What Parents of Children Born with a Cleft Lip and/or Palate Want to Know About the Care for their Child.

OBJECTIVE: Adequate health information that matches the needs of care recipients is a prerequisite for patient-centered care. To facilitate the provision of tailored and timely information, it isimportant to understand the information needs of parents of children and adolescents with cleft lip and/or palate (CL/P) themselves, and in addition they were asked how they experienced the provided care-related information. DESIGN: A cross-sectional study employing questionnaires and semi-structured interviews. SETTING: Participants were recruited from a cleft palate-craniofacial care unit in a major tertiary hospital in the Netherlands. PARTICIPANTS: Participants were parents or guardians of children with CL/P, and two adolescents with CLP. They were recruited through the outpatient clinic during multidisciplinary consultation or after clinical admission. RESULTS: In total, fifty-five questionnaires were completed by parents or guardians and eleven interviews were conducted with nine parents of children with CL/P and two adolescents with CL/P. In general, participants reported to be satisfied with provided information during hospital admission or multidisciplinary cleft team consultations (mean 8.0, scale 0-10). In addition, 25.5% (n = 14) indicated that information to prepare for hospital admission was lacking (eg, practical information). Thematic qualitative analysis yielded five main information needs: 1) Clear communication during the care process, 2) Overview of the care trajectory, 3) Specific care plan information, 4) Presentation of information and 5) Guidance and support. CONCLUSIONS: Our findings emphasize the importance of gaining insights into wishes and information needs from care recipients who can provide insights in their information needs. With these findings, information provision should be redesigned to improve and to foster the further transition to family-centered care.

A usability evaluation of the perceived user friendliness, accessibility, and inclusiveness of a personalized digital care pathway tool.

OBJECTIVE: This study aimed to acquire insight into the perceived user friendliness, accessibility and inclusiveness of a personalized digital care pathway. MATERIALS & METHODS: Usability of the tool was tested in an experimental setting. Mixed methods data collection consisted of scenario-based eye tracking tests in a web- or mobile-based prototype of the tool, followed by a questionnaire assessing user friendliness (System Usability Scale; SUS) and a structured interview. Inclusiveness was assessed by subgroup comparisons based on language proficiency, age and education level. Via purposive sampling a heterogeneous population of users (N = 24) was recruited. Eye tracking was used to measure gaze behavior. RESULTS: Overall, participants were satisfied with the tool (scale 0-10, 7.5; SD = 1.29). User friendliness of the mobile version (68.3; SD = 21.6) was higher than the web version (50.9; SD = 17.3) measured by SUS score (0-100). With regard to accessibility, eye tracking scenarios showed that the menu bar was hard to find (17% mobile, 55% web). In all scenario's, information was found faster in the mobile version than the web version. Attention was easily drawn to images. Regarding inclusiveness of the tool, we found significantly longer completing time of the scenario tasks for low language proficiency (p-value = 0.029) and higher age subgroups (p-value = 0.049). Lower language proficiency scored a significant lower SUS score (p-value = 0.012). CONCLUSIONS: Overall, user friendliness and accessibility were positively evaluated. Assessment of inclusiveness emphasized the need for tailoring digital tools to those with low language proficiency and/or an older age. Co-creation of digital care tools with users is therefore important to match users' needs, make tools easily understandable and accessible to all users, and ultimately result in better uptake and impact.

Quality improvements of healthcare trajectories by learning from aggregated patient-reported outcomes: a mixed-methods systematic literature review.

BACKGROUND: In healthcare, analysing patient-reported outcome measures (PROMs) on an aggregated level can improve and regulate healthcare for specific patient populations (meso level). This mixed-methods systematic review aimed to summarize and describe the effectiveness of quality improvement methods based on aggregated PROMs. Additionally, it aimed to describe barriers, facilitators and lessons learned when using these quality improvement methods. METHODS: A mixed-methods systematic review was conducted. Embase, MEDLINE, CINAHL and the Cochrane Library were searched for studies that described, implemented or evaluated a quality improvement method based on aggregated PROMs in the curative hospital setting. Quality assessment was conducted via the Mixed Methods Appraisal Tool. Quantitative data were synthesized into a narrative summary of the characteristics and findings. For the qualitative analysis, a thematic synthesis was conducted. RESULTS: From 2360 unique search records, 13 quantitative and three qualitative studies were included. Four quality improvement methods were identified: benchmarking, plan-do-study-act cycle, dashboards and internal statistical analysis. Five studies reported on the effectiveness of the use of aggregated PROMs, of which four identified no effect and one a positive effect. The qualitative analysis identified the following themes for facilitators and barriers: (1) conceptual (i.e. stakeholders, subjectivity of PROMs, aligning PROMs with clinical data, PROMs versus patient-reported experience measures [PREMs]); (2a) methodological-data collection (i.e. choice, timing, response rate and focus); (2b) methodological-data processing (i.e. representativeness, responsibility, case-mix control, interpretation); (3) practical (i.e. resources). CONCLUSION: The results showed little to no effect of quality improvement methods based on aggregated PROMs, but more empirical research is needed to investigate different quality improvement methods. A shared stakeholder vision, selection of PROMs, timing of measurement and feedback, information on interpretation of data, reduction of missing data, and resources for data collection and feedback infrastructure are important to consider when implementing and evaluating quality improvement methods in future research.

Strategies to improve the implementation of infection control link nurse programmes in acute-care hospitals.

BACKGROUND: Infection control practitioners face several challenges when implementing infection control link nurse (ICLN) programmes. Identification of strategies to address these can improve the impact of current ICLN programmes and guide their future implementation. AIM: We aimed to identify implementation strategies for ICLN programmes in acute-care hospitals with the Consolidated Framework for Implementation Research (CFIR)-Expert Recommendations for Implementing Change (ERIC) Implementation Strategy Matching tool. METHODS: An expert panel matched 19 implementation and sustainment barriers, identified in our previous studies, to the most fitting CFIR constructs. Subsequently, we applied the CFIR-ERIC Matching Tool and generated a list of implementation strategies to address these barriers. FINDINGS: Barriers were predominantly found within the CFIR domains 'inner setting' (characteristics of the implementing organization) and 'process' (stages of implementation). With the ERIC Matching Tool, we identified the 10 most important strategies to address barriers of implementation of ICLN programmes: identify and prepare champions, conduct local consensus discussions, assess for readiness and identify barriers and facilitators, inform local opinion leaders, use facilitation, create a learning collaborative, conduct local needs assessments, develop a formal implementation blueprint, build a coalition, and identify early adopters. CONCLUSION: The CFIR domains 'inner setting' and 'process' appeared to be the most important to impede implementation of ICLN programmes in acute-care hospitals. Application of the CFIR-ERIC tool highlighted the identification and preparation of champions as the leading strategy for the successful implementation of these programmes. With this tool, strategies can be specifically tailored towards local implementation and sustainment barriers.

Feasibility of reusing routinely recorded data to monitor the safe preparation and administration of injectable medication: A multicenter cross-sectional study.

BACKGROUND: Reusing routinely recorded data from electronic hospital records (EHR) may offer a less-time consuming, and more real time alternative for monitoring compliance by nurses with a protocol for the safe preparation and administration of injectable medication. However, at present it is unknown if the data necessary to calculate the quality indicators (QIs) are recorded in EHRs, or if these data are suitable for automated QI calculation. Therefore, the aim of this study was to determine the feasibility of monitoring compliance by nurses with a protocol for the safe injectable medication preparation and administration by reusing routinely recorded EHR data for the automated calculation of QIs. METHODS: A cross-sectional study in 12 Dutch hospitals (October 2015-May 2016). The checks included in the currently prevailing national protocol for the safe preparation and administration of injectable medication were translated into 16 data elements required to calculate the QIs. At each hospital, one interview was conducted using a structured questionnaire to decide whether the data elements were available in EHRs. To present these results, descriptive statistics were used. RESULTS: In total, 20 health-care professionals were interviewed and four different EHR systems were evaluated. The availability of data elements was comparable between the four evaluated EHR systems. Nine of the 16 required data elements were recorded in EHRs, eight in a structured format. The seven missing data elements were mainly related to checks such as 'gather all materials needed' or 'conduct hand hygiene'. Furthermore, changes were identified in the process for the preparation and administration of injectable medication. These changes are mostly related to the increased use of electronic medication administration registration and barcode medication administration systems. CONCLUSIONS: Reusing EHR data to monitor compliance by nurses with the currently prevailing protocol for the safe preparation and administration of injectable medication is not entirely feasible. A decision should be made on which checks should be recorded in the EHRs and which checks should be audited in order to minimize the registration burden for nurses. Moreover, the currently prevailing protocol should be revised to bring it in line with work-as-done. Our results can be used as guidance for such a revision and also for designing new QIs that can be calculated by reusing routinely recorded EHR data.

Correction to: Towards a patient journey perspective on causes of unplanned readmissions using a classification framework: results of a systematic review with narrative synthesis.

Due to an error introduced during copyediting of this article [1], following corrections need to be made.

Towards a patient journey perspective on causes of unplanned readmissions using a classification framework: results of a systematic review with narrative synthesis.

BACKGROUND: Several literature reviews have been published focusing on the prevalence and/or preventability of hospital readmissions. To our knowledge, none focused on the different causes which have been used to evaluate the preventability of readmissions. Insight into the range of causes is crucial to understand the complex nature of readmissions. We conducted a systematic review to: (1) evaluate the range of causes of unplanned readmissions in a patient journey, and (2) present a cause classification framework that can support future readmission studies. METHODS: A literature search was conducted in PUBMED and EMBASE using "readmission" and "avoidability" or "preventability" as key terms. Studies that specified causes of unplanned readmissions were included. The causes were classified into eight preliminary root causes: Technical, Organization (integrated care), Organization (hospital department level), Human (care provider), Human (informal caregiver), Patient (self-management), Patient (disease), and Other. The root causes were based on expert opinions and the root cause analysis tool of PRISMA (Prevention and Recovery Information System for Monitoring and Analysis). The range of different causes were analyzed using Microsoft Excel. RESULTS: Forty-five studies that reported 381 causes of readmissions were included. All studies reported causes related to organization of care at the hospital department level. These causes were often reported as preventable. Twenty-two studies included causes related to patient's self-management and 19 studies reported causes related to patient's disease. Studies differed in which causes were seen as preventable or unpreventable. None reported causes related to technical failures and causes due to integrated care issues were reported in 18 studies. CONCLUSIONS: This review showed that causes for readmissions were mainly evaluated from a hospital perspective. However, causes beyond the scope of the hospital can also play a major role in unplanned readmissions. Opinions regarding preventability seem to depend on contextual factors of the readmission. This study presents a cause classification framework that could help future readmission studies to gain insight into a broad range of causes for readmissions in a patient journey.

Guideline compliance for bridging anticoagulation use in vitamin-K antagonist patients; practice variation and factors associated with non-compliance.

BACKGROUND: Bridging anticoagulation is used in vitamin-K antagonist (VKA) patients undergoing invasive procedures and involves complex risk assessment in order to prevent thromboembolic and bleeding outcomes. OBJECTIVES: Our aim was to assess guideline compliance and identify factors associated with bridging and especially, non-compliant bridging. METHODS: A retrospective review of 256 patient records in 13 Dutch hospitals was performed. Demographic, clinical, surgical and care delivery characteristics were collected. Compliance to the American College of Chest Physicians ninth edition guideline (AT9) was assessed. Multilevel regression models were built to explain bridging use and predict non-compliance. RESULTS: Bridging use varied from 15.0 to 83.3% (mean = 41.8%) of patients per hospital, whereas guideline compliance varied from 20.0 to 88.2% (mean = 68.5%) per hospital. Both established thromboembolic risk factors and characteristics outside thromboembolic risk assessment were associated with bridging use. Predictors for overuse were gastrointestinal surgery (OR 14.85, 95% CI 2.69-81.99), vascular surgery (OR 13.01, 95% CI 1.83-92.30), non-elective surgery (OR 8.67, 95% CI 1.67-45.14), lowest 25th percentile socioeconomic status (OR 0.33, 95% CI 0.11-1.02) and use of VKA reversal agents (OR 0.22, 95% CI 0.04-1.16). CONCLUSION: Bridging anticoagulation practice was not compliant with the AT9 in 31.5% of patients. The aggregated AT9 thromboembolic risk was inferior to individual thromboembolic risk factors and other characteristics in explaining bridging use. Therefor the AT9 risk seems less important for the decision making in everyday practice. Additionally, a heterogeneous implementation of the guideline between hospitals was found. Further research and interventions are needed to improve bridging anticoagulation practice in VKA patients.

Effect of a cluster randomised team training intervention on adverse perinatal and maternal outcomes: a stepped wedge study.

OBJECTIVE: To study the effect of an intervention based on Crew Resource Management team training, including a tool for structured communication, on adverse perinatal and maternal outcomes. DESIGN: Stepped wedge. SETTING: The Netherlands. POPULATION OR SAMPLE: Registry data of 8123 women referred from primary care to a hospital during childbirth, at ≥ 32.0 weeks of singleton gestation and with no congenital abnormalities, in the period 2012-15. METHODS: Obstetric teams of five hospitals and their surrounding primary-care midwifery practices participated in the intervention. In total, 49 team training sessions were organised for 465 care professionals (75.5% participated). Adverse perinatal and maternal outcomes before, during and after the intervention were analysed using multivariate logistic regression analyses. MAIN OUTCOME MEASURES: Adverse Outcome Index (AOI-5), a composite measure involving; intrapartum or neonatal death, admission to neonatal intensive care unit, Apgar < 7 at 5 minutes, postpartum haemorrhage and/or perineal tear. RESULTS: In total, an AOI-5 score was reported in 11.3% of the study population. No significant difference was found in the incidence of the AOI-5 score after the intervention compared with before the intervention (OR 1.07: 95% CI 0.92-1.24). CONCLUSIONS: We found no effect of the intervention on adverse perinatal and maternal outcomes for women who were referred during childbirth. Team training is appreciated in practice, but evidence on the long-term impact is still limited. Upcoming studies should build on previous research and consider more sensitive outcome measures. TWEETABLE ABSTRACT: A cluster randomised team training intervention showed no effect on adverse perinatal and maternal outcomes for women referred during childbirth.

Guidelines' risk assessment recommendations for venous thromboembolism prophylaxis: A comparison and implementability appraisal.

INTRODUCTION: Venous thromboembolism (VTE) prophylaxis guidelines for non-surgical patients recommend VTE- and bleeding risk assessment to guide prophylactic strategies. These recommendations differ between guidelines and implementation is suboptimal. Assessing a guideline's implementability characteristics helps predicting the ease of implementation and reveals barriers. OBJECTIVES: We aimed to compare guidelines' risk assessment recommendations and critically appraise the implementability characteristics. MATERIAL AND METHODS: Two guidelines, one from the American College of Chest Physicians and one from the National Institute for Health and Care Excellence were selected for comparison. Risk assessment methods and subsequent prophylactic recommendations were compared. Eight experts then appraised the guideline recommendations on intrinsic implementability characteristics using the GuideLine Implementability Appraisal (GLIA) instrument. GLIA identifies barriers and facilitators for guideline implementation in nine dimensions. RESULTS: Eleven out of 20 individual VTE-risk factors and 2 out of 19 individual bleeding-risk factors used, were present in both guidelines. Additionally, a high VTE- or bleeding risk was defined differently between the two guidelines. The GLIA appraisal identified implementation barriers within all recommendations analyzed. On content level, barriers were identified in recommendations addressing bleeding risk assessment, mechanical prophylaxis and critical care patients. On implementability level, barriers were identified in decidability, flexibility, effect on process of care and computability dimensions. CONCLUSION: Depending on the guideline used, VTE-prophylaxis will most likely be provided to different non-surgical patient populations, primarily due to discordance in bleeding risk assessment. Revising the recommendations, taking into account the most apparent implementation barriers, should be considered. However, insufficient evidence to support the recommendations currently complicates this.

Imaging of respiratory muscles in neuromuscular disease: A review.

Respiratory muscle weakness frequently occurs in patients with neuromuscular disease. Measuring respiratory function with standard pulmonary function tests provides information about the contribution of all respiratory muscles, the lungs and airways. Imaging potentially enables the study of different respiratory muscles, including the diaphragm, separately. In this review, we provide an overview of imaging techniques used to study respiratory muscles in neuromuscular disease. We identified 26 studies which included a total of 573 patients with neuromuscular disease. Imaging of respiratory muscles was divided into static and dynamic techniques. Static techniques comprise chest radiography, B-mode (brightness mode) ultrasound, CT and MRI, and are used to assess the position and thickness of the diaphragm and the other respiratory muscles. Dynamic techniques include fluoroscopy, M-mode (motion mode) ultrasound and MRI, used to assess diaphragm motion in one or more directions. We discuss how these imaging techniques relate with spirometric values and whether these can be used to study the contribution of the different respiratory muscles in patients with neuromuscular disease.

Benchmarking the use of blood products in cardiac surgery to stimulate awareness of transfusion behaviour : Results from a four-year longitudinal study.

INTRODUCTION: Cardiac operations account for a large proportion of the blood transfusions given each year, leading to high costs and an increased risk to patient safety. Therefore, it is important to explore initiatives to reduce transfusion rates. This study aims to provide a benchmark for transfusion practice by inter-hospital comparison of transfusion rates, blood product use and costs related to patients undergoing coronary artery bypass grafting (CABG), valve surgery or combined CABG and valve surgery. METHODS: Between 2010 and 2013, patients from four Dutch hospitals undergoing CABG, valve surgery or combined CABG and valve surgery (n = 11,150) were included by means of a retrospective longitudinal study design. RESULTS: In CABG surgery the transfusion rate ranged between 43 and 54%, in valve surgery between 54 and 67%, and in combined CABG and valve surgery between 80 and 88%. With the exception of one hospital, the trend in transfusion rate showed a significant decrease over time for all procedures. Hospitals differed significantly in the units of blood products given to each patient, and in the use of specific transfused combinations of blood products, such as red blood cells (RBCs) and a combination of RBCs, fresh frozen plasma (FFP) and platelets. CONCLUSION: This study indicates that benchmarking blood product usage stimulates awareness of transfusion behaviour, which may lead to better patient safety and lower costs. Further studies are warranted to improve awareness of transfusion behaviour and increase the standardisation of transfusion practice in cardiac surgery.

High shear stress relates to intraplaque haemorrhage in asymptomatic carotid plaques.

BACKGROUND AND AIMS: Carotid artery plaques with vulnerable plaque components are related to a higher risk of cerebrovascular accidents. It is unknown which factors drive vulnerable plaque development. Shear stress, the frictional force of blood at the vessel wall, is known to influence plaque formation. We evaluated the association between shear stress and plaque components (intraplaque haemorrhage (IPH), lipid rich necrotic core (LRNC) and/or calcifications) in relatively small carotid artery plaques in asymptomatic persons. METHODS: Participants (n = 74) from the population-based Rotterdam Study, all with carotid atherosclerosis assessed on ultrasound, underwent carotid MRI. Multiple MRI sequences were used to evaluate the presence of IPH, LRNC and/or calcifications in plaques in the carotid arteries. Images were automatically segmented for lumen and outer wall to obtain a 3D reconstruction of the carotid bifurcation. These reconstructions were used to calculate minimum, mean and maximum shear stresses by applying computational fluid dynamics with subject-specific inflow conditions. Associations between shear stress measures and plaque composition were studied using generalized estimating equations analysis, adjusting for age, sex and carotid wall thickness. RESULTS: The study group consisted of 93 atherosclerotic carotid arteries of 74 participants. In plaques with higher maximum shear stresses, IPH was more often present (OR per unit increase in maximum shear stress (log transformed) = 12.14; p = 0.001). Higher maximum shear stress was also significantly associated with the presence of calcifications (OR = 4.28; p = 0.015). CONCLUSIONS: Higher maximum shear stress is associated with intraplaque haemorrhage and calcifications.

The year of transparency: measuring quality of cardiac care.

The assessment of quality of care is becoming increasingly important in healthcare, both globally and in the Netherlands. The Dutch Minister of Health declared 2015 to be the year of transparency, thereby aiming to improve quality of care by transparent reporting of outcome data. With the increasing importance of transparency, knowledge on quality measurement will be essential for a cardiologist in daily clinical care. To that end, this paper provides a comprehensive overview of the Dutch healthcare structure, quality indicators and the current and future assessment of quality of cardiac care in the Netherlands.

Policy evaluation in diabetes prevention and treatment using a population-based macro simulation model: the MICADO model.

AIMS: To test a simulation model, the MICADO model, for estimating the long-term effects of interventions in people with and without diabetes. METHODS: The MICADO model includes micro- and macrovascular diseases in relation to their risk factors. The strengths of this model are its population scope and the possibility to assess parameter uncertainty using probabilistic sensitivity analyses. Outcomes include incidence and prevalence of complications, quality of life, costs and cost-effectiveness. We externally validated MICADO's estimates of micro- and macrovascular complications in a Dutch cohort with diabetes (n = 498,400) by comparing these estimates with national and international empirical data. RESULTS: For the annual number of people undergoing amputations, MICADO's estimate was 592 (95% interquantile range 291-842), which compared well with the registered number of people with diabetes-related amputations in the Netherlands (728). The incidence of end-stage renal disease estimated using the MICADO model was 247 people (95% interquartile range 120-363), which was also similar to the registered incidence in the Netherlands (277 people). MICADO performed well in the validation of macrovascular outcomes of population-based cohorts, while it had more difficulty in reflecting a highly selected trial population. CONCLUSIONS: Validation by comparison with independent empirical data showed that the MICADO model simulates the natural course of diabetes and its micro- and macrovascular complications well. As a population-based model, MICADO can be applied for projections as well as scenario analyses to evaluate the long-term (cost-)effectiveness of population-level interventions targeting diabetes and its complications in the Netherlands or similar countries.

Data quality issues impede comparability of hospital treatment delay performance indicators.

AIM: To assess the comparability of five performance indicator scores for treatment delay among patients diagnosed with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention in relation to the quality of the underlying data. METHODS: Secondary analyses were performed on data from 1017 patients in seven Dutch hospitals. Data were collected using standardised forms for patients discharged in 2012. Comparability was assessed as the number of occasions the indicator threshold was reached for each hospital. RESULTS: Hospitals recorded different time points based on different interpretations of the definitions. This led to substantial differences in indicator scores, ranging from 57 to 100 % of the indictor threshold being reached. Some hospitals recorded all the required data elements for calculating the performance indicators but none of the data elements could be retrieved in a fully automated way. Moreover, recording accessibility and completeness of time points varied widely within and between hospitals. CONCLUSION: Hospitals use different definitions for treatment delay and vary greatly in the extent to which the necessary data are available, accessible and complete, impeding comparability between hospitals. Indicator developers, users and hospitals providing data should be aware of these issues and aim to improve data quality in order to facilitate comparability of performance indicators.

Adherence to guidelines for the prescription of secondary prevention medication at hospital discharge after acute coronary syndrome: a multicentre study.

BACKGROUND: The prescription of guideline-recommended medication for secondary prevention after acute coronary syndrome has been suboptimal in the past. In the present study, guideline adherence and associated patient, care and hospital characteristics at hospital discharge after acute coronary syndrome were studied. METHODS: Charts of patients with acute coronary syndrome discharged from 13 Dutch hospitals in 2012 were reviewed. Guideline adherence was defined as the prescription of acetylsalicylic acid, P2Y12 receptor inhibitor, statin, beta-blocker and angiotensin-converting enzyme (ACE) inhibitor at discharge, or a documented contraindication. Associated characteristics were identified by means of generalized linear mixed models for binary outcomes. RESULTS: In total, 2471 patients were included. Complete guideline adherence was achieved in 69.1 % of the patients, ranging from 42.1 to 87.0 % between hospitals. The ACE inhibitor was most often missing (21.2 %). Patients with non-ST-segment elevation myocardial infarction or unstable angina, patients with a history of coronary artery bypass grafting or elderly women were less likely to be discharged with the guideline-recommended medication. CONCLUSIONS: Guideline adherence for secondary prevention medication following acute coronary syndrome was substantial; however, variation between hospitals and patient groups was found. Efforts to increase guideline adherence can focus on underperforming hospitals and undertreated patient groups.

Monitoring guideline adherence in the management of acute coronary syndrome in hospitals: design of a multicentre study.

BACKGROUND: Increasing guideline adherence in the management of acute coronary syndrome (ACS) in hospitals potentially reduces heart failure and mortality. Therefore, an expert panel identified three guideline recommendations as the most important aims for improvement in ACS care, i.e. timely invasive treatment, use of risk scoring instruments and prescription of secondary prevention medication at discharge. AIMS: This study aims to evaluate in-hospital guideline adherence in the care of patients diagnosed with ACS and to identify associated factors. METHODS: The study has a cross-sectional design. Data are collected in 13 hospitals in the Netherlands by means of retrospective chart review of patients discharged in 2012 with a diagnosis of ACS. The primary outcomes will be the percentages of patients receiving timely invasive treatment, with a documented cardiac risk score, and with a prescription of the guideline-recommended discharge medication. In addition, factors associated with guideline adherence will be studied using generalised linear (mixed) models. DISCUSSION: This study explores guideline adherence in Dutch hospitals in the management of patients diagnosed with ACS, using a data source universally available in hospitals. The results of this study can be informative for professionals involved in ACS care as they facilitate targeted improvement efforts.

Statistical coronary motion models for 2D+t/3D registration of X-ray coronary angiography and CTA.

Accurate alignment of intra-operative X-ray coronary angiography (XA) and pre-operative cardiac CT angiography (CTA) may improve procedural success rates of minimally invasive coronary interventions for patients with chronic total occlusions. It was previously shown that incorporating patient specific coronary motion extracted from 4D CTA increases the robustness of the alignment. However, pre-operative CTA is often acquired with gating at end-diastole, in which case patient specific motion is not available. For such cases, we investigate the possibility of using population based coronary motion models to provide constraints for the 2D+t/3D registration. We propose a methodology for building statistical motion models of the coronary arteries from a training population of 4D CTA datasets. We compare the 2D+t/3D registration performance of the proposed statistical models with other motion estimates, including the patient specific motion extracted from 4D CTA, the mean motion of a population, the predicted motion based on the cardiac shape. The coronary motion models, constructed on a training set of 150 patients, had a generalization accuracy of 1mm root mean square point-to-point distance. Their 2D+t/3D registration accuracy on one cardiac cycle of 12 monoplane XA sequences was similar to, if not better than, the 4D CTA based motion, irrespective of which respiratory model and which feature based 2D/3D distance metric was used. The resulting model based coronary motion estimate showed good applicability for registration of a subsequent cardiac cycle.

Statistical tracking of tree-like tubular structures with efficient branching detection in 3D medical image data.

The segmentation of tree-like tubular structures such as coronary arteries and airways is an essential step for many 3D medical imaging applications. Statistical tracking techniques for the extraction of elongated structures have received considerable attention in recent years due to their robustness against image noise and pathological changes. However, most tracking methods are limited to a specific application and do not support branching structures efficiently. In this work, we present a novel statistical tracking approach for the extraction of different types of tubular structures with ringlike cross-sections. Domain-specific knowledge is learned from training data sets and integrated into the tracking process by simple adaption of parameters. In addition, an efficient branching detection algorithm is presented. This approach was evaluated by extracting coronary arteries from 32 CTA data sets and distal airways from 20 CT scans. These data sets were provided by the organizers of the workshop '3D Segmentation in the Clinic: A Grand Challenge II-Coronary Artery Tracking (CAT08)' and 'Extraction of Airways from CT 2009 (EXACT'09)'. On average, 81.5% overlap and 0.51 mm accuracy for the tracking of coronary arteries were achieved. For the extraction of airway trees, 51.3% of the total tree length, 53.6% of the total number of branches and a 4.98% false positive rate were attained. In both experiments, our approach is comparable to state-of-the-art methods.