Hospital Variation in Cholecystectomies in The Netherlands: A Nationwide Observational Study

Background: Practice variation generally raises concerns about the quality of care. This study determined the longitudinal degree of hospital variation in proportion of patients with gallstone disease undergoing cholecystectomy, while adjusted for case-mix, and the effect on clinical outcomes. Methods: A nationwide, longitudinal, database study was performed in all hospitals in the Netherlands in 2013–2015. Patients with gallstone disease were collected from the diagnosis-related group database. Hospital variation in case-mix-adjusted cholecystectomy rates was calculated per year. Clinical outcomes after cholecystectomy were compared between hospitals in the lowest/highest 20th percentile of the distribution of adjusted cholecystectomy rates in all 3 subsequent years. Results: In total, 96,673 patients with gallstones were included. The cholecystectomy rate was 73.6%. In 2013–2015, the case-mix-adjusted performance of cholecystectomies was in hospitals with high rates 1.5–1.6 times higher than in hospitals with low rates. Hospitals with a high adjusted cholecystectomy rate had a higher laparoscopy rate, shorter time to surgery, and less emergency department visits after a cholecystectomy compared to hospitals with a low-adjusted cholecystectomy rate. Conclusion: Hospital variation in cholecystectomies in the Netherlands is modest, cholecystectomy rates varies by <2-fold, and variation is stable over time. Cholecystectomies in hospitals with high adjusted cholecystectomy rates are associated with improved outcomes.

Download Full-text

Variation in practice and outcomes after inguinal hernia repair: a nationwide observational study

BMC Surgery ◽

10.1186/s12893-020-01030-0 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Carmen S. S. Latenstein ◽

Floris M. Thunnissen ◽

Mitchell Harker ◽

Stef Groenewoud ◽

Mark W. Noordenbos ◽

...

Keyword(s):

Emergency Department ◽

Inguinal Hernia ◽

The Netherlands ◽

Hernia Repair ◽

Inguinal Hernia Repair ◽

Clinical Outcomes ◽

Emergency Department Visits ◽

Case Mix ◽

Hospital Variation ◽

Operation Rate

Abstract Background Inguinal hernia repair has often been used as a showcase to illustrate practice variation in surgery. This study determined the degree of hospital variation in proportion of patients with an inguinal hernia undergoing operative repair and the effect of this variation on clinical outcomes. Methods A nationwide, longitudinal, database study was performed in all hospitals in the Netherlands between 2013 and 2015. Patients with inguinal hernias were collected from the Diagnosis-Related-Group (DRG) database. The case-mix adjusted operation rate in patients with a new DRG determines the observed variation. Hospital variation in case-mix adjusted inguinal hernia repair-rates was calculated per year. Clinical outcomes after surgery were compared between hospitals with high and low adjusted operation-rates. Results In total, 95,637 patients were included. The overall operation rate was 71.6%. In 2013–2015, the case-mix adjusted performance of inguinal hernia repairs in hospitals with high rates was 1.6–1.9 times higher than in hospitals with low rates. Moreover, in hospitals with high adjusted rates of inguinal hernia repair the time to surgery was shorter, more laparoscopic procedures were performed, less emergency department visits were recorded post-operatively, while more emergency department visits were recorded when patients were treated conservatively compared to hospitals with low adjusted operation rates. Conclusion Hospital variation in inguinal hernia repair in the Netherlands is modest, operation-rates vary by less than two-fold, and variation is stable over time. Hernia repair in hospitals with high adjusted rates of inguinal hernia repair are associated with improved outcomes.

Download Full-text

Is Textbook Outcome a valuable composite measure for short-term outcomes of gastrointestinal treatments in the Netherlands using hospital information system data?A retrospective cohort study

BMJ Open ◽

10.1136/bmjopen-2017-019405 ◽

2018 ◽

Vol 8 (2) ◽

pp. e019405 ◽

Cited By ~ 11

Author(s):

Nèwel Salet ◽

Rolf H Bremmer ◽

Marc A M T Verhagen ◽

Vivian E Ekkelenkamp ◽

Bettina E Hansen ◽

...

Keyword(s):

Information Systems ◽

Cancer Screening ◽

The Netherlands ◽

Clinical Care ◽

Gallstone Disease ◽

Hospital Information Systems ◽

Short Term ◽

Patient Counselling ◽

Clinical Indicator ◽

Hospital Variation

ObjectiveTo develop a feasible model for monitoring short-term outcome of clinical care trajectories for hospitals in the Netherlands using data obtained from hospital information systems for identifying hospital variation.Study designRetrospective analysis of collected data from hospital information systems combined with clinical indicator definitions to define and compare short-term outcomes for three gastrointestinal pathways using the concept of Textbook Outcome.Setting62 Dutch hospitals.Participants45 848 unique gastrointestinal patients discharged in 2015.Main outcome measureA broad range of clinical outcomes including length of stay, reintervention, readmission and doctor–patient counselling.ResultsPatients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for gallstone disease (n=4369), colonoscopy for inflammatory bowel disease (IBD; n=19 330) and colonoscopy for colorectal cancer screening (n=22 149) were submitted to five suitable clinical indicators per treatment. The percentage of all patients who met all five criteria was 54%±9% (SD) for ERCP treatment. For IBD this was 47%±7% of the patients, and for colon cancer screening this number was 85%±14%.ConclusionThis study shows that reusing data obtained from hospital information systems combined with clinical indicator definitions can be used to express short-term outcomes using the concept of Textbook Outcome without any excess registration. This information can provide meaningful insight into the clinical care trajectory on the level of individual patient care. Furthermore, this concept can be applied to many clinical trajectories within gastroenterology and beyond for monitoring and improving the clinical pathway and outcome for patients.

Download Full-text

P14.31 Between hospital variation in timings to multidisciplinary glioblastoma care in the Dutch Brain Tumor Registry

Neuro-Oncology ◽

10.1093/neuonc/noab180.152 ◽

2021 ◽

Vol 23 (Supplement_2) ◽

pp. ii44-ii44

Author(s):

M E De Swart ◽

V K Y Ho ◽

F J Lagerwaard ◽

D Brandsma ◽

M P Broen ◽

...

Keyword(s):

Brain Tumor ◽

The Netherlands ◽

Multidisciplinary Treatment ◽

Case Mix ◽

National Guidelines ◽

Tumor Registry ◽

Hospital Variation ◽

Long Time ◽

Newly Diagnosed Glioblastoma ◽

Brain Tumor Diagnosis

Abstract BACKGROUND Delay in cancer care may adversely affect emotional distress, treatment outcome and survival. Optimal timings in multidisciplinary glioblastoma care are a matter of debate and clear national guidelines only exist for time to neurosurgery. We evaluated the between-hospital variation in timings to neurosurgery and adjuvant radiotherapy and chemotherapy in newly diagnosed glioblastoma patients in the Netherlands. MATERIAL AND METHODS Data were obtained from the nation-wide Dutch Brain Tumor Registry between 2014 and 2018. All adult patients with glioblastoma were included, covering all 18 neurosurgical hospitals, 28 radiotherapy hospitals, and 33 oncology hospitals. Long time-to-surgery (TTS) was defined as >3 weeks from the date of first brain tumor diagnosis to surgery, long time-to-radiotherapy (TTR) as either >4 or >6 weeks after surgery, and long time-to-chemotherapy (TTC) as either >4 or >6 weeks after completion of radiotherapy. Between-hospital variation in standardized rate of long timings was analyzed in funnel plots after case-mix correction. RESULTS A total of 4203 patients were included. Median TTS was 20 days and 52.4% of patients underwent surgery within 3 weeks. Median TTR was 20 days and 24.6% of patients started radiotherapy within 4 weeks and 84.2% within 6 weeks after surgery. Median TTC was 28 days and 62.6% of patients received chemotherapy within 4 weeks and 91.8% within 6 weeks after radiotherapy. After case-mix correction, three (16.7%) neurosurgical hospitals had significantly more patients with longer than expected TTS. Three (10.7%) and one (3.6%) radiotherapy hospitals had significantly more patients with longer than expected TTR for >4 and >6 weeks, respectively. In seven (21.2%) chemotherapy hospitals, significantly less patients with TTC >4 weeks were observed than expected. In four (12.1%) chemotherapy hospitals, significantly more patients with TTC >4 weeks were observed than expected. CONCLUSION Between-hospital variation in timings to multidisciplinary treatment was observed in glioblastoma care in the Netherlands. A substantial percentage of patients experienced timings longer than anticipated.

Download Full-text

Practice variation on hospital level in the systemic treatment of metastatic colorectal cancer in the Netherlands: A population-based study.

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.6612 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. 6612-6612

Author(s):

Lotte Keikes ◽

Miriam Koopman ◽

Martijn M. Stuiver ◽

Valery Lemmens ◽

Martijn G.H. van Oijen ◽

...

Keyword(s):

Colorectal Cancer ◽

The Netherlands ◽

Metastatic Colorectal Cancer ◽

Systemic Therapy ◽

Systemic Treatment ◽

Real Life ◽

Population Based ◽

Practice Variation ◽

Current Guideline ◽

Hospital Variation

6612 Background: Population-based data on the implementation of guidelines for cancer patients in daily practice are scarce. Therefore, we evaluated practice variation patterns and associated variables in the systemic treatment of metastatic colorectal cancer (mCRC) between 2008 and 2015 in the Netherlands. Methods: We selected a random sample of adult mCRC patients diagnosed from 2008 to 2015 from the National Cancer Registry in 20 Dutch hospitals. We examined the influence of patient, demographic and tumor characteristics on the odds of being treated with systemic therapy according to the current guideline and assessed its association with survival. Results: Our study population consisted of 2222 mCRC patients of whom 1307 patients received systemic therapy for mCRC. Practice variation was most obvious in the use of bevacizumab and anti-EGFR therapy in patients with (K)RAS wild-type tumors. Administration rates did not differ between hospital types but fluctuated between individual hospitals for bevacizumab (8-92%; p<0·0001) and anti-EGFR therapy (10-75%; p=0·05). Bevacizumab administration was inversely correlated to higher age (OR:0·2; 95% CI: 0·1-0·3) comorbidity (OR:0·6; 95% CI: 0·5-0·8) and the presence of metachronous metastases (OR:0·5; 95% CI: 0·3-0·7), but patient characteristics did not differ between hospitals with low or high bevacizumab administration rates. Exposure to bevacizumab (HR:0·8; 95% CI: 0·7-0·9) and anti-EGFR therapy (HR:0·6; 95% CI: 0·5-0·8) was associated with prolonged survival. Conclusions: We identified significant inter-hospital variation in targeted therapy administration for mCRC patients, which may affect outcome. Age and comorbidity were inversely correlated with non-administration of bevacizumab, but did not explain inter-hospital practice variation. Our data strongly indicate that practice variation is based on individual strategy of hospitals rather than guideline recommendations or patient-driven decisions. Individual hospital strategies are an additional factor that may explain the observed differences between real-life data and results obtained from clinical trials.

Download Full-text

261 LENGTH OF HOSPITAL STAY AND THE ASSOCIATION WITH READMISSION AFTER UNCOMPLICATED ESOPHAGECTOMY. SIGNIFICANT HOSPITAL VARIATION IN THE NETHERLANDS.

Diseases of the Esophagus ◽

10.1093/dote/doaa087.53 ◽

2020 ◽

Vol 33 (Supplement_1) ◽

Author(s):

D Voeten ◽

L Werf ◽

J Sandick ◽

R Hillegersberg ◽

M Berge Henegouwen

Keyword(s):

Esophageal Cancer ◽

The Netherlands ◽

Hospital Stay ◽

Hospital Costs ◽

Length Of Hospital Stay ◽

Short Length ◽

Case Mix ◽

Readmission Rates ◽

Admission Rates ◽

Hospital Variation

Abstract Prolonged length of hospital stay is a negative outcome of esophageal cancer surgery, not only for the patient; it also leads to increased hospital costs. Within the scope of value-based health care, this study aimed to analyze Dutch hospital performance in terms of length of hospital stay and to investigate its association with readmission rates. Since both parameters are influenced by the occurrence of complications, this study only included patients after an uncomplicated esophagectomy. Methods All patients registered in the Dutch Upper GI Cancer Audit (DUCA) who underwent a potentially curative esophageal cancer resection between 2015 and 2018 were considered for inclusion. Patients were excluded if they had an intraoperative and/or postoperative complication, if they were retransferred to the intensive care unit, or if they had undergone a re-intervention. Length of hospital stay was dichotomized around the national median into “short admissions” and “long admissions”. Hospital variation was evaluated using a case-mix corrected funnel plot based on multivariable logistic regression analyses. Association of length of hospital stay with readmission rates was investigated using the χ2-statistic. Results A total of 1,007 patients was included for analyses. National median length of hospital stay was 9 days, ranging from 6.5–12.5 days among 17 hospitals. The percentage of “short admissions” per hospital ranged from 7.7% to 93.5%. After correction for case-mix variables, 2 hospitals had significantly higher “short admission” rates and 4 hospitals had significantly lower “short admission” rates (figure 1). Overall, 6.2% (hospital variation [0.0%–13.2%]) of patients was readmitted. Hospital readmission rates were not significantly different between hospitals with a short length of hospital stay and those with a long length of hospital stay (5.5% versus 7.6%; p = 0.19). Conclusion Based on these nationwide audit data, length of hospital stay after an uncomplicated esophagectomy varied significantly between hospitals and ranged from 6.5 to 12.5 days among Dutch hospitals. Short length of hospital stay was not associated with a higher readmission rate. The hospital variation indicates that enhanced recovery programs are not implemented at the same level of efficacy among hospitals in the Netherlands. Nationwide improvement might lead to a substantial reduction of hospital costs.

Download Full-text

Variation in length of stay after minimally invasive lung resection: a reflection of perioperative care routines?

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezz303 ◽

2019 ◽

Cited By ~ 1

Author(s):

Erik M von Meyenfeldt ◽

Fieke Hoeijmakers ◽

Geertruid M H Marres ◽

Eric R E van Thiel ◽

Elske Marra ◽

...

Keyword(s):

Length Of Stay ◽

Minimally Invasive ◽

Perioperative Care ◽

Lung Resection ◽

Practice Variation ◽

Case Mix ◽

Hospital Characteristic ◽

Complication Rates ◽

Hospital Variation ◽

Lung Resections

Abstract OBJECTIVES Good perioperative care is aimed at rapid recovery, without complications or readmissions. Length of stay (LOS) is influenced not only by perioperative care routines but also by patient factors, tumour factors, treatment characteristics and complications. The present study examines variation in LOS between hospitals after minimally invasive lung resections for both complicated and uncomplicated patients to assess whether LOS is a hospital characteristic influenced by local perioperative routines or other factors. METHODS Dutch Lung Cancer Audit (surgery) data were used. Median LOS was calculated on hospital level, stratified by the severity of complications. Lowest quartile (short) LOS per hospital, corrected for case-mix factors by multivariable logistic regression, was presented in funnel plots. We correlated short LOS in complicated versus uncomplicated patients to assess whether short LOS clustered in the same hospitals regardless of complications. RESULTS Data from 6055 patients in 42 hospitals were included. Median LOS in uncomplicated patients varied from 3 to 8 days between hospitals and increased most markedly for patients with major complications. Considerable between-hospital variation persisted after case-mix correction, but more in uncomplicated than complicated patients. Short LOS in uncomplicated and complicated patients were significantly correlated (r = 0.53, P < 0.001). CONCLUSIONS LOS after minimally invasive anatomical lung resections varied between hospitals particularly in uncomplicated patients. The significant correlation between short LOS in uncomplicated and complicated patients suggests that LOS is a hospital characteristic potentially influenced by local processes. Standardizing and optimizing perioperative care could help limit practice variation with improved LOS and complication rates.

Download Full-text

Hospital Variation in Cancer Treatments and Survival Outcomes of Advanced Melanoma Patients: Nationwide Quality Assurance in The Netherlands

Cancers ◽

10.3390/cancers13205077 ◽

2021 ◽

Vol 13 (20) ◽

pp. 5077

Author(s):

Jesper van Breeschoten ◽

Alfonsus J.M. van den Eertwegh ◽

Liesbeth C. de Wreede ◽

Doranne L. Hilarius ◽

Erik W. van Zwet ◽

...

Keyword(s):

The Netherlands ◽

Significant Variation ◽

Empirical Bayes ◽

Treatment Patterns ◽

Case Mix ◽

Survival Probabilities ◽

Hospital Variation ◽

Significant Difference ◽

Melanoma Treatment ◽

Systemic Therapies

Background: To assure a high quality of care for patients treated in Dutch melanoma centers, hospital variation in treatment patterns and outcomes is evaluated in the Dutch Melanoma Treatment Registry. The aim of this study was to assess center variation in treatments and 2-year survival probabilities of patients diagnosed between 2013 and 2017 in the Netherlands. Methods: We selected patients diagnosed between 2013 and 2017 with unresectable IIIC or stage IV melanoma, registered in the Dutch Melanoma Treatment Registry. Centers’ performance on 2-year survival was evaluated using Empirical Bayes estimates calculated in a random effects model. Treatment patterns of the centers with the lowest and highest estimates for 2-year survival were compared. Results: For patients diagnosed between 2014 and 2015, significant center variation in 2-year survival probabilities was observed even after correcting for case-mix and treatment with new systemic therapies. The different use of new systemic therapies partially explained the observed variation. From 2016 onwards, no significant difference in 2-year survival was observed between centers. Conclusion: Our data suggest that between 2014 and 2015, after correcting for patient case-mix, significant variation in 2-year survival probabilities between Dutch melanoma centers existed. The use of new systemic therapies could partially explain this variation. In 2013 and between 2016 and 2017, no significant variation between centers existed.

Download Full-text

The contribution of case mix, skill mix and care processes to the outcomes of community hospitals

European Journal of Public Health ◽

10.1093/eurpub/ckaa165.463 ◽

2020 ◽

Vol 30 (Supplement_5) ◽

Author(s):

J Lenzi ◽

K Y C Adja ◽

D Pianori ◽

C Reno ◽

M P Fantini

Keyword(s):

Older People ◽

Unmet Needs ◽

Working Hours ◽

Case Mix ◽

Community Hospitals ◽

Organizational Models ◽

Skill Mix ◽

Processes Of Care ◽

Hospital Variation ◽

Care Processes

Abstract Background The rapid increase in the proportion of older people underscores the need for new organizational models to face the unmet needs of frail patients with multiple conditions. Community hospitals (CHs) could be a solution to tackle these needs and foster integration between acute and primary care. The aim of this study was to investigate which patients' characteristics and which care processes affect clinical outcomes, in order to identify who could benefit the most from CH care and the best skill mix to deliver in this setting of care. Methods This study included all patients aged ≥65 and discharged in 2017 from the 16 CHs of Emilia-Romagna, northern Italy. Data sources were the regional CH informative system and hospital discharge records. CH skill mix and processes of care were collected with a survey; 3 non-respondent CHs were excluded. The study outcome was in-hospital variation of the Barthel index (BI) (≥10 vs. <10). We performed a 2-level random-intercept logistic regression analysis, and used the variance partition coefficient (VPC) to quantify the proportion of BI improvement that lay at CH level. Results Of the 13 CHs, 7 admitted ≥150 patients, 8 had a general practitioner medical support model, and 6 had >12 nurses' working hours/week/bed. Overall, 53% of the patients had a BI improvement ≥10 (4% to 71% across CHs). The patient case mix (i.e. baseline BI, female, older age, transfer from acute care) explained a portion of variability across CHs, as shown by the VPC that decreased from 0.32 to 0.26. Skill mix and processes of care were not associated with BI change, and the VPC resulting from controlling for these variables was virtually unchanged (0.28). Conclusions Patients' characteristics explained part of between-CH variation in BI improvement. Professional skill mix and processes of care, albeit fundamental to achieve appropriate care and respond to the unmet needs of the frail elderly, did not account for differences in CH-specific outcomes. Key messages A combination of quantitative and qualitative methods might better explain the outcome variability across intermediate care services. Multidisciplinary CH teams and services can be helpful to address the unmet needs of older people, but further studies are necessary.

Download Full-text

Predicting emergency department visits in a large teaching hospital

International Journal of Emergency Medicine ◽

10.1186/s12245-021-00357-6 ◽

2021 ◽

Vol 14 (1) ◽

Author(s):

Nathan Singh Erkamp ◽

Dirk Hendrikus van Dalen ◽

Esther de Vries

Keyword(s):

Emergency Department ◽

The Netherlands ◽

Teaching Hospital ◽

Time Trend ◽

Prediction Models ◽

Emergency Department Visits ◽

Weather Data ◽

Negative Consequences ◽

Weather Variables ◽

Ed Visits

Abstract Background Emergency department (ED) visits show a high volatility over time. Therefore, EDs are likely to be crowded at peak-volume moments. ED crowding is a widely reported problem with negative consequences for patients as well as staff. Previous studies on the predictive value of weather variables on ED visits show conflicting results. Also, no such studies were performed in the Netherlands. Therefore, we evaluated prediction models for the number of ED visits in our large the Netherlands teaching hospital based on calendar and weather variables as potential predictors. Methods Data on all ED visits from June 2016 until December 31, 2019, were extracted. The 2016–2018 data were used as training set, the 2019 data as test set. Weather data were extracted from three publicly available datasets from the Royal Netherlands Meteorological Institute. Weather observations in proximity of the hospital were used to predict the weather in the hospital’s catchment area by applying the inverse distance weighting interpolation method. The predictability of daily ED visits was examined by creating linear prediction models using stepwise selection; the mean absolute percentage error (MAPE) was used as measurement of fit. Results The number of daily ED visits shows a positive time trend and a large impact of calendar events (higher on Mondays and Fridays, lower on Saturdays and Sundays, higher at special times such as carnival, lower in holidays falling on Monday through Saturday, and summer vacation). The weather itself was a better predictor than weather volatility, but only showed a small effect; the calendar-only prediction model had very similar coefficients to the calendar+weather model for the days of the week, time trend, and special time periods (both MAPE’s were 8.7%). Conclusions Because of this similar performance, and the inaccuracy caused by weather forecasts, we decided the calendar-only model would be most useful in our hospital; it can probably be transferred for use in EDs of the same size and in a similar region. However, the variability in ED visits is considerable. Therefore, one should always anticipate potential unforeseen spikes and dips in ED visits that are not shown by the model.

Download Full-text