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Kallen MC, Hulscher MEJL, Elzer B, Geerlings SE, van der Linden PD, Teerenstra S, Natsch S, Opmeer BC, Prins JM. A multicentre cluster-randomized clinical trial to improve antibiotic use and reduce length of stay in hospitals: comparison of three measurement and feedback methods. J Antimicrob Chemother 2021; 76:1625-1632. [PMID: 33638644 PMCID: PMC8120330 DOI: 10.1093/jac/dkab035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/20/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Various metrics of hospital antibiotic use might assist in guiding antimicrobial stewardship (AMS). OBJECTIVES To compare patient outcomes in association with three methods to measure and feedback information on hospital antibiotic use when used in developing an AMS intervention. METHODS Three methods were randomly allocated to 42 clusters from 21 Dutch hospitals: (1) feedback on quantity of antibiotic use [DDD, days-of-therapy (DOT) from hospital pharmacy data], versus feedback on (2) validated, or (3) non-validated quality indicators from point prevalence studies. Using this feedback together with an implementation tool, stewardship teams systematically developed and performed improvement strategies. The hospital length of stay (LOS) was the primary outcome and secondary outcomes included DOT, ICU stay and hospital mortality. Data were collected before (February-May 2015) and after (February-May 2017) the intervention period. RESULTS The geometric mean hospital LOS decreased from 9.5 days (95% CI 8.9-10.1, 4245 patients) at baseline to 9.0 days (95% CI 8.5-9.6, 4195 patients) after intervention (P < 0.001). No differences in effect on LOS or secondary outcomes were found between methods. Feedback on quality of antibiotic use was used more often to identify improvement targets and was preferred over feedback on quantity of use. Consistent use of the implementation tool seemed to increase effectiveness of the AMS intervention. CONCLUSIONS The decrease in LOS versus baseline likely reflects improvement in the quality of antibiotic use with the stewardship intervention. While the outcomes with the three methods were otherwise similar, stewardship teams preferred data on the quality over the quantity of antibiotic use.
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Affiliation(s)
- M C Kallen
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
| | - M E J L Hulscher
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - B Elzer
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
| | - S E Geerlings
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
| | - P D van der Linden
- Tergooi Hospital, Department of Clinical Pharmacy, Van Riebeeckweg 212, Hilversum, The Netherlands
| | - S Teerenstra
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department for Health Evidence, Group Biostatistics, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - S Natsch
- Radboud University Medical Center, Department of Pharmacy, Geert Grooteplein Zuid 10, Nijmegen, The Netherlands
| | - B C Opmeer
- Amsterdam UMC, University of Amsterdam, Clinical Research Unit, Meibergdreef 9, Amsterdam, The Netherlands
| | - J M Prins
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, Amsterdam, The Netherlands
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2
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Thilly N, Pereira O, Schouten J, Hulscher MEJL, Pulcini C. Proxy indicators to estimate the appropriateness of medications prescribed by paediatricians in infectious diseases: a cross-sectional observational study based on reimbursement data. JAC Antimicrob Resist 2020; 2:dlaa086. [PMID: 34223041 PMCID: PMC8209962 DOI: 10.1093/jacamr/dlaa086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 09/08/2020] [Indexed: 11/14/2022] Open
Abstract
Background We previously developed proxy indicators (PIs) that can be used to estimate the appropriateness of medications used for infectious diseases (in particular antibiotics) in primary care, based on routine reimbursement data that do not include clinical indications. Objectives To: (i) select the PIs that are relevant for children and estimate current appropriateness of medications used for infectious diseases by French paediatricians and its variability while using these PIs; (ii) assess the clinimetric properties of these PIs using a large regional reimbursement database; and (iii) compare performance scores for each PI between paediatricians and GPs in the paediatric population. Methods For all individuals living in north-eastern France, a cross-sectional observational study was performed analysing National Health Insurance data (available at prescriber and patient levels) regarding antibiotics prescribed by their paediatricians in 2017. We measured performance scores of the PIs, and we tested their clinimetric properties, i.e. measurability, applicability and room for improvement. Results We included 116 paediatricians who prescribed a total of 44 146 antibiotic treatments in 2017. For all four selected PIs (seasonal variation of total antibiotic use, amoxicillin/second-line antibiotics ratio, co-prescription of anti-inflammatory drugs and antibiotics), we found large variations between paediatricians. Regarding clinimetric properties, all PIs were measurable and applicable, and showed high improvement potential. Performance scores did not differ between these 116 paediatricians and 3087 GPs. Conclusions This set of four proxy indicators might be used to estimate appropriateness of prescribing in children in an automated way within antibiotic stewardship programmes.
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Affiliation(s)
- N Thilly
- Université de Lorraine, APEMAC, Nancy, France.,Université de Lorraine, CHRU-Nancy, Département Méthodologie, Promotion, Investigation, Nancy, France
| | - O Pereira
- Direction Régionale du Service Médical Grand Est, Nancy, France
| | - J Schouten
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Department of Intensive Care Medicine, Nijmegen, The Netherlands
| | - M E J L Hulscher
- Radboud University Medical Centre, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Nijmegen, The Netherlands
| | - C Pulcini
- Université de Lorraine, APEMAC, Nancy, France.,Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, Nancy, France
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3
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Verweij MF, Rump BO, Timen A, Hulscher MEJL. [Ethically responsible care for MDRO carriers]. Ned Tijdschr Geneeskd 2020; 164:D4286. [PMID: 32073788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Dutch healthcare institutions are relatively successful in preventing outbreaks of antibiotic-resistant pathogens, thus protecting vulnerable patients. However, measures taken to prevent the introduction and spread of MDROs can be burdensome for asymptomatic carriers of such bacteria or for people who may have been exposed to them. This leads to ethical dilemmas. On the basis of a study of the impact of being a carrier and precautionary measures on carrier well-being, we present an ethical framework for responsible care for carriers. We argue that solidarity requires that the burden of prevention and control of resistance is to be shouldered by society as a whole. It is not right to see this problem primarily as a conflict between the protection of vulnerable patients on the one hand and carriers on the other.
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Affiliation(s)
- M F Verweij
- Wageningen University & Research, afd. Communication, Philosophy and Technology
- Contact: M.F. Verweij
| | - B O Rump
- Rijksinstituut voor Volksgezondheid en Milieu, Centrum Infectieziektebestrijding, Bilthoven
| | - A Timen
- Rijksinstituut voor Volksgezondheid en Milieu, Centrum Infectieziektebestrijding, Bilthoven
| | - M E J L Hulscher
- Radboudumc, Scientific Center for Quality of Healthcare (IQ healthcare), Nijmegen
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4
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Kallen MC, Ten Oever J, Prins JM, Kullberg BJ, Schouten JA, Hulscher MEJL. A survey on antimicrobial stewardship prerequisites, objectives and improvement strategies: systematic development and nationwide assessment in Dutch acute care hospitals. J Antimicrob Chemother 2019; 73:3496-3504. [PMID: 30252063 DOI: 10.1093/jac/dky367] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/15/2018] [Indexed: 12/30/2022] Open
Abstract
Background Stewardship guidelines define three essential building blocks for successful hospital antimicrobial stewardship programmes (ASPs): stewardship prerequisites, stewardship objectives and improvement strategies. Objectives We systematically developed a survey, based on these building blocks, to evaluate the current state of antimicrobial stewardship in hospitals. We tested this survey in 64 Dutch acute care hospitals. Methods We performed a literature review on surveys of antimicrobial stewardship. After extraction and categorization of survey questions, five experts merged and rephrased questions during a consensus meeting. After a pilot study, the survey was sent to 80 Dutch hospitals. Results The final survey consisted of 46 questions, categorized into hospital characteristics, stewardship prerequisites, stewardship objectives and stewardship strategies. The response rate was 80% (n = 64). Ninety-four percent of hospitals had established an antimicrobial stewardship team, consisting of at least one hospital pharmacist and one clinical microbiologist. An infectious diseases specialist was present in 68% of the teams. Nine percent had dedicated IT support. Forty-one percent of the teams were financially supported, with a median of 0.6 full-time equivalents (FTE; 0.1-1.8). The majority of hospitals performed monitoring of restricted antibiotic agents (91%), dose optimization (65%), bedside consultation (56%) and intravenous-to-oral switch (53%). Fifty-eight percent of the hospitals provided education to residents and 28% to specialists. Conclusions The survey provides information on the progress that is being made in hospitals regarding the three building blocks of a successful ASP, and provides clear aims to strengthen ASPs. Ultimately, these data will be related to national data on antibiotic consumption and resistance.
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Affiliation(s)
- M C Kallen
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, Meibergdreef 9, 1105 AZ Amsterdam, Amsterdam, The Netherlands
| | - J Ten Oever
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, Meibergdreef 9, 1105 AZ Amsterdam, Amsterdam, The Netherlands
| | - B J Kullberg
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - J A Schouten
- Department of Intensive Care Medicine, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands.,Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - M E J L Hulscher
- Scientific Center for Quality of Healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
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5
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Kallen MC, Binda F, Ten Oever J, Tebano G, Pulcini C, Murri R, Beovic B, Saje A, Prins JM, Hulscher MEJL, Schouten JA. Comparison of antimicrobial stewardship programmes in acute-care hospitals in four European countries: A cross-sectional survey. Int J Antimicrob Agents 2019; 54:338-345. [PMID: 31200022 DOI: 10.1016/j.ijantimicag.2019.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 05/20/2019] [Accepted: 06/02/2019] [Indexed: 12/17/2022]
Abstract
Antimicrobial stewardship programmes (ASPs) are designed to improve antibiotic use. A survey was systematically developed to assess ASP prerequisites, objectives and improvement strategies in hospitals. This study assessed the current state of ASPs in acute-care hospitals throughout Europe. A survey containing 46 questions was disseminated to acute-care hospitals: all Dutch (n = 80) and Slovenian (n = 29), 215 French (25%, random stratified sampling) and 62 Italian (49% of hospitals with an infectious diseases department, convenience sampling) acute-care hospitals, for a Europe-wide assessment. Response rates for the Netherlands (Nl), Slovenia (Slo), France (Fr) and Italy (It) were 80%, 86%, 45% and 66%. There was variation between countries in the prerequisites met and the objectives and improvement strategies chosen. A formal ASP was present mainly in the Netherlands (90%) and France (84%) compared with Slovenia (60%) and Italy (60%). Presence of an antimicrobial stewardship (AMS) team ranged from 42% (Fr) to 94% (Nl). Salary support for AMS teams was provided in 68% (Fr), 51% (Nl), 33% (Slo) and 12% (It) of surveyed hospitals. Quantity of antibiotic use was monitored in the majority of hospitals, ranging from 72% (Nl) to 100% (Slo and Fr) of acute-care hospitals. Participating countries varied substantially in the use of 'prospective monitoring and advice' as a strategy to improve AMS objectives. ASP prerequisites, objectives and improvement activities vary considerably across Europe, with room for improvement. Stimulating appropriate system prerequisites throughout Europe, e.g. by introducing staffing standards and financial support for ASPs, seems a first priority.
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Affiliation(s)
- M C Kallen
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, Amsterdam, the Netherlands.
| | - F Binda
- Université de Lorraine, APEMAC, Nancy, France; University of Milan, Department of Biomedical and Clinical Sciences 'Luigi Sacco', Milan, Italy
| | - J Ten Oever
- Radboud University Medical Center, Department of Internal Medicine, Geert Grooteplein Zuid 10, Nijmegen, the Netherlands
| | - G Tebano
- Department of Infectious Diseases, Pitié-Salpêtrière Hospital, AP-PH, Paris, France; Sorbonne University, UPMC Univ. Paris 06, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
| | - C Pulcini
- Université de Lorraine, APEMAC, Nancy, France; Université de Lorraine, CHRU-Nancy, Infectious Diseases Department, Nancy, France
| | - R Murri
- Institute of Infectious Diseases, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - B Beovic
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - A Saje
- Department of Infectious Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - J M Prins
- Amsterdam UMC, University of Amsterdam, Department of Internal Medicine, Division of Infectious Diseases, Meibergdreef 9, Amsterdam, the Netherlands
| | - M E J L Hulscher
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Geert Grooteplein Zuid 10, Nijmegen, the Netherlands
| | - J A Schouten
- Radboud University Medical Center, Radboud Institute for Health Sciences, Scientific Center for Quality of Healthcare (IQ healthcare), Geert Grooteplein Zuid 10, Nijmegen, the Netherlands; Radboud University Medical Center, Department of Intensive Care Medicine, Geert Grooteplein Zuid 10, Nijmegen, the Netherlands.
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6
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Kallen MC, Natsch S, Opmeer BC, Hulscher MEJL, Schouten JA, Prins JM, van der Linden P. How to measure quantitative antibiotic use in order to support antimicrobial stewardship in acute care hospitals: a retrospective observational study. Eur J Clin Microbiol Infect Dis 2018; 38:347-355. [PMID: 30478815 DOI: 10.1007/s10096-018-3434-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 11/12/2018] [Indexed: 10/27/2022]
Abstract
A cornerstone of antimicrobial stewardship programs (ASPs) is monitoring quantitative antibiotic use. Frequently used metrics are defined daily dose (DDD) and days of therapy (DOT). The purpose of this study was (1) to explore for the hospital setting the possibilities of quantitative data retrieval on the level of medical specialty and (2) to describe factors affecting the usability and interpretation of these quantitative metrics. We performed a retrospective observational study, measuring overall systemic antibiotic use at specialty level over a 1-year period, from December 1st 2014 to December 1st 2015, in one university and 13 non-university hospitals in the Netherlands. We distinguished surgical and non-surgical adult specialties. The association between DDDs, calculated from aggregated dispensing data, and DOTs, calculated from patient-level prescription data, was explored descriptively and related to organizational factors, data sources (prescription versus dispensing data), data registration, and data extraction. Twelve hospitals were able to extract dispensing data (DDD), three of which on the level of medical specialty; 13 hospitals were able to extract prescription data (DOT), 11 of which by medical specialty. A large variation in quantitative antibiotic use was found between hospitals and the correlation between DDDs and DOTs at specialty level was low. Differences between hospitals related to organizational factors, data sources, data registration, and data extraction procedures likely contributed to the variation in quantitative use and the low correlation between DDDs and DOTs. The differences in healthcare organization, data sources, data registration, and data extraction procedures contributed to the variation in reported quantitative use between hospitals. Uniform registration and extraction procedures are necessary for appropriate measurement and interpretation and benchmarking of quantitative antibiotic use.
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Affiliation(s)
- Marlot C Kallen
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - S Natsch
- Department of Clinical Pharmacy, Radboud University Medical Center, Comeniuslaan 4, 6525 HP, Nijmegen, The Netherlands
| | - B C Opmeer
- Clinical Research Unit, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M E J L Hulscher
- Scientific Center for Quality of healthcare (IQ healthcare), Radboud Institute for Health Sciences, Radboud University Medical Center, Comeniuslaan 4, 6525 HP, Nijmegen, The Netherlands
| | - J A Schouten
- Department of Intensive Care Medicine, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands.,Department of Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Comeniuslaan 4, 6525 HP, Nijmegen, The Netherlands
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Paul van der Linden
- Department of Clinical Pharmacy, Tergooi Hospital, Van Riebeeckweg 212, 1213 XZ, Hilversum, The Netherlands.
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7
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Ten Oever J, Harmsen M, Schouten J, Ouwens M, van der Linden PD, Verduin CM, Kullberg BJ, Prins JM, Hulscher MEJL. Human resources required for antimicrobial stewardship teams: a Dutch consensus report. Clin Microbiol Infect 2018; 24:1273-1279. [PMID: 30036665 DOI: 10.1016/j.cmi.2018.07.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 07/07/2018] [Accepted: 07/08/2018] [Indexed: 12/19/2022]
Abstract
SCOPE Antimicrobial stewardship teams are responsible for implementing antimicrobial stewardship programmes (ASP). However, in many countries, lack of funding challenges this obligation. A consensus procedure was performed to investigate which structural activities need to be performed by Dutch stewardship teams and how much time (and thus full-time equivalent (FTE) labor) is needed to perform these activities. METHODS In 2015, an electronic survey, based on a nonsystematic literature search and interviews with seven experienced stewardship teams, was sent to 21 stewardship teams that performed an ASP. This was followed by a semistructured face-to-face consensus meeting. Fourteen stewardship teams completed the survey (18% of Dutch acute-care hospitals), and 13 participated in the consensus meeting. RECOMMENDATIONS The hours needed each year are dependent on hospital size and number of stewardship objectives monitored. If all activities are performed at a minimal base (one stewardship objective; minimal staffing standard), time investment was estimated to be 1393 to 2680 hours annually in the early phase, corresponding with 0.87 (300 beds) to 1.68 FTE (1200 beds), with a further increase to minimally 1.25 to 3.18 FTE in the following years with three stewardship objectives monitored (optimal staffing standards during the first few years of implementing an ASP). This consensus on required human resources provides a directive for structural financial support of stewardship teams in the Dutch context. Some stewardship activities (and related time investments) might be specific to the Dutch context and hospital setting. To develop standards for other settings, our methodology could be applied.
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Affiliation(s)
- J Ten Oever
- Department of Internal Medicine, Radboud University Medical Center, The Netherlands; Radboud Center for Infectious Diseases, Nijmegen, The Netherlands.
| | - M Harmsen
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, The Netherlands
| | - J Schouten
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, The Netherlands; Department of Intensive Care Medicine, Radboud University Medical Center, The Netherlands; Radboud Center for Infectious Diseases, Nijmegen, The Netherlands
| | - M Ouwens
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, The Netherlands
| | - P D van der Linden
- Department of Clinical Pharmacy, Tergooi Hospital, Hilversum, The Netherlands
| | - C M Verduin
- Laboratory for Medical Microbiology, Stichting PAMM, Veldhoven, The Netherlands
| | - B J Kullberg
- Department of Internal Medicine, Radboud University Medical Center, The Netherlands; Radboud Center for Infectious Diseases, Nijmegen, The Netherlands
| | - J M Prins
- Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - M E J L Hulscher
- Scientific Center for Quality of Healthcare (IQ Healthcare), Radboud University Medical Center, The Netherlands; Radboud Center for Infectious Diseases, Nijmegen, The Netherlands
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8
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Hulscher MEJL, Prins JM. Antibiotic stewardship: does it work in hospital practice? A review of the evidence base. Clin Microbiol Infect 2017; 23:799-805. [PMID: 28750920 DOI: 10.1016/j.cmi.2017.07.017] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 07/13/2017] [Accepted: 07/15/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Guidelines for developing and implementing stewardship programmes include recommendations on appropriate antibiotic use to guide the stewardship team's choice of potential stewardship objectives. They also include recommendations on behavioural change interventions to guide the team's choice of potential interventions to ensure that professionals actually use antibiotics appropriately in daily practice. AIMS To summarize the evidence base of both appropriate antibiotic use recommendations (the 'what') and behavioural change interventions (the 'how') in hospital practice. SOURCES Published systematic reviews/Medline. CONTENT The literature shows low-quality evidence of the positive effects of appropriate antibiotic use in hospital patients. The literature shows that any behavioural change intervention might work to ensure that professionals actually perform appropriate antibiotic use recommendations in daily practice. Although effects were overall positive, there were large differences in improvement between studies that tested similar change interventions. IMPLICATIONS The literature showed a clear need for studies that apply appropriate study designs- (randomized) controlled designs-to test the effectiveness of appropriate antibiotic use on achieving meaningful outcomes. Most current studies used designs prone to confounding by indication. In the process of selecting behavioural change interventions that might work best in a chosen setting, much should be learned from behavioural sciences. The challenge for stewardship teams lies in selecting change interventions on the careful assessment of barriers and facilitators, and on a theoretical base while linking determinants to change interventions. Future studies should apply more robust designs and evaluations when assessing behavioural change interventions.
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Affiliation(s)
- M E J L Hulscher
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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9
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van Daalen FV, Kallen MC, van den Bosch CMA, Hulscher MEJL, Geerlings SE, Prins JM. Clinical condition and comorbidity as determinants for blood culture positivity in patients with skin and soft-tissue infections. Eur J Clin Microbiol Infect Dis 2017; 36:1853-1858. [PMID: 28589426 PMCID: PMC5602079 DOI: 10.1007/s10096-017-3001-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 04/24/2017] [Indexed: 11/28/2022]
Abstract
The utility of performing blood cultures in patients with a suspected skin infection is debated. We investigated the association between blood culture positivity rates and patients' clinical condition, including acute disease severity and comorbidity. We performed a retrospective study, including patients with cellulitis and wound infection who had been enrolled in three Dutch multicenter studies between 2011 and 2015. Patients' acute clinical condition was assessed using the Modified Early Warning Score (MEWS; severe: MEWS ≥2) and comorbidity with the Charlson Comorbidity Index (CCI; severe: CCI ≥2). A total of 334 patients with a suspected skin infection were included. Blood cultures were performed in 175 patients (52%), 28 of whom (16%) had a positive blood culture. Data on the clinical condition were collected in 275 patients. Blood cultures were performed in 76% of the patients with a severe acute condition, compared with 48% with a non-severe acute condition (OR 3.5; 95% confidence interval: 2.0-6.2; p < 0.001). Blood cultures were positive in 18% and 12% respectively (OR 1.7 (0.7-4.1); p = 0.3). Blood cultures were performed in 53% of patients with severe comorbidity, compared with 61% without severe comorbidity (OR 0.7; 0.4-1.2; p = 0.2). Blood cultures were positive in 25% and 10% respectively (OR = 3.1; 1.2-7.5; p = 0.02). The blood culture positivity rate among hospitalized patients diagnosed with skin infections was higher than the rates reported by the Infectious Diseases Society of America guidelines, particularly in patients with severe comorbidity. Therefore, the recommendations concerning blood culture performance in patients with a skin infection should be reconsidered.
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Affiliation(s)
- F V van Daalen
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Room F4-132, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands.
| | - M C Kallen
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Room F4-132, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - C M A van den Bosch
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Room F4-132, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - M E J L Hulscher
- Department of Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Center, Nijmegen, the Netherlands
| | - S E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Room F4-132, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Room F4-132, Meibergdreef 9, 1105 AZ, Amsterdam, the Netherlands
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10
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Hommel I, Wollersheim H, Tack CJ, Mulder J, van Gurp PJ, Hulscher MEJL. Impact of a multifaceted strategy to improve perioperative diabetes care. Diabet Med 2017; 34:278-285. [PMID: 27087429 DOI: 10.1111/dme.13130] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2016] [Indexed: 11/29/2022]
Abstract
AIMS To assess the impact of a multifaceted strategy to improve perioperative diabetes care throughout the hospital care pathway. METHODS We conducted a controlled before-and-after study in six hospitals. The purpose of the strategy was to target four predominant barriers that obstruct optimal care delivery. We provided feedback on baseline indicator performance, developed a multidisciplinary protocol and patient information, and provided professional education. After a 6-month intervention, we determined the performance changes against three outcome indicators and nine process indicators using data on 811 patients with diabetes who underwent major surgery. The progress of the interventions was monitored closely. RESULTS Two process indicators improved significantly in the intervention hospitals: the proportion of patients for whom glycaemic control had been evaluated preoperatively increased by 9% (P < 0.002) and the proportion of patients with blood glucose measurements within 1 h after surgery increased by 29% (P < 0.0001). Four other process indicators and all three outcome indicators improved more in the intervention hospitals than in the control hospitals, but the differences were not statistically significant. These included the proportion of patients with all glucose values at 6-10 mmol/l (+3%) and the proportion of patients with hyperglycaemia (-8%). The implementation of the multidisciplinary protocol was still ongoing after the 6-month intervention period. CONCLUSIONS The multifaceted improvement strategy had a limited impact on the quality of perioperative diabetes care. This study demonstrates the complexity of improving perioperative diabetes care throughout the multiprofessional hospital care pathway.
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Affiliation(s)
- I Hommel
- Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
| | - H Wollersheim
- Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
| | - C J Tack
- Department of Internal Medicine, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - J Mulder
- Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
| | - P J van Gurp
- Department of Internal Medicine, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - M E J L Hulscher
- Scientific Institute for Quality of Healthcare, Nijmegen, The Netherlands
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11
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van Daalen FV, Prins JM, Opmeer BC, Boermeester MA, Visser CE, van Hest RM, Branger J, Mattsson E, van de Broek MFM, Roeleveld TC, Karimbeg AA, Haak EAF, van den Hout HC, van Agtmael MA, Hulscher MEJL, Geerlings SE. Effect of an antibiotic checklist on length of hospital stay and appropriate antibiotic use in adult patients treated with intravenous antibiotics: a stepped wedge cluster randomized trial. Clin Microbiol Infect 2017; 23:485.e1-485.e8. [PMID: 28159671 DOI: 10.1016/j.cmi.2017.01.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/24/2017] [Accepted: 01/25/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Quality indicators (QIs) have been developed to define appropriate antibiotic use in hospitalized patients. We evaluated whether a checklist based on these QIs affects appropriate antibiotic use and length of hospital stay. METHODS An antibiotic checklist for patients treated with intravenous antibiotics was introduced in nine Dutch hospitals in a stepped wedge cluster randomized trial. Prophylaxis was excluded. We included a random sample before (baseline), and all eligible patients after (intervention) checklist introduction. Baseline and intervention outcomes were compared. Primary endpoint was length of stay (LOS), analysed by intention to treat. Secondary endpoints, including QI performances, QI sum score (performance on all QIs per patient), and quality of checklist use, were analysed per protocol. RESULTS Between 1 November 2014 and 1 October 2015 we included 853 baseline and 5354 intervention patients, of whom 993 (19%) had a completed checklist. The LOS did not change (baseline geometric mean 10.0 days (95% CI 8.6-11.5) versus intervention 10.1 days (95% CI 8.9-11.5), p 0.8). QI performances increased between +3.0% and +23.9% per QI, and the percentage of patients with a QI sum score above 50% increased significantly (OR 2.4 (95% CI 2.0-3.0), p<0.001). Higher QI sum scores were significantly associated with shorter LOS. Discordance existed between checklist-answers and actual performance. CONCLUSIONS Use of an antibiotic checklist resulted in a significant increase in appropriateness of antibiotic use, but not in a reduction of LOS. Low overall checklist completion rates and discordance between checklist-answers and actual provided care might have attenuated the impact of the checklist.
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Affiliation(s)
- F V van Daalen
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, The Netherlands.
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, The Netherlands
| | - B C Opmeer
- Clinical Research Unit, Academic Medical Centre, Amsterdam, The Netherlands
| | - M A Boermeester
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - C E Visser
- Department of Microbiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - R M van Hest
- Department of Pharmacy, Academic Medical Centre, Amsterdam, The Netherlands
| | - J Branger
- Department of Internal Medicine, Flevoziekenhuis, Almere, The Netherlands
| | - E Mattsson
- Department of Medical Microbiology, Reinier de Graaf, Delft, The Netherlands
| | - M F M van de Broek
- Department of Internal Medicine, Antoniusziekenhuis, Nieuwegein, The Netherlands
| | - T C Roeleveld
- Department of Internal Medicine, Spaarnegasthuis, Hoofddorp, The Netherlands
| | - A A Karimbeg
- Department of Internal Medicine, Westfriesgasthuis, Hoorn, The Netherlands
| | - E A F Haak
- Department of Hospital Pharmacy, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - H C van den Hout
- Department of Internal Medicine, Spaarnegasthuis, Haarlem, The Netherlands
| | - M A van Agtmael
- Department of Internal Medicine, Division of Infectious Diseases, VU Medical Centre, Amsterdam, The Netherlands
| | - M E J L Hulscher
- Department of Scientific Institute for Quality of Healthcare (IQ healthcare), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - S E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, The Netherlands
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12
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Lesuis N, Verhoef LM, Nieboer LM, Bruyn GA, Baudoin P, van Vollenhoven RF, Hulscher MEJL, van den Hoogen FHJ, den Broeder AA. Implementation of protocolized tight control and biological dose optimization in daily clinical practice: results of a pilot study. Scand J Rheumatol 2016; 46:152-155. [DOI: 10.1080/03009742.2016.1194457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- N Lesuis
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - LM Verhoef
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - LM Nieboer
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - GA Bruyn
- Department of Rheumatology, MC Zuiderzee, Lelystad, The Netherlands
| | - P Baudoin
- Department of Rheumatology, MC Zuiderzee, Lelystad, The Netherlands
| | - RF van Vollenhoven
- Unit for Clinical Therapy Research, Inflammatory Diseases (ClinTRID), Karolinska Institute, Stockholm, Sweden
| | - MEJL Hulscher
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - FHJ van den Hoogen
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
- Department of Rheumatology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - AA den Broeder
- Department of Rheumatology, Sint Maartenskliniek, Nijmegen, The Netherlands
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13
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van den Bosch CMA, Hulscher MEJL, Natsch S, Wille J, Prins JM, Geerlings SE. Applicability of generic quality indicators for appropriate antibiotic use in daily hospital practice: a cross-sectional point-prevalence multicenter study. Clin Microbiol Infect 2016; 22:888.e1-888.e9. [PMID: 27432770 DOI: 10.1016/j.cmi.2016.07.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 07/05/2016] [Accepted: 07/07/2016] [Indexed: 01/01/2023]
Abstract
The ability to monitor the appropriateness of hospital antibiotic use is a key element of an effective antibiotic stewardship program. A set of 11 generic quality indicators (QIs) was previously developed to assess the quality of antibiotic use in hospitalized adults treated for a bacterial infection. The primary aim of the current study was to assess the clinimetric properties of these QIs (nine process and two structure indicators) in daily clinical practice. In a cross-sectional point-prevalence survey, performed in 2011 and 2012, 1890 inpatients from 22 hospitals in the Netherlands treated with antibiotics for a suspected bacterial infection were included, and data were extracted from medical records. In this cohort we tested the measurability, applicability, reliability, room for improvement and case mix stability of the previously developed QIs. Low applicability (≤10% of reviewed patients) was found for the QIs 'therapeutic drug monitoring', 'adapting antibiotics to renal function' and 'discontinue empirical therapy in case of lack of clinical and/or microbiological evidence of infection'. For the latter, we also found a low inter-observer agreement (kappa <0.4). One QI showed low improvement potential. The remaining seven QIs had sound clinimetric properties. Case-mix correction was necessary for most process QIs. For all QIs, we found ample room for improvement and large variation between hospitals. Establishing the clinimetric properties was essential, as four of the 11 previously selected QIs showed unsatisfactory properties in this practice test. Since the quality of antibiotic use and the process of documenting data is changing over time and may vary per country, QIs should always be tested in practice first.
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Affiliation(s)
- C M A van den Bosch
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - M E J L Hulscher
- Department of Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboud University Medical Centre, Nijmegen, The Netherlands
| | - S Natsch
- Department of Pharmacy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - J Wille
- Department of Centre for Infectious Diseases Epidemiology and Surveillance, The National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - S E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
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14
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Lesuis N, den Broeder AA, Hulscher MEJL, van Vollenhoven RF. Practice what you preach? An exploratory multilevel study on rheumatoid arthritis guideline adherence by rheumatologists. RMD Open 2016; 2:e000195. [PMID: 27252892 PMCID: PMC4879343 DOI: 10.1136/rmdopen-2015-000195] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 03/06/2016] [Accepted: 03/09/2016] [Indexed: 11/03/2022] Open
Abstract
Objectives To assess variation in and determinants of rheumatologist guideline adherence in patients with rheumatoid arthritis (RA), in daily practice. Methods In this retrospective observational study, guideline adherence in the first year of treatment was assessed for 7 predefined parameters on diagnostics, treatment and follow-up in all adult patients with RA with a first outpatient clinic visit at the study centre, from September 2009 to March 2011. Variation in guideline adherence was assessed on parameter and rheumatologist level. Determinants for guideline adherence were assessed in patients (demographic characteristics, rheumatoid factor (RF) and/or anti-cyclic citrullinated peptide antibody (aCCP) positivity, erythrocyte sedimentation rate, erosive disease, comorbidity and the number of available disease modifying anti-rheumatic drug (DMARD) treatment options) and rheumatologists (demographic and practice characteristics, guideline knowledge and agreement, outcome expectancy, cognitive bias, thinking style, numeracy and personality). Results A total of 994 visits in 137 patients with RA were reviewed. Variation in guideline adherence among parameters was present (adherence between 21% and 72%), with referral to the physician assistant as lowest scoring and referral to a specialised nurse as highest scoring parameter. Variation in guideline adherence among rheumatologists was also present (adherence between 22% and 100%). Patient sex, the number of DMARD options, presence of erosions, comorbidity, RF/aCCP positivity, type of patient and the rheumatologists' scientific education status were associated with adherence to 1 or more guideline parameters. Conclusions Guideline adherence varied considerably among the guideline parameters and rheumatologists, showing that there is room for improvement. Guideline adherence in our sample was related to several patient and rheumatologist determinants.
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Affiliation(s)
- N Lesuis
- Department of Rheumatology , Sint Maartenskliniek , Nijmegen , The Netherlands
| | - A A den Broeder
- Department of Rheumatology , Sint Maartenskliniek , Nijmegen , The Netherlands
| | - M E J L Hulscher
- IQ Healthcare, Radboud University Medical Centre , Nijmegen , The Netherlands
| | - R F van Vollenhoven
- Unit for Clinical Therapy Research , Inflammatory Diseases (ClinTRID), Karolinska Institute , Stockholm , Sweden
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15
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van Daalen FV, Geerlings SE, Prins JM, Hulscher MEJL. A survey to identify barriers of implementing an antibiotic checklist. Eur J Clin Microbiol Infect Dis 2016; 35:545-53. [PMID: 26810059 PMCID: PMC4819538 DOI: 10.1007/s10096-015-2569-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 12/28/2015] [Indexed: 12/31/2022]
Abstract
A checklist is an effective implementation tool, but addressing barriers that might impact on the effectiveness of its use is crucial. In this paper, we explore barriers to the uptake of an antibiotic checklist that aims to improve antibiotic use in daily hospital care. We performed an online questionnaire survey among medical specialists and residents with various professional backgrounds from nine Dutch hospitals. The questionnaire consisted of 23 statements on anticipated barriers hindering the uptake of the checklist. Furthermore, it gave the possibility to add comments. We included 219 completed questionnaires (122 medical specialists and 97 residents) in our descriptive analysis. The top six anticipated barriers included: (1) lack of expectation of improvement of antibiotic use, (2) lack of expected patients' satisfaction by checklist use, (3) lack of feasibility of the checklist, (4) negative previous experiences with other checklists, (5) the complexity of the antibiotic checklist and (6) lack of nurses' expectation of checklist use. Remarkably, 553 comments were made, mostly (436) about the content of the checklist. These insights can be used to improve the specific content of the checklist and to develop an implementation strategy that addresses the identified barriers.
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Affiliation(s)
- F V van Daalen
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, Academic Medical Centre, Room F4-106, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - S E Geerlings
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, Academic Medical Centre, Room F4-106, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J M Prins
- Department of Internal Medicine, Division of Infectious Diseases, Centre for Infection and Immunity Amsterdam, Academic Medical Centre, Room F4-106, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M E J L Hulscher
- Scientific Institute for Quality of Healthcare, Radboud University Medical Centre, Nijmegen, The Netherlands
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16
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Spoorenberg V, Hulscher MEJL, Geskus RB, de Reijke TM, Opmeer BC, Prins JM, Geerlings SE. [Better antibiotic use in complicated urinary tract infections; multicentre cluster randomised trial of 2 improvement strategies]. Ned Tijdschr Geneeskd 2016; 160:D460. [PMID: 27438395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To compare the effectiveness of two strategies to improve antibiotic use in patients with a complicated urinary tract infection. DESIGN Multicentre cluster randomised unblinded trial. METHOD The departments of Internal Medicine and Urology from 19 hospitals in the Netherlands took part in this trial. Based on retrospective patient record investigations we performed baseline measurements on the scores of a validated set of quality indicators for antibiotic use in a minimum of 50 patients with a complicated urinary tract infection per department in 2009. A similar post-trial measurement took place in 2012. In 2010 we randomised the hospitals between 2 improvement strategies: a multifaceted strategy that included results of the baseline measurements, education, reminders and assistance with optional improvement interventions, and a competitive feedback strategy, in which the departments only received results of the baseline measurements and non-anonymous results from the other departments in this study arm. The primary outcome measure was improvement of the quality indicator scores. Secondary outcome measures were determinants of improvement of the indicators. (Netherlands Trial Register: NTR1742) RESULTS: The baseline and post-trial measurements were performed on 1,964 patients and 2,027 patients, respectively. Post-trial measurements revealed a significant, but limited, improvement of several indicators compared with baseline measurements. We found no significant difference in improvement between the two strategies for any indicator. The intensity with which the departments implemented improvement strategies was mostly suboptimal, but intensive implementation of a strategy was associated with greater improvement. CONCLUSION The effectiveness of both improvement strategies was comparable, but limited. For real improvement in antibiotic use in patients with complicated urinary tract infections, improvement interventions should be developed and applied by local professionals themselves.
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Affiliation(s)
- V Spoorenberg
- *Dit onderzoek werd eerder gepubliceerd in PLOS ONE (2015;10:e0142672) met als titel 'A cluster-randomized trial of two strategies to improve antibiotic use for patients with a complicated urinary tract infection'. Afgedrukt met toestemming
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17
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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18
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Hommel I, van Gurp PJ, Tack CJ, Liefers J, Mulder J, Wollersheim H, Hulscher MEJL. Perioperative diabetes care: room for improving the person centredness. Diabet Med 2015; 32:561-8. [PMID: 25308875 DOI: 10.1111/dme.12600] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 08/07/2014] [Accepted: 10/06/2014] [Indexed: 01/26/2023]
Abstract
AIMS Person centredness is an important principle for delivering high-quality diabetes care. In this study, we assess the level of person centredness of current perioperative diabetes care. METHODS We conducted a survey in six Dutch hospitals, among 690 participants with diabetes who underwent major abdominal, cardiac or large-joint orthopaedic surgery. The survey included questions regarding seven dimensions of person-centred perioperative diabetes care. RESULTS Complete data were obtained from 298 participants. The survey scores were low for many of the dimensions of person centredness. The dimensions 'information', 'patient involvement' and 'coordination and integration of care' had the lowest scores. Only half the participants had received information about perioperative diabetes treatment, and approximately one-third had received information about the effect of surgery on blood glucose values, target glucose values and glucose measurement times. Similarly, half the participants had an opportunity to ask questions preoperatively, and only one-third of the participants felt involved in the decision-making regarding diabetes treatment. Most participants knew neither the caregiver in charge of perioperative diabetes treatment nor whom to contact in case of diabetes-related problems during their hospital stay. CONCLUSIONS Current perioperative diabetes care is characterized by a lack of patient information and limited patient involvement. These results indicate that there is ample room for improving the person centredness of perioperative diabetes care.
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Affiliation(s)
- I Hommel
- Department of IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
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19
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Huis A, Belfroid E, Timen A, van Steenbergen JE, Hulscher MEJL. Quality measures defining the healthcare system’s preparedness to infectious disease outbreaks. Eur J Public Health 2014. [DOI: 10.1093/eurpub/cku165.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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20
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Spoorenberg V, Hulscher MEJL, Akkermans RP, Prins JM, Geerlings SE. Appropriate Antibiotic Use for Patients With Urinary Tract Infections Reduces Length of Hospital Stay. Clin Infect Dis 2013; 58:164-9. [DOI: 10.1093/cid/cit688] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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21
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Belfroid E, Hautvast JLA, van der Velden J, Hulscher MEJL, Timen A. Development of critical recommendations representing good quality of response to infectious disease outbreaks. Eur J Public Health 2013. [DOI: 10.1093/eurpub/ckt126.197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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22
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Kreuwel IAM, van Peperstraten AM, Hulscher MEJL, Kremer JAM, Grol RPTM, Nelen WLDM, Hermens RPMG. Evaluation of an effective multifaceted implementation strategy for elective single-embryo transfer after in vitro fertilization. Hum Reprod 2012. [DOI: 10.1093/humrep/des371] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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23
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Engel MF, Postma DF, Hulscher MEJL, Teding van Berkhout F, Emmelot-Vonk MH, Sankatsing S, Gaillard CAJM, Bruns AHW, Hoepelman AIM, Oosterheert JJ. Barriers to an early switch from intravenous to oral antibiotic therapy in hospitalised patients with CAP. Eur Respir J 2012; 41:123-30. [DOI: 10.1183/09031936.00029412] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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24
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Ruijs WLM, Hautvast JLA, van Ansem WJC, Akkermans RP, van't Spijker K, Hulscher MEJL, van der Velden K. Measuring vaccination coverage in a hard to reach minority. Eur J Public Health 2011; 22:359-64. [DOI: 10.1093/eurpub/ckr081] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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25
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Ruijs WLM, Hautvast JLA, van 't Spijker K, van der Velden K, Hulscher MEJL. Information on vaccination: meeting the needs of unvaccinated youngsters in the Netherlands. Eur J Public Health 2010; 21:344-6. [DOI: 10.1093/eurpub/ckq172] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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26
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Schipper LG, van Hulst LTC, Grol R, van Riel PLCM, Hulscher MEJL, Fransen J. Meta-analysis of tight control strategies in rheumatoid arthritis: protocolized treatment has additional value with respect to the clinical outcome. Rheumatology (Oxford) 2010; 49:2154-64. [DOI: 10.1093/rheumatology/keq195] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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27
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van Hulst LTC, Fransen J, den Broeder AA, Grol R, van Riel PLCM, Hulscher MEJL. Development of quality indicators for monitoring of the disease course in rheumatoid arthritis. Ann Rheum Dis 2009; 68:1805-10. [PMID: 19447827 DOI: 10.1136/ard.2009.108555] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To suppress rheumatoid arthritis (RA) patients' disease activity, it should be periodically measured and patients should be treated on the basis of the disease activity outcomes. Insight into the actual care, by using quality indicators, is the first step in achieving optimal care. The objective of this study was to develop a set of quality indicators to evaluate RA disease course monitoring of rheumatologists in daily clinical practice. METHODS A RAND-modified Delphi method in a five-step procedure was applied: a literature search for quality indicators and recommendations about disease course monitoring; a first questionnaire round; a consensus meeting; a second questionnaire round and drawing up the final set. RESULTS The systematic procedure resulted in the development of 18 quality indicators: 10 process, five structure and three outcome indicators that describe seven domains of disease course monitoring: schedule follow-up visits; measure disease activity; functional impairment; structural damage; change medication; preconditions for measuring disease activity and outcome measures in terms of disease activity. CONCLUSIONS This quality indicator set can be used to assess the quality of disease course monitoring of rheumatologists in daily clinical practice, and to determine for which aspects of disease course monitoring rheumatologists perform well, or where there is room for improvement. This information can be used to improve the quality of disease course monitoring.
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Affiliation(s)
- L T C van Hulst
- Department of Rheumatology (470), Radboud University Nijmegen Medical Centre, 6500 HB Nijmegen, The Netherlands.
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Hermanides HS, Hulscher MEJL, Schouten JA, Prins JM, Geerlings SE. Development of Quality Indicators for the Antibiotic Treatment of Complicated Urinary Tract Infections: A First Step to Measure and Improve Care. Clin Infect Dis 2008; 46:703-11. [DOI: 10.1086/527384] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Abstract
BACKGROUND Primary care physicians hold a strategic position in delivering preventive services. However discrepancies exist between evidence based guidelines and practice. OBJECTIVES To assess the effects of interventions to improve the delivery of preventive services in primary care. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (November 1995; August 1999), MEDLINE (1980 to 1995) and hand searched relevant journals. SELECTION CRITERIA Randomised trials, controlled before and after studies, and interrupted time series analyses of interventions to improve preventive services by primary care professionals responsible for patient care. DATA COLLECTION AND ANALYSIS Two researchers independently extracted data and assessed study quality. MAIN RESULTS Fifty-five studies were included, involving more than 2000 health professionals and 99,000 people, with 83 comparisons between intervention and control groups. Post intervention differences between intervention and control groups varied widely within and across categories of interventions. Most interventions were found to be effective in some studies, but not in others. Five comparisons of group education versus no intervention showed absolute change of preventive services varying between -4% and +31%. Nine comparisons of physician reminders versus no intervention showed absolute change of preventive services varying between 5% and 24%. Fourteen comparisons of multifaceted interventions versus no intervention showed absolute change of preventive services varying between -3% and +64%. Six comparisons of multifaceted interventions versus group education reported absolute changes varying between -31% and +28%. All these comparisons used randomised groups. Ten comparisons of multifaceted interventions versus no intervention used non-randomised groups and showed absolute change of preventive services varying between -5% and +21%. The remaining planned comparisons within categories of interventions contained less than five comparisons. AUTHORS' CONCLUSIONS There is currently no solid basis for assuming that a particular intervention or package of interventions will work. Effective interventions to increase preventive activities in primary care exist, but there is considerable variation in the level of change achieved, with effect sizes usually small or moderate. Tailoring interventions to address specific barriers to change in a particular setting is probably important. Multifaceted interventions may be more effective than single interventions, because more barriers to change can be addressed. Future research should analyse barriers to change and interventions to implement preventive services in more detail, to clarify how interventions relate to specific barriers. Since more complex interventions are likely to be more effective but also more costly, economic evaluations should also be included.
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Affiliation(s)
- M E J L Hulscher
- University of Nijmegen, Centre for Quality of Care Research (WOK), PO Box 9101, 6500 HB Nijmegen, Netherlands, 6500 HB.
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Hermens RPMG, Siebers BG, Hulscher MEJL, Braspenning JCC, van Doremalen JHM, Hanselaar A, Grol RPTM, van Weel C. Follow-up of Abnormal or Inadequate Cervical Smears Using Two Guidance Systems: RCT on Effectiveness. J Low Genit Tract Dis 2006. [DOI: 10.1097/00128360-200607000-00099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Schouten JA, Hulscher MEJL, Wollersheim H, Braspennning J, Kullberg BJ, van der Meer JWM, Grol RPTM. Quality of antibiotic use for lower respiratory tract infections at hospitals: (how) can we measure it? Clin Infect Dis 2005; 41:450-60. [PMID: 16028151 DOI: 10.1086/431983] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2005] [Accepted: 04/06/2005] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND To assess and improve the quality of antibiotic use in patients with community-acquired pneumonia (CAP) and acute exacerbation of chronic bronchitis or chronic obstructive pulmonary disease (AECB), a valid set of quality indicators is required. This set should also be applicable in practice. METHODS Guidelines and literature were reviewed to derive potential indicators for quality of antibiotic use in treating hospitalized patients with lower respiratory tract infection (LRTI). To assess the evidence base of each indicator, a literature review was performed. Grade A recommendations were considered valid. For grade B-D recommendations, an expert panel performed a consensus procedure on the indicator's relevance to patient health, reduction of antimicrobial resistance, and cost containment. To test applicability in practice, feasibility, opportunity for improvement, reliability, and case-mix stability were determined for a data set of 899 hospitalized patients with LRTI. RESULTS None of the potential indicators from guidelines and literature were supported by grade A evidence. Nineteen indicators were selected by consensus procedure (12 indicators for CAP and 7 indicators for AECB). Lack of feasibility and of opportunity for improvement led to the exclusion of 4 indicators. A final set of 15 indicators was defined (9 indicators for CAP and 6 indicators for AECB). CONCLUSIONS A valid set of quality indicators for antibiotic use in hospitalized patients with LRTI was developed by combining evidence and expert opinion in a carefully planned procedure. Subjecting indicators to an applicability test is essential before using them in quality-improvement projects. In our demonstration setting, 4 of the 19 indicators were inapplicable in practice.
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Affiliation(s)
- J A Schouten
- Centre for Quality of Care Research, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Schouten JA, Hulscher MEJL, Natsch S, Grol RPTM, van der Meer JWM. Antibiotic control measures in Dutch secondary care hospitals. Neth J Med 2005; 63:24-30. [PMID: 15719849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Control measures for the use of antibiotics are essential because of the potential harmful consequences of side effects. Various methods have been developed to help curb undesirable antibiotic prescription. We performed a survey in Dutch secondary care hospitals (response rate 73%) to make an inventory of these measures and elucidate possible shortcomings. Almost every hospital was using an antibiotic formulary (97%), sometimes supported by extra restrictions in antibiotic choice (55%). Local practice guidelines (95%) were commonly present, but effective implementation, for example using intranet applications, could be improved (21%). National guidelines had received little attention in the composition process of local guidelines (19%). Other measures such as educational programmes for specialists (11%) and feedback on antibiotic prescription (52%) remained largely underused, although their effective implementation may optimise antibiotic prescription in hospitals.
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Affiliation(s)
- J A Schouten
- Centre for Quality of Care Research (229), Department of internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands.
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Lobo CM, Frijling BD, Hulscher MEJL, Bernsen RMD, Grol RPTM, Prins A, van der Wouden JC. Effect of a comprehensive intervention program targeting general practice staff on quality of life in patients at high cardiovascular risk: a randomized controlled trial. Qual Life Res 2004; 13:73-80. [PMID: 15058789 DOI: 10.1023/b:qure.0000015285.08673.42] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND We implemented a comprehensive intervention program targeting general practice staff, that proved successful in optimizing practice organization and clinical decision-making. In this paper, health-related quality of life (HRQL) is investigated as a clinical outcome. OBJECTIVE To evaluate the effect of the implementation of an intervention program on the HRQL in patients at high cardiovascular risk. RESEARCH DESIGN Randomized controlled trial. Intervention practices (n = 62) received a comprehensive intervention program (by means of outreach visitors) lasting 21 months. HRQL of patients at high cardiovascular risk was assessed by the MOS 36-Item Short-Form Health Survey (SF-36), at baseline and after intervention. Three patient categories were distinguished: diabetes mellitus, cardiovascular disease and hypertension. RESULTS HRQL deteriorated in all respondents, but more pronounced in the control group. In diabetes patients the differences between intervention and control group were significant for the Vitality and Mental Health scales, with mean difference in change of 3.93 (95% CI: 1.08-6.78) and 3.71 (95% CI: 0.73-6.68), respectively. Patients with cardiovascular disease had significantly different changes on three scales: physical functioning (3.57, 95% CI: 0.71-6.43), vitality (3.01, 95% CI: 0.72-5.30) and social functioning (3.96, 95% CI: 0.50-7.42). In patients with hypertension, there were no differences between the intervention and control group. CONCLUSION Our comprehensive intervention program resulted in changes in HRQL on several domains, particularly in patients with diabetes and cardiovascular disease.
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Affiliation(s)
- C M Lobo
- Department of General Practice, Erasmus MC--University Medical Center Rotterdam, Rotterdam, The Netherlands
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Frijling BD, Lobo CM, Hulscher MEJL, Akkermans RP, van Drenth BB, Prins A, van der Wouden JC, Grol RPTM. Intensive support to improve clinical decision making in cardiovascular care: a randomised controlled trial in general practice. Qual Saf Health Care 2003; 12:181-7. [PMID: 12792007 PMCID: PMC1743704 DOI: 10.1136/qhc.12.3.181] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the effects of feedback reports combined with outreach visits from trained non-physicians on the clinical decision making of general practitioners (GPs) in cardiovascular care. DESIGN Pragmatic cluster controlled trial with randomisation of practices to support (intervention group) or no special attention (control group); analysis after 2 years. SETTING 124 general practices in The Netherlands. PARTICIPANTS 185 GPs. MAIN OUTCOME MEASURES Compliance rates for 12 evidence-based indicators for the management of patients with hypertension, hypercholesterolaemia, angina pectoris, or heart failure. The evaluation relied on the prospective recording of patient encounters by the participating GPs. RESULTS The GPs reported 30 101 clinical decisions at baseline and 22 454 decisions after the intervention. A significant improvement was seen for five of the 12 indicators: assessment of risk factors in patients with hypercholesterolaemia (odds ratio 2.04; 95% CI 1.44 to 2.88) or angina pectoris (3.07; 1.08 to 8.79), provision of information and advice to patients with hypercholesterolaemia (1.58, 1.17 to 2.13) or hypertension (1.55, 1.35 to 1.77), and checking for clinical signs of deterioration in patients with heart failure (4.11, 2.17 to 7.77). Single handed practices, non-training practices, and practices with older GPs gained particular benefit from the intervention. CONCLUSIONS Intensive support from trained non-physicians can alter certain aspects of the clinical decision making of GPs in cardiovascular care. The effect is small and the strategy needs further development.
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Affiliation(s)
- B D Frijling
- Centre for Quality of Care Research, University of Nijmegen, P O Box 9101, 6500 HB Nijmegen, The Netherlands.
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Abstract
To design potentially successful quality improvement (QI) interventions, it is crucial to make use of detailed breakdowns of the implementation processes of successful and unsuccessful interventions. Process evaluation can throw light on the mechanisms responsible for the result obtained in the intervention group. It enables researchers and implementers to (1). describe the intervention in detail, (2). check actual exposure to the intervention, and (3). describe the experience of those exposed. This paper presents a framework containing features of QI interventions that might influence success. Attention is paid to features of the target group, the implementers or change agents, the frequency of intervention activities, and features of the information imparted. The framework can be used as a starting point to address all three aspects of process evaluation mentioned above. Process evaluation can be applied to small scale improvement projects, controlled QI studies, and large scale QI programmes; in each case it plays a different role.
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Affiliation(s)
- M E J L Hulscher
- Centre for Quality of Care Research (WOK), University Medical Centre Nijmegen, 6500 HB Nijmegen, The Netherlands.
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Frijling BD, Lobo CM, Hulscher MEJL, Akkermans RP, Braspenning JCC, Prins A, van der Wouden JC, Grol RPTM. Multifaceted support to improve clinical decision making in diabetes care: a randomized controlled trial in general practice. Diabet Med 2002; 19:836-42. [PMID: 12358871 DOI: 10.1046/j.1464-5491.2002.00810.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIMS To evaluate the effectiveness of a multifaceted intervention to improve the clinical decision making of general practitioners (GPs) for patients with diabetes. To identify practice characteristics which predict success. METHODS Cluster randomized controlled trial with 124 practices and 185 GPs in The Netherlands. The intervention group received feedback reports and support from a facilitator; the control group received no special attention. Outcome measures were the compliance rates with evidence-based recommendations pertaining to discussion of body weight control, discussion of problems with medication, blood pressure measurement, foot examination, eye examination, initiating anti-diabetic medication or increasing the dosage in cases of uncontrolled blood glucose, and scheduling a follow-up appointment. RESULTS The GPs reported on their clinical decision making in 1410 consultations with Type 2 diabetic patients at baseline and 1449 consultations after the intervention period. The intervention resulted in statistically significant improvement for two of the seven outcome measures: foot examination (odds ratio 1.68; 95% confidence interval 1.19-2.39) and eye examination (1.52; 1.07-2.16). Discussion of problems with medication showed a near significant trend towards increased benefit for the intervention group (1.52; 0.99-2.32). Practice characteristics were not found to be related to the success of the intervention. CONCLUSIONS Feedback reports with support from facilitators appear to increase rates of foot examination and eye examination in general practice. Alternative interventions should be explored to improve the pursuit of metabolic control by GPs.
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Affiliation(s)
- B D Frijling
- Centre for Quality of Care Research, Universities of Nijmegen and Maastricht, Erasmus University Rotterdam, The Netherlands.
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