Lack of effect of shorter turnaround time of microbiological procedures on clinical outcomes: a randomised controlled trial among hospitalised patients in the Netherlands.

Shortening the turnaround time of microbiological procedures was associated with an improved clinical outcome in two studies performed in the USA. To study the clinical impact of a shortened turnaround time in a northwest European setting in which an automated system was used for bacterial identification and susceptibility testing, a single-blind, prospective, randomised controlled trial was conducted in a hospital in the Netherlands. All hospitalised patients with a bacterial infection confirmed by culture were randomly assigned to a control (conventional) group or an intervention (rapid) group.

Patients and nurses determine variation in adherence to guidelines at Dutch hospitals more than internists or settings.

Aims: To measure adherence to recently developed diabetes guidelines at Dutch hospital outpatient clinics and distinguish determinants for variations in care on hospital, internist and patient levels.

Methods: Thirteen general hospitals with 58 internists recruited 1950 diabetic patients. Data were extracted from medical files (n = 1915) and from patient questionnaires (n = 1465).

Lifetime health effects and costs of diabetes treatment.

Background: This article presents cost-effectiveness analyses of the major diabetes interventions as formulated in the revised Dutch guidelines for diabetes type 2 patients in primary and secondary care. The analyses consider two types of care: diabetes control and the treatment of complications, each at current care level and according to the guidelines.

Methods: A validated probabilistic diabetes model describes diabetes and its complications over a lifetime in the Dutch population, computing quality-adjusted life years and medical costs.

Cost-effectiveness of glycemic control and ophthalmological care in diabetic retinopathy.

Aims: Glycemic control and ophthalmological care are known to significantly diminish the risk of visual impairment and blindness by diabetic retinopathy (DRP). The (cost-)effectiveness of both strategies was studied to highlight their benefits for patients and care providers.

Methods: A computer analysis was developed, following the progression of DRP and the effectiveness of metabolic control and ophthalmological care continuously and individually in cohorts of type I and type II DM patients with divergent degrees of compliance.

Medical audit: threat or opportunity for the medical profession. A comparative study of medical audit among medical specialists in general hospitals in The Netherlands and England, 1970-1999.

Medical audit has been introduced among hospital specialists in both the Netherlands and England. In the Netherlands following some local experiments, medical audit was promoted nationally as early as 1976 by the medical profession itself and became a mandatory activity under the Hospital Licensing Act of 1984. In England it was the government who promoted medical audit as a compulsory activity for medical specialists, in particular since 1989.

[Postoperative wound infections: a useful indicator of quality of care?].

An indicator can be defined as a measurable element of care that gives an impression of the quality of care. It can be used for screening on potential quality problems, for monitoring of well-defined processes and for a check after the introduction of quality improvement activities. Although the notion of an indicator appears to be an attractive concept in quality management, some questions have to be answered before a specific indicator can be used.

Diabetes nephropathy in the Netherlands: a cost effectiveness analysis of national clinical guidelines.

Background: In the Netherlands a program on quality assurance in medical care has started in 1996. Clinical professionals, patient organizations and health services researchers formulate evidence based guidelines with a concomitant cost-effectiveness analysis.

Objectives: To examine the cost-effectiveness of guideline recommendations for prevention of nephropathy in diabetes mellitus type 1 and 2.

[Appropriate treatment of benign prostatic hyperplasia; refining the indications for treatment by systematic analysis of expert opinion].

Objective: To assess systematically the opinion of urology experts regarding the appropriateness of indications for treatment of benign prostatic hyperplasia (BPH) and to evaluate the potential use of these expert opinions for the refinement of treatment guidelines.

Design: Modified Delphi procedure.

Methods: A panel of 12 Dutch urologists judged the appropriateness of three common treatments (surgery, alpha-adrenergic antagonists, finasteride) for 1152 hypothetical cases of BPH.

Continuous computer simulation analysis of the cost-effectiveness of screening and treating diabetic retinopathy.

This paper analyzes the cost-effectiveness of screening and treating diabetic retinopathy (DR) by simulating the disease progress continuously with existing data. A new computer simulation based on Monte Carlo techniques and logistic transformation follows cohorts from diabetes onset until death in five care scenarios. For younger-onset patients, ophthalmic care reduces the prevalence of blindness by 52% or greater while savings in disability facilities and production losses surpass direct costs.

Treatment choice for benign prostatic hyperplasia: a matter of urologist preference?

Purpose: New treatment modalities for benign prostatic hyperplasia (BPH) have considerably altered the decision making process in daily clinical practice. Guidelines provide a framework for treatment choice but leave much room for physician personal opinions. We identified and quantified determinants of treatment choice for BPH among urologists focusing on urologist treatment preferences.

[Therapy and prevention of coronary heart diseases through lowering of the serum cholesterol levels; third consensus 'Cholesterol'. Consensus Working Group, CBO].

For the second time the consensus text for lipid lowering therapy is revised. In angiographic studies it was shown that a decrease in the total cholesterol as well as the low-density lipoprotein cholesterol level results in a reduction of the progression of vascular disease. Furthermore, intervention trials demonstrated that therapy with cholesterol synthesis inhibitors reduces not only both the cardiovascular and total mortality, but also other manifestations of coronary heart disease (CHD).

[Guidelines and costs].

There is a growing interest in developing clinical guidelines which support the efficiency of medical care by weighting the potential benefits against the costs of interventions. In the recently developed Dutch guideline on reduction of serum cholesterol concentration a formal cost-effectiveness analysis is included. Based on epidemiological arguments a cost-effectiveness ratio of 40,000 Dutch guilders per life year gained was found.

Need for consensus development in prehospital emergency medicine: effect of an expert panel approach.

The objective of this study was to look at the need for consensus development in prehospital emergency medicine, and to determine the effect of an expert panel approach. The study took place in Euregio Scheldemond, comprising Sealand Flanders, The Netherlands, and Belgian Flanders, Belgium. Firstly, seven experts rated in organized mailings 153 (random selection out of 505) existing cases of acute or critically ill patients, situated in Dutch Sealand-Flanders.

Dissemination of guidelines: which sources do physicians use in order to be informed?

Objective: To gain insight into processes of dissemination of clinical guidelines, sources of information physicians use to become informed about them, and factors influencing these processes.

Design: National survey among a random sample of family physicians using a structured questionnaire.

Setting: Family practice in The Netherlands; evaluation of a national programme of (evidence based) practice guidelines.

Quality management of occupational health services: the necessity of a powerful medical profession.

Over the past few years there has been a growing interest in quality management in occupational health services. In this article the central role of the medical profession in this area is highlighted from a personal point of view. It is argued that a powerful and active profession is needed as a countervailing power in the field of tension between employees and the company, and for balancing the interests of these two main clients.

Coping strategies of enrolled nurses in nursing homes: shifting between organizational imperatives and residents' needs.

In today's nursing homes, which can be considered modern versions of "total institutions", enrolled nurses expend much energy coping with problems which arise from the day-to-day care of seriously impaired patients. The problems they encounter include the burden of never ending work, having to cope with deviant and problematic behaviour, handling emotional disturbance and, on a more abstract level, balancing self-interest and power with love and affection. The grounded theory approach was used to discover the coping strategies employed by enrolled nurses.

Quality systems in Dutch health care institutions.

The implementation of quality systems in Dutch health care was supervised by a national committee during 1990-1995. To monitor the progress of implementation a large survey was conducted in the beginning of 1995. The survey enclosed all subsectors in health care.

The use of outcome assessment: the clinician's concerns.

In the last few years increasing attention has been paid to outcome assessment within effectiveness studies, policy analysis and quality management. Dimensions of patients outcome that can be discerned are mortality, clinical parameters, health status and patient satisfaction. Some critical remarks have been placed on outcome assessment by clinicians.

Interpretation of uroflowmetry curves by urologists.

Purpose: Uroflowmetry has become a routine investigation in patients with symptoms of the lower urinary tract. Little is known about the variation in the use of uroflowmetry and in the interpretation of its outcomes. We investigated the diagnostic value of uroflowmetry as a freestanding test, and examined the interobserver and intra-observer variation in the interpretation of uroflowmetry curves.

[Free admission to stress electrocardiography with subsequent cardiological advice and feedback to the family physician: favorable effect on referral patterns].

Objective: To improve the patient referral by general practitioners to the cardiology outpatient clinic for evaluation of (possibly) anginal complaints, by giving access to in-hospital bicycle exercise testing with cardiological advice and feedback.

Design: Prospective.

Setting: Department of non-invasive cardiology 'De Weezenlanden' Hospital, Zwolle, the Netherlands.

[Variation in the diagnosis and treatment of benign prostatic hyperplasia in urological practice].

Objective: To analyse practice variation among urologists and its determinants with respect to diagnostics and therapy choice in benign prostatic hyperplasia (BPH).

Design: Cross-sectional.

Setting: Stratified sample of 12 urological practices throughout the Netherlands.

Quality of care: a comparison of preferences between medical specialists and patients with chronic diseases.

Unlabelled: In this study, we have looked for differences between medical specialists and patients with chronic diseases (COPD, rheumatoid arthritis and diabetes mellitus) in preferences of aspects of care in relation to the quality of care. Firstly, to enumerate relevant aspects for chronic diseases, open interviews and a concept mapping were conducted among patients with chronic disease, and medical specialists treating them. Here, the respondents have been asked to evaluate statements in relation to the quality of care.

The ambiguous relationship between practice variation and appropriateness of care: an agenda for further research.

The analysis of variation in the use of health care services, and particularly of practice variation, has been the subject of renewed interest because of the view that the inappropriate use of procedures could be a major cause of these differences. In this article, recent literature is reviewed and the results of personal research are described on both the variation in care provision and on appropriateness assessment. In the few studies which have focussed on both subjects no evidence has yet been found to suggest that practice variation is to be explained by differences in appropriateness rates.