[show abstract][hide abstract] ABSTRACT: Objective
To develop a prognostic model for antenatal prediction of neonatal mortality in infants threatening to be born very preterm (< 32 weeks).
Nationwide cohort study in The Netherlands between 1999 and 2007. We studied 8,500 singletons born between 25+0 and 31+6 weeks of gestation where fetus was alive at birth without congenital anomalies. We developed a multiple logistic regression model to estimate the risk of neonatal mortality within 28 days after birth, based on characteristics that are known before birth. We used bootstrapping techniques for internal validation. Discrimination (AUC), accuracy (Brier score) and calibration (graph, c-statistics) were used to assess the model's predictive performance.
Neonatal mortality occurred in 766 (90 per 1000) live births. The final model consisted of seven variables. Predictors were low gestational age, no antental corticosteroids, male gender, maternal age ≥ 35 years, Caucasian ethnicity, non-cephalic presentation and non-3rd level of hospital. The predicted probabilities ranged from 0.003 to 0.697 (IQR 0.02-0.11). The model had an AUC of 0.83, the Brier score was 0.065. The calibration graph showed good calibration, and the test for the Hosmer Lemeshow c-statistic showed no lack of fit (p = 0.43).
Neonatal mortality can be predicted for very preterm births based on the antenatal factors gestational age, antental corticosteroids, fetal gender, maternal age, ethnicity, presentation and level of hospital. This model can be helpful in antenatal counselling.
European Journal of Obstetrics & Gynecology and Reproductive Biology. 01/2014;
[show abstract][hide abstract] ABSTRACT: The aim of this study was to assess the classification accuracy of an e-Nose in detecting acute liver failure (ALF) in rats. Exhaled breath from 14 rats was repeatedly sampled by e-Nose (8 sensors) and an additional external CO2 sensor at three stages: healthy period; portacaval shunt; and during the development of ALF due to surgically induced complete liver ischemia. We performed principal component analysis (PCA) on the (grouped) sensor data in each stage and the classification accuracy of the first two principal components was assessed by the leave-one-out approach. In addition we performed gas chromatography-mass spectrometry (GC-MS) analysis of the exhaled breath from three rats. The first and second principal components from the PCA analysis of e-Nose data accounted for more than 95% variance in the data. Measurements in the ALF stage were contrasted with the measurements in the control stage. Leave-one-out validation showed classification accuracy of 96%. This accuracy was reached after 3h of ALF development, and was reached already after 2h when data of an external CO2 sensor were also included. GC-MS identified 2-butanol, 2-butanone, 2-pentanone and 1-propanol to be possibly elevated in the ALF stage. This is the first study to demonstrate that ALF in rats can be detected by e-Nose data analysis of the exhaled breath. Confirmation of these results in humans will be an important step forward in the non-invasive diagnosis of ALF.
[show abstract][hide abstract] ABSTRACT: Polypharmacy, and specifically the use of multiple fall-risk-increasing drugs (FRID), have been associated with increased risk of falling in older age. However, it is not yet clear whether the known set of FRIDs can be extrapolated to recurrent fallers, since they form a distinct group of more vulnerable older persons with different characteristics.
We aim to investigate which classes of medications are associated with recurrent falls in elderly patients visiting the Emergency Department (ED) after a fall.
This study had a cross-sectional design and was conducted in the ED of an academic medical center. Patients who sustained a fall, 65 years or older, and who visited the ED between 2004 and 2010 were invited to fill in a validated fall questionnaire designed to assess patient and fall characteristics (CAREFALL Triage Instrument [CTI]). We translated self-reported medications to anatomical therapeutic chemical (ATC) codes (at the second level). Univariate logistic regression analysis was performed to explore the association between medication classes and the outcome parameter (recurrent fall). Multivariate logistic regression was used to assess the associations after adjustment to potential confounders.
In total 2,258 patients participated in our study, of whom 39 % (873) had sustained two or more falls within the previous year. After adjustment for the potential confounders, drugs for acid-related disorders (adjusted odds ratio [aOR] 1.29; 95 % CI 1.03-1.60), analgesics (aOR 1.22; 95 % CI 1.06-1.41), anti-Parkinson drugs (aOR 1.59; 95 % CI 1.02-2.46), nasal preparations (aOR 1.49; 95 % CI 1.07-2.08), ophthalmologicals (aOR 1.51; 95 % CI 1.10-2.09); antipsychotics (aOR 2.21; 95 % CI 1.08-4.52), and antidepressants (aOR 1.64; 95 % CI 1.13-2.37) remained statistically significantly associated with an ED visit due to a recurrent fall.
Known FRIDs, such as psychotropic drugs, also increase the risk of recurrent falls. However, we found four relatively new classes that showed significant association with recurrent falls. In part, these classes may act as markers of frailty and comorbidity, or they may reflect differences in the risk factors affecting the older, frailer population that tends to sustain recurrent falls. Further investigation is needed to elucidate causes and ways to prevent recurrent falls.
[show abstract][hide abstract] ABSTRACT: To analyze the influence of using mortality 1, 3, and 6 months after intensive care unit (ICU) admission instead of in-hospital mortality on the quality indicator standardized mortality ratio (SMR).
A cohort study of 77,616 patients admitted to 44 Dutch mixed ICUs between 1 January 2008 and 1 July 2011. Four Acute Physiology and Chronic Health Evaluation (APACHE) IV models were customized to predict in-hospital mortality and mortality 1, 3, and 6 months after ICU admission. Models' performance, the SMR and associated SMR rank position of the ICUs were assessed by bootstrapping.
The customized APACHE IV models can be used for prediction of in-hospital mortality as well as for mortality 1, 3, and 6 months after ICU admission. When SMR based on mortality 1, 3 or 6 months after ICU admission was used instead of in-hospital SMR, 23, 36, and 30 % of the ICUs, respectively, received a significantly different SMR. The percentages of patients discharged from ICU to another medical facility outside the hospital or to home had a significant influence on the difference in SMR rank position if mortality 1 month after ICU admission was used instead of in-hospital mortality.
The SMR and SMR rank position of ICUs were significantly influenced by the chosen endpoint of follow-up. Case-mix-adjusted in-hospital mortality is still influenced by discharge policies, therefore SMR based on mortality at a fixed time point after ICU admission should preferably be used as a quality indicator for benchmarking purposes.
European Journal of Intensive Care Medicine 08/2013; · 5.17 Impact Factor
[show abstract][hide abstract] ABSTRACT: To assess the impact of applying a multifaceted activating performance feedback strategy on intensive care patient outcomes compared with passively receiving benchmark reports.
The Information Feedback on Quality Indicators study was a cluster randomized trial, running from February 2009 to May 2011.
Thirty Dutch closed-format ICUs that participated in the national registry. Study duration per ICU was sixteen months.
We analyzed data on 25,552 admissions. Admissions after coronary artery bypass graft surgery were excluded.
The intervention aimed to activate ICUs to undertake quality improvement initiatives by formalizing local responsibility for acting on performance feedback, and supporting them with increasing the impact of their improvement efforts. Therefore, intervention ICUs established a local, multidisciplinary quality improvement team. During one year, this team received two educational outreach visits, monthly reports to monitor performance over time, and extended, quarterly benchmark reports. Control ICUs only received four standard quarterly benchmark reports.
The extent to which the intervention was implemented in daily practice varied considerably among intervention ICUs: the average monthly time investment per quality improvement team member was 4.1 hours (SD, 2.3; range, 0.6-8.1); the average number of monthly meetings per quality improvement team was 5.7 (SD, 4.5; range, 0-12). ICU length of stay did not significantly reduce after 1 year in intervention units compared with controls (hazard ratio, 1.02 [95% CI, 0.92-1.12]). Furthermore, the strategy had no statistically significant impact on any of the secondary measures (duration of mechanical ventilation, proportion of out-of-range glucose measurements, and all-cause hospital mortality).
In the context of ICUs participating in a national registry, applying a multifaceted activating performance feedback strategy did not lead to better patient outcomes than only receiving periodical registry reports.
Critical care medicine 08/2013; 41(8):1893-1904. · 6.37 Impact Factor
[show abstract][hide abstract] ABSTRACT: To propose a combined disease management and process modeling approach for evaluating and improving care processes, and demonstrate its usability and usefulness in a real-world fall management case study.
We identified essential disease management related concepts and mapped them into explicit questions meant to expose areas for improvement in the respective care processes. We applied the disease management oriented questions to a process model of a comprehensive real world fall prevention and treatment program covering primary and secondary care. We relied on interviews and observations to complete the process models, which were captured in UML activity diagrams. A preliminary evaluation of the usability of our approach by gauging the experience of the modeler and an external validator was conducted, and the usefulness of the method was evaluated by gathering feedback from stakeholders at an invitational conference of 75 attendees.
The process model of the fall management program was organized around the clinical tasks of case finding, risk profiling, decision making, coordination and interventions. Applying the disease management questions to the process models exposed weaknesses in the process including: absence of program ownership, under-detection of falls in primary care, and lack of efficient communication among stakeholders due to missing awareness about other stakeholders' workflow. The modelers experienced the approach as usable and the attendees of the invitational conference found the analysis results to be valid.
The proposed disease management view of process modeling was usable and useful for systematically identifying areas of improvement in a fall management program. Although specifically applied to fall management, we believe our case study is characteristic of various disease management settings, suggesting the wider applicability of the approach.
International Journal of Medical Informatics 07/2013; · 2.06 Impact Factor
[show abstract][hide abstract] ABSTRACT: Patients with atrial fibrillation (AF) are at increased risk for stroke. Antithrombotic treatment reduces this risk. Antithrombotic treatment consists of either administration of oral anticoagulants (OAC) or the provision of an antiplatelet drug. International guidelines provide advice on the preferred treatment, thereby balancing the risks and benefits of OAC. However, adherence to these guidelines is reported to be as low as 50%. There is paucity in research on why adherence rates are low. Recent studies have shown decision support systems can improve guideline adherence. We investigate the use of a clinical decision support system to improve guideline adherence among general practitioners (GPs) treating patients with AF and study reasons for guideline non-adherence.
The study is a randomized controlled trial, which is performed among Dutch general practitioners. Initially, GPs in the vicinity of the Academic Medical Center (AMC) in Amsterdam will be included, after which other practices will be recruited. We have developed a novel decision support system that displays a list with pending messages for the on-screen medical record in real time,. Messages are generated on a server that evaluates a decision rule based on the atrial fibrillation guideline of the Dutch College of General Practitioners. By interacting with the list, messages can be opened for a description and explanation, or be ignored. GPs are allocated into three groups: 1) control group; 2) intervention group A, in which messages can be ignored without justification; and 3) intervention group B, in which messages can only be ignored with justification.Our main outcome measure is the between-group difference in the proportion of patients receiving antithrombotic prescriptions in adherence to the Dutch GP guideline for atrial fibrillation. Secondary outcomes are reasons GPs state for deviating from the guideline and the effect on guideline adherence of requiring justification when ignoring a message.
This paper describes the protocol for a cluster randomized trial to study the effects of a clinical decision support system in patients with atrial fibrillation. The system is characterized by a non-interruptive presentation and real-time messages that are updated after each relevant action the GP performs.Trial registration: This trial is registered with the Dutch Trial Register under registration number 3570.
[show abstract][hide abstract] ABSTRACT: & Aims: Guidelines recommend prescribing gastroprotective agents (proton-pump inhibitors, misoprostol) to older patients (primarily ≥65 y old) taking non-steroidal anti-inflammatory drugs (NSAIDs) to prevent gastrointestinal ulcers. Older individuals are under-represented in clinical trials of these agents. We systematically reviewed evidence from observational studies on the use of gastroprotective agents in elderly patients and their ability to prevent NSAID-related ulcers in this population.
We performed a systematic search of Embase and MedLine, and identified 23 observational studies that focused on elderly patients and reported data on co-prescription of gastroprotective agents and NSAIDs and/or the effectiveness of the agents in preventing gastrointestinal events in NSAID users. We collected data on rates of co-prescription and NSAID-related gastrointestinal events in patients with and without gastroprotection.
A median of 24% (range 10%-69%) of elderly patients taking NSAIDs received a co-prescription for gastroprotective agents; this percentage was only slightly higher in the oldest age groups. All studies of efficacy showed a positive effect of gastroprotection. However, the adjusted results were not suitable for synthesis, and the 5 studies reporting unadjusted results were too heterogeneous for meta-analysis (I(2) =97%). The studies differed in outcomes, definitions of co-prescription, and differences in baseline risk factors between patients with and without gastroprotection. None of the studies assessed adverse effects of gastroprotective agents. The 2 cost-effectiveness studies reached opposing conclusions.
In a systematic review, the observational evidence for the efficacy of gastroprotective agents in preventing NSAID-associated gastrointestinal events was in agreement with results of randomized controlled trials. However, due to heterogeneity of included studies, it is not clear what the effect would be if more patients were treated, or at what age gastroprotection should be recommended. We offer suggestions to facilitate comparison with other work and address the questions of risk and benefit in relation to age.
Clinical gastroenterology and hepatology: the official clinical practice journal of the American Gastroenterological Association 06/2013; · 5.64 Impact Factor
[show abstract][hide abstract] ABSTRACT: OBJECTIVE:: To assess the impact of applying a multifaceted activating performance feedback strategy on intensive care patient outcomes compared with passively receiving benchmark reports. DESIGN:: The Information Feedback on Quality Indicators study was a cluster randomized trial, running from February 2009 to May 2011. SETTING:: Thirty Dutch closed-format ICUs that participated in the national registry. Study duration per ICU was sixteen months. PATIENTS:: We analyzed data on 25,552 admissions. Admissions after coronary artery bypass graft surgery were excluded. INTERVENTION:: The intervention aimed to activate ICUs to undertake quality improvement initiatives by formalizing local responsibility for acting on performance feedback, and supporting them with increasing the impact of their improvement efforts. Therefore, intervention ICUs established a local, multidisciplinary quality improvement team. During one year, this team received two educational outreach visits, monthly reports to monitor performance over time, and extended, quarterly benchmark reports. Control ICUs only received four standard quarterly benchmark reports. MEASUREMENTS AND RESULTS:: The extent to which the intervention was implemented in daily practice varied considerably among intervention ICUs: the average monthly time investment per quality improvement team member was 4.1 hours (SD,2.; range, 0.6-8.1); the average number of monthly meetings per quality improvement team was 5.7 (SD, 4.5; range, 0-12). ICU length of stay did not reduce significantly after 1 year in intervention units compared with controls (hazard ratio, 1.02 [95% CI, 0.92-1.12]). Furthermore, the strategy had no statistically significant impact on any of the secondary measures (duration of mechanical ventilation, proportion of out-of-range glucose measurements, and all-cause hospital mortality). CONCLUSIONS:: In the context of ICUs participating in a national registry, applying a multifaceted activating performance feedback strategy did not lead to better patient outcomes than only receiving periodical registry reports.
Critical care medicine 06/2013; · 6.37 Impact Factor
[show abstract][hide abstract] ABSTRACT: OBJECTIVES:: To assess the mortality risk of ICU patients after hospital discharge and compare it to mortality of the general Dutch population. DESIGN:: Cohort study of ICU admissions from a national ICU registry linked to administrative records from an insurance claims database. SETTING:: Eighty-one Dutch ICUs. PATIENTS:: ICU patients (n = 91,203) who were discharged alive from the hospital between January 1, 2007, and October 1, 2010. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: The unadjusted observed survival was inspected by Kaplan-Meier curves. Mortality risk at 1, 2, and 3 years after hospital discharge was 12.5%, 19.3%, and 27.5%, respectively. The 3-year mortality after hospital discharge in ICU patients was higher than the weighted average of the gender and age-specific death risks of the general Dutch population (27.5% versus 8.2%). The 1-year mortality after hospital discharge was adjusted for case-mix differences by a set of determinants which showed a statistically significant influence on the outcome in a 10-fold cross validation. The elective and cardiac surgical patients have statistically significantly better mortality outcomes (adjusted hazard ratio, 0.73 and 0.28, respectively), whereas medical patients and patients admitted for cancer have statistically significantly worse mortality outcomes (adjusted hazard ratio, 1.41, 1.94, respectively) compared with other ICU patients. Urgent surgery patients and patients with a subarachnoid hemorrhage, trauma, acute renal failure, or severe community-acquired pneumonia did not differ statistically from the other ICU patients after adjustment for case-mix differences. CONCLUSIONS:: In-hospital mortality underestimates the true mortality of ICU patients as the mortality in the first months after hospital discharge is substantial. Most ICU patients still have an increased mortality risk in the subsequent years after hospital discharge compared with the general Dutch population. The mortality after hospital discharge differs widely between ICU subgroups. Future studies should focus on the analysis of mortality after hospital discharge that is attributable to the former ICU admission.
Critical care medicine 05/2013; 41(5):1229-1236. · 6.37 Impact Factor
[show abstract][hide abstract] ABSTRACT: OBJECTIVES:: First, to conduct a literature review on the long-term mortality of ICU patients and its determinants. Second, to assess the influence of the found determinants on the 3, 6, and 12 months mortality after hospital discharge in the Dutch ICU population. DESIGN:: Combination of a literature review to evaluate determinants of long-term mortality and a Dutch cohort study in which the found determinants are applied. SETTING:: PubMed and EMBASE were searched on English written articles published between 1966 and 2011. The cohort study was conducted in ICU patients from 81 Dutch mixed ICUs. DATA:: A total of 24 articles with a main focus on describing or predicting the case-mix adjusted long-term mortality of the general ICU population were identified. The cohort study consisted of 48,107 ICU patients who were discharged alive from the hospital between January 1, 2007 and October 1, 2010. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS:: The included articles are summarized on patient and study characteristics, methods, results, and determinants used for case-mix adjustment. Additionally, the quality of the included articles was assessed using a checklist for studies on long-term survival. The median mortality rate of the general ICU population 1 yr after ICU admission was 24% (range 16% to 44%). The determinants used for case-mix adjustment differed widely between the studies. In the cohort study, we found that age, reason for ICU admission, and comorbidities were associated with all long-term mortality endpoints. However, the magnitude and direction of the influence by these determinants differed for the different endpoints (i.e., 3, 6, and 12 months after hospital discharge). CONCLUSIONS:: The long-term mortality found in the included articles was difficult to compare due to low quality, variation in case-mix, study design, and differences in case-mix adjustment. The most commonly used determinants in the literature were comparable to the most important determinants found in the Dutch cohort study.
Critical care medicine 02/2013; · 6.37 Impact Factor
[show abstract][hide abstract] ABSTRACT: Abstract Objective: To evaluate whether maternal ethnicity affects perinatal mortality by week of gestation from 39 weeks onwards. Study design: In this cohort study, we used data from the nationwide Netherlands Perinatal Registry from 1999 until 2008. All singleton infants born between 39+0 and 42+6 weeks of gestation without congenital anomalies were included. We used crude and multivariate logistic regression analyses with white Europeans as the reference to calculate the adjusted odds ratios (aOR) of South Asian, African and Mediterranean women. The main outcome measure was perinatal mortality (antepartum and intrapartum/neonatal mortality within 7 days after birth). Results: We studied 1,092,255 singleton deliveries. Perinatal mortality occurred in 2315 infants (2.1‰). There was interaction between gestational age and ethnicity (P<0.0001). In week 40 (40+0-40+6) South Asian (aOR 1.9; 95% CI 1.1-3.4) and Mediterranean (aOR 1.3; 95% CI 1.04-1.7) women had an increased risk of perinatal mortality. The perinatal mortality risk became greater in week 41 for South Asian (aOR 4.5 95% CI 2.8-7.2), African (aOR 2.2; 95%CI 1.4-3.4) and Mediterranean (aOR 2.2; 95% CI 1.8-2.9) women, especially among small for gestational age infants. Conclusion: With increasing gestational age beyond 39 weeks, perinatal mortality risk increases more strongly among South Asian, African and Mediterranean women compared to European whites.
Journal of Perinatal Medicine 01/2013; · 1.95 Impact Factor
[show abstract][hide abstract] ABSTRACT: The internet is viewed as an important channel for patient empowerment, enabling patients to feel more knowledgeable and take action to improve their own health. Internet use among seniors in the Netherlands is increasing, but it is not known if they also use it for health information, nor if seeking information on the internet has different consequences for empowerment than seeking information from other sources. We sought to investigate seniors' use of the internet compared to other resources for health information, and the consequences in terms of both subjective responses and actions taken. Using an email invitation and a web survey, we surveyed 100 elderly internet users, of which 85% had used the internet for health information. The consequences were similar for information found via internet and other sources, and generally positive. Over half reported feeling more knowledgeable and 51% reported making lifestyle changes, but fewer reported having taken other actions (e.g. discussing the information with their doctor). Encouraging the translation of knowledge into action represents an opportunity for empowerment in this population.
Studies in health technology and informatics 01/2013; 192:457-60.
[show abstract][hide abstract] ABSTRACT: Dutch general practices have a high adoption rate for computerized patient records and clinical decision support. We sought to measure the attitudes and experience of Dutch general practitioners towards clinical decision support. Methods: A preliminary survey was created based on questions from published surveys, modified with the results of interviews. The final web-based survey was administered to 43 general practitioners in a practice area where a decision support implementation is planned. Results: Thirty general practitioners (70%) completed the survey. Most felt that decision support is a good idea (23/30), although fewer reported positive experience with decision support (10/30). Participants were supportive of rules and guidelines, but commonly had the sense that there were too many alerts. Conclusion: Dutch clinicians are positive about decision support, but future efforts should try to reduce the perception of overload, for example by ensuring that alerts are relevant and choosing less interruptive forms of notification for less severe alerts.
Studies in health technology and informatics 01/2013; 186:56-60.
[show abstract][hide abstract] ABSTRACT: To determine adequacy of antithrombotic treatment in patients with non-valvular atrial fibrillation. To determine risk factors for under- and over-treatment.
Retrospective, cross-sectional study of electronic health records from 36 general practitioners in 2008.
General practice in the Netherlands.
Primary care physicians (n = 36) and patients (n = 981) aged 65 years and over.
Rates of adequate, under and over-treatment, risk factors for under and over-treatment.
Of the 981 included patients with a mean of age 78, 18% received no antithrombotic treatment (under-treatment), 13% received antiplatelet drugs and 69% received oral anticoagulation (OAC). Further, 43% of the included patients were treated adequately, 26% were under-treated, and 31% were over-treated. Patients with a previous ischaemic stroke were at high risk for under-treatment (OR 2.4, CI 1.6-3.5), whereas those with contraindications for OAC were at high risk for over-treatment (OR 37.0, CI 18.1-79.9). Age over 75 (OR 0.2, CI: 0.1-0.3]), diabetes (OR 0.1, CI: 0.1-0.3), heart failure (OR 0.2, CI: 0.1-0.3), hypertension (OR 0.1, CI: 0.1-0.2) and previous ischaemic stroke (OR 0.04, CI: 0.02-0.11) protected against over-treatment.
In general practice, CHADS2-criteria are being used, but the antithrombotic treatment of patients with atrial fibrillation frequently deviates from guidelines on this topic. Patients with previous stroke are at high risk of not being prescribed OAC. Contraindications for OAC, however, seem to be frequently overlooked.
PLoS ONE 01/2013; 8(7):e67806. · 3.73 Impact Factor