Day-to-day fluctuations of fatigue severity in individuals with knee osteoarthritis: an ecological momentary assessment approach.

Objective: The variable course of fatigue adds to the disease burden of patients with OA yet it has been poorly understood. This study aimed to describe within-person fluctuations of fatigue severity and explore its associations with pain, positive affect, negative affect, sleep, and perceived exertion of physical activity. Methods: Individuals with chronic knee pain or a clinical diagnosis of knee OA ≥40 years of age completed daily assessments about fatigue, pain, positive affect, negative affect, sleep, perceived exertion of physical activity (numeric rating scale 0-10), and overwhelming fatigue (yes/no) on a smartphone over 14 days. Within-person fluctuations of fatigue severity were described by the probability of acute changes (PACs) and s.d.s. Associations with pain, positive affect, negative affect, sleep, and perceived exertion of physical activity were explored using multilevel models. Results: Forty-nine individuals were included (mean age 63.4 years; 82% female). PACs and s.d.s of within-person daily fatigue fluctuations ranged from 0.00 to 0.80 and 0.35 to 2.95, respectively. Within-person associations of fatigue severity were moderate for positive affect [ß = -0.57 (95% CI -0.67, -0.47)], weak for pain [ß = 0.41 (95% CI 0.29, 0.53)] and negative affect [ß = 0.40 (95% CI 0.21, 0.58)], and negligible for sleep [ß = -0.13 (95% CI -0.18, -0.08)] and perceived exertion of physical activity [ß = 0.18 (95% CI 0.09, 0.26)]. Conclusion: Some individuals showed almost stable day-to-day levels of fatigue severity, whereas others experienced a substantial number of clinically relevant fluctuations. To reduce the burden of daily fatigue fluctuations, our results suggest that pain, positive and negative affect rather than sleep and perceived exertion of physical activity should be considered as potential targets.

Pain descriptors and determinants of pain sensitivity in knee osteoarthritis: a community-based cross-sectional study.

Objectives: The aim was to explore pain characteristics in individuals with knee OA (KOA), to compare pain sensitivity across individuals with KOA, individuals with chronic back pain (CBP) and pain-free individuals (NP) and to examine the relationship between clinical characteristics and pain sensitivity and between pain characteristics and pain sensitivity in KOA. Methods: We carried out a cross-sectional, community-based online survey. Two data sets were combined, consisting of Dutch individuals ≥40 years of age, who were experiencing chronic knee pain (KOA, n = 445), chronic back pain (CBP, n = 504) or no pain (NP, n = 256). Demographic and clinical characteristics, global health, physical activity/exercise and pain characteristics, including intensity, spreading, duration, quality (short-form McGill pain questionnaire) and sensitivity (pain sensitivity questionnaire), were assessed. Differences between (sub)groups were examined using analyses of variance or χ2 tests. Regression analyses were performed to examine determinants of pain sensitivity in the KOA group. Results: The quality of pain was most commonly described as aching, tender and tiring-exhausting. Overall, the KOA group had higher levels of pain sensitivity compared with the NP group, but lower levels than the CBP group. Univariately, pain intensity, its variability and spreading, global health, exercise and having co-morbidities were weakly related to pain sensitivity (standardized ß: 0.12-0.27). Symptom duration was not related to pain sensitivity. Older age, higher levels of continuous pain, lower levels of global health, and exercise contributed uniquely, albeit modestly, to pain sensitivity (P < 0.05). Conclusion: Continuous pain, such as aching and tenderness, in combination with decreased physical activity might be indicative for a subgroup of individuals at risk for pain sensitivity and, ultimately, poor treatment outcomes.

Increased adherence to perioperative safety guidelines associated with improved patient safety outcomes: a stepped-wedge, cluster-randomised multicentre trial.

BACKGROUND: National Dutch guidelines have been introduced to improve suboptimal perioperative care. A multifaceted implementation programme (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) has been developed to support hospitals in applying these guidelines. This study evaluated the effectiveness of IMPROVE on guideline adherence and the association between guideline adherence and patient safety. METHODS: Nine hospitals participated in this unblinded, superiority, stepped-wedge, cluster RCT in patients with major noncardiac surgery (mortality risk ≥1%). IMPROVE consisted of educational activities, audit and feedback, reminders, organisational, team-directed, and patient-mediated activities. The primary outcome of the study was guideline adherence measured by nine patient safety indicators on the process (stop moments from the composite STOP bundle, and timely administration of antibiotics) and on the structure of perioperative care. Secondary safety outcomes included in-hospital complications, postoperative wound infections, mortality, length of hospital stay, and unplanned care. RESULTS: Data were analysed for 1934 patients. The IMPROVE programme improved one stop moment: 'discharge from recovery room' (+16%; 95% confidence interval [CI], 9-23%). This stop moment was related to decreased mortality (-3%; 95% CI, -4% to -1%), fewer complications (-8%; 95% CI, -13% to -3%), and fewer unscheduled transfers to the ICU (-6%; 95% CI, -9% to -3%). IMPROVE negatively affected one other stop moment - 'discharge from the hospital' - possibly because of the limited resources of hospitals to improve all stop moments together. CONCLUSIONS: Mixed implementation effects of IMPROVE were found. We found some positive associations between guideline adherence and patient safety (i.e. mortality, complications, and unscheduled transfers to the ICU) except for the timely administration of antibiotics. CLINICAL TRIAL REGISTRATION: NTR3568 (Dutch Trial Registry).

Reducing work pressure and IT problems and facilitating IT integration and audit & feedback help adherence to perioperative safety guidelines: a survey among 95 perioperative professionals.

BACKGROUND: To improve perioperative patient safety, guidelines for the preoperative, peroperative, and postoperative phase were introduced in the Netherlands between 2010 and 2013. To help the implementation of these guidelines, we aimed to get a better understanding of the barriers and drivers of perioperative guideline adherence and to explore what can be learned for future implementation projects in complex organizations. METHODS: We developed a questionnaire survey based on the theoretical framework of Van Sluisveld et al. for classifying barriers and facilitators. The questionnaire contained 57 statements derived from (a) an instrument for measuring determinants of innovations by the Dutch Organization for Applied Scientific Research, (b) interviews with quality and safety policy officers and perioperative professionals, and (c) a publication of Cabana et al. The target group consisted of 232 perioperative professionals in nine hospitals. In addition to rating the statements on a five-point Likert scale (which were classified into the seven categories of the framework: factors relating to the intervention, society, implementation, organization, professional, patients, and social factors), respondents were invited to rank their three most important barriers in a separate, extra open-ended question. RESULTS: Ninety-five professionals (41%) completed the questionnaire. Fifteen statements (26%) were considered to be barriers, relating to social factors (N = 5), the organization (N = 4), the professional (N = 4), the patient (N = 1), and the intervention (N = 1). An integrated information system was considered an important facilitator (70.4%) as well as audit and feedback (41.8%). The Barriers Top-3 question resulted in 75 different barriers in nearly all categories. The most frequently reported barriers were as follows: time pressure (16% of the total number of barriers), emergency patients (8%), inefficient IT structure (4%), and workload (3%). CONCLUSIONS: We identified a wide range of barriers that are believed to hinder the use of the perioperative safety guidelines, while an integrated information system and local data collection and feedback will also be necessary to engage perioperative teams. These barriers need to be locally prioritized and addressed by tailored implementation strategies. These results may also be of relevance for guideline implementation in general in complex organizations. TRIAL REGISTRATION: Dutch Trial Registry: NTR3568.

Substitution of general practitioners by nurse practitioners in out-of-hours primary care home visits: A quasi-experimental study.

BACKGROUND: General practitioners experience a high workload during out-of-hours care. A possible solution is the shifting of care to nurse practitioners. OBJECTIVES: To provide insight into patient- and care characteristics, safety, efficiency, and patient satisfaction of substituting general practitioners with nurse practitioners for home visits by out-of-hours primary care services. DESIGN: Quasi-experimental non-randomised study comparing home visits by nurse practitioners (intervention group; one out-of-hours care service) with home visits by general practitioners (control group; two out-of-hours care services) for 24 protocolised health problems. SETTING: Three out-of-hours primary care services in the East of the Netherlands. PARTICIPANTS: 1601 patients who received a home visit by a nurse practitioner (N = 386) or a general practitioner (N = 1215). Of these patients, 639 gave informed consent to be included in the protocol adherence assessment and follow-up record review (nurse practitioner: N = 358; general practitioner: N = 281). METHODS: Five nurse practitioners with experience in ambulance care were recruited and trained. From September 2016 to March 2017 the nurse practitioners took over home visits under supervision of a general practitioners. This was evaluated using: (1) data-extraction from the patient registration system, (2) follow-up record review in the patients' general practices, and (3) patient satisfaction survey. Two general practitioners independently assessed protocol adherence based on the extracted registration data. RESULTS: Nurse practitioners prescribed medication significantly less often than general practitioners (19.9% versus 30.6%), and referred patients significantly more often to the hospital (24.1% versus 15.9%). The mean length of the home visit was significantly longer for nurse practitioners (34.1 versus 21.1 min). Nurse practitioners adhered to the protocol significantly more often than general practitioners (84.9% versus 76.2%) and their medication prescribing was significantly more often appropriate (93.7% versus 79.5%). There were no differences in the number of missed diagnoses and complications. The number of follow-up contacts was also similar in both groups. Patient satisfaction was generally high and significantly higher for nurse practitioners on several items. CONCLUSIONS: Nurse practitioners with experience in ambulance care can safely, efficiently, and satisfactorily perform low complex out-of-hours primary care home visits. It is recommended to study the safety and efficiency of nurse practitioners' home visits in other regions and with nurse practitioners with different educational levels and different specialisations. In addition, we recommend to evaluate the cost-effectiveness and if it leads increased quality of care.

Availability of Dutch General Practitioners for After-Hours Palliative Care.

BACKGROUND: Continuity of care is important for palliative patients in their end of life. In the Netherlands, after-hours primary care for palliative patients is either provided by large-scale general practitioner (GP) cooperatives or GPs choose to give palliative care by themselves while they are not on duty. AIM: To examine the availability of, perceived problems by, and attitude of Dutch GPs regarding providing palliative care for their own patients outside office hours. DESIGN AND SETTING: Cross-sectional observational study among 1772 GPs from 10 Dutch regions. METHOD: Online questionnaire among GPs affiliated with 10 GP cooperatives. RESULTS: Five hundred twenty-four (29.6%) eligible questionnaires were returned. Of the GPs, 60.8% were personally available outside office hours for their own palliative patients on their own private cell phone and performed home visits if needed. In 33.0%, GPs were willing to make home visits in private time instigated by the GP cooperative and 26.8% were only accessible for telephone consultation by the GP cooperative. In 12.2%, the GP delegated after-hours palliative care completely to the GP cooperative. The GPs predominantly reported "time pressure" problems (17.3%) as a barrier and 61.7% stated that after-hours palliative care is the responsibility of the own GP. CONCLUSION: The large majority of Dutch GPs is personally available for telephone consultation and/or willing to provide palliative care for their own patients outside office hours. For the future, it is important to maintain the willingness of GPs to remain personally available for their palliative patients.

Ambulance dispatch versus general practitioner home visit for highly urgent out-of-hours primary care.

Background: Patients with life-threatening conditions who contact out-of-hours primary care either receive a home visit from a GP of a GP cooperative (GPC) or are handed over to the ambulance service. Objective: The objective of this study was to determine whether highly urgent visits, after a call to the GPC, are delivered by the most appropriate healthcare provider: GPC or ambulance service. Methods: We performed a cross-sectional study using patient record data from a GPC and ambulance service in an urban district in The Netherlands. During a 21-month period, all calls triaged as life-threatening (U1) to the GPCs were included. The decision to send an ambulance or not was made by the triage nurse following a protocolized triage process. Retrospectively, the most appropriate care was judged by the patient's own GP, using a questionnaire. Results: Patient and care characteristics from 1081 patients were gathered: 401 GPC visits, 570 ambulance responses and 110 with both ambulance and GPC deployment. In 598 of 1081 (55.3%) cases, questionnaires were returned by the patients' own GP. About 40% of all visits could have been carried out with a lower urgency in retrospect, and almost half of all visits should have received a different type of care or different provider. In case of ambulance response, 60.7% concerned chest pain. Conclusion: Research should be done on the process of triage and allocation of care to optimize labelling complaints with the appropriate urgency and to deploy the appropriate healthcare provider, especially for patients with chest pain.

Effects of access to radiology in out-of-hours primary care in the Netherlands: a prospective observational study.

Background: In the Netherlands, out-of-hours primary care is provided in general-practitioner-cooperatives (GPCs). These are increasingly located on site with emergency departments (ED), forming Emergency-Care-Access-Points (ECAP). A more efficient and economical organization of out-of-hours primary emergency care could be realized by increased collaboration at an ECAP. In this study, we compared the effects of different models with respect to access to (hospital) radiology by the GPC. We investigated patient and care characteristics, indication for diagnostics and outcomes at GPCs with and without access to radiology. Methods: A prospective observational record review study of patients referred for conventional radiology for trauma by one of five GPCs in the period April 2014-October 2015, covering three organizational models. Results: The mean age was 31 years and 56% was female. Extremities were predominately involved (91%). There was a medical indication for radiology in 85% and the assessed risk by requesting GPs on abnormalities was high in 66%. There was a significant difference in outcomes between models. Radiological abnormalities (fractures/luxations) were present in 51% without direct access and in 35% with partial and unlimited access. Overall, 61% of the included patients were referred to the ED; 100% in the models without access and 38% in the models with (partial) access. Conclusions: GPC access to radiology is beneficial for patients and professionals. The diagnostics were adequately used. With access to radiology, unnecessary referrals and specialist care are prevented. This may lead to a decrease in ED attendance and overcrowding.

The impact of the implementation of physician assistants in inpatient care: A multicenter matched-controlled study.

BACKGROUND: Medical care for admitted patients in hospitals is increasingly reallocated to physician assistants (PAs). There is limited evidence about the consequences for the quality and safety of care. This study aimed to determine the effects of substitution of inpatient care from medical doctors (MDs) to PAs on patients' length of stay (LOS), quality and safety of care, and patient experiences with the provided care. METHODS: In a multicenter matched-controlled study, the traditional model in which only MDs are employed for inpatient care (MD model) was compared with a mixed model in which besides MDs also PAs are employed (PA/MD model). Thirty-four wards were recruited across the Netherlands. Patients were followed from admission till one month after discharge. Primary outcome measure was patients' LOS. Secondary outcomes concerned eleven indicators for quality and safety of inpatient care and patients' experiences with the provided care. RESULTS: Data on 2,307 patients from 34 hospital wards was available. The involvement of PAs was not significantly associated with LOS (ß 1.20, 95%CI 0.99-1.40, p = .062). None of the indicators for quality and safety of care were different between study arms. However, the involvement of PAs was associated with better experiences of patients (ß 0.49, 95% CI 0.22-0.76, p = .001). CONCLUSIONS: This study did not find differences regarding LOS and quality of care between wards on which PAs, in collaboration with MDs, provided medical care for the admitted patients, and wards on which only MDs provided medical care. Employing PAs seems to be safe and seems to lead to better patient experiences. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01835444.

A clinical audit of the utilisation of red cell products in elective total hip replacement surgery.

BACKGROUND: Previous studies have documented a marked variation in transfusion practice for total hip replacement (THR) surgery. OBJECTIVE: To audit red cell product utilisation for THR at two Western Cape tertiary referral hospitals (HY and HG). METHODS: The folders of 207 consecutive patients undergoing elective THR surgery from January 2013 to December 2013 were reviewed. Information relating to age, sex, clinical observations, indications for surgery, pre- and postoperative haemoglobin (Hb) values, comorbidities, length of hospital stay and transfusion history was recorded. RESULTS: The transfusion rate at HY (41.6%) was significantly higher than that at HG (10.0%). The mean postoperative Hb in the transfused patients at HG was 8.3 g/dL v. 9.1 g/dL at HY. Females had a significantly higher transfusion rate (33.0%) than males (15.0%) (p<0.05), and the mean age of transfused patients was significantly greater than that of untransfused patients (p<0.005). Although patients with comorbidities had a higher transfusion rate than those without, this did not reach statistical significance. Of 120 patients with complete data, 113 (94.2%) had a blood bank order, of which the vast majority, 102/113 (90.3%), were group-and-screen (G&S) requests; 29/113 (25.7%) were converted to a full crossmatch. CONCLUSIONS: Overall, the transfusion rate for both hospitals was 25.8%, which is well within published rates. A guideline Hb trigger of 8.0 g/dL is recommended as per published guidelines, with the caveat that the clinical judgement of the attending clinician whether a transfusion is indicated is paramount. Causes of preoperative anaemia should be investigated and treated. Routine cross-matching preoperatively is unnecessary, and a G&S order is sufficient.

A Clinical Audit of the Utilisation of Red Cell Products in Elective Total Hip Replacement Surgery

Background. Previous studies have documented a marked variation in transfusion practice for total hip replacement (THR) surgery.Objective. To audit red cell product utilisation for THR at two Western Cape tertiary referral hospitals (HY and HG).Methods. The folders of 207 consecutive patients undergoing elective THR surgery from January 2013 to December 2013 were reviewed. Information relating to age; sex; clinical observations; indications for surgery; pre- and postoperative haemoglobin (Hb) values; comorbidities; length of hospital stay and transfusion history was recorded.Results. The transfusion rate at HY (41.6%) was significantly higher than that at HG (10.0%). The mean postoperative Hb in the transfused patients at HG was 8.3 g/dL v. 9.1 g/dL at HY. Females had a significantly higher transfusion rate (33.0%) than males (15.0%) (p0.05); and the mean age of transfused patients was significantly greater than that of untransfused patients (p0.005). Although patients with comorbidities had a higher transfusion rate than those without; this did not reach statistical significance. Of 120 patients with complete data; 113 (94.2%) had a blood bank order; of which the vast majority; 102/113 (90.3%); were group-and-screen (GetS) requests; 29/113 (25.7%) were converted to a full crossmatch.Conclusions. Overall; the transfusion rate for both hospitals was 25.8%; which is well within published rates. A guideline Hb trigger of 8.0 g/dL is recommended as per published guidelines; with the caveat that the clinical judgement of the attending clinician whether a transfusion is indicated is paramount. Causes of preoperative anaemia should be investigated and treated. Routine cross-matching preoperatively is unnecessary; and a GetS order is sufficient

Contacts with out-of-hours primary care for nonurgent problems: patients' beliefs or deficiencies in healthcare?

BACKGROUND: In the Netherlands, about half of the patient contacts with a general practitioner (GP) cooperative are nonurgent from a medical perspective. A part of these problems can wait until office hours or can be managed by the patient himself without further professional care. However, from the patient's perspective, there may be a need to contact a physician immediately. Our objective was to determine whether contacts with out-of-hours primary care made by patients with nonurgent problems are the result of patients' beliefs or of deficiencies in the healthcare system. METHODS: We performed a survey among 2000 patients with nonurgent health problems in four GP cooperatives in the Netherlands. Two GPs independently judged the medical necessity of the contacts of all patients in this study. We examined characteristics, views and motives of patients with medically necessary contacts and those without medically necessary contacts. Descriptive statistics were used to describe the characteristics, views and reasons of the patients with medically unnecessary contacts and medically necessary contacts. Differences between these groups were tested with chi-square tests. RESULTS: The response rate was 32.3 % (N = 646). Of the nonurgent contacts 30.4 % were judged as medically necessary (95 % CI 27.0-34.2). Compared to patients with nonurgent but medically necessary contacts, patients with medically unnecessary contacts were younger and were more often frequent attenders. They had longer-existing problems, lower self-assessed urgency, and more often believed GP cooperatives are intended for all help requests. Worry was the most frequently mentioned motive for contacting a GP cooperative for patients with a medically unnecessary contact (45.3 %) and a perceived need to see a GP for patients with a medically necessary contact (44.2 %). Perceived availability (5.8 %) and accessibility (8.3 %) of a patient's own GP played a role for some patients. CONCLUSION: Motives for contacting a GP cooperative are mostly patient-related, but also deficiencies in access to general practice may partly explain medically unnecessary use. Efforts to change the use of GP cooperatives should focus on education of subgroups with an increased likelihood of contact for medically unnecessary problems. Improvement of access to daytime primary care may also decrease use of the GP cooperative.

Association between general practice characteristics and use of out-of-hours GP cooperatives.

BACKGROUND: The use of out-of-hours healthcare services for non-urgent health problems is believed to be related to the organisation of daytime primary care but insight into underlying mechanisms is limited. Our objective was to examine the association between daytime general practice characteristics and the use of out-of-hours care GP cooperatives. METHODS: A cross-sectional observational study in 100 general practices in the Netherlands, connected to five GP cooperatives. In each GP cooperative, we took a purposeful sample of the 10 general practices with the highest use of out-of-hours care and the 10 practices with the lowest use. Practice and population characteristics were obtained by questionnaires, interviews, data extraction from patient registration systems and telephone accessibility measurements. To examine which aspects of practice organisation were associated with patients' use of out-of-hours care, we performed logistic regression analyses (low versus high out-of-hours care use), correcting for population characteristics. RESULTS: The mean out-of-hours care use in the high use group of general practices was 1.8 times higher than in the low use group. Day time primary care practices with more young children and foreigners in their patient populations and with a shorter distance to the GP cooperative had higher out-of-hours primary care use. In addition, longer telephone waiting times and lower personal availability for palliative patients in daily practice were associated with higher use of out-of-hours care. Moreover, out-of-hours care use was higher when practices performed more diagnostic tests and therapeutic procedures and had more assistant employment hours per 1000 patients. Several other aspects of practice management showed some non-significant trends: high utilising general practices tended to have longer waiting times for non-urgent appointments, lower availability of a telephone consulting hour, lower availability for consultations after 5 p.m., and less frequent holiday openings. CONCLUSIONS: Besides patient population characteristics, organisational characteristics of general practices are associated with lower use of out-of-hours care. Improving accessibility and availability of day time primary day care might be a potential effective way to improve the efficient use of out-of-hours care services.

Stable recombinants of bovine viral diarrhea virus containing a hepatitis C virus insert.

Here we report on a segment in the genomic 3' non-translated region (3'NTR) of bovine viral diarrhea virus (BVDV) that is accessible for the insertion of foreign sequence elements such as the 5'NTR of hepatitis C virus. Recombinant viruses exhibited replication kinetics similar to those of the parental strain, and characterization of RNA species after several passages revealed that foreign inserts had the same genetic stability as the BVDV 3'NTR. The generation of such BVDV recombinants is relevant for several applications.