A quality improvement study on how a simulation model can help decision making on organization of ICU wards.

BACKGROUND: Intensive Care Unit (ICU) capacity management is essential to provide high-quality healthcare for critically ill patients. Yet, consensus on the most favorable ICU design is lacking, especially whether ICUs should deliver dedicated or non-dedicated care. The decision for dedicated or non-dedicated ICU design considers a trade-off in the degree of specialization for individual patient care and efficient use of resources for society. We aim to share insights of a model simulating capacity effects for different ICU designs. Upon request, this simulation model is available for other ICUs. METHODS: A discrete event simulation model was developed and used, to study the hypothetical performance of a large University Hospital ICU on occupancy, rejection, and rescheduling rates for a dedicated and non-dedicated ICU design in four different scenarios. These scenarios either simulate the base-case situation of the local ICU, varying bed capacity levels, potential effects of reduced length of stay for a dedicated design and unexpected increased inflow of unplanned patients. RESULTS: The simulation model provided insights to foresee effects of capacity choices that should be made. The non-dedicated ICU design outperformed the dedicated ICU design in terms of efficient use of scarce resources. CONCLUSIONS: The choice to use dedicated ICUs does not only affect the clinical outcome, but also rejection- rescheduling and occupancy rates. Our analysis of a large university hospital demonstrates how such a model can support decision making on ICU design, in conjunction with other operation characteristics such as staffing and quality management.

Time-dependent association between STOPP and START criteria and gastrointestinal bleeding in older patients using routinely collected primary care data.

PURPOSE: Only few studies have assessed the preventive effect of the STOPP/START criteria on adverse events. We aim to quantify 1) the association between nonadherence to STOPP/START criteria and gastrointestinal bleedings, and 2) the association between exposure to the potentially harmful START-medications and gastrointestinal bleedings. DESIGN: A retrospective cohort study using routinely collected data of patients aged ≥ 65 years from the electronic health records (EHR) of 49 general practitioners (GPs) in 6 GP practices, from 2007 to 2014. The database is maintained in the academic research network database (AHA) of Amsterdam UMC, the Netherlands. METHODS: Gastrointestinal bleedings were identified using ICPC codes and free text inspections. Three STOPP and six START criteria pertaining to gastrointestinal bleedings were selected. Cox proportional hazards regression with time-dependent covariate analysis was performed to assess the independent association between nonadherence to the STOPP/START criteria and gastrointestinal bleedings. The analysis was performed with all criteria as a composite outcome, as well as separately for the individual criteria. RESULTS: Out of 26,576 participants, we identified 19,070 Potential Inappropriate Medications (PIM)/Potential Prescribing Omission (PPO) instances for 3,193 participants and 146 gastrointestinal bleedings in 143 participants. The hazard ratio for gastrointestinal bleedings of STOPP/STARTs, taken as composite outcome, was 5.45 (95% CI 3.62-8.21). When analysed separately, two out of nine STOPP/STARTs showed significant associations. CONCLUSION: This study demonstrates a significant positive association between nonadherence to the STOPP/START criteria and gastrointestinal bleeding. We emphasize the importance of adherence to the relevant criteria for gastrointestinal bleeding, which may be endorsed by decision support systems.

Recommendations of the International Medical Informatics Association (IMIA) on Education in Biomedical and Health Informatics: Second Revision.

BACKGROUND: The purpose of educational recommendations is to assist in establishing courses and programs in a discipline, to further develop existing educational activities in the various nations, and to support international initiatives for collaboration and sharing of courseware. The International Medical Informatics Association (IMIA) has published two versions of its international recommendations in biomedical and health informatics (BMHI) education, initially in 2000 and revised in 2010. Given the recent changes to the science, technology, the needs of the healthcare systems, and the workforce of BMHI, a revision of the recommendations is necessary. OBJECTIVE: The aim of these updated recommendations is to support educators in developing BMHI curricula at different education levels, to identify essential skills and competencies for certification of healthcare professionals and those working in the field of BMHI, to provide a tool for evaluators of academic BMHI programs to compare and accredit the quality of delivered programs, and to motivate universities, organizations, and health authorities to recognize the need for establishing and further developing BMHI educational programs. METHOD: An IMIA taskforce, established in 2017, updated the recommendations. The taskforce included representatives from all IMIA regions, with several having been involved in the development of the previous version. Workshops were held at different IMIA conferences, and an international Delphi study was performed to collect expert input on new and revised competencies. RESULTS: Recommendations are provided for courses/course tracks in BMHI as part of educational programs in biomedical and health sciences, health information management, and informatics/computer science, as well as for dedicated programs in BMHI (leading to bachelor's, master's, or doctoral degree). The educational needs are described for the roles of BMHI user, BMHI generalist, and BMHI specialist across six domain areas - BMHI core principles; health sciences and services; computer, data and information sciences; social and behavioral sciences; management science; and BMHI specialization. Furthermore, recommendations are provided for dedicated educational programs in BMHI at the level of bachelor's, master's, and doctoral degrees. These are the mainstream academic programs in BMHI. In addition, recommendations for continuing education, certification, and accreditation procedures are provided. CONCLUSION: The IMIA recommendations reflect societal changes related to globalization, digitalization, and digital transformation in general and in healthcare specifically, and center on educational needs for the healthcare workforce, computer scientists, and decision makers to acquire BMHI knowledge and skills at various levels. To support education in BMHI, IMIA offers accreditation of quality BMHI education programs. It supports information exchange on programs and courses in BMHI through its Working Group on Health and Medical Informatics Education.

Potentially inappropriate medications and their effect on falls during hospital admission.

OBJECTIVE: to investigate the effect of potentially inappropriate medications (PIMs) on inpatient falls and to identify whether PIMs as defined by STOPPFall or the designated section K for falls of STOPP v2 have a stronger association with inpatient falls when compared to the general tool STOPP v2. METHODS: a retrospective observational matching study using an electronic health records dataset of patients (≥70 years) admitted to an academic hospital (2015-19), including free text to identify inpatient falls. PIMs were identified using the STOPP v2, section K of STOPP v2 and STOPPFall. We first matched admissions with PIMs to those without PIMs on confounding factors. We then applied multinomial logistic regression analysis and Cox proportional hazards analysis on the matched datasets to identify effects of PIMs on inpatient falls. RESULTS: the dataset included 16,678 hospital admissions, with a mean age of 77.2 years. Inpatient falls occurred during 446 (2.7%) admissions. Adjusted odds ratio (OR) (95% confidence interval (CI)) for the association between PIM exposure and falls were 7.9 (6.1-10.3) for STOPP section K, 2.2 (2.0-2.5) for STOPP and 1.4 (1.3-1.5) for STOPPFall. Adjusted hazard ratio (HR) (95% CI) for the effect on time to first fall were 2.8 (2.3-3.5) for STOPP section K, 1.5 (1.3-1.6) for STOPP and 1.3 (1.2-1.5) for STOPPFall. CONCLUSIONS: we identified an independent association of PIMs on inpatient falls for all applied (de)prescribing tools. The strongest effect was identified for STOPP section K, which is restricted to high-risk medication for falls. Our results suggest that decreasing PIM exposure during hospital stay might benefit fall prevention, but intervention studies are warranted.

Potentially inappropriate prescribing in older hospitalized Dutch patients according to the STOPP/START criteria v2: a longitudinal study.

PURPOSE: To investigate prevalence, independent associations, and variation over time of potentially inappropriate prescriptions in a population of older hospitalized patients. METHODS: A longitudinal study using a large dataset of hospital admissions of older patients (≥ 70 years) based on an electronic health records cohort including data from 2015 to 2019. Potentially inappropriate medication (PIM) and potential prescribing omission (PPO) prevalence during hospital stay were identified based on the Dutch STOPP/START criteria v2. Univariate and multivariate logistic regression were used for analyzing associations and trends over time. RESULTS: The data included 16,687 admissions. Of all admissions, 56% had ≥ 1 PIM and 58% had ≥ 1 PPO. Gender, age, number of medications, number of diagnoses, Charlson score, and length of stay were independently associated with both PIMs and PPOs. Additionally, number of departments and number of prescribing specialties were independently associated with PIMs. Over the years, the PIM prevalence did not change (OR = 1.00, p = .95), whereas PPO prevalence increased (OR = 1.08, p < .001). However, when corrected for changes in patient characteristics such as number of diagnoses, the PIM (aOR = 0.91, p < .001) and PPO prevalence (aOR = 0.94, p < .001) decreased over the years. CONCLUSION: We found potentially inappropriate prescriptions in the majority of admissions of older patients. Prescribing relatively improved over time when considering complexity of the admissions. Nevertheless, the high prevalence shows a clear need to better address this issue in clinical practice. Studies seeking effective (re)prescribing interventions are warranted.

Factors associated with depression over time in head and neck cancer patients: A systematic review.

OBJECTIVE: To systematically review the literature on factors associated with a clinical diagnosis of depression or symptoms of depression (depression) among head and neck cancer (HNC) patients. METHODS: The search was conducted in PubMed, PsycINFO, and CINAHL. Studies were included if they investigated factors associated with depression among HNC patients, they were of prospective or longitudinal nature, and English full text was available. The search, data extraction, and quality assessment were performed by two authors. Based on the data extraction and quality assessment, the level of evidence was determined. RESULTS: In total, 35 studies were included: 21 on factors associated with depression at a single (later) time point, 10 on the course of depression, and four on both. In total, 77 sociodemographic, lifestyle, clinical, patient-reported outcome measures, and inflammatory factors were extracted. Regarding depression at a single time point, there was strong evidence that depression at an earlier time point was significantly associated. For all other factors, evidence was inconclusive, although evidence suggests that age, marital status, education, ethnicity, hospital/region, sleep, smoking, alcohol, surgery, treatment, tumor location, and recurrence are not important associated factors. Regarding the course of depression, we found inconclusive evidence for all factors, although evidence suggests that gender, age, chemotherapy, pain, disease stage, treatment, and tumor location are not important associated factors. CONCLUSION: Depression at an earlier time point is significantly associated with depression later on. Several sociodemographic and clinical factors seem not to be important factors associated with depression. For other factors, further research is warranted.

How do patients value and prioritize patient portal functionalities and usage factors? A conjoint analysis study with chronically ill patients.

BACKGROUND: Patient portal use can be a stimulant for patient engagement. Yet, the heterogeneous landscape of tethered patient portals, is a major barrier to further portal development and implementation. A variety in portal access means, functionalities, usability and usefulness exists; without having accurate sight on patient perspectives. We aimed to get insights on possible coherence between patients' preferred usage factors of portals and patients' prioritization of functionalities, within the complexity of their disease management across different healthcare organizations. METHODS: A conjoint analysis questionnaire was sent to patient panels of two large patient associations in The Netherlands, centered on heart and vascular diseases and lung diseases. RESULTS: Of 1294 patient respondents, 81% were 55+ years old and 49% were 65+ years old. Overall respondents significantly prioritized user-friendly access to a portal, via a laptop or desktop. Patients aged < 65 were less negative about using tablets to access a portal compared to the total respondents. Patients had no preference for a digital interoperable export functionality; most respondents preferred to create printable overviews. Built-in publication delay of two weeks for medical information was not preferred. Our results show no significant preference of patients between 'instant publication' versus 'publication after new information has been explained by a healthcare provider'. Overall respondents and experienced portal users had a strong preference to be able to communicate with their provider via a portal and to use a portal providing information from multiple providers. Lung patients preferred information from one provider and did not require the possibility to ask online questions. CONCLUSIONS: Heart and vascular patients as well as lung patients prefer similar technical patient portal aspects, independent of their medical condition. Yet, in current portals consistency on this matter is lacking. It is highly assumable that offering a more consistent user-experience across the variety of patient portals could help increase patient portal acceptance, ultimately helping to stimulate patient engagement via patient portal use. We further affirm the need for customization on medical information publication and sharing information of various providers through patient portals, where information provision can be adapted to preferences of patients related to their medical condition(s).

An email-based intervention to improve the number and timeliness of letters sent from the hospital outpatient clinic to the general practitioner: A pair-randomized controlled trial.

OBJECTIVE: Letters from the hospital to the general practitioner are important for maintaining continuity of care. Although doctors feel letters are important, they are often not written on time. To improve the number and timeliness of letters sent from the hospital outpatient department to the general practitioner using an email-based intervention evaluated in a randomized controlled trial. MATERIALS AND METHODS: Users were interviewed to determine the requirements for the intervention. Due to high between-doctor variation at baseline, doctors were matched for baseline performance and pair-randomized. The effectiveness of the intervention was assessed using meta-analytic methods. The primary outcome was the number of patient visits which should have generated a letter that had a letter by 90 days after the visit. Satisfaction was assessed with an anonymous survey. RESULTS: The intervention consisted of a monthly email reminder for each doctor containing a list of his or her patients who were (over)due for a letter. Doctors in the intervention group had 21% fewer patient visits which did not have a letter by 90 days (OR = 5.7, p = 0.0020). Satisfaction with the system was very high. DISCUSSION: This study examines the effect of a simple reminder in absence of other interventions, and provides an example of an effective non-interruptive decision support intervention. CONCLUSION: A simple email reminder improved the number and timeliness of letters from the outpatient department to the general practitioner, and was viewed as a useful service by its users.

The Association Between the STOPP/START Criteria and Gastro-Intestinal Track Bleedings in Elderly Patients.

Potentially inappropriate prescribing is a common problem, especially in elderly care. To tackle this problem, Irish medical experts have developed a list of criteria when medication should be added or omitted based upon the patient's physical condition and medication use, known as the STOPP and START criteria. The STOPP and START criteria have been formulated to identify the prescribing of potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs). One of the most common problems of inappropriate prescribing is gastro-intestinal track bleedings. For this purpose, nine of the 87 STOPP and START criteria are designed to prevent this. However, the prevalence of gastro-intestinal track bleedings has not been established when these nine STOPP and START criteria are violated. The database contained 182,000 patients belonging to 49 general practitioners in the region of Amsterdam, The Netherlands. We estimated both the incidence of PIMs and PPOs and whether harm, in this case a gastro-intestinal track bleeding, occurred. We found that although violation of the nine STOPP or START criteria were possibly associated with harm (OR = 1.30), this association was not statistically significant (p = 0.323). Searching for evidence for harm informs decision support design aimed at improving quality of medication prescription as it prioritizes the many suggested criteria based on their relevance.

Prescription Pattern Analysis of Nonsteroidal Anti-inflammatory Drugs in the Northeastern Iranian Population.

OBJECTIVE: Inappropriate nonsteroidal anti-inflammatory drugs (NSAIDs) therapy is a common cause of actual and potential adverse effects, such as bleeding and gastrointestinal ulceration, which exacerbates the patient's medical condition and might even be life threatening. We aimed to evaluate and analyze the prescription pattern of NSAIDs in Northeastern Iranian population and also provide suggestions for a more rational prescription behavior for such drugs. METHODS: In this cross-sectional retrospective study, pattern of 1-year prescriptions was inspected based on 9.3 million prescriptions from two insurance companies. Type of NSAIDs, all dispensed doses and the number of NSAIDs ordered per prescription, and the route of administration for each patient were extracted from the databases. The prescription pattern of NSAIDs was analyzed seasonally. FINDINGS: Out of 9,303,585 prescriptions, 19.3% contained at least one NSAID. Diclofenac was the most commonly prescribed NSAID (49.21%). At least two NSAIDs were simultaneously prescribed in 7% of prescriptions. General practitioners prescribed NSAIDs more frequently (67%) than specialists. Orthopedic surgeons and internists more frequently prescribed NSAIDs in comparison with other physicians (6% and 4%, respectively). Gastroprotective agents (GPAs) were coprescribed to only 7.62% of prescriptions. CONCLUSION: The frequency of NSAIDs prescription was relatively high in Northeast of Iran. A significant number of prescriptions were associated with irrational prescribing in both coadministration of NSAIDs and GPAs and NSAIDs combination. A strategy must be developed and implemented for prescribing and rational use of medications, e.g., continuing medical education regarding the potential risks of NSAIDs, importance of their appropriate and rational use, and necessity of appropriate prescription writing regarding both content and indication.

Health information-seeking behavior of seniors who use the Internet: a survey.

BACKGROUND: The Internet is viewed as an important source for health information and a medium for patient empowerment. However, little is known about how seniors use the Internet in relation to other sources for health information. OBJECTIVE: The aim was to determine which information resources seniors who use the Internet use and trust for health information, which sources are preferred, and which sources are used by seniors for different information needs. METHODS: Questions from published surveys were selected based on their relevance to the study objectives. The Autonomy Preference Index was used to assess information needs and preferences for involvement in health decisions. Invitation to participate in this online survey was sent to the email list of a local senior organization (298 addresses) in the Netherlands. RESULTS: There were 118 respondents with a median age of 72 years (IQR 67-78 years). Health professionals, pharmacists, and the Internet were the most commonly used and trusted sources of health information. Leaflets, television, newspapers, and health magazines were also important sources. Respondents who reported higher use of the Internet also reported higher use of other sources (P<.001). Use of health professionals, pharmacists, leaflets, telephone, television, and radio were not significantly different; use of all other resources was significantly higher in frequent Internet users. When in need of health information, preferred sources were the Internet (46/105, 43.8%), other sources (eg, magazines 38/105, 36.2%), health professionals (18/105, 17.1%), and no information seeking (3/105, 2.8%). Of the 51/107 respondents who indicated that they had sought health information in the last 12 months, 43 sought it after an appointment, 23 were preparing for an appointment, and 20 were deciding if an appointment was needed. The source used varied by the type of information sought. The Internet was used most often for symptoms (27/42, 64%), prognosis (21/31, 68%), and treatment options (23/41, 62%), whereas health professionals were asked for additional information on medications (20/36, 56%), side effects (17/36, 47%), coping (17/31, 55%), practical care (12/14, 86%), and nutrition/exercise (18/30, 60%). CONCLUSIONS: For these seniors who use the Internet, the Internet was a preferred source of health information. Seniors who report higher use of the Internet also report higher use of other information resources and were also the primary consumers of paper-based resources. Respondents most frequently searched for health information after an appointment rather than to prepare for an appointment. Resources used varied by health topic. Future research should seek to confirm these findings in a general elderly population, investigate how seniors seek and understand information on the Internet, and investigate how to reach seniors who prefer not to use the Internet for health information.

The consequences of seniors seeking health information using the internet and other sources.

The internet is viewed as an important channel for patient empowerment, enabling patients to feel more knowledgeable and take action to improve their own health. Internet use among seniors in the Netherlands is increasing, but it is not known if they also use it for health information, nor if seeking information on the internet has different consequences for empowerment than seeking information from other sources. We sought to investigate seniors' use of the internet compared to other resources for health information, and the consequences in terms of both subjective responses and actions taken. Using an email invitation and a web survey, we surveyed 100 elderly internet users, of which 85% had used the internet for health information. The consequences were similar for information found via internet and other sources, and generally positive. Over half reported feeling more knowledgeable and 51% reported making lifestyle changes, but fewer reported having taken other actions (e.g. discussing the information with their doctor). Encouraging the translation of knowledge into action represents an opportunity for empowerment in this population.

Medintel: decision support for general practitioners: a case study.

Short consultations and a large and growing amount of available medical information make searching for suitable information difficult for general practitioners. Thus information is often not searched for or not found, diminishing the quality of care. We propose a system that offers decision support by combining medical information sources with data from the electronic patient record. A first evaluation shows that a system like Medintel can be a useful supportive tool and can increase the quality of care provided by general practitioners.

Automated test selection in decision-support systems: a case study in oncology.

Decision-support systems in medicine should be equipped with a facility that provides patient-tailored information about which test had best be performed in which phase of the patient's management. A decision-support system with a good test-selection facility may result in ordering fewer tests, decreasing financial costs, improving a patient's quality of life, and in an improvement of medical care in general. In close cooperation with two experts in oncology, we designed such a facility for a decision-support system for the staging of cancer of the oesophagus. The facility selects tests based upon a patient's health status and closely matches current routines. We feel that by extending our decision-support system with the facility, it provides further support for a patient's management and will be more interesting for use in daily medical practice. In this paper, we describe the test-selection facility that we designed for our decision-support system in oncology and present some initial results.

Generalised reliability characteristics for probabilistic networks.

BACKGROUND: In the medical domain, establishing a diagnosis typically amounts to reasoning about the unobservable truth, based upon a set of indirect observations from diagnostic tests. A diagnostic test may not be perfectly reliable, however. To avoid misdiagnosis, therefore, the reliability characteristics of the test should be taken into account upon reasoning. OBJECTIVE: In this paper, we address the issue of modelling the reliability characteristics of diagnostic tests in a probabilistic network. METHOD: To this end, we study the mathematical foundation of a test's characteristics and collate them with the probabilities required for a probabilistic network. RESULTS: We show that the standard reliability characteristics that are generally available from the literature have to be further detailed and stratified, for example by experts, before they can be included in a network. We demonstrate these modelling issues by means of a real-life probabilistic network in oncology.

On the use of vignettes for eliciting test-selection strategies.

Decision-support systems often include a strategy for selecting tests in their field of application. This strategy in essence captures procedural knowledge and serves to provide support for the reasoning processes involved. Generally, a test-selection strategy is offered in which tests are selected sequentially. For our field of application, we noticed that such a strategy would be an oversimplification, and decided to acquire knowledge about the actual strategy used by the experts. To this end, we composed a method that comprised an unstructured interview to gain general insight in the test-selection strategy used, and a subsequent structured interview, simulating daily practice through vignettes, to acquire full details. We used the method with two experts in our field of application and found that it closely fitted in with their daily practice and resulted in a large amount of detailed knowledge.