Nd:YAG laser capsulotomy rates in the Netherlands: practice variation and association with physician practice styles.

PURPOSE: To determine the practice variation in the rate of Nd:YAG laser capsulotomy within 1 year after cataract surgery and to identify possible associations with physician practice styles. SETTING: All hospitals and private clinics in the Netherlands. DESIGN: Retrospective observational study. METHODS: In the national medical claims database, we identified all laser capsulotomies performed in the Netherlands within a year after cataract surgery in the years 2016 and 2017. Centers with the lowest and highest percentages of Nd:YAG laser capsulotomies were interviewed on their physician practice styles related to the development of posterior capsule opacification. RESULTS: The incidence of Nd:YAG laser capsulotomy varied between 1.2% and 26.0% in 2016 (median 5.0%) and between 0.9% and 22.7% in 2017 (median 5.0%). The rate of capsulotomy was highly consistent over time for each center (Pearson correlation coefficient, 0.89, P < .001). In general, ophthalmology centers with a high rate of Nd:YAG laser capsulotomy more often did not (routinely) polish the posterior lens capsule, performed cortex removal with coaxial irrigation/aspiration (I/A, instead of bimanual), and more often used hydrophilic intraocular lenses (IOLs) (compared with only using hydrophobic IOLs). CONCLUSIONS: We found a significant practice variation in performing Nd:YAG laser capsulotomy within 1 year after cataract surgery in the Netherlands. Routinely polishing the posterior capsule, using bimanual I/A, and the use of hydrophobic IOLs are associated with a lower incidence in Nd:YAG laser capsulotomy. Incorporating these practice styles may lower the practice variation and thus prevent added medical burden for the patient and decrease costs.

Outcomes After Lumbar Disk Herniation Surgery in the Dutch Population.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: There is only limited data on the outcome of primary surgery of lumbar disk herniation (LDH) in Dutch patients. The objective of this study is to describe undesirable outcomes after primary LDH. METHODS: The National Claims Database (Vektis) was searched for primary LDH operations performed from July 2015 until June 2016, for reoperations within 18 months, prescription of opioids between 6 to 12 months and nerve root block within 1 year. A combined outcome measure was also made. Group comparisons were analyzed with the Student's t-test. RESULTS: Primary LDH surgery was performed in 6895 patients in 70 hospitals. Weighted mean of reoperations was 7.3%, nerve root block 6.7% and opioid use 15.6%. In total, 23.0% of patients had one or more undesirable outcomes after surgery. The 95% CI interval exceeded the 50% incidence line for 14 out of 26 hospitals with less than 50 surgical interventions per year. Although the data suggested a volume effect on undesired outcomes, the t-tests between hospitals with volume thresholds of 100, 150 and 200 interventions per year did not support this (P values 0.078, 0.129, 0.114). CONCLUSION: This unique nationwide claims-based study provides insight into patient-relevant undesirable outcomes such as reoperation, nerve root block and opioid use after LDH surgery. About a quarter of the patients had a serious complication in the first follow up year that prompted further medical treatment. There is a wide variation in complication rates between hospitals with a trend that supports concentration of LDH care.

Practice Variation in Skin Cancer Treatment and Follow-Up Care: A Dutch Claims Database Analysis.

BACKGROUND: Quality indicators are used to benchmark and subsequently improve quality of healthcare. However, defining good quality indicators and applying them to high-volume care such as skin cancer is not always feasible. OBJECTIVES: To determine whether claims data could be used to benchmark high-volume skin cancer care and to assess clinical practice variation. METHODS: All skin cancer care-related claims in dermatology in 2016 were extracted from a nationwide claims database (Vektis) in the Netherlands. RESULTS: For over 220,000 patients, a skin cancer diagnosis-related group was reimbursed in 124 healthcare centres. Conventional excision reflected 75% of treatments for skin cancer but showed large variation between practices. Large practice variation was also found for 5-fluorouracil and imiquimod creams. The practice variation of Mohs micrographic surgery and photodynamic therapy was low under the 75th percentile, but outliers at the 100th percentile were detected, which indicates that few centres performed these therapies far more often than average. On average, patients received 1.8 follow-up visits in 2016. CONCLUSIONS: Claims data demonstrated large practice variation in treatments and follow-up visits of skin cancer and may be a valid and feasible data set to extract quality indicators. The next step is to investigate whether detected practice variation is unwarranted and if a reduction improves quality and efficiency of care.

Use of Palliative Chemotherapy and ICU Admissions in Gastric and Esophageal Cancer Patients in the Last Phase of Life: A Nationwide Observational Study.

Since intensive care unit (ICU) admission and chemotherapy use near death impair the quality of life, we studied the prevalence of both and their correlation with hospital volume in incurable gastroesophageal cancer patients as both impair the quality of life. We analyzed all Dutch patients with incurable gastroesophageal cancer who died in 2017-2018. National insurance claims data were used to determine the prevalence of ICU admission and chemotherapy use (stratified on previous chemotherapy treatment) at three and one month(s) before death. We calculated correlations between hospital volume (i.e., the number of included patients per hospital) and both outcomes. We included 3748 patients (mean age: 71.4 years; 71.4% male). The prevalence of ICU admission and chemotherapy use were, respectively, 5.6% and 21.2% at three months and 4.2% and 8.0% at one month before death. Chemotherapy use at three and one months before death was, respectively, 4.3 times (48.0% vs. 11.2%) and 3.7 times higher (15.7% vs. 4.3%), comparing patients with previous chemotherapy treatment to those without. Hospital volume was negatively correlated with chemotherapy use in the final month (rweighted = -0.23, p = 0.04). ICU admission and chemotherapy use were relatively infrequent. Oncologists in high-volume hospitals may be better equipped in selecting patients most likely to benefit from chemotherapy.

[Increase in opioid prescribing in extramural care in the Netherlands: assessment of use and prescription behaviour, based on claims data]. / Toename in extramuraal opioïdgebruik in Nederland.

OBJECTIVE: Describe the trends in extramural prescription of opioids in the Netherlands. DESIGN: Descriptive, retrospective research based on claims data of Dutch health insurers. METHOD: For each healthcare-insured Dutch resident we selected claims data for all opioids, except codeine and buprenorphine, for the period 2010-2017. We calculated the total numbers of opioid and oxycodone users, and stratified these numbers by age and sex. The average number of prescribed Defined Daily Doses (DDD), the chronicity of use, the type of prescriber, and regional patterns in opioid use were investigated. RESULTS: A total of 3,655,265 different insured persons used opioids during the research period. The yearly number of opioid users increased from 650,864 in 2010 to 1,010,474 in 2017. This increase was mainly driven by an increase in oxycodone prescriptions. Elderly and female patients were more frequent users of opioids. The ratio of short- versus long-term opioid users remained steady during the research period, with opioids being used for four months or longer in 21% of cases. General practitioners prescribed 82% of the DDDs of all opioids in 2017. The percentage of DDDs of oxycodone prescribed by medical specialists increased from 2.8% in 2010 to 14.2% in 2017. CONCLUSION: Opioid use is increasing in the Netherlands, but the long-term vs short-term use ratio has not changed in recent years. General practitioners prescribe the largest share of opioids, but a growing number of prescriptions originates from medical specialists.

Mortality differences in acute myocardial infarction patients in the Netherlands: The weekend-effect.

Objective: Several studies have shown that patients admitted with an acute myocardial infarction during the weekends have a higher mortality rate than those admitted during weekdays, possibly attributable to less trained personnel available and a lower use of medical procedures. The current study aimed to assess this 'weekend-effect' in a nationwide registry. Methods: In the Netherlands, all inhabitants are, by law, obliged to have health insurance and all claim data are centrally registered. In 2012 and 2013, all national diagnose-codings of STEMI and NSTEMI patients were acquired. One-year mortality rates and treatment with percutaneous coronary intervention (PCI) were compared between weekdays and weekends (holidays included). Results: In total, 59,534 patients (67 ± 13 years, 39,545(66%) male) were included of whom 33,904(57%) had a NSTEMI. Overall 6857(12%) patients died in the year following the acute myocardial infarction registration. In STEMI patients, no differences in one-year mortality rates were observed between admission on weekdays or weekends. In NSTEMI patients, one-year mortality was higher in those admitted during weekends (weekdays 11% versus weekends 13%, P < .001). Furthermore, STEMI patients admitted during weekends were more often treated with PCI (weekdays 77% versus weekends 81%, P < .001). Conversely, NSTEMI patients admitted during weekends were less often treated with PCI (weekdays 35% versus weekends 32%, P < .001). Conclusion: Differences in treatment and mortality rates exist between acute myocardial infarction patients admitted during weekdays and weekends. NSTEMI patients admitted during weekends are less often treated with PCI and have a higher mortality rate than patients admitted during weekdays.

How much does a heart valve implantation cost and what are the health care costs afterwards?

Objective: In the era of limited healthcare budgets, healthcare costs of heart valve implantations need to be considered to inform cost-effectiveness analyses. We aimed to provide age group-specific costs estimates of heart valve implantations, related complications and other healthcare utilisation following the intervention. Methods: We performed retrospective analyses of healthcare costs of patients who had undergone heart valve implantations in 2010-2013 and controls using claims data from Dutch health insurers. Heart valve implantations included surgical valve replacement and transcatheter valve implantation in all heart valve positions. Patients were divided in four age groups. Control groups were created by taking random samples of the Dutch population stratified by age, gender, socioeconomic status and comorbidities. We applied non-parametric bootstrapping to address uncertainty of the cost estimates. The association of patient and intervention characteristics with costs was determined by (multilevel) generalised linear models. Results: The baseline characteristics of 18 903 patients and 188 925 controls were comparable. The annual healthcare costs were substantially higher for surgical heart valve replacement patients than for controls, especially in the year of heart valve implantation. Factors associated with increased annual healthcare costs for patients were older age, female gender, comorbidities, low socioeconomic status and complications. Conclusions: We provided a comprehensive overview of age group-specific incidence of heart valve implantations, subsequent survival and complications as well as associated healthcare costs of all patients in the Netherlands. Our results provide real-world costs estimates that can be used as a benchmark for costs of future innovative heart valve implantations.