Turning green: the impact of changing to more eco-friendly respiratory healthcare - a carbon and cost analysis of Dutch prescription data.

OBJECTIVES: Dry powder inhalers (DPIs) and soft mist inhalers have a substantially lower global warming potential than pressurised metered-dose inhalers (pMDIs). To help mitigate climate change, we assessed the potential emission reduction in CO2 equivalents when replacing pMDIs by non-propellant inhalers (NPIs) in Dutch respiratory healthcare and estimated the associated cost. DESIGN: We performed a descriptive analysis of prescription data from two national databases of two independent governmental bodies. First, we calculated the number of patients with chronic obstructive pulmonary disease (COPD) and asthma that were using inhalation medication (2020). Second, we calculated the number and total of daily defined doses of pMDIs and NPIs including DPIs and soft mist inhalers, as well as the number of dispensed spacers per patient (2020). Third, we estimated the potential emission reduction in CO2 equivalents if 70% of patients would switch from using pMDIs to using NPIs. Fourth, we performed a budget impact analysis. SETTING: Dutch respiratory healthcare. PRIMARY AND SECONDARY OUTCOME MEASURES: The carbon footprint of current inhalation medication and the environmental and financial impact of replacing pMDIs with NPIs. RESULTS: In 2020, 1.4 million patients used inhalers for COPD or asthma treatment. A total of 364 million defined daily doses from inhalers were dispensed of which 49.6% were dispensed through pMDIs. We estimated that this could be reduced by 70% which would lead to an annual reduction in greenhouse gas emission of 63 million kg.CO2 equivalents saving at best EUR 49.1 million per year. CONCLUSIONS: In the Netherlands, substitution of pMDIs to NPIs for eligible patients is theoretically safe and in accordance with medical guidelines, while reducing greenhouse gas emission by 63 million kg.CO2 equivalents on average and saving at best EUR 49.1 million per year. This study confirms the potential climate and economic benefit of delivering a more eco-friendly respiratory care.

Improving quality of vascular access care for hemodialysis patients.

BACKGROUND: Because quality of care for patients with end-stage renal disease (ESRD) has improved, they require long-term vascular access for hemodialysis. Construction of a native vein arteriovenous fistula (AVF) on the arm is considered best practice; a prosthetic graft (PG) AVF on the arm is a good alternative, although insertion of a central venous catheter (CVC), the third choice, is sometimes necessary. A quality improvement project was initiated at the dialysis unit of Rijnland Hospital (The Netherlands) to improve quality of vascular access care. METHODS: Seventy-four patients were treated from January 2001 through June 2002. The list of preferred access operations was adapted from evidence-based guidelines. The percentages of CVCs and PGs were chosen as quality indicators. RESULTS: Twelve of 19 patients (34%) appeared to be using CVCs unnecessarily. Actions were taken, and the CVC indicator decreased by 11%. The PG indicator decreased gradually from 24% to 8%. DISCUSSION: Reductions in the use of CVCs and PGs suggest that the vascular access improvement project resulted in improvement of long-term vascular access for hemodialysis patients. A considerable decrease in the use of PGs and CVCs was achieved in 2001. However, a decrease of CVCs to < 20% has still not been realized, perhaps because new hemodialysis patients referred to the dialysis unit have already had CVCs inserted. SUMMARY AND CONCLUSION: Considerable improvement, as reflected in the number of hemodialysis patients with CVCs or PGs, can be achieved with a minimum of costs.

Developing a national continuous quality improvement system for neuromodulation treatment in The Netherlands.

BACKGROUND: Because neuromodulation was not included in the national health insurance system, the Dutch Neuromodulation Group (DNG) developed national standards and a continuous quality improvement (CQI) system for consistency in application of neuromodulation techniques and in the quality of outcomes. DEVELOPING THE NATIONAL QUALITY IMPROVEMENT SYSTEM: A stepwise approach was used in which the following ten steps were taken: (1) selected participating medical specialists and their centers, (2) described the treatment protocol, (3) collected data in a national database, (4) organized feedback sessions for the DNG, (5) formulated quality indicators, (6) adjusted the process of treatment, (7) formalized the structure of the DNG, (8) defined responsibilities, (9) established procedures for future development, and (10) made agreements with payers. DISCUSSION: Making reimbursement for expensive health care interventions contingent on a national CQI system created a powerful financial incentive to continuously provide effective care in an efficient manner.