Development of quality indicators for diagnosis and treatment of patients with non-small cell lung cancer: a first step toward implementing a multidisciplinary, evidence-based guideline.

BACKGROUND: While developing and distributing clinical practice guidelines are important in optimising clinical healthcare, insight into actual care is necessary to achieve successful implementation. Developing quality indicators may be the first step to becoming aware of actual care. The Dutch national practice guideline Non-small cell lung cancer: staging and treatment is one of the first clinical, multidisciplinary guidelines for oncology in the Netherlands for which quality indicators were developed systematically. We describe indicator development based on this guideline as a practical experience. METHODS: To develop a set of indicators for diagnosis and treatment of patients with non-small cell lung cancer, we systematically achieved consensus on the basis of a national, multidisciplinary, evidence-based guideline and the opinions of professionals and patients. After the researchers extracted the recommendations from the guideline, we carried out a so-called Rand-modified-Delphi procedure. This consisted of three rounds: a national panel of professionals and representatives of the national patient organization scored all recommendations, the professionals had a consensus meeting, and the final set of indicators was e-mailed for a last check. Subsequently, some clinimetric characteristics of this final set were assessed in a practice test. RESULTS: Thirty-two of 83 recommendations were selected in the first round. After the consensus meeting, 8 recommendations met the final criteria and were incorporated into 15 indicators, which were tested in practice. The most successful indicators for quality improvement are indicators that are measurable, have potential for improvement, have a broad range between practices and are applicable to a large part of the population. CONCLUSIONS: For successful implementation of evidence-based guidelines, each new guideline should be developed and tested with a set of indicators based on the guideline. The procedure we describe can serve as an example for other new guidelines.

Costs of introducing autologous BMT in the treatment of lymphoma and acute leukaemia in The Netherlands.

In a retrospective study we calculated the costs of introducing autologous BMT in the treatment of patients with malignant lymphoma and acute leukaemia in The Netherlands. The cost analysis has been performed in five university hospitals and one cancer centre, in a series of patients with intermediate and high grade non-Hodgkin's lymphoma (NHL) and patients with AML. Conventional treatment consisted of chemotherapy. The average costs of the conventional NHL treatment varied from US$3120 to U$12,900. The costs of autologous BMT amounted to US$40,220. In the AML group the costs of conventional treatment amounted to about US$11,040, as only 50% of the patients were treated further. The costs of autologous BMT including a follow-up period of 2 years, amounted to US$55,440. In The Netherlands the total number of autologous BMTs per year in these patient groups was estimated at 230; 180 in the NHL group and 50 in the AML group. The costs of introducing autologous BMT to the NHL group will vary between 4.93 and 6.68 million dollars and for the AML group these costs were estimated at 2.22 million dollars. As a result, the total extra costs of introducing autologous BMTs are expected to be between 7.15 and 8.9 million dollars.

[Total hip replacement arthroplasty in the Netherlands]. / De totaleheupprothese in Nederland.

The total hip arthroplasty (THA) is an effective treatment of osteoarthritis of the hip joint. Each year, more than 16,000 THAs are performed in the Netherlands. The incidence of THA had doubled between 1980 and 1994. The medical indication has extended to younger and older patients. Due to the success of the THA the number of alternative treatments, such as arthrodesis and osteotomy decreased. The number of revision surgeries increased more than four folds, to 1,400 in 1994. Based on these data the increase of primary and revision hip arthroplasties is expected to continue, but it is unknown how much the exact increase will be. In view of the increased demand it is important to gain more insight into the numbers of primary and revision surgical procedures to be expected, so that a better estimation can be made of the health care capacity and financial resources required in the future.

[An estimate of the intramural costs of the placement of a total hip prosthesis]. / Een raming van de intramurale kosten van plaatsing van een totaleheupprothese.

OBJECTIVE: Determining the intramural costs of the (re) placement of a total hip prostheses. DESIGN: Retrospective, descriptive. SETTING: Utrecht University Hospital (AZU) and the De Weezenlanden Hospital in Zwolle (ZWZ), the Netherlands. PATIENTS AND METHOD: From the records of 137 patients in whom an uncomplicated primary placement or revision of 151 total hip prostheses had taken place in the AZU or the ZWZ during the period 1990-93, data were collected on the number of days hospitalised, the length of the operation, the medical materials used, the number of radiological procedures, ECG's and laboratory determinations, and the visits to the outpatient clinic. The costs of a hip replacement were determined on the basis of the salary costs, tariffs and purchase prices. RESULTS: The average total cost was f 9381 for the placement of a cemented prosthesis, f 10,796 for the placement of a cement-free prosthesis, and f 17,879 for a revision operation. About 90% of the total costs were due to the price of hospitalization, surgery and prosthesis. With 14,000 primary placements and 1400 revisions annually, the cost is approximately 186 million guilders. An expected increase in the number of hip replacements and their cost should be taken into consideration.