Non-ST-elevation myocardial infarction in the Netherlands: room for improvement!

AIM: To analyse non-ST-elevation myocardial infarction (NSTEMI) care in the Netherlands and to identify modifiable factors to improve NSTEMI healthcare. METHODS: This retrospective cohort study analysed hospital and pharmacy claims data of all NSTEMI patients in the Netherlands in 2015. The effect of percutaneous coronary intervention (PCI) during hospitalisation on 1­year mortality was investigated in the subcohort alive 4 days after NSTEMI. The effect of medical treatment on 1­year mortality was assessed in the subcohort alive 30 days after NSTEMI. The effect of age, gender and co-morbidities was evaluated. PCI during hospitalisation was defined as PCI within 72 h after NSTEMI and optimal medical treatment was defined as the combined use of an aspirin species, P2Y12 inhibitor, statin, beta-blocker and angiotensin converting enzyme inhibitor/angiotensin II receptor blocker, started within 30 days after NSTEMI. RESULTS: Data from 17,997 NSTEMI patients (age 69.6 (SD = 12.8) years, 64% male) were analysed. Of the patients alive 4 days after NSTEMI, 43% had a PCI during hospitalisation and 1­year mortality was 10%. In the subcohort alive 30 days after NSTEMI, 47% of patients were receiving optimal medical treatment at 30 days and 1­year mortality was 7%. PCI during hospitalisation (odds ratio (OR) 0.42; 95% confidence interval (CI) 0.37-0.48) and optimal medical treatment (OR 0.59; 95% CI 0.51-0.67) were associated with a lower 1­year mortality. CONCLUSION: In Dutch NSTEMI patients, use of PCI during hospitalisation and prescription of optimal medical treatment are modest. As both are independently associated with a lower 1­year mortality, this study provides direction on how to improve the quality of NSTEMI healthcare in the Netherlands.

Introduction of diabetes passports involving both patients and professionals to improve hospital outpatient diabetes care.

AIM: To investigate whether a comprehensive strategy involving both patients and professionals, with the introduction of a diabetes passport as a key component, improves diabetes care. METHODS: The first 150 consecutive patients who visited their internist for a diabetes check up at the internal medicine outpatient departments at each of nine Dutch general hospitals were included in this 1 year clustered, randomised, controlled trial. Health care professionals attended an educational meeting about the use and dissemination of the diabetes passport which is a patient held record. They also received aggregated feedback on baseline data and personal feedback. Educational meetings were also organised for patients. Patient files were used in conjunction with questionnaires to determine adherence rates. Data were analysed using multilevel regression analysis. RESULTS: Small but significant changes were found in mean HbA1c levels. In the intervention group, positive health changes for patients were found (-0.3%) when compared to those in the control group (+0.2%). Diastolic blood pressure improved slightly, but no changes were found in systolic blood pressure or cholesterol. Improvements were found with regard to levels of examination of patients' feet and in patient education. CONCLUSIONS: Efforts to improve professional practice involving both professionals and patients led to small improvements in HbA1c and diastolic blood pressure levels. Further study is needed to establish whether a better structured health care delivery, operating in a more supportive environment can enhance these effects.

Patients and nurses determine variation in adherence to guidelines at Dutch hospitals more than internists or settings.

AIMS: To measure adherence to recently developed diabetes guidelines at Dutch hospital outpatient clinics and distinguish determinants for variations in care on hospital, internist and patient levels. METHODS: Thirteen general hospitals with 58 internists recruited 1950 diabetic patients. Data were extracted from medical files (n = 1915) and from patient questionnaires (n = 1465). Multilevel logistic regression analysis was performed to explain differences in adherence rates to the guidelines. RESULTS: Adherence to process measures was high, except for the examination of feet, calculation of the body mass index and patient education activities (the mean of 12 process measures was 64%). Adherence to intermediate outcome indicators was moderate. The mean percentage of patients with HbA(1c) < 7.0% was 23%. Adherence variation on a hospital level was very small (0.6-7.9%), on an internist level moderate (0.4-18.8%) and on a patient level high (74.4-98.8%). Adherence to all process measures and most of the intermediate outcome indicators was highest in the patients seen by a diabetes specialist nurse. DISCUSSION: More focus on patient involvement in diabetic care and the contribution of diabetes specialist nurses may be important factors in improving the quality of diabetes care.

Neonatal herpes policy in The Netherlands. Five years after a consensus conference.

In order to establish whether the recommendations of an in 1987 organized consensus conference about neonatal herpes policy in the Netherlands had been followed, an inquiry was held in January 1992 among gynecologists, pediatricians and microbiologists. Compared with the results of an inquiry that was held five years before, it was found that the incidence of neonatal herpes had not increased in the last ten years (approximately five cases annually or one per 35,000 neonates) despite the lower frequency of caesarean sections (more than 50 sections a year before 1987 and less than 10 sections a year after 1987). It is concluded that the consensus statements not only have been followed, but that they also proved to be sound.