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

Cancers ◽  
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.

scholarly journals Hospital variation in cancer treatments and survival outcomes of advanced melanoma patients: Nationwide quality assurance in the Netherlands.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. e18641-e18641
Author(s):  
Jesper van Breeschoten ◽  
Alfonsus Johannes Maria van den Eertwegh ◽  
Liesbeth De Wreede ◽  
Erik W. van Zwet ◽  
Doranne Hilarius ◽  
...  
Keyword(s):  
The Netherlands ◽  
Proportional Hazards ◽  
Proportional Hazards Model ◽  
Cox Proportional Hazards ◽  
Cox Proportional Hazards Model ◽  
Hospital Variation ◽  
Hazards Model ◽  
Unresectable Stage ◽  
Melanoma Treatment ◽  
Systemic Therapies

e18641 Background: The introduction of new systemic treatments for advanced melanoma has markedly changed the outcome of patients with metastatic melanoma. To assure high quality of care for patients treated in Dutch melanoma centers, hospital variation in treatment patterns and outcomes are 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 2013-2017 in the Netherlands. Methods: We selected patients diagnosed between 2013-2017 with unresectable stage IIIC or IV melanoma, registered in the Dutch Melanoma Treatment Registry. Centers’ performance on 2-year survival was compared by means of a multivariable Cox proportional hazards model with a random effect for center ID. Variation between centers was expressed by median hazard ratios. Therapy with BRAF/MEK inhibitors, anti-PD-1 antibodies or ipilimumab plus nivolumab was added to the Cox proportional hazards model as a time dependent covariate to assess the influence of new systemic therapies on center variation. Results: Between 2013-2017, 3820 patients were diagnosed with unresectable stage IIIC or IV melanoma. For patients diagnosed between 2013-2015, significant center variation in 2-year survival probabilities was observed. Median hazard ratio was 1.17 (95%CI: 1.09-1.31) for patients diagnosed between 2013-2015 after correcting for case-mix and treatment with BRAF/MEK inhibitors, anti-PD-1 antibodies or ipilimumab plus nivolumab. Use of new systemic therapies had a significant effect on up to 2-year survival (hazard ratio = 0.83, 95%CI (0.73-0.94)) with no use of the new systemic therapies as a reference. From 2016 onwards, no significant difference in 2-years survival was observed between centers. Conclusions: The different use of new cancer treatment of metastatic melanoma had an effect on survival outcomes in the Netherlands. A platform such as the Dutch Melanoma Treatment Registry, in which melanoma centers collaborate and have insight in variation in treatment patterns and outcomes between centers, results in fast implementation of new clinical developments across all Dutch melanoma centers.

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

2020 ◽  
Vol 37 (6) ◽  
pp. 488-494
Author(s):  
Carmen S.S. Latenstein ◽  
Sarah Z. Wennmacker ◽  
Stef Groenewoud ◽  
Mark W. Noordenbos ◽  
Femke Atsma ◽  
...  
Keyword(s):  
The Netherlands ◽  
Clinical Outcomes ◽  
Gallstone Disease ◽  
Practice Variation ◽  
Emergency Department Visits ◽  
Case Mix ◽  
Hospital Variation ◽  
Improved Outcomes ◽  
Related Group ◽  
Nationwide Observational Study

<b><i>Background:</i></b> 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. <b><i>Methods:</i></b> 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. <b><i>Results:</i></b> 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. <b><i>Conclusion:</i></b> Hospital variation in cholecystectomies in the Netherlands is modest, cholecystectomy rates varies by &#x3c;2-fold, and variation is stable over time. Cholecystectomies in hospitals with high adjusted cholecystectomy rates are associated with improved outcomes.

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

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 &gt;3 weeks from the date of first brain tumor diagnosis to surgery, long time-to-radiotherapy (TTR) as either &gt;4 or &gt;6 weeks after surgery, and long time-to-chemotherapy (TTC) as either &gt;4 or &gt;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 &gt;4 and &gt;6 weeks, respectively. In seven (21.2%) chemotherapy hospitals, significantly less patients with TTC &gt;4 weeks were observed than expected. In four (12.1%) chemotherapy hospitals, significantly more patients with TTC &gt;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.

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

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.

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

BMC Surgery ◽  
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.

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

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. &lt;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 &gt;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.

scholarly journals Operational experience of the Dutch helicopter emergency medical services (HEMS) during the initial phase of the COVID-19 pandemic: jeopardy on the prehospital care system?

2021 ◽  
Author(s):  
Quinten G. H. Rikken ◽  
Sarah Mikdad ◽  
Mathijs T. Carvalho Mota ◽  
Marcel A. De Leeuw ◽  
Patrick Schober ◽  
...  
Keyword(s):  
The Netherlands ◽  
Initial Phase ◽  
Prehospital Care ◽  
Operational Experience ◽  
Level Of Evidence ◽  
Historical Cohort ◽  
Significant Difference ◽  
One Year ◽  
Retrospective Comparative Study ◽  
Global And Local

Abstract Purpose The SARS-CoV-2 virus has disrupted global and local medical supply chains. To combat the spread of the virus and prevent an uncontrolled outbreak with limited resources, national lockdown protocols have taken effect in the Netherlands since March 13th, 2020. The aim of this study was to describe the incidence, type and characteristics of HEMS and HEMS-ambulance ‘Lifeliner 1’ dispatches during the initial phase of the COVID-19 pandemic compared to the same period one year prior. Methods A retrospective review of all HEMS and HEMS-ambulance ‘Lifeliner 1’ dispatches was performed from the start of Dutch nationwide lockdown orders from March 13th until May 13th, 2020 and the corresponding period one year prior. Dispatch-, operational-, patient-, injury-, and on-site treatment characteristics were extracted for analysis. In addition, the rate of COVID-19 positively tested HEMS personnel and the time physicians were unable to take call was described. Results During the initial phase of the COVID-19 pandemic, the HEMS and HEMS-ambulance was requested in 528 cases. One year prior, a total of 620 requests were received. The HEMS (helicopter and ambulance) was cancelled after deployment in 56.4% of the COVID-19 cohort and 50.7% of the historical cohort (P = 0.05). Incident location type did not differ between the two cohorts, specifically, there was no significant difference in the number of injuries that occurred at home in pandemic versus non-pandemic circumstances. Besides a decrease in the number of falls, the distribution of mechanisms of injury remained similar during the COVID-19 study period. There was no difference in self-inflicted injuries observed. Prehospital interventions remained similar during the COVID-19 pandemic compared to one year prior. Specifically, prehospital intubation did not differ between the two cohorts. The rate of COVID-19 positively tested HEMS personnel was 23.1%. Physicians who tested positive were unable to take call for a mean of 25 days (range 8–53). Conclusion A decrease in the number of deployments and increase in the number of cancelled missions was observed during the COVID-19 study period. No major differences in operational- and injury characteristics were found for HEMS and HEMS-ambulance dispatches between the initial phase of the COVID-19 pandemic in the Netherlands and the same period one year prior. These findings highlight the importance of continued operability of the HEMS, even during pandemic circumstances. Level of evidence III, retrospective comparative study.

Between-Hospital Variation in Revision Rates After Total Hip and Knee Arthroplasty in the Netherlands

2020 ◽  
Vol 102 (4) ◽  
pp. 315-324 ◽  
Author(s):  
Peter van Schie ◽  
Liza N. van Steenbergen ◽  
Leti van Bodegom-Vos ◽  
Rob G.H.H. Nelissen ◽  
Perla J. Marang-van de Mheen
Keyword(s):  
The Netherlands ◽  
Knee Arthroplasty ◽  
Total Hip ◽  
Hospital Variation ◽  
Hip And Knee Arthroplasty

scholarly journals Community-acquired bacteraemia in COVID-19 in comparison to influenza A and influenza B: a retrospective cohort study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Julinha M. Thelen ◽  
A. G. ( Noud) Buenen ◽  
Marjan van Apeldoorn ◽  
Heiman F. Wertheim ◽  
Mirjam H. A. Hermans ◽  
...  
Keyword(s):  
Cohort Study ◽  
Blood Culture ◽  
The Netherlands ◽  
Retrospective Cohort Study ◽  
Retrospective Cohort ◽  
Influenza A ◽  
Blood Cultures ◽  
Influenza B ◽  
Significant Difference ◽  
All Cause Mortality

Abstract Background During the coronavirus disease 2019 (COVID-19) pandemic in the Netherlands it was noticed that very few blood cultures from COVID-19 patients turned positive with clinically relevant bacteria. This was particularly evident in comparison to the number of positive blood cultures during previous seasonal epidemics of influenza. This observation raised questions about the occurrence and causative microorganisms of bacteraemia in COVID-19 patients, especially in the perspective of the widely reported overuse of antibiotics and the rising rate of antibiotic resistance. Methods We conducted a retrospective cohort study on blood culture results in influenza A, influenza B and COVID-19 patients presenting to two hospitals in the Netherlands. Our main outcome consisted of the percentage of positive blood cultures. The percentage of clinically relevant blood cultures, isolated bacteria and 30-day all-cause mortality served as our secondary outcomes. Results A total of 1331 viral episodes were analysed in 1324 patients. There was no statistically significant difference (p = 0.47) in overall occurrence of blood culture positivity in COVID-19 patients (9.0, 95% CI 6.8–11.1) in comparison to influenza A (11.4, 95% CI 7.9–14.8) and influenza B patients (10.4, 95% CI 7.1–13.7,). After correcting for the high rate of contamination, the occurrence of clinically relevant bacteraemia in COVID-19 patients amounted to 1.0% (95% CI 0.3–1.8), which was statistically significantly lower (p = 0.04) compared to influenza A patients (4.0, 95% CI 1.9–6.1) and influenza B patients (3.0, 95% CI 1.2–4.9). The most frequently identified bacterial isolates in COVID-19 patients were Escherichia coli (n = 2) and Streptococcus pneumoniae (n = 2). The overall 30-day all-cause mortality for COVID-19 patients was 28.3% (95% CI 24.9–31.7), which was statistically significantly higher (p = <.001) when compared to patients with influenza A (7.1, 95% CI 4.3–9.9) and patients with influenza B (6.4, 95% CI 3.8–9.1). Conclusions We report a very low occurrence of community-acquired bacteraemia amongst COVID-19 patients in comparison to influenza patients. These results reinforce current clinical guidelines on antibiotic management in COVID-19, which only advise utilization of antibiotics when a bacterial co-infection is suspected.

scholarly journals Regional and hospital variation in commonly performed paediatric otolaryngology procedures in the Netherlands: a population-based study of healthcare utilisation between 2016 and 2019

BMJ Open ◽  
2021 ◽  
Vol 11 (7) ◽  
pp. e046840
Author(s):  
Juliëtte J C M van Munster ◽  
Joost J G Wammes ◽  
Rolf H Bremmer ◽  
Amir H Zamanipoor Najafabadi ◽  
Raphael J Hemler ◽  
...  
Keyword(s):  
The Netherlands ◽  
Healthcare Utilisation ◽  
Care Process ◽  
Resource Utilisation ◽  
Ventilation Tube ◽  
Tube Insertion ◽  
High Quality ◽  
Cross Sectional ◽  
Referral Rates ◽  
Hospital Variation

ObjectiveIn the past few decades, there has been an increase in high-quality studies providing evidence on the effectiveness of commonly performed procedures in paediatric otolaryngology. We believe that now is the time to re-evaluate the care process. We aimed to analyse (1) the regional variation in incidence and referrals of adenoidectomies, tonsillectomies and ventilation tube insertions in children in the Netherlands between 2016 and 2019, (2) whether regional surgical rates, referral rates and in-hospital surgical rates were associated with one another, and (3) the hospital variation in healthcare costs, which indicates the utilisation of resources.DesignRepeated cross-sectional analysis.SettingFour neighbouring Dutch provinces comprising 2.8 million inhabitants and 14 hospitals.ParticipantsChildren aged 0–15 years.Outcome measuresWe analysed variation in regional surgical rates and referral rates per 1000 inhabitants and in-hospital surgical rates per 1000 clinic visitors, adjusted for age and socioeconomic status. Furthermore, the relationships between referral rates, regional surgical rates and in-hospital surgical rates were estimated. Lastly, variation in resource utilisation between hospitals was estimated.ResultsAdenoidectomy rates differed sixfold between regions. Twofold differences were observed for adenotonsillectomy rates, ventilation tube insertion rates and referral rates. Referral rates were negatively associated with in-hospital surgical rates for adenotonsillectomies, but not for adenoidectomies and ventilation tube insertions. In-hospital surgical rates were positively associated with regional rates for adenoidectomies and adenotonsillectomies. Significant variation between hospitals was observed in costs for all resources.ConclusionsWe observed low variation in tonsillectomies and ventilation tube insertion and high variation in adenoidectomies. Indications for a tonsillectomy and ventilation tube insertion are well defined in Dutch guidelines, whereas this is not the case for an adenoidectomy. Lack of agreement on indications can be expected and high-quality effectiveness research is required to improve evidence-based guidelines on this topic.

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