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Lin H, Li Y, Ou S, Jiao X, Wang W, Humaidan P, Zhang Q. Role of the total progressive motile sperm count (TPMSC) in different infertility factors in IUI: a retrospective cohort study. BMJ Open 2021; 11:e040563. [PMID: 33550233 PMCID: PMC7925936 DOI: 10.1136/bmjopen-2020-040563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/26/2020] [Accepted: 12/02/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE The objective of this retrospective cohort study was to explore the optimal range of the total progressive motile sperm count (TPMSC) for live birth in couples with varying infertility diagnosis undergoing intrauterine insemination (IUI) in a university-affiliated teaching hospital. METHODS A total of 2647 couples and 5171 IUI cycles were included between January 2015 and December 2018. Of those, 1542 cycles were performed due to unexplained infertility, 1228 cycles due to anovulation, 1120 cycles due to mild male factor infertility and 122 cycles due to mild endometriosis. The primary outcome measure was live birth rate (LBR). The secondary outcome measure was clinical pregnancy rate (CPR). RESULTS The CPR and LBR were highest in patients with a diagnosis of anovulation compared with the other three groups of patients. The CPR and LBR in patients with unexplained, mild male factor and mild endometriosis were comparable. For the patients with mild male factor infertility, the CPR with prewash TPMSC of >75.0 M and postwash TPMSC of 65.10 M was above 10%, statistically significantly higher than other quartiles of TPMSC (p<0.05). The LBR with postwash TPMSC of >65.10 M was statistically significantly higher than other groups (p<0.05). However, in patients with unexplained infertility, the CPR and LBR were not statistically different in quartiles of TPMSC, being less than 10%. Overall, there was only one clinical pregnancy and no live birth in patients >40 years of age. CONCLUSIONS In conclusion, the infertility diagnosis plays a significant role for the patient undergoing IUI. Thus, the anovulatory patients benefitted most from IUI, irrespective of TPMSC. For patients with unexplained infertility, TPMSC does not affect the success rate of IUI. Overall,female patients more than 40 years old should not be referred to IUI.
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Affiliation(s)
- Haiyan Lin
- Reproductive center, Department of Obestetrics and Gynecology, Sun Yat-Sen University, Sun Yat-Sen Memorial Hospital, Guangzhou, China
| | - Yu Li
- Reproductive center, Department of Obestetrics and Gynecology, Sun Yat-Sen University, Sun Yat-Sen Memorial Hospital, Guangzhou, China
| | - Songbang Ou
- Reproductive center, Department of Obestetrics and Gynecology, Sun Yat-Sen University, Sun Yat-Sen Memorial Hospital, Guangzhou, China
| | - Xuedan Jiao
- Reproductive center, Department of Obestetrics and Gynecology, Sun Yat-Sen University, Sun Yat-Sen Memorial Hospital, Guangzhou, China
| | - Wenjun Wang
- Reproductive center, Department of Obestetrics and Gynecology, Sun Yat-Sen University, Sun Yat-Sen Memorial Hospital, Guangzhou, China
| | - Peter Humaidan
- The Fertility Clinic, Skive Regional Hospital, Skive, Faculty of Health, Aarhus University, Denmark
| | - Qingxue Zhang
- Reproductive center, Department of Obestetrics and Gynecology, Sun Yat-Sen University, Sun Yat-Sen Memorial Hospital, Guangzhou, China
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IJsbrandy C, Ottevanger PB, Gerritsen WR, van Harten WH, Hermens RPMG. Determinants of adherence to physical cancer rehabilitation guidelines among cancer patients and cancer centers: a cross-sectional observational study. J Cancer Surviv 2020; 15:163-177. [PMID: 32986232 PMCID: PMC7822788 DOI: 10.1007/s11764-020-00921-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 07/25/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE To tailor implementation strategies that maximize adherence to physical cancer rehabilitation (PCR) guidelines, greater knowledge concerning determinants of adherence to those guidelines is needed. To this end, we assessed the determinants of adherence to PCR guidelines in the patient and cancer center. METHODS We investigated adherence variation of PCR guideline-based indicators regarding [1] screening with the Distress Thermometer (DT), [2] information provision concerning physical activity (PA) and physical cancer rehabilitation programs (PCRPs), [3] advice to take part in PA and PCRPs, [4] referral to PCRPs, [5] participation in PCRPs, and [6] PA uptake (PAU) in nine cancer centers. Furthermore, we assessed patient and cancer center characteristics as possible determinants of adherence. Regression analyses were used to determine associations between guideline adherence and patient and cancer center characteristics. In these analyses, we assumed the patient (level 1) nested within the cancer center (level 2). RESULTS Nine hundred and ninety-nine patients diagnosed with cancer between January 2014 and June 2015 were included. Of the 999 patients included in the study, 468 (47%) received screening with the DT and 427 (44%) received information provision concerning PA and PCRPs. Subsequently, 550 (56%) patients were advised to take part in PA and PCRPs, which resulted in 174 (18%) official referrals. Ultimately, 280 (29%) patients participated in PCRPs, and 446 (45%) started PAU. Screening with the DT was significantly associated with information provision concerning PA and PCRPs (OR 1.99, 95% CI 1.47-2.71), advice to take part in PA and PCRPs (OR 1.79, 95% CI 1.31-2.45), referral to PCRPs (OR 1.81, 95% CI 1.18-2.78), participation in PCRPs (OR 2.04, 95% CI 1.43-2.91), and PAU (OR 1.69, 95% CI 1.25-2.29). Younger age, male gender, breast cancer as the tumor type, ≥2 cancer treatments, post-cancer treatment weight gain/loss, employment, and fatigue were determinants of guideline adherence. Less variation in scores of the indicators between the different cancer centers was found. This variation between centers was too low to detect any association between center characteristics with the indicators. CONCLUSIONS The implementation of PCR guidelines is in need of improvement. We found determinants at the patient level associated with guideline-based PCR care. IMPLICATIONS FOR CANCER SURVIVORS Implementation strategies that deal with the determinants of adherence to PCR guidelines might improve the implementation of PCR guidelines and the quality of life of cancer survivors.
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Affiliation(s)
- Charlotte IJsbrandy
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Science (RIHS), Radboud University Medical Center Nijmegen, PO Box 9101, Nijmegen, 6500, HB, The Netherlands. .,Department of Medical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands. .,Department of Radiation Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Petronella B Ottevanger
- Department of Medical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Winald R Gerritsen
- Department of Medical Oncology, Radboud Institute for Health Science (RIHS), Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Wim H van Harten
- Division of Psychosocial Research and Epidemiology, Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Health Technology and Services Research, MB-HTSR, University of Twente, Enschede, The Netherlands
| | - Rosella P M G Hermens
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud Institute for Health Science (RIHS), Radboud University Medical Center Nijmegen, PO Box 9101, Nijmegen, 6500, HB, The Netherlands
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Evaluating Adherence to Guideline-Based Quality Indicators for Postpartum Hemorrhage Care in the Netherlands Using Video Analysis. Obstet Gynecol 2018; 132:656-667. [DOI: 10.1097/aog.0000000000002781] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kang Y(S, Miller NA, Tzeng HM(HM, Zhang T. Race and mental health disorders’ impact on older patients’ nursing home admissions upon hospital discharge. Arch Gerontol Geriatr 2018; 78:269-274. [DOI: 10.1016/j.archger.2018.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 07/02/2018] [Accepted: 07/03/2018] [Indexed: 11/16/2022]
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Kersten FAM, Nelen WLDM, van den Boogaard NM, van Rumste MM, Koks CA, IntHout J, Verhoeve HR, Pelinck MJ, Boks DES, Gianotten J, Broekmans FJM, Goddijn M, Braat DDM, Mol BWJ, Hermens RPGM. Implementing targeted expectant management in fertility care using prognostic modelling: a cluster randomized trial with a multifaceted strategy. Hum Reprod 2017; 32:1648-1657. [PMID: 28591847 DOI: 10.1093/humrep/dex213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 05/19/2017] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION What is the effectiveness of a multifaceted implementation strategy compared to usual care on improving the adherence to guideline recommendations on expectant management for couples with unexplained infertility? SUMMARY ANSWER The multifaceted implementation strategy did not significantly increase adherence to guideline recommendations on expectant management compared to care as usual. WHAT IS KNOWN ALREADY Intrauterine insemination (IUI) with or without ovarian hyperstimulation has no beneficial effect compared to no treatment for 6 months after the fertility work-up for couples with unexplained infertility and a good prognosis of natural conception. Therefore, various professionals and policy makers have advocated the use of prognostic profiles and expectant management in guideline recommendations. STUDY DESIGN, SIZE, DURATION A cluster randomized controlled trial in 25 clinics in the Netherlands was conducted between March 2013 and May 2014. Clinics were randomized between the implementation strategy (intervention, n = 13) and care as usual (control, n = 12). The effect of the implementation strategy was evaluated by comparing baseline and effect measurement data. Data collection was retrospective and obtained from medical record research and a patient questionnaire. PARTICIPANTS/MATERIALS, SETTING, METHODS A total of 544 couples were included at baseline and 485 at the effect measurement (247 intervention group/238 control group). MAIN RESULTS AND THE ROLE OF CHANCE Guideline adherence increased from 49 to 69% (OR 2.66; 95% CI 1.45-4.89) in the intervention group, and from 49 to 61% (OR 2.03; 95% CI 1.38-3.00) in the control group. Multilevel analysis with case-mix adjustment showed that the difference of 8% was not statistically significant (OR 1.31; 95% CI 0.67-2.59). The ongoing pregnancy rate within six months after fertility work-up did not significantly differ between intervention and control group (25% versus 27%: OR 0.72; 95% CI 0.40-1.27). LIMITATIONS REASONS FOR CAUTION There is a possible selection bias, couples included in the study had a higher socio-economic status than non-responders. How this affects guideline adherence is unclear. Furthermore, when powering for this study we did not take into account the unexpected improvement of adherence in the control group. WIDER IMPLICATIONS OF THE FINDINGS Generalization of our results to other countries with recommendations on expectant management might be questionable because barriers for expectant management can be very different in other countries. Furthermore, due to a large variation in improved adherence rate in the intervention group it will be interesting to further analyse the process of implementation in each clinic with a process evaluation on professionals and couples' exposure to and experiences with the strategy. STUDY FUNDING/COMPETING INTEREST(S) Supported by Netherlands Organisation for Health Research and Development (ZonMW, project number 171203005). No competing interests. TRIAL REGISTRATION NUMBER Dutch trial Register, www.trialregister.nl NTR3405. TRIAL REGISTRATION DATE 19 April 2012. DATE OF FIRST PATIENT'S ENROLMENT 10 July 2012.
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Affiliation(s)
- F A M Kersten
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - W L D M Nelen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - N M van den Boogaard
- Department of Obstetrics and Gynaecology, VU University Medical Center, University of Amsterdam, PO Box 7057, Amsterdam MB 1007, The Netherlands
| | - M M van Rumste
- Department of Obstetrics and Gynaecology, Catharina Medical Center, PO Box 1350, 5602ZA Eindhoven, The Netherlands
| | - C A Koks
- Department of Obstetrics and Gynaecology, Maxima Medical Center, PO Box 7777, 5500 MB Veldhoven, The Netherlands
| | - J IntHout
- Radboud Institute for Health Sciences, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - H R Verhoeve
- Department of Obstetrics and Gynaecology, OLVG (Oost), PO Box 95500, 1090 HM Amsterdam, The Netherlands
| | - M J Pelinck
- Department of Obstetrics and Gynaecology, Scheper Ziekenhuis, PO Box 30002, 7800 RA Emmen, The Netherlands
| | - D E S Boks
- Department of Obstetrics and Gynaecology, Spaarne Ziekenhuis, PO Box 770, 2130 AT Hoofddorp, The Netherlands
| | - J Gianotten
- Department of Obstetrics and Gynaecology, Kennemer Gasthuis, PO Box 417, 2026 BW Haarlem, The Netherlands
| | - F J M Broekmans
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands
| | - M Goddijn
- Centre for Reproductive Medicine, Academic Medical Centre, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - D D M Braat
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - B W J Mol
- School of Paediatrics and Reproductive Health, University of Adelaide, The Robinson Institute, 5005 SA Adelaide, Australia
| | - R P G M Hermens
- Scientific institute for Quality of Healthcare, Radboud University Medical Center, PO Box 9101, 6500 HB Nijmegen, The Netherlands
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Kersten FAM, Hermens RPGM, Braat DDM, Tepe E, Sluijmer A, Kuchenbecker WK, Van den Boogaard N, Mol BWJ, Goddijn M, Nelen WLDM. Tailored expectant management in couples with unexplained infertility does not influence their experiences with the quality of fertility care. Hum Reprod 2015; 31:108-16. [PMID: 26573527 DOI: 10.1093/humrep/dev277] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 10/13/2015] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION Do couples who were eligible for tailored expectant management (TEM) and did not start treatment within 6 months after the fertility work-up, have different experiences with the quality of care than couples that were also eligible for TEM but started treatment right after the fertility work-up? SUMMARY ANSWER Tailored expectant management of at least 6 months in couples with unexplained infertility is not associated with the experiences with quality of care or trust in their physician. WHAT IS KNOWN ALREADY In couples with unexplained infertility and a good prognosis of natural conception within 1 year, expectant management for 6-12 months does not compromise ongoing birth rates and is equally as effective as starting medically assisted reproduction immediately. Therefore, TEM is recommended by various international clinical guidelines. Implementation of TEM is still not optimal because of existing barriers on both patient and professional level. An important barrier is the hesitance of professionals to counsel their patients for TEM because they fear that patients will be dissatisfied with care. However, if and how adherence to TEM actually affects the couples' experience with care is unknown. Experiences with the quality care can be measured by evaluating the patient-centredness of care and the patients' trust in their physician. STUDY DESIGN, SIZE, DURATION This is a retrospective cross-sectional study. A survey with written questionnaires was performed among all couples who participated in the retrospective audit of guideline adherence on TEM in 25 Dutch clinics. PARTICIPANTS/MATERIALS, SETTING, METHODS Couples were eligible to participate if they were diagnosed with unexplained infertility and had a good prognosis (>30%) of natural conception within 1 year based on the Hunault prediction model. We used patient's questionnaires to collect data on the couples' experience with the quality of care and possible confounders for their experiences other than having undergone TEM or not. Multilevel regression analyses were performed to investigate case-mix adjusted association of TEM with the patient-centredness of care (PCQ-Infertility) and the patients' trust in their physician (Wake Forest Trust Scale). MAIN RESULTS AND THE ROLE OF CHANCE Couples who adhered to TEM experienced the quality of care on the same level as couples who were exposed to early treatment, i.e. started fertility treatment within 6 months after fertility work-up. There were no associations between adherence to TEM and the patient-centredness of care or the patients' trust in their physician. LIMITATIONS, REASONS FOR CAUTION Because this study is retrospective, recall bias might occur. Furthermore, we were unable to measure the difference in experience with care over time. Therefore, our results have to be interpreted carefully. WIDER IMPLICATIONS OF THE FINDINGS Prospective research on couples undergoing TEM have to be performed to provide more detailed insight in the patients' experiences with the decision making process and subsequently the expectant period. Tackling the barriers surrounding TEM, i.e. better counselling and more patient information material, could further improve patient experiences with the quality of care for couples who are advised TEM. STUDY FUNDING/COMPETING INTERESTS Supported by Netherlands Organisation for Health Research and Development (ZonMW). ZonMW had no role in designing the study, data collection, analysis and interpretation of data or writing of the report. Competing interests: none. TRIAL REGISTRATION NUMBER www.trialregister.nl NTR3405.
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Affiliation(s)
- F A M Kersten
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - R P G M Hermens
- Scientific institute for Quality of Healthcare, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - D D M Braat
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - E Tepe
- Department of Obstetrics and Gynaecology, Slingeland Ziekenhuis, PO Box 169, 7000 AD, Doetinchem, The Netherlands
| | - A Sluijmer
- Department of Obstetrics and Gynaecology, Wilhelmina Ziekenhuis Assen, PO Box 30001, 9400 RA, Assen, The Netherlands
| | - W K Kuchenbecker
- Department of Obstetrics and Gynaecology, Isala Clinics, PO Box 10400, 8000 GK, Zwolle, The Netherlands
| | - N Van den Boogaard
- Department of Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, PO Box 22660, Amsterdam DD 1100, The Netherlands
| | - B W J Mol
- The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, 5005 SA Adelaide, Australia
| | - M Goddijn
- Centre for Reproductive Medicine, Academic Medical Centre, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - W L D M Nelen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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Spoorenberg V, Geerlings SE, Geskus RB, de Reijke TM, Prins JM, Hulscher MEJL. Appropriate antibiotic use for patients with complicated urinary tract infections in 38 Dutch Hospital Departments: a retrospective study of variation and determinants. BMC Infect Dis 2015; 15:505. [PMID: 26553143 PMCID: PMC4640398 DOI: 10.1186/s12879-015-1257-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2015] [Accepted: 10/31/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Appropriate antibiotic use in patients with complicated urinary tract infections can be measured by a valid set of nine quality indicators (QIs). We evaluated the performance of these QIs in a national setting and investigated which determinants influenced appropriate antibiotic use. For the latter, we distinguished patient, department and hospital characteristics, including organizational interventions aimed at improving the quality of antibiotic use (antibiotic stewardship elements). METHODS A retrospective, observational multicentre study included 1964 patients (58% male sex) with a complicated urinary tract infection treated at Internal Medicine and Urology departments of 19 Dutch university and non-university hospitals. Data of 50 patients per department were extracted from medical charts. QI performance scores were calculated using previously constructed algorithms. Department and hospital characteristics were collected using questionnaires filled in by an internal medicine physician and an urologist. Regression analysis was performed to identify determinants of QI performance. Clustering at department and hospital level was taken into account through inclusion of random effects in a multi-level model. RESULTS Median QI performance of departments varied between 31% ('Treat urinary tract infection in men according to local guideline') and 77% ('Perform urine culture'). The patient characteristics non-febrile urinary tract infection, female sex and presence of a urinary catheter were negatively associated with performance on many QIs. The presence of an infectious diseases physician and an antibiotic formulary were positively associated with 'Prescribe empirical therapy according to guideline'. No other department or hospital characteristics, including stewardship elements, were consistently associated with better QI performance. CONCLUSIONS A large inter-department variation was demonstrated in the appropriateness of antibiotic use. In particular certain patient characteristics (more than department or hospital characteristics) influenced the quality of antibiotic use. Some, but not all antibiotic stewardship elements did translate into better QI performance.
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Affiliation(s)
- V Spoorenberg
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands.
| | - S E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands.
| | - R B Geskus
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, Amsterdam, The Netherlands.
| | - T M de Reijke
- Department of Urology, Academic Medical Centre, Amsterdam, The Netherlands.
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, Academic Medical Centre, Amsterdam, The Netherlands.
| | - M E J L Hulscher
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Stienen JJC, Hermens RPMG, Wennekes L, van de Schans SAM, van der Maazen RWM, Dekker HM, Liefers J, van Krieken JHJM, Blijlevens NMA, Ottevanger PB. Variation in guideline adherence in non-Hodgkin's lymphoma care: impact of patient and hospital characteristics. BMC Cancer 2015; 15:578. [PMID: 26253203 PMCID: PMC4529707 DOI: 10.1186/s12885-015-1547-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 07/14/2015] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND The objective of this observational study was to assess the influence of patient, tumor, professional and hospital related characteristics on hospital variation concerning guideline adherence in non-Hodgkin's lymphoma (NHL) care. METHODS Validated, guideline-based quality indicators (QIs) were used as a tool to assess guideline adherence for NHL care. Multilevel logistic regression analyses were used to calculate variation between hospitals and to identify characteristics explaining this variation. Data for the QIs regarding diagnostics, therapy, follow-up and organization of care, together with patient, tumor and professional related characteristics were retrospectively collected from medical records; hospital characteristics were derived from questionnaires and publically available data. RESULTS Data of 423 patients diagnosed with NHL between October 2010 and December 2011 were analyzed. Guideline adherence, as measured with the QIs, varied considerably between the 19 hospitals: >20 % variation was identified in all 20 QIs and high variation between the hospitals (>50 %) was seen in 12 QIs, most frequently in the treatment and follow-up domain. Hospital variation in NHL care was associated more than once with the characteristics age, extranodal involvement, multidisciplinary consultation, tumor type, tumor aggressiveness, LDH level, therapy used, hospital region and availability of a PET-scanner. CONCLUSION Fifteen characteristics identified at the patient level and at the hospital level could partly explain hospital variation in guideline adherence for NHL care. Particularly age was an important determinant: elderly were less likely to receive care as measured in the QIs. The identification of determinants can be used to improve the quality of NHL care, for example, for standardizing multidisciplinary consultations in daily practice.
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Affiliation(s)
- Jozette J C Stienen
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center (Radboud umc), PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Rosella P M G Hermens
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center (Radboud umc), PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Lianne Wennekes
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center (Radboud umc), PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | - Saskia A M van de Schans
- Netherlands Comprehensive Cancer Organisation, Department of Registry and Research, PO box 19079, 3501 DB, Utrecht, the Netherlands.
| | | | - Helena M Dekker
- Department of Radiology, Radboud university medical center, Nijmegen, the Netherlands.
| | - Janine Liefers
- Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud university medical center (Radboud umc), PO Box 9101, 6500 HB, Nijmegen, the Netherlands.
| | | | - Nicole M A Blijlevens
- Department of Hematology, Radboud university medical center, Nijmegen, The Netherlands.
| | - Petronella B Ottevanger
- Department of Medical Oncology, Radboud university medical center, Nijmegen, the Netherlands.
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Kersten FAM, Hermens RPGM, Braat DDM, Hoek A, Mol BWJ, Goddijn M, Nelen WLDM. Overtreatment in couples with unexplained infertility. Hum Reprod 2014; 30:71-80. [PMID: 25336712 DOI: 10.1093/humrep/deu262] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
STUDY QUESTION What is the percentage of overtreatment, i.e. fertility treatment started too early, in couples with unexplained infertility who were eligible for tailored expectant management? SUMMARY ANSWER Overtreatment occurred in 36% of couples with unexplained infertility who were eligible for an expectant management of at least 6 months. WHAT IS KNOWN ALREADY Prognostic models in reproductive medicine can help to identify infertile couples that would benefit from fertility treatment. In couples with unexplained infertility with a good chance of natural conception within 1 year, based on the Hunault prediction model, an expectant management of 6-12 months, as recommended in international fertility guidelines, prevents unnecessary treatment. STUDY DESIGN, SIZE, DURATION A retrospective cohort study in 25 participating clinics, with follow-up of all couples who were seen for infertility in 2011-2012. PARTICIPANTS/MATERIALS, SETTING, METHODS In all, 9818 couples were seen for infertility in the participating clinics. Couples were eligible to participate if they were diagnosed with unexplained infertility and had a good prognosis of natural conception (>30%) within 1 year based on the Hunault prediction model. Data to assess overtreatment were collected from medical records. Multilevel regression analyses were performed to investigate associations of overtreatment with patient and clinic characteristics. MAIN RESULTS AND THE ROLE OF CHANCE Five hundred and forty-four couples eligible for expectant management were included in this study. Among these, overtreatment, i.e. starting medically assisted reproduction within 6 months, occurred in 36%. The underlying quality indicators showed that in 34% no prognosis was calculated and that in 42% expectant management was not recommended. Finally, 16% of the couples for whom a correct recommendation of expectant management for at least 6 months was made, started treatment within 6 months anyway. Overtreatment was associated with childlessness, higher female age and a longer duration of infertility. No associations between overtreatment and clinic characteristics were found. LIMITATIONS, REASONS FOR CAUTION The response rate was low compared with other fertility studies. Evaluation of possible selection bias showed that responders had a higher socio-economic status than non-responders. WIDER IMPLICATIONS OF THE FINDINGS Our findings show that developing and publishing guideline recommendations on tailored expectant management (TEM) is not enough and that overtreatment still occurs frequently. Future research should focus on tailored efforts to implement guideline recommendations on TEM. STUDY FUNDING/COMPETING INTERESTS Supported by Netherlands Organisation for Health Research and Development (ZonMW). ZonMW had no role in designing the study, data collection, analysis and interpretation of data or writing of the report. Competing interests: none. TRIAL REGISTRATION NUMBER www.trialregister.nl NTR3405.
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Affiliation(s)
- F A M Kersten
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, Nijmegen 6500 HB, The Netherlands
| | - R P G M Hermens
- Scientific Institute for Quality of Healthcare, Radboud University Medical Center, PO Box 9101, Nijmegen 6500 HB, The Netherlands
| | - D D M Braat
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, Nijmegen 6500 HB, The Netherlands
| | - A Hoek
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, PO Box 30.001, Groningen 9700 RB, The Netherlands
| | - B W J Mol
- The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, 5005 SA Adelaide, Australia
| | - M Goddijn
- Centre for Reproductive Medicine, Academic Medical Centre, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - W L D M Nelen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, PO Box 9101, Nijmegen 6500 HB, The Netherlands
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