BACKGROUND: In the Netherlands a program on quality assurance in medical care has started in 1996. Clinical professionals, patient organizations and health services researchers formulate evidence based guidelines with a concomitant cost-effectiveness analysis. OBJECTIVES: To examine the cost-effectiveness of guideline recommendations for prevention of nephropathy in diabetes mellitus type 1 and 2. RESEARCH DESIGN: A semi-Markov compartment model was developed. Data from international publications on epidemiological surveys and randomized trials, together with national data on health care use and costs, were used to feed the model. A cohort of diabetes patients without renal disease enters the model. MEASURES: Complication (end-stage renal disease) free years, QALY's, and life-time medical costs per patient treated according to guideline recommendations or current anti-diabetic strategy. RESULTS: Guideline treatment for type 1 diabetes yields 4.2 complication free life years, at a cost-effectiveness ratio of 13 500 (Dutch guilders) NLG per QALY. Type 2 diabetes patients gain 0.2 complication free life years at a cost-effectiveness ratio of 31 000 NLG per QALY. CONCLUSION: Guideline development for diabetes nephropathy, with concomitant cost-effectiveness calculations, has resulted in a transparent guideline with explicit information on long-term cost and effects. The project has brought health care providers and health services researchers together.

[Postoperative wound infections: a useful indicator of quality of care?]. / Postoperatieve wondinfecties: een bruikbare indicator voor de kwaliteit van zorg?

An indicator can be defined as a measurable element of care that gives an impression of the quality of care. It can be used for screening on potential quality problems, for monitoring of well-defined processes and for a check after the introduction of quality improvement activities. Although the notion of an indicator appears to be an attractive concept in quality management, some questions have to be answered before a specific indicator can be used. The first question regards the validity of the indicator: to what extent does the indicator reflect the quality of the care? Next is the question of registration: can the indicator be measured in a valid and reliable way? The third question is whether appropriate activities will be initiated after the indicator has given a signal. Postoperative wound infections appears to be a valid outcome indicator because of the relationship between process of care (infection prevention policy) and outcome of care (the number of infections). The weak point lies in the reliability of the registration of wound infections.

[Appropriate treatment of benign prostatic hyperplasia; refining the indications for treatment by systematic analysis of expert opinion]. / Passende behandeling bij benigne prostaathyperplasie; verfijning van de indicatiestelling door systematische analyse van klinische expertise.

OBJECTIVE: To assess systematically the opinion of urology experts regarding the appropriateness of indications for treatment of benign prostatic hyperplasia (BPH) and to evaluate the potential use of these expert opinions for the refinement of treatment guidelines. DESIGN: Modified Delphi procedure. METHODS: A panel of 12 Dutch urologists judged the appropriateness of three common treatments (surgery, alpha-adrenergic antagonists, finasteride) for 1152 hypothetical cases of BPH. These cases consisted of all combinations of 9 diagnostic characteristics considered relevant to treatment choice. The study population was restricted to patients for whom current (evidence-based) guidelines do not provide clear indications on the most appropriate treatment. The panel members individually rated the appropriateness of the three active treatments using a 1 to 9 scale, each in comparison with 'watchful waiting'. By combining the results on agreement and appropriateness, aggregate panel judgements were calculated for each indication (appropriate, inappropriate, uncertain). The relationship between diagnostic characteristics and panel opinions was studied using logistic regression methods. RESULTS: For patients without previous treatment for BPH, surgery was considered appropriate in 44% of cases. For alpha-blocking drugs and finasteride, these values were 70% and 3% respectively. Logistic regression analysis revealed a strong and consistent relationship between the several diagnostic characteristics and the panel judgement 'appropriate indication'. CONCLUSION: Systematic analysis of clinical expertise can offer a meaningful contribution to the refinement of indications for BPH treatments.

Continuous computer simulation analysis of the cost-effectiveness of screening and treating diabetic retinopathy.

This paper analyzes the cost-effectiveness of screening and treating diabetic retinopathy (DR) by simulating the disease progress continuously with existing data. A new computer simulation based on Monte Carlo techniques and logistic transformation follows cohorts from diabetes onset until death in five care scenarios. For younger-onset patients, ophthalmic care reduces the prevalence of blindness by 52% or greater while savings in disability facilities and production losses surpass direct costs. For older-onset patients, less favorable results appear. Financial benefits surpass costs for juvenile-onset patients. For other patients, the net costs of ophthalmic care seem lower than in other health care programs.

Treatment choice for benign prostatic hyperplasia: a matter of urologist preference?

PURPOSE: New treatment modalities for benign prostatic hyperplasia (BPH) have considerably altered the decision making process in daily clinical practice. Guidelines provide a framework for treatment choice but leave much room for physician personal opinions. We identified and quantified determinants of treatment choice for BPH among urologists focusing on urologist treatment preferences. MATERIALS AND METHODS: The study population consisted of 670 consecutive patients with BPH 50 years old or older newly referred to 1 of 39 urologists in a stratified sample of 13 hospitals throughout The Netherlands. Data on patient characteristics were retrieved from patient questionnaires (symptomatology, bothersomeness, sexual function), medical records (diagnostic outcomes, co-morbidity) and urologist questionnaire (initial treatment choice and main considerations for this decision). Urologist treatment preferences were inventoried using a mailed questionnaire. Polychotomous logistic regression analysis was used to study the impact of patient characteristics and urologist preferences on treatment choice. RESULTS: Among the patient characteristics maximum flow rate, residual urine and prostate volume were strongly associated with the probability of surgery and watchful waiting. However, the influence of urologist preferences on actual decisions was also significant. Adjusted for case mix the differences in low and high preferences revealed a 2.2 times greater probability of surgery. For alpha-blockers and finasteride these ratios were 1.8 and 9.4, respectively. An additional independent effect was seen for urologist extent of experience. CONCLUSIONS: The influence of urologist personal preferences on treatment choice in BPH is considerable. Given the different efficacy and side effects of the various treatments, further consensus development is needed to enhance appropriate treatment decisions and eliminate undue costs.

[Guidelines and costs]. / Richtlijnen en kosten.

There is a growing interest in developing clinical guidelines which support the efficiency of medical care by weighting the potential benefits against the costs of interventions. In the recently developed Dutch guideline on reduction of serum cholesterol concentration a formal cost-effectiveness analysis is included. Based on epidemiological arguments a cost-effectiveness ratio of 40,000 Dutch guilders per life year gained was found. In comparison with other preventive health care programmes this amount was considered acceptable. In the past physicians have often taken costs into account in an implicit way when making clinical decisions. The results of the cost-effectiveness analysis vary particularly with the costs of the used statins. In the past physicians have often taken costs into account in an implicit way when making clinical decisions. However, in view of the increase in health care expenditures, it has become the responsibility of physicians to take costs into account more explicitly. Clinical guidelines with a cost-effectiveness analysis can be useful in helping physicians to provide efficient medical care.

[Therapy and prevention of coronary heart diseases through lowering of the serum cholesterol levels; third consensus 'Cholesterol'. Consensus Working Group, CBO]. / Behandeling en preventie van coronaire hartziekten door verlaging van de serumcholesterolconcentratie; derde consensus 'Cholesterol'.

For the second time the consensus text for lipid lowering therapy is revised. In angiographic studies it was shown that a decrease in the total cholesterol as well as the low-density lipoprotein cholesterol level results in a reduction of the progression of vascular disease. Furthermore, intervention trials demonstrated that therapy with cholesterol synthesis inhibitors reduces not only both the cardiovascular and total mortality, but also other manifestations of coronary heart disease (CHD). Hypercholesterolaemia is treated with a low-fat diet and normalisation of the weight. For individuals, this might result in a reduction of the risk for myocardial infarction or death and for the population in a decrease of the mean serum cholesterol concentration and the incidence of CHD. The indication for drug therapy is founded on the expected effectiveness to reduce the incidence of (new manifestations of) CHD, which is related to the level of the absolute risk of vascular disease. In persons without known vascular diseases this risk is calculated from the total and high-density lipoprotein cholesterol ratio, age, sex, blood pressure, diabetes mellitus, and smoking. Treatment with cholesterol synthesis inhibitors must be considered in (a) patients with familial hypercholesterolaemia, (b) all patients with a history of myocardial infarction or other symptomatic vascular disease with a total cholesterol concentration above 5.0 mmol/l and a life expectancy of at least five years; (c) persons with a combination of diabetes mellitus, hypertension, hypercholesterolaemia and high risk for development of CHD, rising from 25% per 10 years at the age of 40 years to 35-40% per 10 years at the age of 70 years, with a life expectancy of at least five years. If these guidelines are followed, the upper limit of the calculated cost-effectiveness is about Dfl. 40,000 per life year gained. The working group judges this reasonable in comparison with other therapeutic interventions in the Netherlands.

Need for consensus development in prehospital emergency medicine: effect of an expert panel approach.

The objective of this study was to look at the need for consensus development in prehospital emergency medicine, and to determine the effect of an expert panel approach. The study took place in Euregio Scheldemond, comprising Sealand Flanders, The Netherlands, and Belgian Flanders, Belgium. Firstly, seven experts rated in organized mailings 153 (random selection out of 505) existing cases of acute or critically ill patients, situated in Dutch Sealand-Flanders. Experts were asked to decide whether assistance from neighbouring Belgian Flanders, consisting of a trauma team with or without the use of a highly equipped ambulance/helicopter, was needed or not in Dutch Sealand-Flanders, at: (1) the site of the incident, and (2) for transport to the hospital. They also had to decide on: (3) the required type of destination hospital (Belgian centre/university, versus Dutch regional). In a subsequent meeting using a modified nominal group technique 23 'worst' cases from the postal rounds with the lowest agreement were discussed and re-rated. We present a framework for the consensus measurement and development procedures. Agreement among experts was poor with multiple rater (Fleiss) kappa values for all 153 postal cases for the first, second and third decisions of 0.32, 0.08 and 0.45, respectively. After group discussions of the 23 'worst' postal cases, kappa values increased significantly and substantially; for the first, second and third decisions from 0.08 to 0.51, from -0.08 to 0.39 and from 0.16 to 0.62, respectively (all p < 0.001). Agreement increased significantly for medical cases, but not for trauma cases. It is concluded that consensus development for prehospital emergency medicine is needed. An expert panel approach seems fruitful in achieving more agreement, which forms a basis for guideline or protocol development.

Quality management of occupational health services: the necessity of a powerful medical profession.

Over the past few years there has been a growing interest in quality management in occupational health services. In this article the central role of the medical profession in this area is highlighted from a personal point of view. It is argued that a powerful and active profession is needed as a countervailing power in the field of tension between employees and the company, and for balancing the interests of these two main clients. Therefore, the medical profession should develop a policy on quality and apply quality management on national and local levels to reach a high professional level. In this way the profession can maintain the clinical autonomy that is necessary to be a countervailing power. Elements of such quality management are national guidelines, local peer review and intercolleagual visitation. These activities must be incorporated in the quality management of the occupational health services unit.

Quality systems in Dutch health care institutions.

The implementation of quality systems in Dutch health care was supervised by a national committee during 1990-1995. To monitor the progress of implementation a large survey was conducted in the beginning of 1995. The survey enclosed all subsectors in health care. A postal questionnaire--derived from the European Quality Award--was sent to 1594 health care institutions; the response was 74%. The results showed that in 13% of the institutions a coherent quality system had been implemented. These institutions reported, among other effects, an increase in staff effort and job satisfaction despite the increased workload; 59% of the institutions had implemented parts of a quality system. It appeared that management pay more attention to human resource management compared to documentation of the quality system. The medical staff pay relatively more attention to protocol development than to quality-assurance procedures. Patients were hardly involved in these quality activities. The research has shown that it is possible to monitor the progress of implementation of quality systems on a national level in all subsectors of health care. The results play an important role in the discussions and policy on quality assurance in health care.

Interpretation of uroflowmetry curves by urologists.

PURPOSE: Uroflowmetry has become a routine investigation in patients with symptoms of the lower urinary tract. Little is known about the variation in the use of uroflowmetry and in the interpretation of its outcomes. We investigated the diagnostic value of uroflowmetry as a freestanding test, and examined the interobserver and intra-observer variation in the interpretation of uroflowmetry curves. MATERIALS AND METHODS: A representative panel of 58 urologists was questioned about the relevance of visual inspection and flow parameters for interpretation. In addition, they individually assessed 25 randomly selected uroflowmetry curves (from patients with no abnormalities and those with various lower urinary tract symptoms) regarding normal findings and the most likely diagnosis. To investigate intra-observer agreement 4 of these curves were studied twice. RESULTS: Voided volume (81%), visual inspection (77%) and maximum flow rate (77%) were most frequently mentioned as relevant for interpretation. Large differences existed between panel opinions and actual case information. For 43% of the normal cases the panel members considered the curves as abnormal. Of the abnormal cases 6% of the curves were regarded as normal. The urologists predicted correctly the actual diagnosis in 36% of all cases. Interobserver agreement was moderate for normalcy (kappa 0.46, standard error 0.087) and poor for the most likely diagnosis (kappa 0.30, standard error 0.043). Intra-observer agreement was also not satisfactory. On average, for the 4 cases studied twice 29% of the panel members chose another option for normalcy, while 41% mentioned another diagnosis the second time. CONCLUSIONS: These results necessitate reconsideration of the diagnostic use of uroflowmetry in daily urological practice.

The use of outcome assessment: the clinician's concerns.

In the last few years increasing attention has been paid to outcome assessment within effectiveness studies, policy analysis and quality management. Dimensions of patients outcome that can be discerned are mortality, clinical parameters, health status and patient satisfaction. Some critical remarks have been placed on outcome assessment by clinicians. They have doubts on the relevance of outcome assessment, mainly because of the ambiguous relationship between process and outcome, especially regarding the dimension of health status. Furthermore, they are concerned about submitting individual patients to policy and clinical guidelines that are derived from outcome assessment of a group of patients. Arguably, what is good for society or for groups need not to be so beneficial to individual patients. To better involve clinicians in outcome assessment, knowledge is required on the extent to which an individual patient belongs to the population for which clinical and policy guidelines are used. Furthermore, more research is needed regarding the relationship between process and outcome, and regarding the connection between the outcome dimensions of clinical parameters, health status and satisfaction.

Coping strategies of enrolled nurses in nursing homes: shifting between organizational imperatives and residents' needs.

In today's nursing homes, which can be considered modern versions of "total institutions", enrolled nurses expend much energy coping with problems which arise from the day-to-day care of seriously impaired patients. The problems they encounter include the burden of never ending work, having to cope with deviant and problematic behaviour, handling emotional disturbance and, on a more abstract level, balancing self-interest and power with love and affection. The grounded theory approach was used to discover the coping strategies employed by enrolled nurses. On the criterium of favouring either organizational imperatives or residents' needs, six strategies were differentiated, and placed into one of two categories. The discovery during research of two distinct nursing teams, each inclining towards the strategies available within one of these two categories, not only has important theoretical implications, but also practical consequences for the training of student nurses, the labour market and the quality of care.

[Free admission to stress electrocardiography with subsequent cardiological advice and feedback to the family physician: favorable effect on referral patterns]. / Vrije toegang tot inspanningselektrocardiografie met aansluitend cardiologisch advies en feedback aan de huisarts: gunstige invloed op het verwijspatroon.

OBJECTIVE: To improve the patient referral by general practitioners to the cardiology outpatient clinic for evaluation of (possibly) anginal complaints, by giving access to in-hospital bicycle exercise testing with cardiological advice and feedback. DESIGN: Prospective. SETTING: Department of non-invasive cardiology 'De Weezenlanden' Hospital, Zwolle, the Netherlands. METHODS: Patients, with no cardiological history, were collected from two comparable groups of general practitioners: an experimental group (n = 90.000 patients), allowed to perform an in-hospital exercise test with concomitant advice of a cardiologist, and a reference group (n = 53.400 patients), who referred directly to the cardiologist without having this facility (as customary in the Dutch health care system). Data were collected prospectively from January 1st 1994 until May 1st 1995. RESULTS: In the experimental group, 615 patients underwent exercise tests; 100 were subsequently referred. In addition, 53 patients were referred directly (total 153 patients; 1.3/1000 patients/year; 95% confidence interval: 1.1-1.5). In 51% of referred patients coronary disease was present, 37% underwent coronary angiography and 23% revascularisation (PTCA or CABG). During follow-up for 2 months no cardiovascular events occurred in non-referred patients. In the reference group, 132 patients were referred directly (1.9/1000 patients/ year; 1.6-2.2; p < 0.01 when compared with the experimental group). Of these patients 13% had coronary disease, 8% underwent coronary angiography and 3% revascularisation. CONCLUSION: Free access to exercise testing with cardiological advice and feedback for general practitioners resulted in a reduction of referrals with improved efficiency.