Clinical practice variation and overtreatment risk in women with abnormal cervical cytology in the Netherlands: two-step versus see-and-treat approach

Background:ANCA associated vasculitis (AAV) is a complex, rare systemic autoimmune disease with an estimated prevalence of 5-18 patients per 100.000 individuals worldwide. Managing a low prevalent disease can be challenging which is reflected in clinical practice variation.Objectives:This study investigated clinical practice variation of the care for AAV patients in the Netherlands.Methods:In a nationwide online survey, AAV patients were selected from academic and non-academic centers. Within centers, patients were eligible when they had a confirmed diagnosis of microscopic polyangiitis (MPA), granulomatosis with polyangiitis (GPA) or eosinophilic granulomatosis with polyangiitis (eGPA) according to the treating physician. There were no exclusion criteria. In each center a comparable number of patients was included. Data capture encompassed a wide set of variables on diagnosis, management and outcomes.Results:From December 2018 to November 2019, 230 AAV patients were recruited in 6 non-academic and 3 academic hospitals (120 vs 110 patients respectively). Differences in clinical diagnoses (GPA, MPA and eGPA) were observed between non-academic and academic centers (p=0.05), which was mainly caused by a higher number of MPA patients in non-academic centers. The year of diagnosis was comparable (median 2013 [2009-2016], p=0.150). The median follow up since diagnosis was 4.8 years [1.8-9.6] with a median in-hospital time-to-diagnosis of 13 days [2-50]. Patients were diagnosed at a mean age of 63 years (±11.18) in non-academic centers and 53 years (±16.92) in academic centers (p<0.001). Besides steroids, oral cyclophosphamide was the most preferred drug (54%) for induction therapy, whereas rituximab was given significantly more often as (part of the) induction therapy in patients treated in academic centers compared to patients in non-academic centers (27% vs 8%, p<0.001). In non-academic centers pneumocystis pneumonia (PCP) prophylaxis was prescribed significantly less (76% vs 91%, p=0.003). Also, screening for Staphylococcus aureus carriership was significantly less (17% vs 68%, p<0.001). With respect to mortality and co-morbidity, 22 patients (10%) died, 100 patients (44%) had at least one infection and 24 patients (10%) suffered from at least one malignancy. We observed no significant differences on these endpoints between academic and non-academic centers.Conclusion:The present study highlights important practice variation in the management of AAV between academic and non-academic hospitals in the Netherlands. A high proportion of patients is treated with oral cyclophosphamide as induction therapy while rituximab is increasingly used in academic centers. Rates of mortality, infections and malignancies were not different. Altogether, this study raises awareness into the variation of management for AAV patients and allows the identification of areas for improvement of clinical care for Dutch AAV patients.Disclosure of Interests:Ebru Dirikgil: None declared, Abraham Rutgers: None declared, Sander Tas: None declared, Cornelis A. Verburgh: None declared, Darius Soonawala: None declared, A. Elisabeth Hak: None declared, Hilde H.F. Remmelts: None declared, Daphne IJpelaar: None declared, Gozewijn D. Laverman: None declared, Jacob M. van Laar Grant/research support from: MSD, Genentech, Consultant of: MSD, Roche, Pfizer, Eli Lilly, BMS, H.J. Bernelot Moens: None declared, Peter Verhoeven: None declared, Willem Jan W. Bos: None declared, Y.K. Onno Teng Grant/research support from: GSK, Consultant of: GSK, Aurinia Pharmaceuticals, Novartis

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Impact of GP reminders on follow-up of abnormal cervical cytology: a before–after study in Danish general practice

British Journal of General Practice ◽

10.3399/bjgp17x691913 ◽

2017 ◽

Vol 67 (661) ◽

pp. e580-e587 ◽

Cited By ~ 4

Author(s):

Bettina Kjær Kristiansen ◽

Berit Andersen ◽

Flemming Bro ◽

Hans Svanholm ◽

Peter Vedsted

Keyword(s):

General Practice ◽

Practice Variation ◽

Cervical Cytology ◽

Loss To Follow Up ◽

Reminder System ◽

Abnormal Cervical Cytology ◽

Status Interaction ◽

Practice Variations ◽

Cohabitation Status

BackgroundDysplasia may progress because of a loss to follow-up after an abnormal cervical cytology. Approximately 18% of Danish women postpone the recommended follow-up, which depends on the cytology results.AimTo investigate if a reminder to the GP about missed follow-up could reduce the proportion of women who fail to act on a recommended follow-up, and to analyse the effect on sociodemographic and general practice variations.Design and settingA national electronic GP reminder system was launched in Denmark in 2012 to target missed follow-up after screening, opportunistic testing, or surveillance indication. The authors compared follow-up proportions in a national observational before–after study.MethodFrom national registries, 1.5 million cervical cytologies (from 2009 to 2013) were eligible for inclusion. Approximately 10% had a recommendation for follow-up. The proportion of cervical cytologies without follow-up was calculated at different time points. Results were stratified by follow-up recommendations and sociodemographic characteristics, and changes in practice variation for follow-up were analysed.ResultsFewer women with a recommendation for follow-up missed follow-up 6 months after a GP reminder. Follow-up improved in all investigated sociodemographic groups (age, ethnicity, education, and cohabitation status). Interaction was found for age and cohabitation status. Variation between practices in loss to follow-up was significantly reduced.ConclusionAn electronic GP reminder system showed potential to improve the quality of cervical cancer screening through reduced loss to follow-up.

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Faculty Opinions recommendation of Guidelines for cardiac management in noncardiac surgery are poorly implemented in clinical practice: results from a peripheral vascular survey in the Netherlands.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1097824.553947 ◽

2008 ◽

Author(s):

Stefan De Hert

Keyword(s):

Clinical Practice ◽

The Netherlands ◽

Noncardiac Surgery ◽

Peripheral Vascular

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The end of the laboratory developed test as we know it? Recommendations from a national multidisciplinary taskforce of laboratory specialists on the interpretation of the IVDR and its complications

Clinical Chemistry and Laboratory Medicine (CCLM) ◽

10.1515/cclm-2020-1384 ◽

2020 ◽

Vol 0 (0) ◽

Author(s):

Paul C. D. Bank ◽

Leo H. J. Jacobs ◽

Sjoerd A. A. van den Berg ◽

Hanneke W. M. van Deutekom ◽

Dörte Hamann ◽

...

Keyword(s):

Clinical Practice ◽

The Netherlands ◽

Medical Devices ◽

Task Force ◽

Large Impact ◽

Guidance Document ◽

Scientific Societies ◽

Clinical Laboratories ◽

The Impact

AbstractThe in vitro diagnostic medical devices regulation (IVDR) will take effect in May 2022. This regulation has a large impact on both the manufacturers of in vitro diagnostic medical devices (IVD) and clinical laboratories. For clinical laboratories, the IVDR poses restrictions on the use of laboratory developed tests (LDTs). To provide a uniform interpretation of the IVDR for colleagues in clinical practice, the IVDR Task Force was created by the scientific societies of laboratory specialties in the Netherlands. A guidance document with explanations and interpretations of relevant passages of the IVDR was drafted to help laboratories prepare for the impact of this new legislation. Feedback from interested parties and stakeholders was collected and used to further improve the document. Here we would like to present our approach to our European colleagues and inform them about the impact of the IVDR and, importantly we would like to present potentially useful approaches to fulfill the requirements of the IVDR for LDTs.

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DNA ploidy measurement and human papillomavirus in abnormal cervical cytology

Cytopathology ◽

10.1111/cyt.12943 ◽

2020 ◽

Author(s):

Ane Francyne Costa ◽

Adriane Pogere ◽

Ana Paula Beltrame Farina Pasinato ◽

Edson Jose Monteiro Bello ◽

Alexandre Sherlley Casimiro Onofre ◽

...

Keyword(s):

Human Papillomavirus ◽

Dna Ploidy ◽

Cervical Cytology ◽

Abnormal Cervical Cytology

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The effect of small peer group continuous quality improvement on the clinical practice of midwives in The Netherlands

Midwifery ◽

10.1016/s0266-6138(03)00040-8 ◽

2003 ◽

Vol 19 (4) ◽

pp. 250-258 ◽

Cited By ~ 7

Author(s):

Yvonne Engels ◽

Nicole Verheijen ◽

Margot Fleuren ◽

Henk Mokkink ◽

Richard Grol

Keyword(s):

Quality Improvement ◽

Clinical Practice ◽

The Netherlands ◽

Continuous Quality Improvement ◽

Peer Group ◽

Continuous Quality

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Cervical cytologic abnormalities and negative colposcopy: histologic assessment

International Journal of Gynecological Cancer ◽

10.1046/j.1525-1438.1994.04050348.x ◽

1994 ◽

Vol 4 (5) ◽

pp. 348-351 ◽

Cited By ~ 4

Author(s):

R. Chenoy ◽

S. Manohar ◽

C. W.E. Redman ◽

D. M. Luesley

Keyword(s):

Cervical Cytology ◽

Histologic Diagnosis ◽

Abnormal Cervical Cytology ◽

Accurate Definition ◽

Cone Biopsy ◽

Histologic Evaluation ◽

Simple Regression Analysis ◽

Definition Of ◽

Cytologic Abnormalities ◽

Intraepithelial Lesions

Colposcopic assessment may be normal in the presence of severe or persistent minor cytologic abnormality. To assess the significance of negative satisfactory colposcopy in patients with abnormal cervical smears, a retrospective review was carried out on 1170 patients who had undergone out-patient loop diathermy excision for abnormal cervical cytology. Of these, 69 patients were treated for abnormal cervical cytology, despite normal colposcopic findings. Cytologic abnormalities ranged from persistent borderline changes to severe dyskariosis. Histologic assessment of the excision specimens revealed cervical intraepithalial neoplasia (CIN) in 43 (62.3%) cases, of which high-grade CIN accounted for 24 (34.8%) cases. There was good correlation between cytologic and histologic diagnosis. Simple regression analysis showedr= 0.46,P< 0.0001. The cytologic abnormality was highly predictive of the corresponding histologic diagnosis. This analysis has shown that significant intraepithelial lesions may exist despite negative colposcopic examination and highlights the need for histologic evaluation in such cases. In these circumstances, loop cone biopsy permits accurate definition of lesion severity, avoids potential undertreatment of significant lesions and causes less morbidity than conventional cone biopsy.

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