[Are guidelines still supportive in clinical practice?] / Zijn richtlijnen nog ondersteunend in de praktijk?

Clinical practice guidelines are fundamental to support knowledge and decision making of healthcare professionals in many disciplines. They can contribute to reducing undesirable practice variation, educating patients, and monitoring care. However, the burden increases if the number and size of guidelines continues to increase and as more side effects occur due to injudicious use, both in the professional and policy setting. Restricting the scope and finding the right balance between completeness and conciseness are major challenges for guideline developers and stakeholders. Ongoing innovation projects are working on improving accessibility, updating, and applicability in multimorbidity through optimal use of digital technologies. As long as healthcare professionals are in the lead in guideline development and involved in policy making, doctors can continue to rely on guidelines, if used correctly for the right care.

Assessment of Tissue Viability Following Amputation Surgery Using Near-Infrared Fluorescence Imaging With Indocyanine Green.

BACKGROUND: Patients with chronic limb threatening ischemia have a risk of undergoing a major amputation within 1 year of nearly 30% with a substantial risk of re-amputation since wound healing is often impaired. Quantitative assessment of regional tissue viability following amputation surgery can identify patients at risk for impaired wound healing. In quantification of regional tissue perfusion, near-infrared (NIR) fluorescence imaging using Indocyanine Green (ICG) seems promising. METHODS: This pilot study included adult patients undergoing lower extremity amputation surgery due to peripheral artery disease or diabetes mellitus. ICG NIR fluorescence imaging was performed within 5 days following amputation surgery using the Quest Spectrum PlatformⓇ. Following intravenous administration of ICG, the NIR fluorescence intensity of the amputation wound was recorded for 10 minutes. The NIR fluorescence intensity videos were analyzed and if a fluorescence deficit was observed, this region was marked as "low fluorescence." All other regions were marked as "normal fluorescence." RESULTS: Successful ICG NIR fluorescence imaging was performed in 10 patients undergoing a total of 15 amputations. No "low fluorescence" regions were observed in 11 out of 15 amputation wounds. In 10 out of these 11 amputations, no wound healing problems occurred during follow-up. Regions with "low fluorescence" were observed in 4 amputation wounds. Impaired wound healing corresponding to these regions was observed in all wounds and a re-amputation was necessary in 3 out of 4. When observing time-related parameters, regions with low fluorescence had a significantly longer time to maximum intensity (113 seconds vs. 32 seconds, P = 0.003) and a significantly lesser decline in outflow after five minutes (80.3% vs. 57.0%, P = 0.003). CONCLUSIONS: ICG NIR fluorescence imaging was able to predict postoperative skin necrosis in all four cases. Quantitative assessment of regional perfusion remains challenging due toinfluencing factors on the NIR fluorescence intensity signal, including camera angle, camera distance and ICG dosage. This was also observed in this study, contributing to a large variety in fluorescence intensity parameters among patients. To provide surgeons with reliable NIR fluorescence cut-off values for prediction of wound healing, prospective studies on the intra-operative use of this technique are required. The potential prediction of wound healing using ICG NIR fluorescence imaging will have a huge impact on patient mortality, morbidity as well as the burden of amputation surgery on health care.

Inaccurate Risk Assessment by the ACS NSQIP Risk Calculator in Aortic Surgery.

OBJECTIVES: The aim of this retrospective study was to assess the predictive performance of the American College of Surgeons (ACS) risk calculator for aortic aneurysm repair for the patient population of a Dutch tertiary referral hospital. METHODS: This retrospective study included all patients who underwent elective endovascular or open aortic aneurysm repair at our institution between the years 2013 and 2019. Preoperative patient demographics and postoperative complication data were collected, and individual risk assessments were generated using five different current procedural terminology (CPT) codes. Receiver operating characteristic (ROC) curves, calibration plots, Brier scores, and Index of Prediction Accuracy (IPA) values were generated to evaluate the predictive performance of the ACS risk calculator in terms of discrimination and calibration. RESULTS: Two hundred thirty-four patients who underwent elective endovascular or open aortic aneurysm repair were identified. Only five out of thirteen risk predictions were found to be sufficiently discriminative. Furthermore, the ACS risk calculator showed a structurally insufficient calibration. Most Brier scores were close to 0; however, comparison to a null model though IPA-scores showed the predictions generated by the ACS risk calculator to be inaccurate. Overall, the ACS risk calculator showed a consistent underestimation of the risk of complications. CONCLUSIONS: The ACS risk calculator proved to be inaccurate within the framework of endovascular and open aortic aneurysm repair in our medical center. To minimize the effects of patient selection and cultural differences, multicenter collaboration is necessary to assess the performance of the ACS risk calculator in aortic surgery.

The Association Between Complications, Incidents, and Patient Experience: Retrospective Linkage of Routine Patient Experience Surveys and Safety Data.

OBJECTIVES: Linkage of safety data to patient experience data may provide information to improve surgical care. This retrospective observational study aimed to assess associations between complications, incidents, patient-reported problems, and overall patient experience. METHODS: Routinely collected data from safety reporting on complications and incidents, as well as patient-reported problems and experience on the Picker Patient Experience Questionnaire 15, covering seven experience dimensions, were linked for 4236 surgical inpatients from an academic center (April 2014-December 2015, 41% response). Associations between complication and/or incident occurrence and patient-reported problems, regarding risk of nonpositive experience (i.e., grade of 1-5 of 10), were studied using multivariable logistic regression. RESULTS: Patient-reported problems were associated with occurrence of complications/incidents among patients with nonpositive experiences (odds ratio [OR] = 2.8, 95% confidence interval [CI] = 1.6-4.9), but not among patients with positive experiences (OR = 1.0, 95% CI = 0.6-1.5). For each experience dimension, presence of patient-reported problems increased risk of nonpositive experience (OR range = 2.7-4.4). Patients with complications or incidents without patient-reported problems were at lower risk of a nonpositive experience than patients with neither complications/incidents nor reported problems (OR = 0.5; 95% CI = 0.3-0.9). Occurrence of complications/incidents only increased risk of nonpositive experience when patients also had problems on "continuity and transition" or "respect for patient preferences" dimensions. CONCLUSIONS: Linking safety data to patient experience data can reveal ways to optimize care. Staff seem able to ensure positive patient experiences despite complications or incidents. Increased attention should be paid to respecting patient preferences, continuity, and transition, particularly when complications or incidents occur.

Editor's Choice - A Systemic Evaluation of the Costs of Elective EVAR and Open Abdominal Aortic Aneurysm Repair Implies Cost Equivalence.

OBJECTIVE: The suggested high costs of endovascular aneurysm repair (EVAR) hamper the choice of insurance companies and financial regulators for EVAR as the primary option for elective abdominal aortic aneurysm (AAA) repair. However, arguments used in this debate are impeded by time related aspects such as effect modification and the introduction of confounding by indication, and by asymmetric evaluation of outcomes. Therefore, a re-evaluation minimising the impact of these interferences was considered. METHODS: A comparative analysis was performed evaluating a period of exclusive open repair (OR; 1998-2000) and a period of established EVAR (2010-2012). Data from four hospitals in The Netherlands were collected to estimate resource use. Actual costs were estimated by benchmark cost prices and a literature review. Costs are reported at 2019 prices. A break even approach, defining the costs for an endovascular device at which cost equivalence for EVAR and OR is achieved, was applied to cope with the large variation in endovascular device costs. RESULTS: One hundred and eighty-six patients who underwent elective AAA repair between 1998 and 2000 (OR period) and 195 patients between 2010 and 2012 (EVAR period) were compared. Cost equivalence for OR and EVAR was reached at a break even price for an endovascular device of €13 190. The main cost difference reflected the longer duration of hospital stay (ward and Intensive Care Unit) of OR (€11 644). Re-intervention rates were similar for OR (24.2%) and EVAR (24.6%) (p = .92). CONCLUSION: Cost equivalence for EVAR and OR occurs at a device cost of €13 000 for EVAR. Hence, for most routine repairs, EVAR is not costlier than OR until at least the five year follow up.

Objective Assessment of Fitness to Perform (FTOP) After Surgical Night Shifts in the Netherlands: An Observational Study Using the Validated FTOP Self-test in Daily Surgical Practice.

BACKGROUND: Surgical skills and decision making are influenced by alertness, reaction time, eye-hand coordination, and concentration. Night shift might impair these functions but it is unclear to what extent. The aim of this study was to investigate whether a night shift routinely impairs the surgeon's fitness to perform and whether this reaches a critical limit as compared to relevant frames of reference. METHODS: Consultants (n = 59) and residents (n = 103) conducted fitness to perform measurements at precall, postcall, and noncall moments. This validated self-test consists of an adaptive tracker that is able to objectively measure alertness, reaction time, concentration, and eye-hand coordination, and multiple visual analog scales to subjectively score alertness. Results are compared to sociolegal (ethanol) and professional (operative skills) frames of reference that refer to a decrease under the influence of 0.06% ethanol. RESULTS: Residents spent 1.7 call hours asleep on average as compared to 5.4 for consultants. Subjective alertness decreased in residents after night shifts (-13, P < 0.001) but not in consultants (-1.2, P = NS). The overnight difference in tracker score was -1.17 (P < 0.001) for residents and 0.46 (P = NS) for surgeons. Postcall subjective alertness only correlated to objective alertness in consultants. For residents, hours slept on-call correlated to objective alertness. For consultants, subsequent night calls significantly correlated to objective alertness, with the third subsequent call related to performance below the reference. CONCLUSIONS: Consultants remain fit to perform after night call, but subsequent calls may compromise clinical activities. This study provides insight and awareness of individual performance with clear frames of reference.

Failure to Rescue - a Closer Look at Mortality Rates Has No Added Value for Hospital Comparisons but Is Useful for Team Quality Assessment in Abdominal Aortic Aneurysm Surgery in The Netherlands.

OBJECTIVES: Failure to rescue (FTR) is a composite quality indicator, defined as the proportion of deceased patients following major complications. The aims of this study were to compare FTR with mortality for hospital comparisons in abdominal aortic aneurysm (AAA) surgery in The Netherlands and investigate hospital volume and associated factors. METHODS: Patients prospectively registered between 2013 and 2015 in the Dutch Surgical Aneurysm Audit (DSAA) were analysed. FTR was analysed for AAA patients and subgroups elective (EAAA) and acute (AAAA; symptomatic or ruptured) aneurysms. Variables and hospital volume were analysed by uni- and multivariable regression analysis. Adjusted hospital comparisons for mortality, major complications, and FTR were presented in funnel plots. Isomortality lines were constructed when presenting FTR and major complication rates. RESULTS: A total of 9258 patients were analysed in 61 hospitals: 7149 EAAA patients (77.2%) and 2109 AAAA patients (22.8%). There were 2785 (30.1%) patients with complications (unadjusted range 5-65% per hospital): 2161 (77.6%) with major and 624 (28.4%) patients with minor complications. Overall mortality was 6.6% (adjusted range 0-16% per hospital) and FTR was 28.4% (n = 613) (adjusted range 0-60% per hospital). Glasgow Coma Scale, age, pulse, creatinine, electrocardiography, and operative setting were independently associated with FTR. Hospital volume was not associated with FTR. In AAAA patients hospital volume was significantly associated with a lower adjusted major complication and mortality rate (OR 0.62, 95% CI 0.49-0.78; and 0.64, 95% CI 0.48-0.87). Four hospitals had a significant lower adjusted FTR with different major complication rates on different isomortality lines. CONCLUSIONS: There was more variation in FTR than in mortality between hospitals. FTR identified the same best performing hospitals as for mortality and therefore was of limited additional value in measuring quality of care for AAA surgery. FTR can be used for internal quality improvement with major complications in funnel plots and diagrams with isomortality lines.

Toward Best Practices for Surgical Morbidity and Mortality Conferences: A Mixed Methods Study.

OBJECTIVE: To assess formats for surgical morbidity and mortality conferences (M&M) for strengths and challenges. DESIGN: A mixed methods approach with local observations to assess key domains of M&M practice (i.e., goals, structure, and process/content) and surveys to assess participants' expectations and experiences. SETTING: Surgical departments of two teaching hospitals (Boston, USA and Leiden, Netherlands). PARTICIPANTS: Participants of surgical M&M, including attending surgeons, residents, physician assistants, and medical students (total n = 135). RESULTS: Surgical M&M practices at both hospitals had education as its overarching goal, but varied in structure and process/content. Expectations were similar at both sites with ≥80% of participants (n = 90; 67% response) expecting M&M to be focused on education as well as quality improvement (QI), blame-free, mandatory for both residents and attendings, and to lead to changes in clinical practice. However, compared to expectations, significantly fewer participants at both sites experienced: a QI focus (both p < 0.001); mandatory faculty attendance (p = 0.004; p < 0.001) and changes to practice (both p < 0.001). In comparison, at the site where an active moderator and QI committee are present, respondents seemed more positive about experiencing a QI focus (73% vs 30%) and changes to practice (44% vs 16%). CONCLUSION: Despite variation in M&M practice, the same (unmet) expectations existed at both hospitals, indicating that certain challenges may be more universal. M&M was reported to be well-focused on education, and certain aspects (e.g., active moderator and QI committee) seemed beneficial, but expectations were not met for the conference's focus and function for QI. Greater exchange of "best practices" for M&M may enhance the conference's value for improving surgical care.

[Trainee feedback: trainer assessment]. / Aiossen koppelen terug: het beoordelen van opleiders.

The quality of medical specialty education depends highly on the trainers, i.e. the specialists. Trainees are very important in the assessment of their trainers because they continuously undergo all the important aspects of the training. Currently, periodical announced visits take place, creating a formal atmosphere. A regular, semi-structured questionnaire for the trainees would be a better way of evaluating the program. Additionally there should be a thorough follow-up leading to a system with a process of continuous quality improvement.

Treatment for peripheral arterial obstructive disease: An appraisal of the economic outcome of complications.

OBJECTIVE: This study determined the average estimated total costs after treatment for peripheral arterial occlusive disease (PAOD) and evaluated the effect of postoperative complications and their consequences for the total costs. METHODS: Cost data on all admissions involving treatment for PAOD from January 2007 until July 2007 were collected. A prospective analysis was made using the patient-related risk factor and comorbidity (Society for Vascular Surgery/International Society of Cardiovascular Surgeons) classification, primary and secondary treatment, and prospectively registered complications. At admission, patients without complications were placed in group A, and those with complications were in group B. Prospectively registered complications were divided into patient management (I), surgical technique (II), patient's disease (III), and outside surgical department (IV). The consequences of these were divided into minor complication, no long-term consequence (1A), additional medication or transfusion (1B), surgical reoperation (2A), prolonged hospital stay (2B), irreversible physical damage (3), and death (4). The main outcome measures were total costs of patients and costs per patient (PP), with or without the presence of complications, cost of complications and costs per complication (PC), and the costs of their consequences calculated in euros (euro). RESULTS: Ninety patients (mean age, 71.4 years; 59% men) were included. Group B patients had a significantly higher American Society of Anesthesiologists (4) and Fontaine (3) classification and more secondary procedures. Total costs were euro 1,716,852: group A, euro 512,811 (PP euro 12,820); and group B, euro 1,204,042 (PP euro 24,081). The costs of the 115 complications were euro 568,500 (PC euro 4943). Split by the cause of the complication, costs were I, euro 95,924 (PC euro 2998); II, euro 163,137 (PC euro 8157); III, euro 289,578 (PC euro 5171); and IV, euro 19,861 (PC euro 2837). The increase of costs in group B was mainly caused by additional medication or transfusion (1B) euro 348,293 (61.3%), a surgical reoperation (2A) euro 118,054 (20.8%), or prolonged hospital stay (2B) euro 60,451 (10.6%). Patients who died caused 23% of the total costs. CONCLUSION: Complications cause an increase of the average estimated total costs in the treatment for peripheral arterial occlusive disease and are responsible for 33% of these total costs. The most expensive complications were errors in surgical technique and patient's disease, resulting in surgical reoperation or additional medication, or both, or transfusion, the two most expensive consequences.

Assessment of three-dimensional stent-graft dynamics by using fluoroscopic roentgenographic stereophotogrammetric analysis.

OBJECTIVE: To validate the use of fluoroscopic roentgenographic stereophotogrammetric analysis (FRSA) for its feasibility and accuracy for measuring the three-dimensional dynamic motion of stent grafts. METHODS: A digital biplane fluoroscopy setup was calibrated (Siemens Axiom Artis dBc). Stereo images were acquired of a static aortic model with a stent graft in different axial positions, imposed by a micromanipulator. The three-dimensional measurement error of FRSA was determined by comparing FRSA measurements with the micromanipulator. An aortic model with a stent graft was constructed and connected to an artificial circulation with a physiological flow and pressure profile. Markers were added to the spine (tantalum spherical markers; diameter 1 mm) and stent (welding tin; diameter 1 mm). The three-dimensional measurement precision was determined by measuring the position of a single (stable) spine marker during two pulsatile cycles. Finally, three-dimensional stent marker motion was analyzed with a frame rate of 30 images per second, including three-dimensional marker position (change), diameter change, and center of circle position change. RESULTS: The mean error of FRSA measurement of displacement was 0.003 mm (SD, 0.019 mm; maximum error, 0.058 mm). A very high precision of position measurement was found (SD, 0.009-0.015 mm). During pulsatile motion, the position (changes) of the markers could be assessed in the x, y, and z directions, as well as the stent diameter change and center of circle position change. CONCLUSIONS: FRSA has proven to be a method with very high accuracy and temporal resolution to measure three-dimensional stent-graft motion in a pulsatile environment. This technique has the potential to contribute significantly to the knowledge of stent-graft behavior after endovascular aneurysm repair and improvements in stent-graft design. The technique is ready for clinical testing.