Low-value chronic prescription of acid reducing medication among Dutch general practitioners: impact of a patient education intervention.

BACKGROUND: Dyspepsia is a commonly encountered clinical condition in Dutch general practice, which is often treated through the prescription of acid-reducing medication (ARM). However, recent studies indicate that the majority of chronic ARM users lack an indication for their use and that their long-term use is associated with adverse outcomes. We developed a patient-focussed educational intervention aiming to reduce low-value (chronic) use of ARM. METHODS: We conducted a randomized controlled study, and evaluated its effect on the low-value chronic prescription of ARM using data from a subset (n = 26) of practices from the Nivel Primary Care Database. The intervention involved distributing an educational waiting room posters and flyers informing both patients and general practitioners (GPs) regarding the appropriate indications for prescription of an ARM for dyspepsia, which also referred to an online decision aid. The interventions' effect was evaluated through calculation of the odds ratio of a patient receiving a low-value chronic ARM prescription over the second half of 2021 and 2022 (i.e. pre-intervention vs. post-intervention). RESULTS: In both the control and intervention groups, the proportion of patients receiving chronic low-value ARM prescriptions slightly increased. In the control group, it decreased from 50.3% in 2021 to 49.7% in 2022, and in the intervention group it increased from 51.3% in 2021 to 53.1% in 2022. Subsequent statistical analysis revealed no significant difference in low-value chronic prescriptions between the control and intervention groups (Odds ratio: 1.11 [0.84-1.47], p > 0.05). CONCLUSION: Our educational intervention did not result in a change in the low-value chronic prescription of ARM; approximately half of the patients of the intervention and control still received low-value chronic ARM prescriptions. The absence of effect might be explained by selection bias of participating practices, awareness on the topic of chronic AMR prescriptions and the relative low proportion of low-value chronic ARM prescribing in the intervention as well as the control group compared to an assessment conducted two years prior. TRIAL REGISTRATION: 10/31/2023 NCT06108817.

The association of the STarT Back Screening Tool and type of leg pain with low back pain disability trajectories: a prospective cohort study.

BACKGROUND: Multiple factors influence the recovery process of low back pain (LBP). The identification and increased knowledge of prognostic factors might contribute to a better understanding of the course of LBP. The purpose of this study is to investigate the association of the STarT Back Screening Tool (SBST) risk score and the type of leg pain (non-radiating LBP, referred non-radicular, and radicular radiating leg pain) with the disability trajectory (at baseline, the slope, and recovery at one year) in adults with low back pain. METHODS: This is a prospective cohort study in 347 patients with low back pain who sought physiotherapy care at three primary care practices in the Netherlands. Linear mixed models were estimated to describe the association of the SBST risk score and the type of leg pain with disability at baseline, the slope in the disability trajectory, and at twelve months follow-up. RESULTS: A medium/high risk score on the SBST is associated with higher baseline disability scores on the Oswestry Disability Index (ODI), faster initial recovery, and still a higher disability ODI score at 12 months follow-up. Non-radicular referred and radicular radiating leg pain were associated with worse baseline disability ODI scores in LBP. This association was not present for the initial recovery or at the 12 months follow-up. CONCLUSION: The SBST is associated with the LBP recovery trajectory. The SBST might be a useful tool to predict the disability trajectory in a heterogeneous group of people with low back pain in primary care and might, therefore, be recommended in future clinical practice guidelines. The type of leg pain was not associated with the recovery trajectory of LBP. Future research might focus on evaluating different types of leg pain. TRIAL REGISTRATION: Clinicaltrials.gov: 109,643.

Design of a Multiple-Behavior Change Intervention for Supporting Self-management in Patients With Chronic Heart Failure: An Intervention Mapping Approach.

BACKGROUND: Nonadherence to medication and low physical activity contribute to morbidity, mortality, and decreased quality of life among patients with chronic heart failure (CHF). Effective interventions that can be delivered during routine clinical care are lacking. OBJECTIVE: We aimed to adapt the feasible and cost-effective Adherence Improving self-Management Strategy (AIMS) for patients with human immunodeficiency virus (HIV) to CHF treatment. Subsequently, we determined its acceptability and feasibility. METHODS: Adherence Improving self-Management Strategy is a systematic, nurse-delivered counseling intervention blended with eHealth to facilitate patient self-management. We used the intervention mapping framework to systematically adapt AIMS-HIV to AIMS-CHF, while preserving essential intervention elements. Therefore, we systematically consulted the scientific literature, patients with CHF and nurses, and pretested intervention materials. RESULTS: Adherence Improving self-Management Strategy-HIV was modified to AIMS-CHF: a multiple-behavior change intervention, focused on medication adherence and physical activity. Key self-management determinants (such as attitudes, self-efficacy, and self-regulatory skills) and organization of care (such as specialized nurses delivering AIMS) were similar for HIV and heart failure care. The AIMS protocol, as well as material content and design, was systematically adapted to CHF. Preliminary testing suggests that AIMS-CHF is likely feasible and acceptable to patients with CHF and care providers. CONCLUSION: Using the intervention mapping protocol, AIMS-HIV could be systematically adapted to AIMS-CHF and seems acceptable and feasible. Evidence from the literature, behavioral theory, and input from nurses and patients were essential in this process. Adherence Improving self-Management Strategy-CHF should now be tested for feasibility and effectiveness in routine care.

Trends in low-value GP care during the COVID-19 pandemic: a retrospective cohort study.

BACKGROUND: Several studies showed that during the pandemic patients have refrained from visiting their general practitioner (GP). This resulted in medical care being delayed, postponed or completely forgone. The provision of low-value care, i.e. care which offers no net benefit for the patient, also could have been affected. We therefore assessed the impact of the COVID-19 restrictions on three types of low-value GP care: 1) imaging for back or knee problems, 2) antibiotics for otitis media acuta (OMA), and 3) repeated opioid prescriptions, without a prior GP visit. METHODS: We performed a retrospective cohort study using registration data from GPs part of an academic GP network over the period 2017-2022. The COVID-19 period was defined as the period between April 2020 to December 2021. The periods before (January 2017 to April 2020) and after the COVID-19 period (January 2022 to December 2022) are the pre- and post-restrictions periods. The three clinical practices examined were selected by two practicing GPs from a top 30 of recommendations originating from the Dutch GP guidelines, based on their perceived prevalence and relevance in practice (van Dulmen et al., BMC Primary Care 23:141, 2022). Multilevel Poisson regression models were built to examine changes in the incidence rates (IR) of both registered episodes and episodes receiving low-value treatment. RESULTS: During the COVID-19 restrictions period, the IRs of episodes of all three types of GP care decreased significantly. The IR of episodes of back or knee pain decreased by 12%, OMA episodes by 54% and opioid prescription rate by 13%. Only the IR of OMA episodes remained significantly lower (22%) during the post-restrictions period. The provision of low-value care also changed. The IR of imaging for back or knee pain and low-value prescription of antibiotics for OMA both decreased significantly during the COVID-restrictions period (by 21% and 78%), but only the low-value prescription rate of antibiotics for OMA remained significantly lower (by 63%) during the post-restrictions period. The IR of inappropriately repeated opioid prescriptions remained unchanged over all three periods. CONCLUSIONS: This study shows that both the rate of episodes as well as the rate at which low-value care was provided have generally been affected by the COVID-19 restrictions. Furthermore, it shows that the magnitude of the impact of the restrictions varies depending on the type of low-value care. This indicates that deimplementation of low-value care requires tailored (multiple) interventions and may not be achieved through a single disruption or intervention alone.

Non-indicated vitamin B12- and D-testing among Dutch hospital clinicians: a cross-sectional analysis in data registries.

OBJECTIVES: To assess the extent of non-indicated vitamin B12- and D-testing among Dutch clinicians and its variation among hospitals. DESIGN: Cross-sectional study using registration data from 2015 to 2019. PARTICIPANTS: Patients aged between 18 and 70 years who received a vitamin B12- or D-test. PRIMARY AND SECONDARY OUTCOME MEASURES: The proportion of non-indicated vitamin B12- and D-testing among Dutch clinicians and its variation between hospitals (n=68) over 2015-2019. RESULTS: Between 2015 and 2019, at least 79.0% of all vitamin B12-tests and 82.0% of vitamin D-tests lacked a clear indication. The number of vitamin B12-tests increased by 2.0% over the examined period, while the number of D-tests increased by 12.2%. The proportion of the unexplained variation in non-indicated vitamin B12- and D-tests that can be ascribed to differences between hospitals remained low. Intraclass correlation coefficients ranged between 0.072 and 0.085 and 0.081 and 0.096 for non-indicated vitamin B12- and D-tests, respectively. The included casemix variables patient age, gender, socioeconomic status and hospital size only accounted for a small part of the unexplained variation in non-indicated testing. Additionally, a significant correlation was observed in non-indicated vitamin B12- and D-testing among the included hospitals. CONCLUSION: Hospital clinicians order vitamin B12- and D-tests without a clear indication on a large scale. Only a small proportion of the unexplained variation could be attributed to differences between hospitals.

Characteristics Associated With Telemonitoring Use Among Patients With Chronic Heart Failure: Retrospective Cohort Study.

BACKGROUND: Chronic heart failure (HF) is a chronic disease affecting more than 64 million people worldwide, with an increasing prevalence and a high burden on individual patients and society. Telemonitoring may be able to mitigate some of this burden by increasing self-management and preventing use of the health care system. However, it is unknown to what degree telemonitoring has been adopted by hospitals and if the use of telemonitoring is associated with certain patient characteristics. Insight into the dissemination of this technology among hospitals and patients may inform strategies for further adoption. OBJECTIVE: We aimed to explore the use of telemonitoring among hospitals in the Netherlands and to identify patient characteristics associated with the use of telemonitoring for HF. METHODS: We performed a retrospective cohort study based on routinely collected health care claim data in the Netherlands. Descriptive analyses were used to gain insight in the adoption of telemonitoring for HF among hospitals in 2019. We used logistic multiple regression analyses to explore the associations between patient characteristics and telemonitoring use. RESULTS: Less than half (31/84, 37%) of all included hospitals had claims for telemonitoring, and 20% (17/84) of hospitals had more than 10 patients with telemonitoring claims. Within these 17 hospitals, a total of 7040 patients were treated for HF in 2019, of whom 5.8% (409/7040) incurred a telemonitoring claim. Odds ratios (ORs) for using telemonitoring were higher for male patients (adjusted OR 1.90, 95% CI 1.50-2.41) and patients with previous hospital treatment for HF (adjusted OR 1.76, 95% CI 1.39-2.24). ORs were lower for higher age categories and were lowest for the highest age category, that is, patients older than 80 years (OR 0.30, 95% CI 0.21-0.44) compared to the reference age category (18-59 years). Socioeconomic status, degree of multimorbidity, and excessive polypharmacy were not associated with the use of telemonitoring. CONCLUSIONS: The use of reimbursed telemonitoring for HF was limited up to 2019, and our results suggest that large variation exists among hospitals. A lack of adoption is therefore not only due to a lack of diffusion among hospitals but also due to a lack of scaling up within hospitals that already deploy telemonitoring. Future studies should therefore focus on both kinds of adoption and how to facilitate these processes. Older patients, female patients, and patients with no previous hospital treatment for HF were less likely to use telemonitoring for HF. This shows that some patient groups are not served as much by telemonitoring as other patient groups. The underlying mechanism of the reported associations should be identified in order to gain a deeper understanding of telemonitoring use among different patient groups.

Sustainable adoption of noninvasive telemonitoring for chronic heart failure: A qualitative study in the Netherlands.

Objective: Noninvasive telemonitoring aims to improve healthcare for patients with chronic heart failure (HF) by reducing hospitalizations and improving patient experiences. Yet, sustainable adoption seems to be limited. Therefore, the goal of our study is to gain insight in the processes that support sustainable adoption of telemonitoring for patients with HF. Methods: We conducted semi-structured interviews with 25 stakeholders that were involved with the adoption of telemonitoring, such as healthcare professionals, policymakers and healthcare insurers. We analyzed the interviews by using a combination of open-coding and the themes of the Non-adoption or Abandonment of technology by individuals and difficulties achieving Scale-up, Spread and Sustainability framework. Results: We found that telemonitoring projects have moved beyond initial pilot phases despite a high level of complexity on multiple topics. The patient selection, the business case, the evidence, the aims of telemonitoring, integration of telemonitoring in the care pathway, reimbursement, and future centralization were items that yielded different and sometimes contradictory opinions. Conclusions: This study showed that the sustainable adoption of telemonitoring for HF is a complex endeavor. Different aims and perspectives play an important role in the patient selection, design, evaluations and envisioned futures of telemonitoring. High conviction among participants of the added value that telemonitoring may support further adoption of telemonitoring. Structural evaluations will be needed to guide cyclical improvement and adapt programs to employ telemonitoring in such a manner that it contributes to collectively supported aims.

Low-value wound care: Are nurses and physicians choosing wisely? A mixed methods study.

BACKGROUND: Choosing Wisely is an international movement that stimulates conversations about unnecessary care. The campaign created five recommendations including a statement that less wound care is sometimes better. AIMS: The study aims to evaluate nurses' and physicians' adherence to the Choosing Wisely recommendations for acute wound care in the Netherlands and the barriers and facilitators to improve this. DESIGN: This is a mixed methods study using a survey and interviews. METHODS: The survey was completed by 171 nurses and 71 physicians from November 2017 to February 2018. A total of 17 nurses and 6 physicians were interviewed. RESULTS: Awareness of the five recommendations ranged from 62% to 89% for nurses and 46% to 85% for physicians. However, up to 15% of the nurses and 28% of physicians were aware but did not adhere to the recommendations. Barriers to adhering were a lack of knowledge, the work environment and perceptions of patients' preferences. Repeated attention, cost-consciousness and an open culture facilitated the implementation. CONCLUSION: Although most nurses and physicians were aware of the recommendations, not all adhered to them. Increasing awareness is not enough for successful implementation. A tailored approach that removes the barriers is necessary, such as increasing knowledge about wounds and changing the work environment.

Effect of ED-based transitional care interventions by healthcare professionals providing transitional care in the emergency department on clinical, process and service use outcomes: a systematic review.

OBJECTIVE: Suboptimal transitional care (ie, needs assessment and coordination of follow-up care) in the emergency department (ED) is an important cause of ED revisits and hospital admissions and may potentially harm patients, especially frail older adults. We aimed to systematically review the effect of ED-based interventions by health professionals who are dedicated to providing transitional care to older adults. DESIGN: Systematic review. MEASUREMENTS: We searched five biomedical databases for published (quasi)experimental studies evaluating the effects of health professionals in the ED dedicated to providing transitional care to older ED patients on clinical, process and/or service use outcomes. Reviewers screened studies for relevance and assessed methodological quality with published criteria (Robins-1 and the Cochrane risk of bias tool). Data were synthesised around study and intervention characteristics and outcomes of interest. RESULTS: From the 6561 references initially extracted from the databases, 12 studies were eligible for inclusion. Two types of interventions were identified, namely, individual needs assessment of ED patients (8 studies; 75%) and discharge planning and coordination of services (4 studies; 25%). Structured individual needs assessment was associated with a significant decrease in hospital admissions, hospital readmissions and ED revisits. Individualised discharge plans from the ED were associated with a significant decrease in ED revisits and hospital readmission. The overall methodological quality of the included studies was relatively low. CONCLUSIONS: Comprehensive assessment of patient needs and ED discharge planning and coordination of services by health professionals interested in transitional care can help optimise the transition of care for older ED patients and reduce the risk of costly and potentially harmful (re)admissions for this population. However, more robust research is needed on the effectiveness of these interventions aiming to improve clinical, process and service use outcomes. PROSPERO REGISTRATION NUMBER: CRD42021237345.

Use of regional transmural agreements to support the right care in the right place for patients with chronic heart failure-a qualitative study.

BACKGROUND: Chronic heart failure (CHF) poses a major challenge for healthcare systems. As these patients' needs vary over time in intensity and complexity, the coordination of care between primary and secondary care is critical for them to receive the right care in the right place. To support the continuum of care needed, Dutch regional transmural agreements (RTAs) between healthcare providers have been developed. However, little is known about how the stakeholders have experienced the development and use of these RTAs. The aim of this study was to gain insight into how stakeholders have experienced the development and use of RTAs for CHF and explore which factors affected this. METHODS: We interviewed 25 stakeholders from 9 Dutch regions based on the Measurement Instrument for Determinants of Innovations framework. Interview recordings were transcribed verbatim and analysed through open thematic coding. RESULTS: In most cases, the RTA development was considered relatively easy. However, the participants noted that sustainable use of the RTAs faced different complexities and influencing factors. These barriers concerned the following themes: education of primary care providers, referral process, patients' willingness, relationships between healthcare providers, reimbursement by health insurance companies, electronic health record (EHR) systems and outcomes. CONCLUSION: Some complexities, such as reimbursement and EHR systems, are likely to benefit from specialised support or a national approach. On a regional level, interregional learning can improve stakeholders' experiences. Future research should focus on quantitative effects of RTAs on outcomes and potential financing models for projects that aim to transition care from one setting to another.

Development of the SPREAD framework to support the scaling of de-implementation strategies: a mixed-methods study.

OBJECTIVE: We aimed to increase the understanding of the scaling of de-implementation strategies by identifying the determinants of the process and developing a determinant framework. DESIGN AND METHODS: This study has a mixed-methods design. First, we performed an integrative review to build a literature-based framework describing the determinants of the scaling of healthcare innovations and interventions. PubMed and EMBASE were searched for relevant studies from 1995 to December 2020. We systematically extracted the determinants of the scaling of interventions and developed a literature-based framework. Subsequently, this framework was discussed in four focus groups with national and international de-implementation experts. The literature-based framework was complemented by the findings of the focus group meetings and adapted for the scaling of de-implementation strategies. RESULTS: The literature search resulted in 42 articles that discussed the determinants of the scaling of innovations and interventions. No articles described determinants specifically for de-implementation strategies. During the focus groups, all participants agreed on the relevance of the extracted determinants for the scaling of de-implementation strategies. The experts emphasised that while the determinants are relevant for various countries, the implications differ due to different contexts, cultures and histories. The analyses of the focus groups resulted in additional topics and determinants, namely, medical training, professional networks, interests of stakeholders, clinical guidelines and patients' perspectives. The results of the focus group meetings were combined with the literature framework, which together formed the supporting the scaling of de-implementation strategies (SPREAD) framework. The SPREAD framework includes determinants from four domains: (1) scaling plan, (2) external context, (3) de-implementation strategy and (4) adopters. CONCLUSIONS: The SPREAD framework describes the determinants of the scaling of de-implementation strategies. These determinants are potential targets for various parties to facilitate the scaling of de-implementation strategies. Future research should validate these determinants of the scaling of de-implementation strategies.

Cascade of decisions meet personal preferences in sciatica treatment decisions.

STUDY DESIGN: An in-depth interview study including patients, general practitioners, neurologists and neurosurgeons. OBJECTIVE: To gain insight in decision-making in sciatica care, by identifying patients' and physicians' preferences for treatment options, and the differences between and within both groups. SUMMARY OF BACKGROUND DATA: Sciatica is a self-limiting condition, which can be treated both conservatively and surgically. The value of both options has been disputed, and the care pathway is known for a substantial amount of practice variation. Most Dutch patients are taken care of by general practitioners before they are referred to hospital-based neurologists, who might refer to a neurosurgeon, who can perform a surgical intervention. Dutch sciatica care thus follows the principles of stepped care, and a cascade of decisions precedes surgery. Better understanding of the decision-making within this cascade might reveal opportunities to improve shared decision-making and to reduce unwarranted practice variation. METHODS: Interviews with 10 patients and 22 physicians were analysed thematically. RESULTS: While physicians were confident of their clinical diagnosis, patients preferred confirmation trough imaging to exclude other possible explanations. Furthermore, many patients showed reluctance towards the use of (strong) opioids, while all physicians favoured this and underlined the benefits of opioids in the management of sciatica complaints, to buy time and to allow patients to recover naturally. Finally, individual physicians differed strongly in their opinion on benefits and optimal timing of surgical treatment and epidural injections. CONCLUSIONS: Dutch sciatica care is characterised by a cascade of decisions preceding surgery. Preferences differ within and between patients and physicians, which adds to the practice variation. To improve decision-making, physicians and patients should invest not necessarily more in the exchange of options or preferences, but in making sure the other understands the rationale behind them.

[From compliance with volume standards to learning from healthcare outcomes]. / Van voldoen aan volumenormen naar leren van zorguitkomsten.

The authors provide an update of an article about volume standards that was published in this journal in 2013. A systematic literature review uncovered trends in volume-outcomes research (2014-2021): studies focused on outcomes after concentration of care in the Netherlands, attempted to define volume thresholds and assessed whether experience in a specific operation can influence outcomes in similar procedures. Available research still does not shed much light on the mechanisms underlying the volume-outcome relationship. Nevertheless, professional associations look beyond volume and include multiple indicators of quality of care in their national quality standards. Professionals have also increasingly collaborated in regional networks where they share, compare and learn from outcomes. Three preconditions to enhance these efforts in "learning networks" are: the availability of reliable information about treatments and outcomes, adequate knowledge and support in selecting meaningful interventions, and lastly, an ambitious, collective goal which garners support from financiers and government bodies.

[Plans of the Rutte IV administration: more control by the government, less personnel, lower budget]. / De zorgplannen van Rutte IV.

The Rutte IV administration can and will spend much less on healthcare than its predecessor. A difficult task. Providing less low-value care, that is healthcare with no or little benefit for the patient given the alternatives, by physicians is one way to improve quality and reduce costs. Less low-value care will therefore play a crucial role in the plans of the Rutte IV administration. Low-value care is attractive on paper, but radical implementation will lead to new dilemmas. The government must therefore be prepared to make and manage more choices itself. Besides tension on professional autonomy, there is also the risk of (even) more administrative burdens for healthcare professionals, which has a bad effect on captivating and retaining healthcare professionals. How to keep the intrinsic motivation of professionals intact within the paradigm of appropriate care could well become the real dilemma for the new administration of Mark Rutte.

Low-value pharmaceutical care among Dutch GPs: a retrospective cohort study.

BACKGROUND: Low-value pharmaceutical care exists in general practice. However, the extent among Dutch GPs remains unknown. AIM: To assess the prevalence of low-value pharmaceutical care among Dutch GPs. DESIGN AND SETTING: Retrospective cohort study using data from patient records. METHOD: The prevalence of three types of pharmaceutical care prescribed by GPs between 2016 and 2019 were examined: topical antibiotics for conjunctivitis, benzodiazepines for non-specific lower back pain, and chronic acid-reducing medication (ARM) prescriptions. Multilevel logistic regression analysis was performed to assess prescribing variation and the influence of patient characteristics on receiving a low-value prescription. RESULTS: Large variation in prevalence as well as practice variation was observed among the types of low-value pharmaceutical GP care examined. Between 53% and 61% of patients received an inappropriate antibiotics prescription for conjunctivitis, around 3% of patients with lower back pain received an inappropriate benzodiazepine prescription, and 88% received an inappropriate chronic ARM prescription during the years examined. The odds of receiving an inappropriate antibiotic or benzodiazepine prescription increased with age (P<0.001), but decreased for chronic inappropriate ARM prescriptions (P<0.001). Sex affected only the odds of receiving a non-indicated chronic ARM, with males being at higher risk (P<0.001). The odds of receiving an inappropriate ARM increased with increasing neighbourhood socioeconomic status (P<0.05). Increasing practice size decreased the odds of inappropriate antibiotic and benzodiazepine prescriptions (P<0.001). CONCLUSION: The results show that the prevalence of low-value pharmaceutical GP care varies among these three clinical problems. Significant variation in inappropriate prescribing exists between different types of pharmaceutical care - and GP practices.

Advance care planning in primary care: a retrospective medical record study among patients with different illness trajectories.

BACKGROUND: Advance Care Planning (ACP) enables physicians to align healthcare with patients' wishes, reduces burdensome life-prolonging medical interventions, and potentially improves the quality of life of patients in the last phase of life. However, little objective information is available about the extent to which structured ACP conversations are held in general practice. Our aim was to examine the documentation of ACP for patients with cancer, organ failure and multimorbidity in medical records (as a proxy for ACP application) in Dutch general practice. METHODS: We chose a retrospective medical record study design in seven primary care facilities. Medical records of 119 patients who died non-suddenly (55 cancer, 28 organ failure and 36 multimorbidity) were analysed. Other variables were: general characteristics, data on ACP documentation, correspondence between medical specialist and general practitioner (GP), and healthcare utilization in the last 2 years of life. RESULTS: In 65% of the records, one or more ACP items were registered by the GP. Most often documented were aspects regarding euthanasia (35%), the preferred place of care and death (29%) and concerns and hopes towards the future (29%). Median timing of the first ACP conversation was 126 days before death (inter-quartile range (IQR) 30-316). ACP was more often documented in patients with cancer (84%) than in those with organ failure (57%) or multimorbidity (42%) (p = 0.000). Patients with cancer had the most frequent (median 3 times, IQR 2-5) and extensive (median 5 items, IQR 2-7) ACP consultations. CONCLUSION: Documentation of ACP items in medical records by GPs is present, however limited, especially in patients with multimorbidity or organ failure. We recommend more attention for - and documentation of - ACP in daily practice, in order to start anticipatory conversations in time and address the needs of all people living with advanced conditions in primary care.

Increased adherence to perioperative safety guidelines associated with improved patient safety outcomes: a stepped-wedge, cluster-randomised multicentre trial.

BACKGROUND: National Dutch guidelines have been introduced to improve suboptimal perioperative care. A multifaceted implementation programme (IMPlementatie Richtlijnen Operatieve VEiligheid [IMPROVE]) has been developed to support hospitals in applying these guidelines. This study evaluated the effectiveness of IMPROVE on guideline adherence and the association between guideline adherence and patient safety. METHODS: Nine hospitals participated in this unblinded, superiority, stepped-wedge, cluster RCT in patients with major noncardiac surgery (mortality risk ≥1%). IMPROVE consisted of educational activities, audit and feedback, reminders, organisational, team-directed, and patient-mediated activities. The primary outcome of the study was guideline adherence measured by nine patient safety indicators on the process (stop moments from the composite STOP bundle, and timely administration of antibiotics) and on the structure of perioperative care. Secondary safety outcomes included in-hospital complications, postoperative wound infections, mortality, length of hospital stay, and unplanned care. RESULTS: Data were analysed for 1934 patients. The IMPROVE programme improved one stop moment: 'discharge from recovery room' (+16%; 95% confidence interval [CI], 9-23%). This stop moment was related to decreased mortality (-3%; 95% CI, -4% to -1%), fewer complications (-8%; 95% CI, -13% to -3%), and fewer unscheduled transfers to the ICU (-6%; 95% CI, -9% to -3%). IMPROVE negatively affected one other stop moment - 'discharge from the hospital' - possibly because of the limited resources of hospitals to improve all stop moments together. CONCLUSIONS: Mixed implementation effects of IMPROVE were found. We found some positive associations between guideline adherence and patient safety (i.e. mortality, complications, and unscheduled transfers to the ICU) except for the timely administration of antibiotics. CLINICAL TRIAL REGISTRATION: NTR3568 (Dutch Trial Registry).

Cost-effectiveness of Restrictive Strategy Versus Usual Care for Cholecystectomy in Patients With Gallstones and Abdominal Pain (SECURE-trial).

OBJECTIVE: To perform a cost-effectiveness analysis of restrictive strategy versus usual care in patients with gallstones and abdominal pain. SUMMARY OF BACKGROUND DATA: A restrictive selection strategy for surgery in patients with gallstones reduces cholecystectomies, but the impact on overall costs and cost-effectiveness is unknown. METHODS: Data of a multicentre, randomized-controlled trial (SECURE-trial) were used. Adult patients with gallstones and abdominal pain were included. Restrictive strategy was economically evaluated against usual care from a societal perspective. Hospital-use of resources was gathered with case-report forms and out-of-hospital consultations, out-of-pocket expenses, and productivity loss were collected with questionnaires. National unit costing was applied. The primary outcome was the cost per pain-free patient after 12 months. RESULTS: All 1067 randomized patients (49.0 years, 73.7% females) were included. After 12 months, 56.2% of patients were pain-free in restrictive strategy versus 59.8% after usual care. The restrictive strategy significantly reduced the cholecystectomy rate with 7.7% and reduced surgical costs with €160 per patient, €162 was saved from a societal perspective. The cost-effectiveness plane showed that restrictive strategy was cost saving in 89.1%, but resulted in less pain-free patients in 88.5%. Overall, the restrictive strategy saved €4563 from a societal perspective per pain-free patient lost. CONCLUSIONS: A restrictive selection strategy for cholecystectomy saves €162 compared to usual care, but results in fewer pain-free patients. The incremental cost per pain-free patient are savings of €4563 per pain-free patient lost. The higher societal willingness to pay for 1 extra pain-free patient, the lower the probability that the restrictive strategy will be cost-effective. TRIAL REGISTRATION: The Netherlands National Trial Register NTR4022. Registered on 5 June 2013.

Overuse of diagnostic testing in healthcare: a systematic review.

BACKGROUND: Overuse of diagnostic testing substantially contributes to healthcare expenses and potentially exposes patients to unnecessary harm. Our objective was to systematically identify and examine studies that assessed the prevalence of diagnostic testing overuse across healthcare settings to estimate the overall prevalence of low-value diagnostic overtesting. METHODS: PubMed, Web of Science and Embase were searched from inception until 18 February 2020 to identify articles published in the English language that examined the prevalence of diagnostic testing overuse using database data. Each of the assessments was categorised as using a patient-indication lens, a patient-population lens or a service lens. RESULTS: 118 assessments of diagnostic testing overuse, extracted from 35 studies, were included in this study. Most included assessments used a patient-indication lens (n=67, 57%), followed by the service lens (n=27, 23%) and patient-population lens (n=24, 20%). Prevalence estimates of diagnostic testing overuse ranged from 0.09% to 97.5% (median prevalence of assessments using a patient-indication lens: 11.0%, patient-population lens: 2.0% and service lens: 30.7%). The majority of assessments (n=85) reported overuse of diagnostic testing to be below 25%. Overuse of diagnostic imaging tests was most often assessed (n=96). Among the 33 assessments reporting high levels of overuse (≥25%), preoperative testing (n=7) and imaging for uncomplicated low back pain (n=6) were most frequently examined. For assessments of similar diagnostic tests, major variation in the prevalence of overuse was observed. Differences in the definitions of low-value tests used, their operationalisation and assessment methods likely contributed to this observed variation. CONCLUSION: Our findings suggest that substantial overuse of diagnostic testing is present with wide variation in overuse. Preoperative testing and imaging for non-specific low back pain are the most frequently identified low-value diagnostic tests. Uniform definitions and assessments are required in order to obtain a more comprehensive understanding of the magnitude of diagnostic testing overuse.