Unexpectedly long hospital stays as an indicator of risk of unsafe care: an exploratory study.

OBJECTIVES: We developed an outcome indicator based on the finding that complications often prolong the patient's hospital stay. A higher percentage of patients with an unexpectedly long length of stay (UL-LOS) compared to the national average may indicate shortcomings in patient safety. We explored the utility of the UL-LOS indicator. SETTING: We used data of 61 Dutch hospitals. In total these hospitals had 1 400 000 clinical discharges in 2011. PARTICIPANTS: The indicator is based on the percentage of patients with a prolonged length of stay of more than 50% of the expected length of stay and calculated among survivors. INTERVENTIONS: No interventions were made. OUTCOME MEASURES: The outcome measures were the variability of the indicator across hospitals, the stability over time, the correlation between the UL-LOS and standardised mortality and the influence on the indicator of hospitals that did have problems discharging their patients to other health services such as nursing homes. RESULTS: In order to compare hospitals properly the expected length of stay was computed based on comparison with benchmark populations. The standardisation was based on patients' age, primary diagnosis and main procedure. The UL-LOS indicator showed considerable variability between the Dutch hospitals: from 8.6% to 20.1% in 2011. The outcomes had relatively small CIs since they were based on large numbers of patients. The stability of the indicator over time was quite high. The indicator had a significant positive correlation with the standardised mortality (r=0.44 (p<0.001)), and no significant correlation with the percentage of patients that was discharged to other facilities than other hospitals and home (r=-0.15 (p>0.05)). CONCLUSIONS: The UL-LOS indicator is a useful addition to other patient safety indicators by revealing variation between hospitals and areas of possible patient safety improvement.

Facts and figures about patient associations in the Netherlands between 2007 and 2009: review of their activities and aims.

INTRODUCTION: To facilitate empowerment, the government encourages patient associations to participate in policy making discussions. To play a crucial role as one of the partners for the government in formulating policy on healthcare, information was needed about the activities and aims of Dutch patient associations. This article describes the development of the monitor in 2005 and 2006 and the most important outcomes and trends for 2007, 2008 and 2009. METHODS: Seven years ago, a yearly monitor of patient associations was started to quantify the activities of the patient and consumer movement in the Netherlands. We analyze individual Dutch patient associations focusing on empowerment and advocacy for their own members. RESULTS: Different types of associations pursue different goals to provide a 'voice' for their members. There was a very slight decline in individual members when comparing 2007 and 2009. More than a third of all associations have professional, paid employees. Organizations for disabled or mental disorders have the most volunteers. Peer support meetings for their own members remain the most popular activities. There are many small organizations and a few big ones. Advocacy remains important although the motives differ between patient associations. CONCLUSION: Dutch patient organizations reported activities they are expected to perform. They try to reduce information asymmetry by informing patients better through several media. They also provide peer support groups to their members. They reach the general public through their social media activities. Their primary focus is providing services to their members.

Muscle imaging: mapping responses to transcranial magnetic stimulation with high-density surface electromyography.

Representations of different body parts or muscles in the human primary motor cortex overlap extensively. At the effector level, most muscles are surrounded by and overlap with several neighbours as well. This hampers the assessment of excitability in individual muscles with transcranial magnetic stimulation (TMS), even if so-called "focal" stimulating coils are used. Here we used a novel mapping paradigm based on high-density surface electromyography (HD-sEMG) to investigate the spatial selectivity of TMS in the forearm musculature. In addition, we tested the hypothesis that selective stimulation can be improved by a voluntary background contraction of the target muscle. We mapped and compared the topographies of motor evoked potential (MEP) amplitudes during rest and during background contractions of two forearm muscles (extensor carpi radialis and extensor digitorum communis). The MEP topographies were also compared to the amplitude topography of voluntary EMG. The results indicate that under many conditions a large proportion of the MEP activity recorded at the surface originated from the target muscle's neighbours. There was a systematic relationship between TMS intensity and the topographic distribution of MEP responses during voluntary contraction. With increasing stimulus intensity, the MEP topography deviated increasingly more from the topography of voluntary EMG. We conclude that when standard EMG montages are used, the recorded MEPs are not necessarily evoked in the target muscle alone. Stimulation during a voluntary background contraction of the target muscle may enhance the selectivity of TMS. It however remains essential to use stimulus intensities as low as possible, to minimize the contribution of surrounding non-target muscles to the MEP.