Budget Impact of Three Improvement Targets for Compression Therapy for Patients with Deep Venous Thrombosis in The Netherlands.

BACKGROUND AND OBJECTIVE: Compression therapy following deep venous thrombosis in the Netherlands is suboptimal. We assessed the budget impact of targeted care improvements. METHODS: We calculated the per-patient and population healthcare resource use and costs concerning 26,500 new patients each year in the Netherlands for the current pathways in region North Holland (divided into two parts: NH-A and NH-B) and region Limburg. Next, we assessed the impact of three improvement targets: optimizing initial compression therapy, early consultation of an occupational therapist, and tailored duration of elastic compression stocking therapy. Inputs were based on interview (n = 30) and survey data (n = 114), literature, and standard prices. The robustness of the results was tested by sensitivity analyses. RESULTS: The current per-patient costs for a 2-year episode were €1046 (NH-A), €947 (NH-B), and €1256 (Limburg). The improvements led to direct savings for region Limburg (€4.7 million). Population costs increased in the first year for NH-A (+ €3.5 million) and NH-B (+ €6.4 million), and decreased in the second and third year resulting in a cost reduction for NH-A (- €2.2 million) but not for NH-B (+ €0.6 million). Workload for occupational therapists and internists in North Holland increased, and workload for home care nurses decreased in all regions. CONCLUSIONS: This study provides a detailed insight into current costs and healthcare resource use associated with compression therapy and the potential impact of implementing three improvement targets. We showed that the improvements resulted in considerable cost savings within 3 years after implementation for region NH-A and Limburg.

A realist evaluation to identify targets to improve the organization of compression therapy for deep venous thrombosis- and chronic venous disease patients.

BACKGROUND: Although compression therapy is well established for patients with deep venous thrombosis (DVT) and chronic venous disease (CVD), considerable variation exists in its organization in clinical practice which may impact patient outcomes. The current study aims to deepen our understanding of the main drivers of the complex care organization for compression therapy and to identify targets for improvement. METHODS: This realist evaluation includes a mixed-method design consisting of semi-structured interviews with patients and health care professionals involved in compression therapy (n = 30), stakeholder meetings (n = 2) and surveys (n = 114). Data were collected to create the content of context-mechanism-outcome-configurations (CMOcs) important in compression therapy. Based on these CMOcs, targets for improvement to optimize the organization of compression care were identified. RESULTS: We identified overarching context factors and mechanisms targeting four optimal outcomes for the organization of compression therapy: selecting initial compression therapy types that support patient's self-reliance (1), evidence based selection of elastic compression stocking type and class (2), patient-based selection of assistive devices (3), individualizing treatment duration for DVT patients (4a) and providing follow-up for CVD patients (4b). We found that increasing health care professionals' knowledge of compression therapy, the availability of unambiguous protocols and guidelines, increasing patient involvement (and if applicable their informal care giver) in the decision making process, the accessible availability of resources, and increasing interdisciplinary consultation enhanced desirable outcomes. These targets triggered mechanisms such as increased health care professionals' willingness, confidence and motivation to provide patient-based care and increased patients' self-confidence and self-efficacy. CONCLUSIONS: This study provides a detailed insight into what needs to be in place to optimize compression care and identified five main targets for improvement.

Development of a Consensus-Based Cross-Domain Protocol for the Management of Elastic Compression Stocking Therapy in Patients With Deep Venous Thrombosis and Chronic Venous Disease: A Modified Delphi Study.

Objective: Elastic compression stocking (ECS) therapy is commonly used in patients with deep venous thrombosis (DVT) and chronic venous disease (CVD). The provision of ECS therapy is complex, and studies indicate a lack of practical guidance and suboptimal collaboration among health care professionals. We aimed to reach consensus on critical issues of ECS therapy among the involved health care professionals and patients. Methods: A three-round modified Delphi analysis was performed in the Netherlands in which 56 health care professionals (internists, dermatologists, general practitioners, emergency room nurses, home care nurses, medical stocking suppliers, and occupational therapists) and seven patients were invited. The 21 statements included in this analysis were based on information collected from a previously conducted Functional Resonance Analysis Method and Realist Evaluation. We used 7-point Likert scale questions and a 75% threshold for consensus. Results: Of the 63 persons invited for this study, 59 (94%) agreed to participate and responded in the first questionnaire round; of whom 52 were health care professionals and seven were patients (five DVT and two CVD). The overall response rate for the three questionnaire rounds was 91%. After completion of the rounds, full consensus was achieved on 19 out of 21 statements. No consensus was reached on the need for a follow-up appointment for CVD patients and who should be responsible to determine the ECS type (custom-made or standard). Conclusion: We identified 19 consensus-driven recommendations on treatment decisions and collaboration in ECS therapy among an interdisciplinary panel of health care professionals and patients. These recommendations form a basis for consensus-driven optimization of ECS therapy and should ideally be incorporated in a general cross-domain protocol for ECS therapy in patients with DVT and CVD.