Adverse events at the end of life of hospital patients with or without a condition relevant for palliative care: a nationwide retrospective record review study in the Netherlands.

BACKGROUND: Patient safety is crucial for quality of care. Preventable adverse events (AEs) occur in 1 of 20 patients in the hospital, but it is unknown whether this is different for patients with a condition relevant for palliative care. The majority of the limited available research on this topic is only focused on patients already receiving palliative care, and do not make comparisons with other patients at the end-of-life. We identified and compared the prevalence, preventability, nature and causes of AEs in patients with and without a condition relevant for palliative care. METHODS: A nationwide retrospective record review study was performed in 20 Dutch hospitals. A total of 2,998 records of patients who died in hospital in 2019 was included. Records were reviewed for AEs. We identified two subgroups: patients with (n = 2,370) or without (n = 248) a condition relevant for palliative care through the selection method of Etkind (2017). Descriptive analyses were performed to calculate prevalence, nature, causes and prevention strategies. T-tests were performed to calculate differences between subgroups. RESULTS: We found no significant differences between subgroups regarding AE prevalence, this was 15.3% in patients with a condition relevant for palliative care, versus 12.0% in patients without a condition relevant for palliative care (p = 0.148). Potentially preventable AE prevalence was 4.3% versus 4.4% (p = 0.975). Potentially preventable death prevalence in both groups was 3.2% (p = 0.938). There were differences in the nature of AEs: in patients with a condition relevant for palliative care this was mostly related to medication (33.1%), and in patients without a condition relevant for palliative care to surgery (50.8%). In both subgroups in the majority of AEs a patient related cause was identified. For the potentially preventable AEs in both subgroups the two most important prevention strategies as suggested by the medical reviewers were reflection and evaluation and quality assurance. DISCUSSION: Patient safety risks appeared to be equally prevalent in both subgroups. The nature of AEs does differ between subgroups: medication- versus surgery-related, indicating that tailored safety measures are needed. Recommendations for practice are to focus on reflecting on AEs, complemented with case evaluations.

Measurement and documentation of quality indicators for the end-of-life care of hospital patients a nationwide retrospective record review study.

BACKGROUND: Quality of care at the end of life in hospitals is often perceived to be lower compared to the care that is provided to people who die in their own home. Documenting and measuring indicators of common end-of-life symptoms could help improve end-of-life care in hospitals. This study provided insight into quality indicators for the end-of-life care of patients who died in a Dutch hospital, and assessed differences between deceased patients who were admitted for palliative/terminal care versus patients admitted for other reasons. METHODS: In a retrospective record review study, trained nurses reviewed electronic health records (EHRs) of patients who died in 2019 (n = 2998), in a stratified sample of 20 Dutch hospitals. The nurses registered whether data was found in de EHRs about quality indicators for end-of-life care. This concerned: symptoms (pain, shortness of breath, anxiety, depressive symptoms), spiritual and psychological support and advance care planning. Multilevel regression analyses were performed to assess differences between patients who had been admitted for palliative/terminal care and patients admitted for other reasons. RESULTS: Common end-of-life symptoms were rarely measured using a standardized method (e.g. Numeric Rating Scale, Visual Analogue Scale or Utrecht Symptom Diary). The symptom burden of pain was measured using a standardized method more often (63.3%) than the symptom burden of shortness of breath (2.2%), anxiety (0.5%) and depressive symptoms (0.3%). Similarly, little information was documented in the EHRs regarding wish to involve a spiritual counsellor, psychologist or social worker. Life expectancy was documented in 66%. The preferred place of death was documented less often (20%). The documentation of some quality indicators differed between patients who were admitted for palliative/terminal care compared to other patients. CONCLUSION: Except for the burden of pain, symptoms are rarely measured with standardized methods in patients who died in Dutch Hospitals. This study underlines the importance of documenting information about symptom burden and aspects related to advance care planning, and spiritual and psychological support to improve the quality of end-of-life care for patients in hospitals. Furthermore, uniformity in measuring methods improves the possibility to compare results between patient groups and settings.

Emergency department crowding and older patients: a nationwide retrospective cohort study.

OBJECTIVE: Emergency department (ED) crowding is a worldwide problem and one of the main causes internationally is an increase in presentations by older patients with complex and chronic care needs. Although there has been a 4,3% reduction in total ED visits from 2016-2019 in the Netherlands, the EDs still experience crowding. National crowding research has not focused on the older group in detail, hence their possible role remains ill defined. The primary aim of this study was to map the trend in ED visits by older patients in the Netherlands. The secondary aim was to identify healthcare utilization 30 days before/after ED visit. METHODS: We conducted a nationwide retrospective cohort study, using longitudinal health insurance claims data (2016-2019). The data encompasses all Dutch patients of 70 years or older who visited the ED. RESULTS: The number of older patients who visited the ED followed by admission, increased from 231,223 patients (2016), to 234,817 (2019). The number without admission also increased from 244,814 patients, to 274,984. There were 696,005 total visits by older patients (2016) increasing to 730,358 visits (2019). CONCLUSION: The slight rise in older patients at the ED is consistent with overall population growth of older people in the Netherlands. These results indicate that Dutch ED crowding cannot be explained by mere numbers of older patients. More research is needed with data on patient level, to study other contributing factors, such as complexity of care needs within the ageing population.

Pseudotumor in metal-on-metal hip arthroplasty: a comparison study of three grading systems with MRI.

OBJECTIVE: Pseudotumors, a well-known complication of metal-on-metal total hip arthroplasty (MoM THA), are well identified on metal artifact-reducing sequences magnetic resonance imaging (MARS-MRI). Several MRI grading systems are described in the orthopedic literature, but their validity is unknown in large clinical studies. Our study was undertaken to describe the classification of pseudotumors in a preselected cohort divided into high- and low-risk patients, using three pseudotumor grading systems applied on MARS-MRI, and to determine the interobserver reliability of the grading systems. PATIENTS AND METHODS: A retrospective study was performed on 377 consecutive patients (240 MRI scans) treated with an M2a-38 and Taperloc stem combination (Biomet, Warsaw, IN, USA). Patients were divided into a high-risk and a low-risk group based on previous published risk factors. Two observers determined the presence of pseudotumors using three different pseudotumor grading systems for classifying MARS-MRI results. RESULTS: The prevalence of pseudotumors as determined with MARS-MRI was 59% in our high-risk group, 0% in the low-risk group and 43% in the control group. Serum cobalt values were increased in the high-risk group. The kappa values of the Anderson, Hauptfleisch and Matthies grading system scores were 0.43, 0.44, and 0.49 respectively. CONCLUSIONS: High-risk patients are at a high risk for pseudotumor development. No pseudotumor development was found in low-risk patients. Interobserver reliability scored best with the Matthies system, but all three grading systems showed only a moderate agreement.

Galectin-9 induced by dietary synbiotics is involved in suppression of allergic symptoms in mice and humans.

BACKGROUND: Prebiotic galacto- and fructo-oligosaccharides (scGOS/lcFOS) resembling non-digestible oligosaccharides in human milk reduce the development of atopic disorders. However, the underlying mechanisms are still unclear. Galectins are soluble-type lectins recognizing ß-galactoside containing glycans. Galectin-9 has been shown to regulate mast cell degranulation and T-cell differentiation. In this study, the involvement of galectin-9 as a mechanism by which scGOS/lcFOS in combination with Bifidobacterium breve M-16V protects against acute allergic symptoms was investigated. METHODS: Mice were sensitized orally to whey, while being fed with a diet containing scGOS/lcFOS and Bifidobacterium breve M-16V (GF/Bb) or a control diet. Galectin-9 expression was determined by immunohistochemistry in the intestine and measured in the serum by ELISA. T-cell differentiation was investigated in the mesenteric lymph nodes (MLN) as well as in galectin-9-exposed peripheral blood mononuclear cells (PBMC) cultures. Sera of the mice were evaluated for the capacity to suppress mast cell degranulation using a RBL-2H3 degranulation assay. In addition, in a double-blind, placebo-controlled multicenter trial, galectin-9 levels were measured in the sera of 90 infants with atopic dermatitis who received hydrolyzed formulae with or without GF/Bb. RESULTS: Galectin-9 expression by intestinal epithelial cells and serum galectin-9 levels were increased in mice and humans following dietary intervention with GF/Bb and correlated with reduced acute allergic skin reaction and mast cell degranulation. In addition, GF/Bb enhanced T(h)1- and T(reg)-cell differentiation in MLN and in PBMC cultures exposed to galectin-9. CONCLUSIONS: Dietary supplementation with GF/Bb enhances serum galectin-9 levels, which associates with the prevention of allergic symptoms.

Depletion of CD4+CD25+ T cells switches the whey-allergic response from immunoglobulin E- to immunoglobulin free light chain-dependent.

BACKGROUND: Symptoms of allergy are largely attributed to an IgE-mediated hypersensitivity response. However, a considerable number of patients also exhibit clinical features of allergy without detectable systemic IgE. Previous work showed that Ig-free light chains (IgLC) may act as an alternate mechanism to induce allergic responses. CD4+CD25+ T cells are crucial in the initiation and regulation of allergic responses and compromised function might affect the response to allergens. OBJECTIVE: To examine the contribution of CD4+CD25+ T cells and IgLC towards the whey-allergic response. METHODS: Mice were sensitized orally with whey using cholera toxin as an adjuvant. CD25+ T cells were depleted in vivo using a CD25 mAb. The acute allergic skin response to whey and ex vivo colon reactivity was measured in the presence or absence of F991, a specific inhibitor of IgLC. Serum whey-specific antibodies and IgLC in serum and mesenteric lymph node (MLN) supernatants were measured. Depletion of CD4+CD25+ T cells was confirmed in the spleen. RESULTS: Anti-CD25 treatment strongly reduced whey-specific antibody levels and resulted in a partial depletion of effector T cells and a major depletion of Foxp3(+) regulatory T cells. Surprisingly, despite the abolished specific IgE response, the acute allergic skin response to whey was not affected. IgLC levels were enhanced in the serum and MLN supernatants of CD25-depleted sensitized mice. F991 inhibited the acute skin response and colon hyperreactivity in anti-CD25-treated mice, indicating that these responses were mainly IgLC dependent. CONCLUSIONS: Depletion of CD4+CD25+ T cells resulted in a switch from an IgE- to an IgLC-dependent acute skin response and functional hyperresponsiveness of the colon. Our data suggest that CD25+ T cells play a crucial role in balancing cow's milk allergy between IgE and IgE-independent responses and both mechanisms might play a role in allergic responses to the same allergen.

Erectile dysfunction prospectively associated with cardiovascular disease in the Dutch general population: results from the Krimpen Study.

The possible relationship between erectile dysfunction and the later occurrence of cardiovascular disease while biologically plausible has been evaluated in only a few studies. Our objective is to determine the relation between ED as defined by a single question on erectile rigidity and the later occurrence of myocardial infarction, stroke and sudden death in a population-based cohort study. In Krimpen aan den IJssel, a municipality near Rotterdam, all men aged 50-75 years, without cancer of the prostate or the bladder, without a history of radical prostectomy, neurogenic bladder disease, were invited to participate for a response rate of 50%. The answer to a single question on erectile rigidity included in the International Continence Society male sex questionnaire was used to define the severity of erectile dysfunction at baseline. Data on cardiovascular risk factors at baseline (age smoking, blood pressure, total- and high-density lipoprotein cholesterol, diabetes) were used to calculate Framingham risk scores. During an average of 6.3 years of follow-up, cardiovascular end points including acute myocardial infarction, stroke and sudden death were determined. Of the 1248 men free of CVD at baseline, 258 (22.8%) had reduced erectile rigidity and 108 (8.7%) had severely reduced erectile rigidity. In 7945 person-years of follow-up, 58 cardiovascular events occurred. In multiple variable Cox proportional hazards model adjusting for age and CVD risk score, hazard ratio was 1.6 (95% confidence interval (CI): 1.2-2.3) for reduced erectile rigidity and 2.6 (95% CI: 1.3-5.2) for severely reduced erectile rigidity. The population attributable risk fraction for reduced and severely reduced erectile rigidity was 11.7%. In this population-based study, a single question on erectile rigidity proved to be a predictor for the combined outcome of acute myocardial infarction, stroke and sudden death, independent of the risk factors used in the Framingham risk profile.

Dental check-up frequency: preferences of Dutch patients.

OBJECTIVE: In 1995, the requirement to visit the dentist for a check-up every six months in The Netherlands was replaced by the obligation to get a routine examination no more than once a year. The aim of this study was to determine patients' opinions about this change in policy, and to assess their preferences regarding frequency and content of regular dental check-up visits. Possible associations between patients' preferences for regular dental check-ups and a number of antecedent variables, such as dental attitudes, were examined as well. BASIC RESEARCH DESIGN: Patients' preferences for regular dental check-ups were assessed by means of a questionnaire, containing a 19-item Likert-type scale, twelve visual analogue scales and seven forced choice items. Items assessing various background variables and a selection of items of the Dental Attitude Questionnaire were also added. This questionnaire was administered to patients of seven dental practices. A total of 428 patients completed the questionnaire. RESULTS: Results indicated that patients prefer to have regular dental check-ups. Patients' evaluation of six-monthly dental check-up visits was significantly more positive than their evaluation of flexible, individualized, check-up frequencies. Factors positively associated with a higher preference for regular dental check-up visits were female gender, being more satisfied with one's teeth, less cynicism toward dental health care professionals and more intrinsic motivation to maintain one's oral health. CONCLUSIONS: Patients seem to prefer to attend their dentist regularly, at fixed intervals of about six months. This fact should be taken into account when deciding about the most appropriate interval between dental examinations.

Incidence rates of erectile dysfunction in the Dutch general population. Effects of definition, clinical relevance and duration of follow-up in the Krimpen Study.

This study aims to describe the incidence rate of erectile dysfunction (ED) in older men in the Netherlands according to three definitions. The influence of the duration of follow-up on the incidence rate is also explored. In a large community-based follow-up study, 1661 men aged 50-75 y completed the International Continence Society sex questionnaire and a question on sexual activity, at baseline and at a mean of 2.1 and 4.2 y of follow-up. We defined 'ED' as a report of erections with 'reduced rigidity' or worse; 'Significant_ED' as 'severely reduced rigidity' or 'no erections'; and 'Clinically_Relevant_ED' as either 'ED' reported as 'quite a problem' or 'a serious problem', or 'Significant_ED' reported as at least 'a bit of a problem'. Incidence rates of ED status were calculated in those men who completed at least one period of follow-up and were not diagnosed with prostate cancer (n = 1604). For 'ED' the incidence rate (cases per 1000 person-years) is 99 and ranges over the 10-y age groups from 77 (50-59 y) to 205 (70-78 y); for 'Significant_ED' these rates were 33, 21, and 97, respectively and for 'Clinically_Relevant_ED' 28, 25, and 39, respectively. In general, incidence rates should not vary with the duration of follow-up. However, for 'ED' the 4.2 y incidence rate is about 69% of the 2.1 y incidence rate. This study presents incidence rates, for the general population, as well as based on a definition of ED that takes concern/bother into account. 'Clinically_Relevant_ED' has a lower increase in incidence with increasing age than other definitions that do not take concern/bother into account. The phenomenon of lower incidence rates with longer duration of follow-up may account for the differences in reported incidence rates between different studies. The effects of differences related to the duration of follow-up should be taken into consideration in future incidence reports.

Information and participation preferences of dental patients.

Dutch dentists have a moral and legal obligation to inform their patients and involve them in the decision-making process. It is unclear, though, to what extent patients prefer information and involvement in decision-making. Therefore, the aim of this study was to determine levels of preference for information and participation in decision-making among emergency patients (n = 96) and regular patients (n = 245). It was hypothesized that female gender, higher education, younger age, and a monitoring coping style are positively associated with higher preferences for information and participation. The results demonstrated that emergency and regular patients have high preferences for information, but that their preferences for actual involvement are significantly lower. Only weak associations were found between the antecedent variables and patients' preferences. It is concluded that, in the study of the etiology of patients' preferences for information and participation, future research should incorporate factors such as dental anxiety and seriousness of the dental condition.

[The relationship between communication styles of dentists and the satisfaction of their patients]. / De relatie tussen communicatiestijl van tandartsen en tevredenheid van hun patiënten.

Patient satisfaction is a rather complicated issue. This paper describes the results of a pilot study regarding the influence of dentists' communication styles on patient satisfaction. A distinction was made between an affective and a control style. The study was conducted among 11 dentists and 22 patients. The results of this study indicated that dentists' communication styles were somewhat associated with patient satisfaction. It was suggested that dentists should not only give information to patients adequately, but should also pay attention to their personal communication style.

Dentists' and patients' communicative behaviour and their satisfaction with the dental encounter.

OBJECTIVE: The aim of this study was to examine the relations between patients' and dentists' communicative behaviour and their satisfaction with the dental encounter. PARTICIPANT: The sample consisted of 90 patients receiving emergency care from 13 different dentists. BASIC RESEARCH DESIGN: Consultations were videotaped in order to assess dentists' and patients' communicative behaviour. Dentists' behaviour was coded by means of the Communication in Dental Setting Scale (CDSS), scores for patients' behaviour included among other things, the number of questions asked during the consultation. MAIN OUTCOME MEASURES: After treatment, patients filled out a questionnaire that assessed their satisfaction with their own and their dentist's communicative behaviour. Dentists also filled out a satisfaction questionnaire after each consultation. RESULTS: Results showed that dentists' satisfaction could not be explained by patients' or dentists' communicative behaviour. Patients' satisfaction was mainly influenced by the communicative behaviour of the dentist. CONCLUSION: Not only is patients' satisfaction positively related to the communicative behaviour of dentists, but the principle of informed consent requires dentists also to inform their patients adequately enough for them to reach a well-informed decision about the treatment. Therefore, it remains important to train dentists in communicative skills.

[Complaints of patients concerning obligation to inform and consent requirements]. / Klachten van patiënten over informatieplicht en toestemmingsvereiste.

Since April 1995, patients' right to information and the duty of the operator to obtain their consent are legally established in the 'Medical Treatment Contract Act'. The aim of this study was to make an inventory of the number and type of information- and consent-complaints of Dutch dental patients, archived by the Dutch Dental Association in the years 1987-2000. By means of a registration form, complaints were analyzed and categorized. The results show that the number of complaints is slightly decreasing since the introduction of the 'Medical Treatment Contract Act'. However, complaints about lack of information on the treatment and consequences of treatment significantly increased. 60% of all complaints officially dealt with is (partly) substantiated. Redressment of done injustice, sometimes combined with a warning, is the sanction most often imposed. Although a substantial minority of the complaints is not substantiated, communication problems between dentist and patient do also seem to play an important role in those complaints. It is therefore necessary that dentists will provide comprehensible information to their patients.

[How do Dutch dentists deal with patients' rights in practice?]. / Hoe gaan tandartsen in de praktijk om met rechten van patiënten?

In the Netherlands patients rights are regulated in the 'Medical Treatment Contract Act'. This article describes how dentists deal with those rights in daily practice. From the registers of the Dutch Dental Association 806 dental practitioners were drawn at random. They received a questionnaire on this topic; 41.6% responded. The results show that the implementation of patient rights in dental practice is far from ideal. Over a third of the respondents has had complaints about a lack of information from their patients. Respondents who attended post-graduate courses on dentist-patient communication dealt better with a number of patient rights than respondents who did not attend such courses. Confusion over how to interpret the rights of patients and the duties of the dentist could underlie the lack of implementation of those rights.

Informed consent in dental practice: experiences of Dutch patients.

AIM: To assess experiences of the Dutch population concerning the implementation of some of their rights by dentists. METHOD: A postal questionnaire. PARTICIPANTS: All 1,616 participants of the 'Consumer Panel Health Care' in the Netherlands. RESULTS: 78.8% of the subjects responded. Patients were satisfied with the general information they received from their dentist. Their experiences of receiving information about specific legislation-related issues, however, were less positive. A considerable percentage of patients indicate that their dentist did not always inform them about risks or alternative treatment options. CONCLUSION: The autonomy of patients, which is the key principle underlying the 1995 Medical Treatment Contract Act, can seriously be undermined without making available this kind of information.

Informed consent in Dutch dental practice: knowledge, attitudes and self-efficacy of dentists.

The introduction of the 'Medical Treatment Contract Act' in the Netherlands 5 years ago, established some major rights and duties of both patients and members of the medical profession. The aim of this study was to assess Dutch dentists' knowledge, attitudes and self-efficacy with regard to several topics of this act. A questionnaire was sent to 806 dental practitioners; 41.6% of them responded. Results show that dentists are well informed about some of the most important topics of this law, such as the requirement to obtain the patient's consent to major dental treatments. The results concerning their attitude and self-efficacy, however, are less positive. A majority of the respondents believe that the principle of informed consent will lead to a commercialization of the dentist-patient relation. Also, fear for legal procedures and difficulty with what patients must be informed about appears present. It is concluded that improvement of the implementation of the requirements of this legislation in dental practice requires both a change in attitude and an enhancement of the communicative skills of dentists.

[Dutch Act of Agreement on Medical Treatment. Knowledge among dentists]. / De wet op de geneeskundige behandelingsovereenkomst. Kennis van tandartsen.

After more than 25 years of debate about the legislation of patient rights in the Netherlands, the 'Agreement on Medical Treatment' act was passed by the Dutch government in 1995. This article descibes the amount of knowledge general dental practitioners have on several topics of this law, four years after its introduction. A questionnaire was send to 806 dental practitioners, random drawn from the registers of the Dutch Dental Association. The response-rate was 41.6%. Results show that respondents are well informed about some of the most important topics of this law, such as the requirement to obtain the patient's consent to major dental treatments and the fact that information must be based on the 'patient need standard'. Other rights and duties however, are less known. For example, it is still not well known that for routine treatments the patient's explicit consent is not needed, but can be assumed. Also, knowledge about the minimal period for retaining patient dossiers is scarcely present. Some explanations for this lack of knowledge are discussed, especially the lack of relevance of some topics of this law for the dental practice.

Assessment of general practitioners by video observation of communicative and medical performance in daily practice: issues of validity, reliability and feasibility.

OBJECTIVES: To develop a video assessment method for General Practitioners (GPs) by analysing issues of validity, reliability and feasibility of observation of videotaped regular consultations. DESIGN: In a cross-sectional study consultations of 93 GPs were video recorded in the practice during 1 week. The GPs registered consultation and patient data in a logbook; 16 consultations per GP were selected using preset criteria. The quality of communicative and medical performance of these consultations was assessed by GP observers with a validated instrument. The validity of the procedure was evaluated by checking the content of each GP's sample using specific sample criteria. Selection bias was estimated by multiple regression analysis, with sample characteristics as independent variables and scores on communication and medical performance as dependent variables. The influence of observation on GPs and patients was assessed by a questionnaire. Generalizability theory was used to estimate reliability. Feasibility was assessed by conducting a questionnaire, by keeping accounts, and by checking the technical quality of the videotaped consultations. SETTING: Universities of Nijmegen and Maastricht, The Netherlands. SUBJECTS: General Practitioners (GPs). RESULTS: The domain of general practice was well covered in the samples; content validity was satisfactory. With regard to the sample characteristics, only the total duration of consultations appeared to correlate significantly with both the score on communication and the score on medical performance. A majority (71%) of GPs reported not being influenced by the observation, except in the first cases, and recognizing their usual daily performance in the videotaped consultations. An acceptable level of reliability was reached after 2.5 hours of observation, i.e. 12 cases by a single observer. The method was well accepted by both GPs and patients. The costs were pound250 per GP. CONCLUSIONS: Video assessment of GPs in daily practice according to the procedures described is a valid and reliable method, one which is useful for education and quality improvement. There is a trade-off between feasibility on one hand and validity, reliability and credibility on the other hand. Compared to investments in observation methods in standardized settings, the costs of video observation of GPs' actual performance are acceptable.