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Background The World Falls Guidelines (WFG) propose an algorithm that classifies patients as low-, intermediate-, and high-risk. We evaluated different operationalizations of the WFG algorithm and compared its predictive performance to other screening tools for falls, namely: the American Geriatrics Society and British Geriatrics Society (AGS/BGS) algorithm, the 3KQ on their own and fall history on its own. Methods We included data from 1509 adults aged ≥65 years from the population-based Longitudinal Aging Study Amsterdam. The outcome was ≥1 fall during 1-year follow-up, which was ascertained using fall calendars. The screening tools' items were retrospectively operationalized using baseline measures, using proxies where necessary. Results Sensitivity ranged between 30.9–48.0% and specificity ranged between 77.0–88.2%. Operationalizing the algorithm with the 3KQ instead of fall history yielded a higher sensitivity but lower specificity, whereas operationalization with the Clinical Frailty Scale (CFS) classification tree instead of Fried's frailty criteria did not affect predictive performance. Compared to the WFG algorithm, the AGS/BGS algorithm and fall history on its own yielded similar predictive performance, whereas the 3KQ on their own yielded a higher sensitivity but lower specificity. Conclusion The WFG algorithm can identify patients at risk of a fall, especially when the 3KQ are included in its operationalization. The CFS and Fried's frailty criteria may be used interchangeably in the algorithm's operationalization. The algorithm performed similarly compared to other screening tools, except for the 3KQ on their own, which have higher sensitivity but lower specificity and lack clinical recommendations per risk category. [ABSTRACT FROM AUTHOR]

Introduction: Preterm birth (PTB) is the leading cause of infant mortality and morbidity worldwide. Rates of PTB in the Netherlands are declining, possibly due to the implementation of preventive strategies. In this study we assessed the overall trend in PTB rates in the Netherlands in recent years, and in more detail in specific subgroups to investigate potential groups that require scrutiny in the near future. Material and methods: Based on the national perinatal registry, we included all pregnancies without severe congenital abnormalities resulting in a birth from 24 to 42 completed weeks of gestation between 2011 and 2019 in the Netherlands. We assessed PTB rates in two different clinical subtypes (spontaneous vs. iatrogenic) and in five gestational age subgroups: 24–27+6 weeks (extreme), 28–31+6 weeks (very), 32–33+6 weeks (moderate, 34–36+6 weeks [late] and, in general, 24–36+6 weeks [overall PTB]). Trend analysis was performed using the Cochran Armitage test. We also compared PTB rates in different subgroups in the first 2 years compared to the last 2 years. Singleton and multiple gestations were analyzed separately. Results: We included 1 447 689 singleton and 23 250 multiple pregnancies in our study. In singletons, we observed a significant decline in PTB from 5.5% to 5.0% (p < 0.0001), mainly due to a decrease in iatrogenic PTBs. When focusing on different gestational age subgroups, there was a decrease in all iatrogenic PTB and in moderate to late spontaneous PTB. However, in spontaneous extreme and very PTB there was an significant increase. When assessing overall PTB risk in different subgroups, the decline was only visible in women with age ≥25 years, nulliparous and primiparous women, women with a medium or high socioeconomic status and hypertensive women. In multiples, the rate of PTB remained fairly stable, from 52.3% in 2011 to 54.1% in 2019 (p = 0.57). Conclusions: In the Netherlands, between 2011 and 2019, PTB decreased, mainly due to a reduction in late PTB, and more in iatrogenic than in spontaneous PTB. Focus for the near future should be on specific subgroups in which the decline was not visible, such as women with a low socioeconomic status or a young age. [ABSTRACT FROM AUTHOR]

Purpose: Only few studies have assessed the preventive effect of the STOPP/START criteria on adverse events. We aim to quantify 1) the association between nonadherence to STOPP/START criteria and gastrointestinal bleedings, and 2) the association between exposure to the potentially harmful START-medications and gastrointestinal bleedings. Design: A retrospective cohort study using routinely collected data of patients aged ≥ 65 years from the electronic health records (EHR) of 49 general practitioners (GPs) in 6 GP practices, from 2007 to 2014. The database is maintained in the academic research network database (AHA) of Amsterdam UMC, the Netherlands. Methods: Gastrointestinal bleedings were identified using ICPC codes and free text inspections. Three STOPP and six START criteria pertaining to gastrointestinal bleedings were selected. Cox proportional hazards regression with time-dependent covariate analysis was performed to assess the independent association between nonadherence to the STOPP/START criteria and gastrointestinal bleedings. The analysis was performed with all criteria as a composite outcome, as well as separately for the individual criteria. Results: Out of 26,576 participants, we identified 19,070 Potential Inappropriate Medications (PIM)/Potential Prescribing Omission (PPO) instances for 3,193 participants and 146 gastrointestinal bleedings in 143 participants. The hazard ratio for gastrointestinal bleedings of STOPP/STARTs, taken as composite outcome, was 5.45 (95% CI 3.62–8.21). When analysed separately, two out of nine STOPP/STARTs showed significant associations. Conclusion: This study demonstrates a significant positive association between nonadherence to the STOPP/START criteria and gastrointestinal bleeding. We emphasize the importance of adherence to the relevant criteria for gastrointestinal bleeding, which may be endorsed by decision support systems. [ABSTRACT FROM AUTHOR]

Background: Falls are the leading cause of injury-related mortality and hospitalization among adults aged ≥ 65 years. An important modifiable fall-risk factor is use of fall-risk increasing drugs (FRIDs). However, deprescribing is not always attempted or performed successfully. The ADFICE_IT trial evaluates the combined use of a clinical decision support system (CDSS) and a patient portal for optimizing the deprescribing of FRIDs in older fallers. The intervention aims to optimize and enhance shared decision making (SDM) and consequently prevent injurious falls and reduce healthcare-related costs. Methods: A multicenter, cluster-randomized controlled trial with process evaluation will be conducted among hospitals in the Netherlands. We aim to include 856 individuals aged ≥ 65 years that visit the falls clinic due to a fall. The intervention comprises the combined use of a CDSS and a patient portal. The CDSS provides guideline-based advice with regard to deprescribing and an individual fall-risk estimation, as calculated by an embedded prediction model. The patient portal provides educational information and a summary of the patient's consultation. Hospitals in the control arm will provide care-as-usual. Fall-calendars will be used for measuring the time to first injurious fall (primary outcome) and secondary fall outcomes during one year. Other measurements will be conducted at baseline, 3, 6, and 12 months and include quality of life, cost-effectiveness, feasibility, and shared decision-making measures. Data will be analyzed according to the intention-to-treat principle. Difference in time to injurious fall between the intervention and control group will be analyzed using multilevel Cox regression. Discussion: The findings of this study will add valuable insights about how digital health informatics tools that target physicians and older adults can optimize deprescribing and support SDM. We expect the CDSS and patient portal to aid in deprescribing of FRIDs, resulting in a reduction in falls and related injuries. Trial registration: ClinicalTrials.gov NCT05449470 (7-7-2022). [ABSTRACT FROM AUTHOR]

Background: Gestational age is positively associated with cognitive development, but socio‐demographic factors also influence school performance. Previous studies suggested possible interaction, putting children with low socio‐economic status (SES) at increased risk of the negative effects of prematurity. Objectives: To investigate the association between gestational age in weeks, socio‐demographic characteristics, and school performance at the age of 12 years among children in regular primary education. Methods: Population‐based cohort study among liveborn singletons (N = 860,332) born in the Netherlands in 1999–2006 at 25–42 weeks' gestation, with school performance from 2011 to 2019. Regression analyses were conducted investigating the association of gestational age and sociodemographic factors with school performance and possible interaction. Results: School performance increased with gestational age up to 40 weeks. This pattern was evident across socio‐demographic strata. Children born at 25 weeks had −0.57 SD (95% confidence interval −0.79, −0.35) lower school performance z‐scores and lower secondary school level compared to 40 weeks. Low maternal education, low maternal age, and non‐European origin were strongly associated with lower school performance. Being born third or later and low socioeconomic status (SES) were also associated with lower school performance, but differences were smaller than among other factors. When born preterm, children from mothers with low education level, low or high age, low SES or children born third or later were at higher risk for lower school performance compared to children of mothers with intermediate education level, aged 25–29 years, with intermediate SES or first borns (evidence of interaction). Conclusions: Higher gestational age is associated with better school performance at the age of 12 years along the entire spectrum of gestational age, beyond the cut‐off of preterm birth and across socio‐demographic differences. Children in socially or economically disadvantaged situations might be more vulnerable to the negative impact of preterm birth. Other important factors in school performance are maternal education, maternal age, ethnicity, birth order and SES. Results should be interpreted with caution due to differential loss to follow‐up. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to assess whether induction of labor at 41 weeks of gestation improved perinatal outcomes in a low‐risk pregnancy compared with expectant management. Material and methods: Registry‐based national cohort study in The Netherlands. The study population comprised 239 971 low‐risk singleton pregnancies from 2010 to 2019, with birth occurring from 41+0 to 42+0 weeks. We used propensity score matching to compare induction of labor in three 2‐day groups to expectant management, and further conducted separate analyses by parity. The main outcome measures were stillbirth, perinatal mortality, 5‐min Apgar <4 and <7, neonatal intensive care unit (NICU) admissions ≥24 h, and emergency cesarean section rate. Results: Compared with expectant management, induction of labor at 41+0 to 41+1 weeks resulted in reduced stillbirths (adjusted odds ratio [aOR] 0.15, 95% confidence interval [CI] 0.05–0.51) in both nulliparous and multiparous women. Induction of labor increased 5‐min Apgar score <7 (aOR 1.30, 95% CI 1.09–1.55) and NICU admissions ≥24 h (aOR 2.12, 95% CI 1.53–2.92), particularly in nulliparous women, and increased the cesarean section rate (aOR 1.42, 95% CI 1.34–1.51). At 41+2–41+3 weeks, induction of labor reduced perinatal mortality (aOR 0.13, 95% CI 0.04–0.43) in both nulliparous and multiparous women. The rate of 5‐min Apgar score <7 was increased (aOR 1.26, 95% CI 1.06–1.50), reaching significance in multiparous women. The cesarean section rate increased (aOR 1.57, 95% CI 1.48–1.67) in both nulliparous and multiparous women. Induction of labor at 41+4 to 41+5 weeks reduced stillbirths (aOR 0.30, 95% CI 0.10–0.93). Induction of labor increased rates of 5‐min Apgar score <4 (aOR 1.61, 95% CI 1.01–2.56) and NICU admissions ≥24 h (aOR 1.52, 95% CI 1.08–2.13) in nulliparous women. Cesarean section rate was increased (aOR 1.47, 95% CI 1.38–1.57) in nulliparous and multiparous women. Conclusions: At 41+2 to 41+3 weeks, induction of labor reduced perinatal mortality, and in all 2‐day groups at 41 weeks, it reduced stillbirths, compared with expectant management. Low 5‐min Apgar score (<7 and <4) and NICU admissions ≥24 h occurred more often with induction of labor, especially in nulliparous women. Induction of labor in all 2‐day groups coincided with elevated cesarean section rates in nulliparous and multiparous women. These findings pertaining to the choice of induction of labor vs expectant management should be discussed when counseling women at 41 weeks of gestation. [ABSTRACT FROM AUTHOR]

Background: Medication non-adherence is a prevalent health problem in people with type 2 diabetes mellitus (T2DM). Interventions have previously been developed to improve medication adherence, but inconsistent outcomes have been reported. A potential explanation for this inconsistency is a 'one size fits all' approach, with interventions not tailored to the needs and preferences of individuals. Therefore, the aim of this study is to evaluate the effectiveness of a personalised intervention programme aimed at improving adherence to oral antidiabetic and/or antihypertensive medication in people with T2DM.Methods: A parallel-group randomised controlled trial will be conducted in 40-50 community pharmacies in the Netherlands and the United Kingdom (UK). A total of 300 participants will be included and followed up for a period of 6 months. Participants will be people with T2DM identified as non-adherent to oral antidiabetic and/or antihypertensive medication, aged 35-75 years and mobile phone users. The intervention group will receive a personalised intervention programme that is based on one or more of the participants' pre-defined non-adherence profile(s), namely (I) Knowledge and perceptions, (II) Practical problems, (III) Side effects and (IV) Negative mood and beliefs. The intervention comprises of one or more supporting modules, namely (I) Brief messaging, (II) Clinical medication review, (III) Medication schedule, (IV) Reminding messaging, (V) Medication dispensing systems, (VI) Smart messaging, (VII) Referral to general practitioner and (VIII) Unguided web-based Self Help Application for low mood. The control group will receive usual care including access to a publicly available informative diabetes website. The primary study outcome is medication adherence measured with a telephone pill count. Secondary outcomes are systolic blood pressure, HbA1c level, self-reported medication adherence, attitude and beliefs toward medication, satisfaction with diabetes treatment, health status and medical consumption and productivity cost. In addition, a process evaluation will be undertaken to establish the fidelity, reach and the extent to which intervention delivery is normalised in the daily practice of community pharmacy teams.Discussion: The study can lead to a personalised intervention programme that improves medication adherence in people with T2DM that are non-adherent to oral antidiabetic and/or antihypertensive medication.Trial Registration: Dutch Trial Register, Trial NL8747 , registered 02 July, 2020; ISRCTN Registry, ISRCTN36009809 , registered 05 February, 2020. [ABSTRACT FROM AUTHOR]

Introduction: The associations of epidural analgesia and low Apgar score found in the Swedish Registry might be a result of confounding by indication. The objective of this study was to assess the possible effect of intrapartum epidural analgesia on low Apgar score and neonatal intensive care unit (NICU) admission in term born singletons with propensity score matching.Material and Methods: This was a propensity score matched study (n = 257 872) conducted in a national cohort of 715 449 term live born singletons without congenital anomalies in the Netherlands. Mothers with prelabor cesarean section were excluded. Main outcome measures were 5-minute Apgar score <7, 5-minute Apgar score <4 and admission to a NICU for at least 24 hours. First, an analysis of the underlying risk factors for low Apgar score <7 was performed. Multivariable analyses were applied to assess the effect of the main risk factor, intrapartum epidural analgesia, on low Apgar score to adjust the results for confounding factors. Second, a propensity score matched analysis on the main risk factors for epidural analgesia was applied. By propensity score matching the (confounding) characteristics of the women who received epidural analgesia with the characteristics of the control women without epidural analgesia, the effect of possible confounding by indication is minimized.Results: Intrapartum epidural analgesia was performed in 128 936 women (18%). Apgar score <7 was present in 1.0%, Apgar score <4 in .2% and NICU admission in .4% of the deliveries. The strongest risk factor for Apgar score <7 was epidural analgesia (adjusted odds ratio [aOR] 1.9, 95% confidence interval [CI] 1.8-2.0). The propensity score matched adjusted analysis of women with epidural analgesia showed significant adverse neonatal outcomes: aOR 1.8 (95% CI 1.7-1.9) for AS <7, aOR 1.6 (95% CI 1.4-1.9) for AS <4 and aOR 1.7 (95% CI 1.6-1.9) for NICU admission. The results of epidural analgesia on AS <7 were also significantly increased for spontaneous start of labor (aOR 2.0, 95% CI 1.8-2.1) and for spontaneous delivery.Conclusions: Intrapartum epidural analgesia at term is strongly associated with low Apgar score and more NICU admissions, especially in spontaneous deliveries. This association needs further research and awareness. [ABSTRACT FROM AUTHOR]

Purpose: To investigate prevalence, independent associations, and variation over time of potentially inappropriate prescriptions in a population of older hospitalized patients. Methods: A longitudinal study using a large dataset of hospital admissions of older patients (≥ 70 years) based on an electronic health records cohort including data from 2015 to 2019. Potentially inappropriate medication (PIM) and potential prescribing omission (PPO) prevalence during hospital stay were identified based on the Dutch STOPP/START criteria v2. Univariate and multivariate logistic regression were used for analyzing associations and trends over time. Results: The data included 16,687 admissions. Of all admissions, 56% had ≥ 1 PIM and 58% had ≥ 1 PPO. Gender, age, number of medications, number of diagnoses, Charlson score, and length of stay were independently associated with both PIMs and PPOs. Additionally, number of departments and number of prescribing specialties were independently associated with PIMs. Over the years, the PIM prevalence did not change (OR = 1.00, p =.95), whereas PPO prevalence increased (OR = 1.08, p <.001). However, when corrected for changes in patient characteristics such as number of diagnoses, the PIM (aOR = 0.91, p <.001) and PPO prevalence (aOR = 0.94, p <.001) decreased over the years. Conclusion: We found potentially inappropriate prescriptions in the majority of admissions of older patients. Prescribing relatively improved over time when considering complexity of the admissions. Nevertheless, the high prevalence shows a clear need to better address this issue in clinical practice. Studies seeking effective (re)prescribing interventions are warranted. [ABSTRACT FROM AUTHOR]

Background Mobile health (mHealth) can improve quality of care and empower cardiac patients. However, large-scale adoption is still lacking, as several challenges continue to be encountered in daily practice. We aimed to explore the mHealth experiences and challenges in cardiac patients, healthcare professionals, healthcare managers and information and communications technology (ICT) developers. Methods A qualitative research was employed where semistructured interviews were conducted in patients, healthcare professionals, managers and ICT developers. We aimed to enrol participants of every stakeholder group, with diversity in sex, age group and occupation. Thematic analysis was used to identify themes reflecting experiences and challenges in mHealth in cardiac patients. Results In total, 24 interviews were conducted in six patients, eight healthcare professionals, five managers and five ICT developers. Monitoring/care at home was reported as important advantage of mHealth (n=20, 83%). Patients valued increase of self-care (n=6, 100%) and remote reassurance (n=6, 100%), but reported medicalisation as important concern (n=4, 67%). Healthcare professionals warned for increased data burden (n=4, 50%). Managers agreed on the importance of device reliability (n=5, 100%) and ICT developers emphasised that the goal of mHealth is to replace care, rather than being supplementary (n=4, 80%). The majority of all participants (n=22, 92%) considered future use of mHealth as promising. Conclusions All stakeholders foresee benefit of mHealth in cardiac patients, especially for remote care and reassurance. Frequently mentioned challenges included the need to replace care with mHealth, rather than adding more workload, and employing reliable devices and applications. If collaboration can be improved and group-specific challenges overcome, success of mHealth in cardiac patients can improve significantly. [ABSTRACT FROM AUTHOR]

Despite the promise of decision support for improving care, alerts are often overridden or ignored. We evaluated Dutch general practitioners' intention to accept decision support in a proposed implementation based on clinical rules regarding care for elderly patients, and their reasons for wanting or not wanting support. We developed a survey based on literature and structured interviews and distributed it to all doctors who would receive support in the proposed implementation (n = 43), of which 65 percent responded. The survey consisted of six questions for each of 20 clinical rules. Despite concerns about interruption, doctors tended to choose more interruptive forms of support. Doctors wanted support when they felt the rule represented minimal care, perceived a need to improve care, and felt responsible for the action and that they might forget to perform the action; doctors declined support due to feeling that it was unnecessary and due to concerns about interruption. [ABSTRACT FROM AUTHOR]

Background A recent survey among Dutch cardiac rehabilitation centers demonstrated considerable between-center variations in the contents of exercise training programs. For patients entering cardiac rehabilitation, current guidelines recommend tailored exercise training programs based on patient characteristics and rehabilitation goals. Objective This study was to analyze to what extent these patient characteristics are determinants of variations in training programs. Design This was a prospective, observational study with cross-sectional measurements among 10 cardiac rehabilitation centers. Methods The following data were obtained about patients entering cardiac rehabilitation: referral diagnosis, rehabilitation goals, and exercise training variables. Primary outcomes were variations in total aerobic training time, intensity, and volume before and after case-mix correction for population differences between centers. Secondary outcomes were variations in other training characteristics and the role of exercise testing in the determination of training intensity. Also, the roles of diagnosis and training goals in determining aerobic training time and intensity were studied. Results Data from 700 participants were analyzed. There were significant variations between centers in all aerobic and most resistance training characteristics. For aerobic training intensity, time, and volume, great variations remained after case-mix correction. An exercise test was performed for 656 participants (93.7%) but was used to determine training intensity in only 344 (52.4%) of these participants. In most centers, referral diagnosis and rehabilitation goals were unrelated to aerobic training time or intensity. Limitations Some form of selection bias cannot be excluded because the competing centers represented a minority of Dutch exercise-based cardiac rehabilitation centers. Conclusions This study showed that the contents of training programs varied considerably between cardiac rehabilitation centers, independent of population differences. Furthermore, aerobic training time and intensity were mostly unrelated to rehabilitation goals and referral diagnosis. [ABSTRACT FROM AUTHOR]

Objective: To assess the underlying risk factors for perinatal mortality in term born small for gestational age infants.Study Design: We performed a population based nationwide cohort study in the Netherlands of 465,532 term born infants from January 2010 to January 2013. Logistic regression analyses were performed. Also audit results were studied for detailed care information.Results: We studied 162 small for gestational age infants who died in the perinatal period. Risk factors were: gestational age at 37completed weeks (adjusted Odds Ratio (aOR) 2.6, 95% Confidence Interval (CI) 1.6-4.3), male gender (aOR 1.4, 95% CI 1.01-1.9), South Asian ethnicity (aOR 3.6, 95% CI 1.6-8.4), African (aOR 3.5, 95% CI 1.9-6.5) and other non-Western ethnicity (aOR 1.9, CI 1.2-3.1). At 37 completed weeks gestation audit results showed that 26% of the women smoked, 91% were boys and in all but one case death occurred before birth. In 61% of all deceased SGA infants born at 37 completed weeks gestation referral from primary care by independent midwives to the obstetrician took place because of antepartum death before labor.Conclusions: Gestational age of 37 completed weeks, male gender, South Asian, African or other non-Western ethnicity and smoking are associated with perinatal mortality in SGA infants. These risk factors concern the complete term population starting at 37 weeks or even earlier. Therefore, it is of utmost importance to develop accurate diagnostic tests to screen for SGA before 36 weeks gestation to prevent perinatal mortality at term in SGA infants. [ABSTRACT FROM AUTHOR]

Background: potentially inappropriate prescribing (PIP) is associated with adverse health effects in older patients. PIP comprises prescription of potentially inappropriate medications (PIMs) and potential prescribing omissions (PPOs). Objective: to estimate the prevalence of PIMs and PPOs among older patients in primary care. Design: retrospective longitudinal study. Setting: routinely collected data of 182,000 patients of 49 general practitioners (GPs) gathered in the GPs' database of the Academic Medical Center of Amsterdam, the Netherlands. Subjects: in each studied year, all patients who were aged 65 years and older at 1st January. Methods: the prevalence of patients with at least one PIM and patients with at least one PPO was measured in 8 subsequent years (2007-14) by application of the Screening Tool of Older Persons potentially inappropriate Prescriptions (STOPP)/Screening Tool to Alert doctors to Right Treatment (START) criteria. Multivariate logistic regression was used to evaluate trends in the prevalence of PIMs and PPOs over the years. Results: on average, 4,537 patients were included per investigated year. The mean prevalence of ≥1 PIM was 34.7% (range 34.0-35.6%) and of ≥1 PPO 84.8% (range 77.4-90.6%). Examples were the prescription of salicylates without a proper indication and the absence of a therapeutically indicated vitamin D prescription. The prevalence of ≥1 PPOs showed a statistically significant decrease over the investigated years (OR 0.87, P < 0.001), whereas the prevalence of PIMs did not change significantly. Conclusions: this study underscores the need for more attention to medication prescribing to older patients. The prevalence of PIP among older patients in primary care is substantial and the prevalence of PIMs did not decrease over time. [ABSTRACT FROM AUTHOR]

Background: Recent trials have shown that multifactorial fall interventions vary in effectiveness, possibly due to lack of adherence to the interventions. The aim of this study was to examine what proportion of older adults recognize their falls risk and prioritize for fall-preventive care, and which factors are associated with this prioritization.Methods: Observational study within the intervention arm of a cluster randomized controlled trial (RCT) on the effect of preventive interventions for geriatric problems in older community-dwellers at risk of functional decline.Setting:  general practices in the Netherlands. Participants were community dwellers (70+) in whom falling was identified as a condition. A comprehensive geriatric assessment (CGA) was performed by a registered community care nurse. Participants were asked which of the identified conditions they recognized and prioritized for in a preventive care plan, and subsequent interventions were started. Multivariable logistic regression was performed to identify which factors were associated with this prioritization. Fall-incidence was measured during one-year follow-up.Results: The RCT included 6668 participants, 3430 were in the intervention arm. Of those, 1209 were at risk of functional decline, of whom 936 underwent CGA. In 380 participants (41 %), falling was identified as a condition; 62 (16 %) recognized this and 37 (10 %) prioritized for it. Factors associated with prioritization for falls-prevention were: recurrent falls in the past year (OR 2.2 [95 % CI 1.1-4.4]), severe fear-of-falling (OR 2.7 [1.2-6.0]) and use of a walking aid (2.3 [1.1-5.0]). Sixty participants received a preventive intervention for falling; 29 had prioritized for falling. Incidence of falls was higher in the priority group than the non-priority group (67 % vs. 37 % respectively) during first six months of follow-up, but similar between groups after 12 months (40.7 % vs. 44.4 %).Conclusions: The proportion of community-dwellers at risk of falls that recognizes this risk and prioritizes for preventive care is small. Recurrent falls in the past year, severe fear-of-falling and use of a walking aid were associated with prioritization. Prioritization was associated with a greater fall-risk during first six months, which appeared to level out at one-year follow-up. These results could aid in the identification of community-dwellings likely to benefit from fall-preventive interventions.Trial Registration: NTR2653 , 17 December 2010. [ABSTRACT FROM AUTHOR]

Objective: To assess guideline adherence of co-prescribing NSAID and gastroprotective medications for elders in general practice over time, and investigate its potential association with the electronic medical record (EMR) system brand used. Methods: We included patients 65 years and older who received NSAIDs between 2005 and 2010. Prescription data were extracted from EMR systems of GP practices participating in the Dutch NIVEL Primary Care Database. We calculated the proportion of NSAID prescriptions with co-prescription of gastroprotective medication for each GP practice at intervals of three months. Association between proportion of gastroprotection, brand of electronic medical record (EMR), and type of GP practice were explored. Temporal trends in proportion of gastroprotection between electronic medical records systems were analyzed using a random effects linear regression model. Results: We included 91,521 patient visits with NSAID prescriptions from 77 general practices between 2005 and 2010. Overall proportion of NSAID prescriptions to the elderly with co-prescription of gastroprotective medication was 43%. Mean proportion of gastroprotection increased from 27% (CI 25–29%) in the first quarter of 2005 with a rate of 1.2% every 3 months to 55%(CI 52–58%) at the end of 2010. Brand of EMR and type of GP practice were independently associated with co-prescription of gastroprotection. Conclusion: Although prescription of gastroprotective medications to elderly patients who receive NSAIDs increased in The Netherlands, they are not co-prescribed in about half of the indicated cases. Brand of EMR system is associated with differences in prescription of gastroprotective medication. Optimal design and utilization of EMRs is a potential area of intervention to improve quality of prescription. [ABSTRACT FROM AUTHOR]

Objective: The objective of the present study is to investigate trends in birth asphyxia and perinatal mortality in the Netherlands over the last decade. Methods: A nationwide cohort study among women with a term singleton pregnancy. We assessed trends in birth asphyxia in relation to obstetric interventions for fetal distress. Birth asphyxia was defined as a 5-minute Apgar score < 7 (any asphyxia) or 5-minute Apgar score < 4 (severe asphyxia). Perinatal mortality was defined as mortality during delivery or within 7 days after birth. Multivariable analyses were used to adjust for confounding factors. Results: The prevalence of birth asphyxia was 0.85% and severe asphyxia 0.16%. Between 1999 and 2010 birth asphyxia decreased significantly with approximately 6% ( p = 0.03) and severe asphyxia with 11% ( p = 0.03). There was no significant change in perinatal mortality rate (0.98 per 1000 live births). Simultaneously the referral rate from primary to secondary care during labor increased from 20% to 24% ( p < 0.0001) and the intervention rate for fetal distress from 5.9% to 7.7% ( p < 0.0001). Conclusion: In the Netherlands, the risk of birth asphyxia among term singletons has slightly decreased over the last decade; without a significant change in perinatal mortality. [ABSTRACT FROM AUTHOR]

Background: Patients with atrial fibrillation (AF) are at increased risk for stroke. Antithrombotic treatment reduces this risk. Antithrombotic treatment consists of either administration of oral anticoagulants (OAC) or the provision of an antiplatelet drug. International guidelines provide advice on the preferred treatment, thereby balancing the risks and benefits of OAC. However, adherence to these guidelines is reported to be as low as 50%. There is paucity in research on why adherence rates are low. Recent studies have shown decision support systems can improve guideline adherence. We investigate the use of a clinical decision support system to improve guideline adherence among general practitioners (GPs) treating patients with AF and study reasons for guideline non-adherence. Methods/Design: The study is a randomized controlled trial, which is performed among Dutch general practitioners. Initially, GPs in the vicinity of the Academic Medical Center (AMC) in Amsterdam will be included, after which other practices will be recruited. We have developed a novel decision support system that displays a list with pending messages for the on-screen medical record in real time. Messages are generated on a server that evaluates a decision rule based on the atrial fibrillation guideline of the Dutch College of General Practitioners. By interacting with the list, messages can be opened for a description and explanation, or be ignored. GPs are allocated into three groups: 1) control group; 2) intervention group A, in which messages can be ignored without justification; and 3) intervention group B, in which messages can only be ignored with justification. Our main outcome measure is the between-group difference in the proportion of patients receiving antithrombotic prescriptions in adherence to the Dutch GP guideline for atrial fibrillation. Secondary outcomes are reasons GPs state for deviating from the guideline and the effect on guideline adherence of requiring justification when ignoring a message. Discussion: This paper describes the protocol for a cluster randomized trial to study the effects of a clinical decision support system in patients with atrial fibrillation. The system is characterized by a non-interruptive presentation and real-time messages that are updated after each relevant action the GP performs. Trial registration: This trial is registered with the Dutch Trial Register under registration number 3570. [ABSTRACT FROM AUTHOR]

Objective: To determine adequacy of antithrombotic treatment in patients with non-valvular atrial fibrillation. To determine risk factors for under- and over-treatment. Design: Retrospective, cross-sectional study of electronic health records from 36 general practitioners in 2008. Setting: General practice in the Netherlands. Subjects: Primary care physicians (n = 36) and patients (n = 981) aged 65 years and over. Main Outcome Measures: Rates of adequate, under and over-treatment, risk factors for under and over-treatment. Results: Of the 981 included patients with a mean of age 78, 18% received no antithrombotic treatment (under-treatment), 13% received antiplatelet drugs and 69% received oral anticoagulation (OAC). Further, 43% of the included patients were treated adequately, 26% were under-treated, and 31% were over-treated. Patients with a previous ischaemic stroke were at high risk for under-treatment (OR 2.4, CI 1.6–3.5), whereas those with contraindications for OAC were at high risk for over-treatment (OR 37.0, CI 18.1–79.9). Age over 75 (OR 0.2, CI: 0.1–0.3]), diabetes (OR 0.1, CI: 0.1–0.3), heart failure (OR 0.2, CI: 0.1–0.3), hypertension (OR 0.1, CI: 0.1–0.2) and previous ischaemic stroke (OR 0.04, CI: 0.02–0.11) protected against over-treatment. Conclusions: In general practice, CHADS2-criteria are being used, but the antithrombotic treatment of patients with atrial fibrillation frequently deviates from guidelines on this topic. Patients with previous stroke are at high risk of not being prescribed OAC. Contraindications for OAC, however, seem to be frequently overlooked. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether maternal ethnicity affects perinatal mortality by week of gestation from 39 weeks onwards. Study design: In this cohort study, we used data from the nationwide Netherlands Perinatal Registry from 1999 until 2008. All singleton infants born between 39+0 and 42+6 weeks of gestation without congenital anomalies were included. We used crude and multivariate logistic regression analyses with white Europeans as the reference to calculate the adjusted odds ratios (aOR) of South Asian, African and Mediterranean women. The main outcome measure was perinatal mortality (antepartum and intra-parrum/neonatal mortality within 7 days after birth). Results: We studied 1,092,255 singleton deliveries. Perinatal mortality occurred in 2315 infants (2.1‰). There was interaction between gestational age and ethnicity (P<0.0001). In week 40 (40+0-40+6) South Asian (aOR 1.9; 95% CI 1.1-3.4) and Mediterranean (aOR 1.3; 95% CI 1.04-1.7) women had an increased risk of perinatal mortality. The perinatal mortality risk became greater in week 41 for South Asian (aOR 4.5 95% CI 2.8-7.2), African (aOR 2.2; 95%CI 1.4-3.4) and Mediterranean (aOR 2.2; 95% CI 1.8-2.9) women, especially among small for gestational age infants. Conclusion: With increasing gestational age beyond 39 weeks, perinatal mortality risk increases more strongly among South Asian, African and Mediterranean women compared to European whites. [ABSTRACT FROM AUTHOR]

Background: To study the prevalence of eighteen geriatric conditions in older patients at admission their reporting rate in discharge summaries and the impact of these conditions on mortality and functional decline one year after admission. Method: A prospective multicenter cohort study conducted between 2006 and 2008 in two tertiary university teaching hospitals and one regional teaching hospital in the Netherlands. Patients of 65 years and older acutely admitted and hospitalized for at least 48 hours were invited to participate. Eighteen geriatric conditions were assessed at hospital admission and outcomes (mortality functional decline) were assessed one year after admission. Results: 639 patients were included with a mean age of 78 years. IADL impairment (83%) polypharmacy (61%) mobility difficulty (59%) high levels of primary caregiver burden (53%) and malnutrition (52%) were most prevalent. Except for polypharmacy and cognitive impairment the reporting rate of the geriatric conditions in discharge summaries was less than 50%. One year after admission 35% had died and 33% suffered from functional decline. A high Charlson comorbidity index score presence of malnutrition high fall risk presence of delirium and premorbid IADL impairment were associated with mortality and overall poor outcome (mortality or functional decline). Obesity lowered the risk for mortality. Conclusion: Geriatric conditions were highly prevalent and associated with poor health outcomes after admission. Early recognition of these conditions in acutely hospitalized older patients and improving the handover to the general practitioner could lead to better health outcomes and reduce the burden of hospital admission for older patients. [ABSTRACT FROM AUTHOR]

Introduction: Previous studies have shown that patients admitted to the intensive care unit (ICU) after 'office hours' are more likely to die. However these results have been challenged by numerous other studies. We therefore analysed this possible relationship between ICU admission time and in-hospital mortality in The Netherlands. Methods: This article relates time of ICU admission to hospital mortality for all patients who were included in the Dutch national ICU registry (National Intensive Care Evaluation, NICE) from 2002 to 2008. We defined office hours as 08:00-22:00 hours during weekdays and 09:00-18:00 hours during weekend days. The weekend was defined as from Saturday 00:00 hours until Sunday 24:00 hours. We corrected hospital mortality for illness severity at admission using Acute Physiology and Chronic Health Evaluation II (APACHE II) score, reason for admission, admission type, age and gender. Results: A total of 149,894 patients were included in this analysis. The relative risk (RR) for mortality outside office hours was 1.059 (1.031-1.088). Mortality varied with time but was consistently higher than expected during 'off hours' and lower during office hours. There was no significant difference in mortality between different weekdays of Monday to Thursday, but mortality increased slightly on Friday (RR 1.046; 1.001-1.092). During the weekend the RR was 1.103 (1.071-1.136) in comparison with the rest of the week. Conclusions: Hospital mortality in The Netherlands appears to be increased outside office hours and during the weekends, even when corrected for illness severity at admission. However, incomplete adjustment for certain confounders might still play an important role. Further research is needed to fully explain this difference. [ABSTRACT FROM AUTHOR]

Background: The process of prognostication has not been described for acutely hospitalized older patients.Objective: To investigate (1) which factors are associated with 90-day mortality risk in a group of acutely hospitalized older medical patients, and (2) whether adding a clinical impression score of nurses or physicians improves the discriminatory ability of mortality prediction.Design: Prospective cohort study.Participants: Four hundred and sixty-three medical patients 65 years or older acutely admitted from November 1, 2002, through July 1, 2005, to a 1024-bed tertiary university teaching hospital.Measurements: At admission, the attending nurse and physician were asked to give a clinical impression score for the illness the patient was admitted for. This score ranged from 1 (high possibility of a good outcome) until 10 (high possibility of a bad outcome, including mortality). Of all patients baseline characteristics and clinical parameters were collected. Mortality was registered up to 90 days after admission.Main Results: In total, 23.8% (n = 110) of patients died within 90 days of admission. Four parameters were significantly associated with mortality risk: functional impairment, diagnosis malignancy, co-morbidities and high urea nitrogen serum levels. The AUC for the baseline model which included these risk factors (model 1) was 0.76 (95% CI 0.71 to 0.82). The AUC for the model using the risk factors and the clinical impression score of the physician (model 2) was 0.77 (0.71 to 0.82). The AUC for the model using the risk factors and the clinical impression score of the nurse (model 3) was 0.76 (0.71 to 0.82) and the AUC for the model, including the baseline covariates and the clinical impression score of both nurses and physicians was 0.77 (0.72 to 0.82). Adding clinical impression scores to model 1 did not significantly improve its accuracy.Conclusion: A set of four clinical variables predicted mortality risk in acutely hospitalized older patients quite well. Adding clinical impression scores of nurses, physicians or both did not improve the discriminating ability of the model. [ABSTRACT FROM AUTHOR]

Women of Black and other non-Western ethnicity and women who live in deprived neighborhoods are at increased risk for preterm birth (PTB). These women may live clustered in certain urban areas. If ethnicity reflects a biological rather than a socioeconomic risk factor, women should have a PTB risk independent of the urban area where they live. In this study we explored the association between urban living and the risk of PTB, combined with knowledge on ethnicity and neighborhood deprivation in these specific urban areas in the Netherlands. National cohort study of 935,381 women (2014–2019) with a singleton pregnancy resulting in live birth between 24.0 and 42.6 weeks. Antepartum death and severe congenital anomalies were excluded. We performed logistic regression analysis and analyzed the impact of living in one of the four main urban areas on PTB. We adjusted for maternal age, parity and fetal gender. We tested for interaction between ethnicity, neighborhood deprivation index (NDI) and urban living. Mean PTB rate among singleton pregnancies in The Netherlands is 5.1%. There was a strong ethnic difference in PTB risk, with the highest prevalence among South Asian women (7.9%) and African women (6.6%). In the most deprived neighborhoods the PTB risk was 5.7%. We found a significant interaction between ethnicity and urban living, and between NDI and urban living. South Asian and African women living in urban areas had the greatest risk of PTB, between 7.0% and 8.8%. Ethnicity remains a fixed biological risk for PTB that cannot be fully explained by socioeconomic status or neighborhood deprivation. Independent of ethnicity and neighborhood deprivation, urban living has a great influence on the risk of preterm birth. Future studies and policies should focus on population-based interventions in those urban areas where South Asian and African ethnic groups live and where the preterm birth risk is the highest. [ABSTRACT FROM AUTHOR]

Drug–drug interactions (DDIs) can harm patients admitted to the intensive care unit (ICU). Yet, clinical decision support systems (CDSSs) aimed at helping physicians prevent DDIs are plagued by low-yield alerts, causing alert fatigue and compromising patient safety. The aim of this multicentre study was to evaluate the effect of tailoring potential DDI alerts to the ICU setting on the frequency of administered high-risk drug combinations. We implemented a cluster randomised stepped-wedge trial in nine ICUs in the Netherlands. Five ICUs already used potential DDI alerts. Patients aged 18 years or older admitted to the ICU with at least two drugs administered were included. Our intervention was an adapted CDSS, only providing alerts for potential DDIs considered as high risk. The intervention was delivered at the ICU level and targeted physicians. We hypothesised that showing only relevant alerts would improve CDSS effectiveness and lead to a decreased number of administered high-risk drug combinations. The order in which the intervention was implemented in the ICUs was randomised by an independent researcher. The primary outcome was the number of administered high-risk drug combinations per 1000 drug administrations per patient and was assessed in all included patients. This trial was registered in the Netherlands Trial Register (identifier NL6762) on Nov 26, 2018, and is now closed. In total, 10 423 patients admitted to the ICU between Sept 1, 2018, and Sept 1, 2019, were assessed and 9887 patients were included. The mean number of administered high-risk drug combinations per 1000 drug administrations per patient was 26·2 (SD 53·4) in the intervention group (n=5534), compared with 35·6 (65·0) in the control group (n=4353). Tailoring potential DDI alerts to the ICU led to a 12% decrease (95% CI 5–18%; p=0·0008) in the number of administered high-risk drug combinations per 1000 drug administrations per patient, after adjusting for clustering and prognostic factors. This cluster randomised stepped-wedge trial showed that tailoring potential DDI alerts to the ICU setting significantly reduced the number of administered high-risk drug combinations. Our list of high-risk drug combinations can be used in other ICUs, and our strategy of tailoring alerts based on clinical relevance could be applied to other clinical settings. ZonMw. [ABSTRACT FROM AUTHOR]

Background: The Internet is viewed as an important source for health information and a medium for patient empowerment. However, little is known about how seniors use the Internet in relation to other sources for health information. Objective: The aim was to determine which information resources seniors who use the Internet use and trust for health information, which sources are preferred, and which sources are used by seniors for different information needs. Methods: Questions from published surveys were selected based on their relevance to the study objectives. The Autonomy Preference Index was used to assess information needs and preferences for involvement in health decisions. Invitation to participate in this online survey was sent to the email list of a local senior organization (298 addresses) in the Netherlands. Results: There were 118 respondents with a median age of 72 years (IQR 67-78 years). Health professionals, pharmacists, and the Internet were the most commonly used and trusted sources of health information. Leaflets, television, newspapers, and health magazines were also important sources. Respondents who reported higher use of the Internet also reported higher use of other sources (P<.001). Use of health professionals, pharmacists, leaflets, telephone, television, and radio were not significantly different; use of all other resources was significantly higher in frequent Internet users. When in need of health information, preferred sources were the Internet (46/105, 43.8%), other sources (eg, magazines 38/105, 36.2%), health professionals (18/105, 17.1%), and no information seeking (3/105, 2.8%). Of the 51/107 respondents who indicated that they had sought health information in the last 12 months, 43 sought it after an appointment, 23 were preparing for an appointment, and 20 were deciding if an appointment was needed. The source used varied by the type of information sought. The Internet was used most often for symptoms (27/42, 64%), prognosis (21/31, 68%), and treatment options (23/41, 62%), whereas health professionals were asked for additional information on medications (20/36, 56%), side effects (17/36, 47%), coping (17/31, 55%), practical care (12/14, 86%), and nutrition/exercise (18/30, 60%). Conclusions: For these seniors who use the Internet, the Internet was a preferred source of health information. Seniors who report higher use of the Internet also report higher use of other information resources and were also the primary consumers of paper-based resources. Respondents most frequently searched for health information after an appointment rather than to prepare for an appointment. Resources used varied by health topic. Future research should seek to confirm these findings in a general elderly population, investigate how seniors seek and understand information on the Internet, and investigate how to reach seniors who prefer not to use the Internet for health information. [ABSTRACT FROM AUTHOR]

Purpose: To assess the extent to which clinical rules (CRs) can be implemented for automatic evaluation of quality of care in general practice.Methods: We assessed 81 clinical rules (CRs) adapted from a subset of Assessing Care of Vulnerable Elders (ACOVE) clinical rules, against Dutch College of General Practitioners (NHG) data model. Each CR was analyzed using the Logical Elements Rule METHOD: (LERM). LERM is a stepwise method of assessing and formalizing clinical rules for decision support. Clinical rules that satisfied the criteria outlined in the LERM method were judged to be implementable in automatic evaluation in general practice.Results: Thirty-three out of 81 (40.7%) Dutch-translated ACOVE clinical rules can be automatically evaluated in electronic medical record systems. Seven out of 7 CRs (100%) in the domain of diabetes can be automatically evaluated, 9/17 (52.9%) in medication use, 5/10 (50%) in depression care, 3/6 (50%) in nutrition care, 6/13 (46.1%) in dementia care, 1/6 (16.6%) in end of life care, 2/13 (15.3%) in continuity of care, and 0/9 (0%) in the fall-related care. Lack of documentation of care activities between primary and secondary health facilities and ambiguous formulation of clinical rules were the main reasons for the inability to automate the clinical rules.Conclusion: Approximately two-fifths of the primary care Dutch ACOVE-based clinical rules can be automatically evaluated. Clear definition of clinical rules, improved GP database design and electronic linkage of primary and secondary healthcare facilities can improve prospects of automatic assessment of quality of care. These findings are relevant especially because the Netherlands has very high automation of primary care. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The aim of this study was to validate and compare the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) IV in the Dutch intensive care unit (ICU) population to the APACHE II and Simplified Acute Physiology Score (SAPS) II. Materials and Methods: This is a prospective study based on data from a national quality registry between 2006 and 2009 from 59 Dutch ICUs. The validation set consisted of 62 737 patients; the 3 models were compared using 44 112 patients. Measures of discrimination, accuracy, and calibration (area under the receiver operating characteristic curve (AUC), Brier score, R 2, and Ĉ-statistic) were calculated using bootstrapping. In addition, the standardized mortality ratios were calculated. Results: The original APACHE IV showed good discrimination and accuracy (AUC = 0.87, Brier score = 0.10, R 2 = 0.29) but poor calibration (Ĉ-statistic = 822.67). Customization significantly improved the performance of the APACHE IV. The overall discrimination and accuracy of the customized APACHE IV were statistically better, and the overall Ĉ-statistic was inferior to those of the customized APACHE II and SAPS II, but these differences were small in perspective of clinical use. Conclusions: The 3 models have comparable capabilities for benchmarking purposes after customization. Main advantage of APACHE IV is the large number of diagnoses that enable subgroup analysis. The APACHE IV coronary artery bypass grafting (CABG) model has a good performance in the Dutch ICU population and can be used to complement the 3 models. [Copyright &y& Elsevier]

Objective: Spontaneous preterm birth is the leading cause of infant morbidity and mortality in the developed world. Environmental socio-economic factors, such as neighborhood deprivation, are known to negatively affect birth outcomes, including overall preterm birth. However, the role of neighborhood deprivation in spontaneous preterm birth (SPTB) is unclear. The aim of the study is to 1) to determine the effect of neighborhood deprivation on SPTB birth and 2) to investigate the trend in rates of SPTB between 2010 and 2019 for each quintile of neighborhood deprivation.Study Design: Based on the national perinatal registry, we included 1,584,225 singleton pregnancies resulting in a birth from 22 to 42 completed weeks of gestation between 2010 and 2019 in the Netherlands. Deprivation scores per neighborhood were derived from the Netherlands Institute of Social Research and were linked to the perinatal registry data, using the woman's home address. The scores were divided into quintiles (Q). Rates of SPTB were calculated, categorized into <37 weeks, <32 weeks and <28 weeks of gestation. We used logistic regression analysis to adjust for maternal age, parity and ethnicity.Results: Compared to the most affluent neighborhoods (Q1), women in all other quintiles had a statistically significant increased risk for SPTB. The largest effect was observed in the most deprived neighborhoods (Q5); adjusted odds ratio 1.16 (95% confidence interval 1.13 - 1.19). From 2010 to 2019, we observed an overall decrease of 0.21% in SPTB < 37 weeks (p < 0.0001). All quintiles showed a decrease in SPTBs < 37 weeks, but only in Q1, Q2 & Q5 this decline in SPTB was statistically significant.Conclusions: Pregnant women in deprived neighborhoods in the Netherlands are more at risk for spontaneous preterm birth. From 2010 to 2019, the rate of spontaneous preterm birth decreased. Efforts should be made by both governmental and medical professionals to develop intervention programs to reduce spontaneous preterm birth in more deprived neighborhoods. [ABSTRACT FROM AUTHOR]

Objectives: Conservative oxygen therapy is aimed at the prevention of harm by iatrogenic hyperoxia while preserving adequate tissue oxygenation. Our aim was to study the effectiveness and clinical outcomes of a two-step implementation of conservative oxygenation targets in the ICU.Design: This was a before and after stepwise implementation study of conservative oxygenation targets, between July 2011 and July 2014. The primary endpoint was the proportion of PaO2 values within the target range. Secondary outcomes included ventilator-free days at day 28, length of stay, and mortality.Setting: Three closed-format ICUs in the Netherlands.Patients: We analyzed data on 15,045 eligible admissions.Interventions: The first implementation phase consisted of providing training and feedback on new guidelines instructing for explicit targets for arterial oxygen tension (PaO2, 55-86 mm Hg) and oxyhemoglobin saturation (SpO2, 92-95%). In the second phase, bedside clinicians were additionally assisted in guideline adherence by a computerized decision-support system.Measurements and Main Results: The proportion of PaO2 in the target range increased from 47% at baseline to 63% in phase 1 and to 68% in phase 2 (p < 0.0001). Episodes of hyperoxia decreased (p < 0.0001), whereas hypoxic episodes remained unchanged (p = 0.06) during the study. Mechanical ventilation time was significantly lower (p < 0.01) during both study phases. After adjustment for potential confounders, ventilator-free days in phase 1 and phase 2 were higher than baseline: adjusted mean difference, 0.55 (95% CI, 0.25-0.84) and 0.48 (95% CI, 0.11-0.86), respectively. Adjusted ICU mortality and ICU-free days did not significantly differ between study phases. Hospital mortality decreased in reference to baseline: adjusted odds ratio, 0.84 (95% CI, 0.74-0.96) for phase 1 and 0.82 (95% CI, 0.69-0.96) for phase 2.Conclusions: Stepwise implementation of conservative oxygenation targets was feasible, effective, and seemed safe in critically ill patients. The implementation was associated with several changes in clinical outcomes, but the causal impact of conservative oxygenation is still to be determined. [ABSTRACT FROM AUTHOR]

Summary: This paper is based on a panel discussion held at the Artificial Intelligence in Medicine Europe (AIME) conference in Amsterdam, The Netherlands, in July 2007. It had been more than 15 years since Edward Shortliffe gave a talk at AIME in which he characterized artificial intelligence (AI) in medicine as being in its “adolescence” (Shortliffe EH. The adolescence of AI in medicine: will the field come of age in the ‘90s? Artificial Intelligence in Medicine 1993;5:93–106). In this article, the discussants reflect on medical AI research during the subsequent years and characterize the maturity and influence that has been achieved to date. Participants focus on their personal areas of expertise, ranging from clinical decision-making, reasoning under uncertainty, and knowledge representation to systems integration, translational bioinformatics, and cognitive issues in both the modeling of expertise and the creation of acceptable systems. [Copyright &y& Elsevier]

Objectives: To illustrate in-depth validation of prediction models developed on multicenter data., Methods: For each hospital in a multicenter registry, we evaluated predictive performance of a 30-day mortality prediction model for transcatheter aortic valve implantation (TAVI) using the Netherlands heart registration (NHR) dataset. We measured discrimination and calibration per hospital in a leave-center-out analysis (LCOA). Meta-analysis was used to calculate I 2 values per performance metric from the LCOA and to compute mean and confidence interval (CI) estimates. Case mix differences between studies were inspected using the framework of Debray et al. for understanding external validation. We also aimed to discover subgroups (SGs) with high model prediction error (PE) and their distribution over the centers., Results: We studied 16 hospitals with 11,599 TAVI patients with an early mortality of 3.7%. The models' area under the curve (AUCs) had a wide range between hospitals from 0.59 to 0.79, and miscalibration occurred in seven hospitals. Mean AUC from meta-analysis was 0.68 (95% CI 0.65-0.70). I 2 values were 0%, 74%, and 0% for AUC, calibration intercept and slope, respectively. Between-hospital case-mix differences were substantial, and model transportability was low. One SG was discovered with marked global PE and was associated with poor performance on validation centers., Conclusion: The illustrated combination of approaches provides useful insights to inspect multicenter-based prediction models, and it exposes their limitations in transportability and performance variability when applied to different populations., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The currently available mortality prediction models (MPM) have suboptimal performance when predicting early mortality (30-days) following transcatheter aortic valve implantation (TAVI) on various external populations. We developed and validated a new TAVI-MPM based on a large number of predictors with recent data from a national heart registry., Methods: We included all TAVI-patients treated in the Netherlands between 2013 and 2018, from the Netherlands Heart Registration. We used logistic-regression analysis based on the Akaike Information Criterion for variable selection. We multiply imputed missing values, but excluded variables with &gt;30% missing values. For internal validation, we used ten-fold cross-validation. For temporal (prospective) validation, we used the 2018-data set for testing. We assessed discrimination by the c-statistic, predicted probability accuracy by the Brier score, and calibration by calibration graphs, and calibration-intercept and calibration slope. We compared our new model to the updated ACC-TAVI and IRRMA MPMs on our population., Results: We included 9144 TAVI-patients. The observed early mortality was 4.0%. The final MPM had 10 variables, including: critical-preoperative state, procedure-acuteness, body surface area, serum creatinine, and diabetes-mellitus status. The median c-statistic was 0.69 (interquartile range [IQR] 0.646-0.75). The median Brier score was 0.038 (IQR 0.038-0.040). No signs of miscalibration were observed. The c-statistic's temporal-validation was 0.71 (95% confidence intervals 0.64-0.78). Our model outperformed the updated currently available MPMs ACC-TAVI and IRRMA (p value &lt; 0.05)., Conclusion: The new TAVI-model used additional variables and showed fair discrimination and good calibration. It outperformed the updated currently available TAVI-models on our population. The model's good calibration benefits preprocedural risk-assessment and patient counseling., (© 2022 The Authors. Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Purpose: To assess, validate and compare the predictive performance of models for in-hospital mortality of COVID-19 patients admitted to the intensive care unit (ICU) over two different waves of infections. Our models were built with high-granular Electronic Health Records (EHR) data versus less-granular registry data., Methods: Observational study of all COVID-19 patients admitted to 19 Dutch ICUs participating in both the national quality registry National Intensive Care Evaluation (NICE) and the EHR-based Dutch Data Warehouse (hereafter EHR). Multiple models were developed on data from the first 24 h of ICU admissions from February to June 2020 (first COVID-19 wave) and validated on prospective patients admitted to the same ICUs between July and December 2020 (second COVID-19 wave). We assessed model discrimination, calibration, and the degree of relatedness between development and validation population. Coefficients were used to identify relevant risk factors., Results: A total of 1533 patients from the EHR and 1563 from the registry were included. With high granular EHR data, the average AUROC was 0.69 (standard deviation of 0.05) for the internal validation, and the AUROC was 0.75 for the temporal validation. The registry model achieved an average AUROC of 0.76 (standard deviation of 0.05) in the internal validation and 0.77 in the temporal validation. In the EHR data, age, and respiratory-system related variables were the most important risk factors identified. In the NICE registry data, age and chronic respiratory insufficiency were the most important risk factors., Conclusion: In our study, prognostic models built on less-granular but readily-available registry data had similar performance to models built on high-granular EHR data and showed similar transportability to a prospective COVID-19 population. Future research is needed to verify whether this finding can be confirmed for upcoming waves., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Personalized prediction of treatment outcomes can aid patients with cancer when deciding on treatment options. Existing prediction models for esophageal and gastric cancer, however, have mostly been developed for survival prediction after surgery (ie, when treatment has already been completed). Furthermore, prediction models for patients with metastatic cancer are scarce. The aim of this study was to develop prediction models of overall survival at diagnosis for patients with potentially curable and metastatic esophageal and gastric cancer (the SOURCE study)., Methods: Data from 13,080 patients with esophageal or gastric cancer diagnosed in 2015 through 2018 were retrieved from the prospective Netherlands Cancer Registry. Four Cox proportional hazards regression models were created for patients with potentially curable and metastatic esophageal or gastric cancer. Predictors, including treatment type, were selected using the Akaike information criterion. The models were validated with temporal cross-validation on their C-index and calibration., Results: The validated model's C-index was 0.78 for potentially curable gastric cancer and 0.80 for potentially curable esophageal cancer. For the metastatic models, the c-indices were 0.72 and 0.73 for esophageal and gastric cancer, respectively. The 95% confidence interval of the calibration intercepts and slopes contain the values 0 and 1, respectively., Conclusions: The SOURCE prediction models show fair to good c-indices and an overall good calibration. The models are the first in esophageal and gastric cancer to predict survival at diagnosis for a variety of treatments. Future research is needed to demonstrate their value for shared decision-making in clinical practice.

Background: Several mortality prediction models (MPM) are used for predicting early (30-day) mortality following transcatheter aortic valve implantation (TAVI). Little is known about their predictive performance in external TAVI populations. We aim to externally validate established MPMs on a large TAVI dataset from the Netherlands Heart Registration (NHR)., Methods: We included data from NHR-patients who underwent TAVI during 2013-2017. We calculated the predicted mortalities per MPM. We assessed the predictive performance by discrimination (Area Under Receiver Operating-characteristic Curve, AU-ROC); the Area Under Precision-Recall Curve, AU-PRC; calibration (using calibration-intercept and calibration-slope); Brier Score and Brier Skill Score. We also assessed the predictive performance among subgroups: tertiles of mortality-risk for non-survivors, gender, and access-route., Results: We included 6177 TAVI-patients with an observed early-mortality rate of 4.5% (n = 280). We applied seven MPMs (STS, EuroSCORE-I, EuroSCORE-II, ACC-TAVI, FRANCE-2, OBSERVANT, and German-AV) on our cohort. The highest AU-ROCs were 0.64 (95%CI 0.61-0.67) for ACC-TAVI and 0.63 (95%CI 0.60-0.67) for FRANCE-2. All MPMs had a very low AU-PRC of ≤0.09. ACC-TAVI had the best calibration-intercept and calibration-slope. Brier Score values ranged between 0.043 and 0.063. Brier Skill Score ranged between -0.47 and 0.004. ACC-TAVI and FRANCE-2 predicted high mortality-risk better than other MPMs. ACC-TAVI outperformed other MPMs in different subgroups., Conclusion: The ACC-TAVI model has relatively the best predictive performance. However, all models have poor predictive performance. Because of the poor discrimination, miscalibration and limited accuracy of the models there is a need to update the existing models or develop new TAVI-specific models for local populations., Competing Interests: Declaration of Competing Interest Hatem Al-Farra, Ameen Abu-Hanna, Bas AJM de Mol, WJ ter Burg, Saskia Houterman, José PS Henriques, and Anita CJ Ravelli declare no conflict of interest. Addendum. The following physicians are the members of the NHR THI Registration Committee. They represent the hospitals that have provided the data for this study. Contact with NHR THI Registration Committee can be via the e-mail info@nederlandsehartregistratie.nl M.M. Vis, Amsterdam University Medical Centers. J. Vos, Amphia Hospital. J. ten Berg, St. Antonius Hospital. W.A.L. Tonino, Catharina Hospital. C.E. Schotborgh, HagaHospital. V. Roolvink, Isala. F. Porta, Leeuwarden Medical Center. M. Stoel, Medisch Spectrum Twente. S. Kats, Maastricht University Medical Center. G. Amoroso, Onze Lieve Vrouwe Gasthuis. H.W. van der Werf, University Medical Center Groningen. P.R. Stella, University Medical Center Utrecht. P. de Jaegere, Erasmus University Medical Center., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Purpose: Drug-drug interactions (DDIs) may cause adverse outcomes in patients admitted to the Intensive Care Unit (ICU). Computerized decision support systems (CDSSs) may help prevent DDIs by timely showing relevant warning alerts, but knowledge on which DDIs are clinically relevant in the ICU setting is limited. Therefore, the purpose of this study was to identify DDIs relevant for the ICU., Materials and Methods: We conducted a modified Delphi procedure with a Dutch multidisciplinary expert panel consisting of intensivists and hospital pharmacists to assess the clinical relevance of DDIs for the ICU. The procedure consisted of two rounds, each included a questionnaire followed by a live consensus meeting., Results: In total the clinical relevance of 148 DDIs was assessed, of which agreement regarding the relevance was reached for 139 DDIs (94%). Of these 139 DDIs, 53 (38%) were considered not clinically relevant for the ICU setting., Conclusions: A list of clinically relevant DDIs for the ICU setting was established on a national level. The clinical value of CDSSs for medication safety could be improved by focusing on the identified clinically relevant DDIs, thereby avoiding alert fatigue., Competing Interests: Declaration of Competing Interest All authors declare that they have no competing interests., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: In the Netherlands, several initiatives started after the publication of the PERISTAT findings that showed the perinatal mortality risk was higher than in other European countries. The objective of this study is 1) to report recent trends in perinatal mortality and in intermediate risk groups (preterm birth, congenital anomalies and small for gestational age (SGA)), 2) describing perinatal mortality risk among children born preterm, with congenital anomalies or SGA, and born in maternal high risk groups (parity, age, ethnicity and socio-economic status (SES))., Methods: A nationwide cohort study in the Netherlands among 996,423 singleton births in 2010-2015 with a gestational age between 24.0 and 42.6 weeks. Trend tests, univariate and multivariable logistic regression analyses were used. We did separate analyses for gestational age subgroups and line of care., Results: The perinatal mortality rate was 5.0 per 1000 and it decreased significantly from 5.6 in 2010 to 4.6 per 1000 in 2015. Preterm birth significantly declined (6.1% in 2010 to 5.6% in 2015). Analysis by gestational age groups showed that the largest decline in perinatal mortality of 32% was seen at 24-27 weeks of gestation where the risk declined from 497 to 339 per 1000. At term, the decline was 23% from 2.2 to 1.7 per 1000. The smallest decline was 3% between 32 and 36 weeks. In children with preterm birth, congenital anomalies or SGA, the perinatal mortality risk significantly declined. Main risk factors for perinatal mortality were African ethnicity (adjusted odds ratio (aOR) 2.1 95%CI [1.9-2.4]), maternal age ≥ 40 years (aOR1.9 95%CI [1.7-2.2]) and parity 2 + (aOR 1.4 95%CI [1.3-1.5]). Among the (post)term born neonates, there was no significant decline in perinatal mortality in women with low age, low or high SES, non-Western ethnicity and among women who started or delivered under primary care., Conclusions: There is a decline in preterm birth and in perinatal mortality between 2010 and 2015. The decline in perinatal mortality is both in stillbirths and in neonatal mortality, most prominently among 24-27 weeks and among (post)term births. A possible future target could be deliveries among 32-36 weeks, women with high maternal age or non-Western ethnicity.

Objective: To study the association of the intended mode of delivery and perinatal morbidity and mortality among breech fetuses who are delivered preterm., Methods: We conducted a nationwide cohort study of women with a singleton pregnancy in breech presentation who delivered preterm (26 0/7-36 6/7 weeks of gestation) in the years 2000-2011. We compared perinatal outcomes according to the intended and actual mode of delivery using multivariate logistic regression analysis. We performed subgroup analyses of gestational age and parity., Results: We studied 8,356 women with a preterm singleton breech delivery. Intended cesarean delivery (n=1,935) was not associated with a significant reduction in perinatal mortality compared with intended vaginal delivery (n=6,421) (1.3% compared with 1.5%; adjusted odds ratio [OR] 0.97, 95% confidence interval [CI] 0.60-1.57). However, the composite of perinatal mortality and morbidity was significantly reduced in the intended cesarean delivery group (8.7% compared with 10.4%; adjusted OR 0.77, 95% CI 0.63-0.93). In the subgroup of women delivering at 28-32 weeks of gestation, intended cesarean delivery was associated with a 1.7% risk of perinatal mortality compared with 4.1% with intended vaginal delivery (adjusted OR 0.27, 95% CI 0.10-0.77) and significantly reduced composite mortality and severe morbidity, 5.9% compared with 10.1% (adjusted OR 0.37, 95% CI 0.20-0.68)., Conclusion: In women delivering a preterm breech fetus, cesarean delivery is associated with reduced perinatal mortality and morbidity., Level of Evidence: II.

Background: Point-of-care testing of blood glucose (BG-POCT) is essential for safe and effective insulin titrations in critically ill patients under glucose control with insulin. The costs associated with this practice are considered substantial, especially when more frequent blood glucose (BG) testing is needed, as with more strict glucose control (SGC) aiming for lower BG levels., Objective: The objective of this study was to estimate, from a hospital perspective, the incremental cost effectiveness of an SGC guideline, aiming for BG levels of 4.4-6.1 mmol/L, compared to the situation before implementation of that guideline (aiming for BG levels <8.3 mmol/L), both using BG-POCT., Methods: This is a secondary analysis of a guideline implementation project aiming for implementation of a guideline of SGC in three intensive care units in The Netherlands. A Markov model including the four health states 'target glucose', 'hyperglycaemia' (defined as BG levels >6.1 mmol/L), 'hypoglycaemia' (defined as BG levels <4.4 mmol/L) and 'in-hospital death' was developed to compare expected costs, number of patients within target and number of life-years saved before and after implementation of the SGC guideline. The effectiveness estimates are based on empirical data from 3195 patients 12 and 24 months before and after implementation of the guideline, respectively. All costs have been converted to price year 2013, and are estimated based on hospital data, the literature and available price lists., Results: The number of BG-POCT increased from 4.8 [interquartile range (IQR) 2.6-6.7] to 8.0 [IQR 4.1-11.2] per patient per day, accruing 58% higher costs for BG-POCT (€13.56 vs. €8.57 per patient) in the SGC protocol versus the situation before implementation. When taking total hospital costs and clinical effects into account, implementation of the SGC guideline increased total hospital costs per patient by 1.8%, i.e., €355 (from €20,617 to €20,972) during the inpatient stay, while the number of patients in target glucose levels increased by 1.4% (i.e., from 881 to 895 per 1000 patients). This translates to an incremental cost-effectiveness ratio of €25 per additional patient within the target glucose level. The model outcomes are most sensitive to changes in ICU length of stay., Conclusion: The increase in the number of patients and time within target glucose levels is achieved with a small increase in total direct hospital costs.

Objective: To examine the risk of recurrence of low Apgar score in a subsequent term singleton pregnancy., Design: Population-based cohort study., Setting: The Netherlands., Population: A total of 190,725 women with two subsequent singleton term live births between 1999 and 2007., Methods: We calculated the recurrence risk of low Apgar score after adjustment for possible confounders. Women with an elective cesarean delivery, fetus in breech presentation or a fetus with congenital anomalies were excluded. Results were reported separately for women with a vaginal delivery or a cesarean delivery at first pregnancy., Main Outcome Measures: Prevalence of birth asphyxia, a 5-min Apgar score <7., Results: The risk for an Apgar score of <7 in the first pregnancy was 0.99% and overall halved in the subsequent pregnancies (0.50%). For those with asphyxia in the first pregnancy, the risk of recurrence of a low Apgar score in the subsequent pregnancy was 1.1% (odds ratio 2.1, 95% confidence interval 1.4-3.3). This recurrence risk was present in women with a previous vaginal delivery (odds ratio 2.1, 95% confidence interval 1.2-3.5) and in women with a previous cesarean delivery (odds ratio 3.8, 95% confidence interval 1.7-8.5). Among women with a small-for-gestational-age infant in the subsequent pregnancy and a previous vaginal delivery, the recurrence risk was 4.8% (adjusted odds ratio 5.8, 95% confidence interval 2.0-16.5)., Conclusion: Women with birth asphyxia of the first born have twice the risk of renewed asphyxia at the next birth compared to women without birth asphyxia of the first born. This should be incorporated in the risk assessment of pregnant women., (© 2014 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: Surviving Sepsis Campaign bundles have been associated with reduced mortality in severe sepsis and septic shock patients. Case-mix adjusted mortality evaluations have not been performed to compare hospitals participating in sepsis bundle programs with those not participating. We aimed to achieve an individual bundle target adherence more than 80% and a relative mortality reduction of at least 15% (absolute mortality reduction 5.2%) at the end of 2012., Design: Prospective multicenter cohort study in participating and nonparticipating centers., Setting: Eighty-two ICUs in The Netherlands., Patients: In total, 213,677 adult ICU patients admitted to all ICUs among which 8,387 severe sepsis patients at 52 participating ICUs and 8,031 severe sepsis patients at 30 nonparticipating ICUs., Interventions: A national program to screen patients for severe sepsis and septic shock and implement Surviving Sepsis Campaign bundles to complete within 6 and 24 hours after ICU admission., Measurements and Main Results: Bundle target adherence and case-mix adjusted in-hospital mortality were evaluated through odds ratios of time since program initiation by logistic generalized estimating equation analyses (July 2009 through January 2013). Outcomes were adjusted for age, gender, admission type, severity of illness, and sepsis diagnosis location. Participation duration was associated with improved bundle target adherence (adjusted odds ratio per month = 1.024 [1.016-1.031]) and decreased in-hospital mortality (adjusted odds ratio per month = 0.992 [0.986-0.997]) equivalent to 5.8% adjusted absolute mortality reduction over 3.5 years. Mortality reduced in screened patients with other diagnoses (1.9% over 3.5 yr, adjusted odds ratio per month = 0.995 [0.9906-0.9996]) and did not change in nonscreened patients in participating ICUs, nor in patients with sepsis or other diagnoses in nonparticipating ICUs., Conclusions: Implementation of a national sepsis program resulted in improved adherence to sepsis bundles in severe sepsis and septic shock patients and was associated with reduced adjusted in-hospital mortality only in participating ICUs, suggesting direct impact of sepsis screening and bundle application on in-hospital mortality.

Objective: To develop a prognostic model for antenatal prediction of neonatal mortality in infants threatening to be born very preterm (<32 weeks)., Study Design: Nationwide cohort study in The Netherlands between 1999 and 2007. We studied 8500 singletons born between 25(+0) and 31(+6) weeks of gestation where fetus was alive at birth without congenital anomalies. We developed a multiple logistic regression model to estimate the risk of neonatal mortality within 28 days after birth, based on characteristics that are known before birth. We used bootstrapping techniques for internal validation. Discrimination (AUC), accuracy (Brier score) and calibration (graph, c-statistics) were used to assess the model's predictive performance., Results: Neonatal mortality occurred in 766 (90 per 1000) live births. The final model consisted of seven variables. Predictors were low gestational age, no antental corticosteroids, male gender, maternal age ≥35 years, Caucasian ethnicity, non-cephalic presentation and non-3rd level of hospital. The predicted probabilities ranged from 0.003 to 0.697 (IQR 0.02-0.11). The model had an AUC of 0.83, the Brier score was 0.065. The calibration graph showed good calibration, and the test for the Hosmer Lemeshow c-statistic showed no lack of fit (p=0.43)., Conclusions: Neonatal mortality can be predicted for very preterm births based on the antenatal factors gestational age, antental corticosteroids, fetal gender, maternal age, ethnicity, presentation and level of hospital. This model can be helpful in antenatal counseling., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Previous efforts such as Assessing Care of Vulnerable Elders (ACOVE) provide quality indicators for assessing the care of elderly patients, but thus far little has been done to leverage this knowledge to improve care for these patients. We describe a clinical decision support system to improve general practitioner (GP) adherence to ACOVE quality indicators and a protocol for investigating impact on GPs' adherence to the rules., Design: We propose two randomized controlled trials among a group of Dutch GP teams on adherence to ACOVE quality indicators. In both trials a clinical decision support system provides un-intrusive feedback appearing as a color-coded, dynamically updated, list of items needing attention. The first trial pertains to real-time automatically verifiable rules. The second trial concerns non-automatically verifiable rules (adherence cannot be established by the clinical decision support system itself, but the GPs report whether they will adhere to the rules). In both trials we will randomize teams of GPs caring for the same patients into two groups, A and B. For the automatically verifiable rules, group A GPs receive support only for a specific inter-related subset of rules, and group B GPs receive support only for the remainder of the rules. For non-automatically verifiable rules, group A GPs receive feedback framed as actions with positive consequences, and group B GPs receive feedback framed as inaction with negative consequences. GPs indicate whether they adhere to non-automatically verifiable rules. In both trials, the main outcome measure is mean adherence, automatically derived or self-reported, to the rules., Discussion: We relied on active end-user involvement in selecting the rules to support, and on a model for providing feedback displayed as color-coded real-time messages concerning the patient visiting the GP at that time, without interrupting the GP's workflow with pop-ups. While these aspects are believed to increase clinical decision support system acceptance and its impact on adherence to the selected clinical rules, systems with these properties have not yet been evaluated., Trial Registration: Controlled Trials NTR3566.

Falls form a major health problem for older persons, and increasingly strain the healthcare system. The Internet is a potentially useful platform for empowering seniors. The aim of this study was therefore to investigate the information-seeking behavior about falls among elderly Internet users. A web-based survey was distributed among all members of an association of elderly people (&gt; 60 years old). Fallers and non-fallers, seniors with and without experience with information seeking and the willingness of elderly for undertaking self-assessment tests on the Internet versus solely receiving information about falls were compared. In general, there was much stated interest in receiving information about conditions and medications that increase the risk of falls and information on safety in the house. Around half of the 62 respondents did not feel that they are well-informed about falls. Searching for fall-related information was not significantly associated with having falls in the previous 12 months (OR 2.11, CI: 0.55-8.16). The majority expressed higher interest in receiving fall-related information than undertaking a self-assessment test. However, only a small proportion had searched for this information already.

The Intensive Care Unit (ICU) population is heterogeneous. At individual ICUs, the quality of care may vary within subgroups. We investigate whether poor outcomes of an ICU can be traced back to excess deaths in specific patient subgroups, by discovering candidate subgroups, with a modified adaptive decision tree boosting algorithm applied to 80 Dutch ICUs. Genuine subgroups were selected from candidate subgroups when the case-mix adjusted outcomes were poorer than those of the five top performing ICUs. For 59 ICUs we discovered 122 genuine subgroups and most were defined by one to four variables, with a median of three [2-4]. Variables Glasgow Coma Scale and age were used most. There were 29 ICUs with overall poor outcomes, and for 22 our algorithm found all excess deaths. A new method based on adaptive decision tree boosting discovered many subgroups of ICU patients for which there is potentially room for outcomes improvement.

Purpose: To analyze the influence of using mortality 1, 3, and 6 months after intensive care unit (ICU) admission instead of in-hospital mortality on the quality indicator standardized mortality ratio (SMR)., Methods: A cohort study of 77,616 patients admitted to 44 Dutch mixed ICUs between 1 January 2008 and 1 July 2011. Four Acute Physiology and Chronic Health Evaluation (APACHE) IV models were customized to predict in-hospital mortality and mortality 1, 3, and 6 months after ICU admission. Models' performance, the SMR and associated SMR rank position of the ICUs were assessed by bootstrapping., Results: The customized APACHE IV models can be used for prediction of in-hospital mortality as well as for mortality 1, 3, and 6 months after ICU admission. When SMR based on mortality 1, 3 or 6 months after ICU admission was used instead of in-hospital SMR, 23, 36, and 30% of the ICUs, respectively, received a significantly different SMR. The percentages of patients discharged from ICU to another medical facility outside the hospital or to home had a significant influence on the difference in SMR rank position if mortality 1 month after ICU admission was used instead of in-hospital mortality., Conclusions: The SMR and SMR rank position of ICUs were significantly influenced by the chosen endpoint of follow-up. Case-mix-adjusted in-hospital mortality is still influenced by discharge policies, therefore SMR based on mortality at a fixed time point after ICU admission should preferably be used as a quality indicator for benchmarking purposes.

Objectives: To propose a combined disease management and process modeling approach for evaluating and improving care processes, and demonstrate its usability and usefulness in a real-world fall management case study., Methods: We identified essential disease management related concepts and mapped them into explicit questions meant to expose areas for improvement in the respective care processes. We applied the disease management oriented questions to a process model of a comprehensive real world fall prevention and treatment program covering primary and secondary care. We relied on interviews and observations to complete the process models, which were captured in UML activity diagrams. A preliminary evaluation of the usability of our approach by gauging the experience of the modeler and an external validator was conducted, and the usefulness of the method was evaluated by gathering feedback from stakeholders at an invitational conference of 75 attendees., Results: The process model of the fall management program was organized around the clinical tasks of case finding, risk profiling, decision making, coordination and interventions. Applying the disease management questions to the process models exposed weaknesses in the process including: absence of program ownership, under-detection of falls in primary care, and lack of efficient communication among stakeholders due to missing awareness about other stakeholders' workflow. The modelers experienced the approach as usable and the attendees of the invitational conference found the analysis results to be valid., Conclusions: The proposed disease management view of process modeling was usable and useful for systematically identifying areas of improvement in a fall management program. Although specifically applied to fall management, we believe our case study is characteristic of various disease management settings, suggesting the wider applicability of the approach., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)