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BackgroundThe use of patient-reported outcome measures (PROMs) is becoming increasingly important in healthcare. However, incorporation of PROMs into routine nephrological care is challenging. This study describes the first experience with PROMs in Dutch routine dialysis care.MethodsA pilot study was conducted in dialysis patients in 16 centres. Patients were invited to complete PROMs at baseline and 3 and 6 months. PROMs consisted of the 12-item short-form and Dialysis Symptom Index to assess health-related quality of life (HRQoL) and symptom burden. Response rates, HRQoL and symptom burden scores were analysed. Qualitative research methods were used to gain insight into patients’ views on using PROMs in clinical practice.ResultsIn total, 512 patients (36%) completed 908 PROMs (24%) across three time points. Response rates varied from 6 to 70% among centres. Mean scores for physical and mental HRQoL were 35.6 [standard deviation (SD) 10.2] and 47.7 (SD 10.6), respectively. Patients experienced on average 10.8 (SD 6.1) symptoms with a symptom burden score of 30.7 (SD 22.0). Only 1–3% of the variation in PROM scores can be explained by differences between centres. Patients perceived discussing their HRQoL and symptom scores as insightful and valuable. Individual feedback on results was considered crucial.ConclusionsThe first results show low average response rates with high variability among centres. Dialysis patients experienced a high symptom burden and poor HRQoL. Using PROMs at the individual patient level is suitable and may improve patient–professional communication and shared decision making. Further research is needed to investigate how the collection and the use of PROMs can be successfully integrated into routine care to improve healthcare quality and outcomes.

A funnel plot is a graphical method to evaluate health‐care quality by comparing hospital performances on certain outcomes. So far, in nephrology, this method has been applied to clinical outcomes like mortality and complications. However, patient‐reported outcomes (PROs; eg, health‐related quality of life [HRQOL]) are becoming increasingly important and should be incorporated into this quality assessment. Using funnel plots has several advantages, including clearly visualized precision, detection of volume‐effects, discouragement of ranking hospitals and easy interpretation of results. However, without sufficient knowledge of underlying methods, it is easy to stumble into pitfalls, such as overinterpretation of standardized scores, incorrect direct comparisons of hospitals and assuming a hospital to be in‐control (ie, to perform as expected) based on underpowered comparisons. Furthermore, application of funnel plots to PROs is accompanied by additional challenges related to the multidimensional nature of PROs and difficulties with measuring PROs. Before using funnel plots for PROs, high and consistent response rates, adequate case mix correction and high‐quality PRO measures are required. In this article, we aim to provide insight into the use and interpretation of funnel plots by presenting an overview of the basic principles, pitfalls and considerations when applied to PROs, using examples from Dutch routine dialysis care., SUMMARY AT A GLANCE The statistical review provides insights into the use and interpretation of funnel plots by presenting an overview of the basic principles, pitfalls and considerations when applied to patient‐reported outcomes using examples from Dutch routine dialysis care.

BackgroundAcute kidney injury (AKI) can affect hospitalized patients with coronavirus disease 2019 (COVID-19), with estimates ranging between 0.5% and 40%. We performed a systematic review and meta-analysis of studies reporting incidence, mortality and risk factors for AKI in hospitalized COVID-19 patients.MethodsWe systematically searched 11 electronic databases until 29 May 2020 for studies in English reporting original data on AKI and kidney replacement therapy (KRT) in hospitalized COVID-19 patients. Incidences of AKI and KRT and risk ratios for mortality associated with AKI were pooled using generalized linear mixed and random-effects models. Potential risk factors for AKI were assessed using meta-regression. Incidences were stratified by geographic location and disease severity.ResultsA total of 3042 articles were identified, of which 142 studies were included, with 49 048 hospitalized COVID-19 patients including 5152 AKI events. The risk of bias of included studies was generally low. The pooled incidence of AKI was 28.6% [95% confidence interval (CI) 19.8–39.5] among hospitalized COVID-19 patients from the USA and Europe (20 studies) and 5.5% (95% CI 4.1–7.4) among patients from China (62 studies), whereas the pooled incidence of KRT was 7.7% (95% CI 5.1–11.4; 18 studies) and 2.2% (95% CI 1.5–3.3; 52 studies), respectively. Among patients admitted to the intensive care unit, the incidence of KRT was 20.6% (95% CI 15.7–26.7; 38 studies). Meta-regression analyses showed that age, male sex, cardiovascular disease, diabetes mellitus, hypertension and chronic kidney disease were associated with the occurrence of AKI; in itself, AKI was associated with an increased risk of mortality, with a pooled risk ratio of 4.6 (95% CI 3.3–6.5).ConclusionsAKI and KRT are common events in hospitalized COVID-19 patients, with estimates varying across geographic locations. Additional studies are needed to better understand the underlying mechanisms and optimal treatment of AKI in these patients.

Background Itching (pruritus) is common in dialysis patients, but little is known about its impact on health-related quality of life (HRQOL), sleep problems and psychological symptoms. This study investigates the impact of itching in dialysis patients by looking into the persistence of itching, the effect of itching on the course of HRQOL and the combined effect of itching with sleep problems and with psychological symptoms on HRQOL. Methods Data were obtained from the RENINE/PROMs registry and included 2978 dialysis patients who completed patient-reported outcome measures between 2018 and 2020. Itching, sleep problems and psychological symptoms were assessed with the Dialysis Symptom Index (DSI) and HRQOL with the 12-item Short Form Health Survey. Effects of itching on HRQOL and interactions with sleep problems and psychological symptoms were investigated cross-sectionally and longitudinally using linear regression and linear mixed models. Results Half of the patients experienced itching and in 70% of them, itching was persistent. Itching was associated with a lower physical and mental HRQOL {−3.35 [95% confidence interval (CI) −4.12 to −2.59) and −3.79 [95% CI −4.56 to −3.03]}. HRQOL remained stable during 2 years and trajectories did not differ between patients with or without itching. Sleep problems (70% versus 52%) and psychological symptoms (36% versus 19%) were more common in patients with itching. These symptoms had an additional negative effect on HRQOL but did not interact with itching. Conclusions The persistence of itching, its impact on HRQOL over time and the additional effect on HRQOL of sleep problems and psychological symptoms emphasize the need for recognition and effective treatment of itching to reduce symptom burden and improve HRQOL.

Rationale & Objective Explore priorities related to outcomes and barriers of adults with chronic kidney disease (CKD) regarding person centred care and care planning. Study design Systematic review of qualitative studies. Search Strategy & Sources In July 2018 six bibliographic databases, and reference lists of included articles were searched for qualitative studies that included adults with CKD stages 1–5, not on dialysis or conservative management, without a previous kidney transplantation. Analytical Approach Three independent reviewers extracted and inductively coded data using thematic synthesis. Reporting quality was assessed using the COREQ and the review reported according to PRISMA and ENTREQ statements. Results Forty-six studies involving 1493 participants were eligible. The period after diagnosis of CKD is characterized by feelings of uncertainty, social isolation, financial burden, resentment and fear of the unknown. Patients show interest in ways to return to normality and remain in control of their health in order to avoid further deterioration of kidney function. However, necessary information is often unavailable or incomprehensible. Although patients and healthcare professionals share the predominant interest of whether or not dialysis or transplantation is necessary, patients value many more outcomes that are often unrecognized by their healthcare professionals. We identified 4 themes with 6 subthemes that summarize these findings: ‘pursuing normality and control’ (‘pursuing normality’; ‘a search for knowledge’); ‘prioritizing outcomes’ (‘reaching kidney failure’; ‘experienced health’; ‘social life’; ‘work and economic productivity’); ‘predicting the future’; and ‘realising what matters’. Reporting quality was moderate for most included studies. Limitations Exclusion of non-English articles. Conclusions The realisation that patients’ priorities do not match those of the healthcare professionals, in combination with the prognostic ambiguity, confirms fatalistic perceptions of not being in control when living with CKD. These insights may contribute to greater understanding of patients’ perspectives and a more person-centred approach in healthcare prioritization and care planning within CKD care.

Background: To compare hospital outcomes of aortic aneurysm surgery, casemix correction for preoperative variables is essential. Most of these variables can be deduced from mortality risk prediction models. Our aim was to identify the optimal set of preoperative variables associated with mortality to establish a relevant and efficient casemix model.Methods: All patients prospectively registered between 2013 and 2016 in the Dutch Surgical Aneurysm Audit (DSAA) were included for the analysis. After multiple imputation for missing variables, predictors for mortality following univariable logistic regression were analyzed in a manual backward multivariable logistic regression model and compared with three standard mortality risk prediction models: Glasgow Aneurysm Score (GAS, mainly clinical parameters), Vascular Biochemical and Haematological Outcome Model (VBHOM, mainly laboratory parameters), and Dutch Aneurysm Score (DAS, both clinical and laboratory parameters). Discrimination and calibration were tested and considered good with a C-statistic > 0.8 and Hosmer-Lemeshow (H-L) P > 0.05.Results: There were 12,401 patients: 9,537 (76.9%) elective patients (EAAA), 913 (7.4%) acute symptomatic patients (SAAA), and 1,951 (15.7%) patients with acute rupture (RAAA). Overall postoperative mortality was 6.5%; 1.8% after EAAA surgery, 6.6% after SAAA, and 29.6% after RAAA surgery. The optimal set of independent variables associated with mortality was a mix of clinical and laboratory parameters: gender, age, pulmonary comorbidity, operative setting, creatinine, aneurysm size, hemoglobin, Glasgow coma scale, electrocardiography, and systolic blood pressure (C-statistic 0.871). External validation overall of VBHOM, DAS, and GAS revealed C-statistics of 0.836, 0.782, and 0.761, with an H-L of 0.028, 0.00, and 0.128, respectively.Conclusions: The optimal set of variables for casemix correction in the DSAA comprises both clinical and laboratory parameters, which can be collected easily from electronic patient files and will lead to an efficient casemix model.

Patient‐reported outcome measures (PROMs) are increasingly being used in nephrology care. However, in contrast to well‐known clinical measures such as blood pressure, health‐care professionals are less familiar with PROMs and the interpretation of PROM scores is therefore perceived as challenging. In this paper, we provide insight into the interpretation of PROM scores by introducing the different types and characteristics of PROMs, and the most relevant concepts for the interpretation of PROM scores. Concepts such as minimal detectable change, minimal important change and response shift are explained and illustrated with examples from nephrology care., SUMMARY AT A GLANCE The review provides insight into the interpretation of PROM scores by introducing the different types and characteristics of PROMs, and the most relevant concepts for the interpretation of PROM scores, ie minimal detectable change, minimal important change and response shift.

Background and Aims Funnel plots are used to evaluate healthcare quality by comparing hospital performances on certain outcomes. So far, in nephrology, only clinical outcomes like mortality and complications are used for this purpose. However, with the increasing importance of patient-reported outcomes (PROs; e.g. health related quality of life [HRQOL]), PROs should also be taken into account in this quality assessment. Understanding the underlying methods and challenges is needed for optimal use of PROs in this context. Therefore, we aim to provide insight into the use and interpretation of funnel plots by presenting an overview of the basic principles and considerations when applied to PROs, using examples from Dutch routine dialysis care. Method Data on PROs (HRQOL and symptom burden), sociodemographic and clinical characteristics of patients receiving dialysis were obtained from the Dutch renal registry and were used to illustrate and explain the different components of a funnel plot, the underlying concepts (e.g. case mix and indirect standardization) and the interpretation of funnel plots. Additionally, some methodological issues are highlighted that should be considered when these methods are applied to PROs. Results A funnel plot is a graphical aid that consists of four components: an indicator, reference standard, measure of precision (usually the sample size) and control limits (see Figure). Funnel plots provide insight into hospitals’ performances by comparing the observed outcome to the expected outcome. A hospital’s expected outcome is calculated using the scores in the reference population (given the hospital’s patient population, i.e. case mix) and represents the outcome that would have been observed if the hospital had performed equal to the reference standard. Hospitals may be considered as under- or overperforming when exceeding the upper or lower 95% control limit. Advantages of funnel plots include: clearly visualized precision, detection of volume-effects, discouragement of ranking hospitals and easy interpretation of results. However, without basic knowledge of underlying methods, it is easy to fall into pitfalls, including: overinterpretation of standardized scores, incorrect direct comparisons of hospitals and to assume a hospital to be in-control based on under-powered comparisons. Furthermore, application to PROs is accompanied with additional challenges such as the multidimensional nature of PROs (e.g. HRQOL) which makes adequate case mix correction more difficult, and difficulties with measuring PROs, for instance to achieve high response rates or the dependence on good psychometric properties of the PRO-measures. Conclusion PROs partly determine the value of nephrological care and should therefore be considered in healthcare quality assessment. Understanding of the underlying methods using funnel plots is necessary for optimal use and correct interpretation of hospital comparisons on PROs. Some challenges need to be addressed before these methods can be applied to PROs, namely: high and consistent response rates, adequate case mix correction and high-quality PRO measures.

Contains fulltext : 229914.pdf (Publisher’s version ) (Open Access) BACKGROUND: While several observational studies suggested a lower postoperative mortality after minimal invasive endovascular aneurysm repair (EVAR) in patients with a ruptured abdominal aortic aneurysm (RAAA) compared to conventional open surgical repair (OSR), landmark randomized controlled trials have not been able to prove the superiority of EVAR over OSR. Randomized controlled trials contain a selected, homogeneous population, influencing external validity. Observational studies are biased and adjustment of confounders can be incomplete. Instrumental variable (IV) analysis (pseudorandomization) may help to answer the question if patients with an RAAA have lower postoperative mortality when undergoing EVAR compared to OSR. METHODS: This is an observational study including all patients with an RAAA, registered in the Dutch Surgical Aneurysm Audit between 2013 and 2017. The risk difference (RD) in postoperative mortality (30 days/in-hospital) between patients undergoing EVAR and OSR was estimated, in which adjustment for confounding was performed in 3 ways: linear model adjusted for observed confounders, propensity score model (multivariable logistic regression analysis), and IV analysis (two-stage least square regression), adjusting for observed and unobserved confounders, with the variation in percentage of EVAR per hospital as the IV instrument. RESULTS: 2419 patients with an RAAA (1489 OSR and 930 EVAR) were included. Unadjusted postoperative mortality was 34.9% after OSR and 22.6% after EVAR (RD 12.3%, 95% CI 8.5-16%). The RD adjusted for observed confounders using linear regression analysis and propensity score analysis was, respectively, 12.3% (95% CI 9.6-16.7%) and 13.2% (95%CI 9.3-17.1%) in favor of EVAR. Using IV analysis, adjusting for observed and unobserved confounders, RD was 8.9% (95% CI -1.1-18.9%) in favor of EVAR. CONCLUSIONS: Adjusting for observed confounders, patients with an RAAA undergoing EVAR had a significant better survival than OSR in a consecutive large cohort. Adjustment for unobserved confounders resulted in a clinical relevant RD. An "EVAR preference strategy" in patients with an RAAA could result in lower postoperative mortality.

Background When comparing hospitals on outcome indicators, proper adjustment for case mix (a combination of patient and disease characteristics) is indispensable. This study examines the need for case mix adjustment in evaluating hospital outcomes for non-small cell lung cancer surgery. Methods Data from the Dutch Lung Cancer Audit for Surgery were used to validate factors associated with postoperative 30-day mortality and complicated course with multivariable logistic regression models. Between-hospital variation in case mix was studied by calculating medians and interquartile ranges for separate factors on the hospital level and the "expected" outcomes per hospital as a composite measure. Results A total of 8,040 patients, distributed over 51 Dutch hospitals, were included for analysis. Mean observed postoperative mortality and complicated course were 2.2% and 13.6%, respectively. Age, American Society of Anesthesiologists classification, Eastern Cooperative Oncology Group performance score, lung function, extent of resection, tumor stage, and postoperative histopathologic findings were individual significant predictors for both outcomes of postoperative mortality and complicated course. A considerable variation of these case mix factors among hospital populations was observed, with the expected mortality and complicated course per hospital ranging from 1.4% to 3.2% and from 11.5% to 17.1%, respectively. Conclusions The between-hospital variation in case mix of patients undergoing surgical treatment for non-small cell lung cancer emphasizes the importance of proper adjustment when comparing hospitals on outcome indicators.

Background Patient-reported outcome measures (PROMs) are becoming increasingly important in healthcare. In nephrology, there is no agreement on which chronic kidney disease (CKD) symptom questionnaire to use. Therefore, the aim of this study is to select a valid symptom questionnaire for routine assessment in patients with advanced CKD. Methods A four-phase mixed methods approach, using qualitative and quantitative research methods, was applied. First, a systematic literature search was conducted to retrieve existing symptom questionnaires. Second, a symptom list was created including all symptoms in existing questionnaires and symptoms mentioned in interviews with patients with CKD, from which symptom clusters were identified. Next, questionnaires were selected based on predefined criteria regarding content validity. Last, two online feedback panels of patients with CKD (n = 151) and experts (n = 6) reviewed the most promising questionnaires. Results The literature search identified 121 questionnaires, of which 28 were potentially suitable for symptom assessment in patients with advanced CKD. 101 unique symptoms and 10 symptom clusters were distinguished. Based on predefined criteria, the Dialysis Symptom Index (DSI) and Palliative Care Outcome Scale-Renal Version (IPOS-Renal) were selected and reviewed by feedback panels. Patients needed 5.4 and 7.5 min to complete the DSI and IPOS-Renal, respectively (p

Objectives: Failure to rescue (FTR) is a composite quality indicator, defined as the proportion of deceased patients following major complications. The aims of this study were to compare FTR with mortality for hospital comparisons in abdominal aortic aneurysm (AAA) surgery in The Netherlands and investigate hospital volume and associated factors.Methods: Patients prospectively registered between 2013 and 2015 in the Dutch Surgical Aneurysm Audit (DSAA) were analysed. FTR was analysed for AAA patients and subgroups elective (EAAA) and acute (AAAA; symptomatic or ruptured) aneurysms. Variables and hospital volume were analysed by uni- and multivariable regression analysis. Adjusted hospital comparisons for mortality, major complications, and FTR were presented in funnel plots. Isomortality lines were constructed when presenting FTR and major complication rates.Results: A total of 9258 patients were analysed in 61 hospitals: 7149 EAAA patients (77.2%) and 2109 AAAA patients (22.8%). There were 2785 (30.1%) patients with complications (unadjusted range 5-65% per hospital): 2161 (77.6%) with major and 624 (28.4%) patients with minor complications. Overall mortality was 6.6% (adjusted range 0-16% per hospital) and FTR was 28.4% (n = 613) (adjusted range 0-60% per hospital). Glasgow Coma Scale, age, pulse, creatinine, electrocardiography, and operative setting were independently associated with FTR. Hospital volume was not associated with FTR. In AAAA patients hospital volume was significantly associated with a lower adjusted major complication and mortality rate (OR 0.62, 95% CI 0.49-0.78; and 0.64, 95% CI 0.48-0.87). Four hospitals had a significant lower adjusted FTR with different major complication rates on different isomortality lines.Conclusions: There was more variation in FTR than in mortality between hospitals. FTR identified the same best performing hospitals as for mortality and therefore was of limited additional value in measuring quality of care for AAA surgery. FTR can be used for internal quality improvement with major complications in funnel plots and diagrams with isomortality lines. (C) 2018 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.

Background and objectiveSeveral early life determinants play a role in childhood obesity. Rapid weight gain and overweight in infancy increases the risk while breast feeding seems to protect against childhood overweight. However, should we worry about exclusively breastfed overweight infants? The aim of the study is to examine the association of feeding type (exclusive breast feeding (EBF), formula feeding or mixed feeding) and overweight at the age of 6 months with the risk of overweight at the age of 5–6 years.MethodsThe Amsterdam Born Children and their Development study is a large prospective population-based birth cohort study conducted in Amsterdam, the Netherlands. Children with complete information pertaining to feeding type and weight status at the age of 6 months and 5–6 years were included (N=3367). EBF was defined as receiving only breast feeding for at least 3 months. Overweight at the ages of 6 months and 5–6 years were defined by the WHO child growth standards and the International Obesity Task Force guidelines, respectively. The association of feeding type and overweight at 6 months with overweight at 5–6 years was assessed using logistic regression analyses.ResultsOverweight infants have a 4.10-fold (95% CI 2.91 to 5.78) higher odds of childhood overweight compared with those who were not overweight, independent of feeding type. EBF did not affect the association between infant overweight and childhood overweight.ConclusionsOverweight in infancy increases the odds of childhood overweight, equally for exclusively breastfed and formula fed infants. Overweight prevention should start before or at birth and applies to formula fed children as well as exclusively breastfed children.

To investigate the impact of the Netherlands national colorectal cancer screening programme on the number of surgical resections for colorectal carcinoma and on waiting times for surgery.Descriptive study.Data were extracted from the Dutch Surgical Colorectal Audit. Patients with primary colorectal cancer surgery between 2011-2015 were included. The volume and median waiting times for the years 2011-2015 are described. Waiting times from first tumor positive biopsy until the operation (biopsy-operation) and first preoperative visit to the surgeon until the operation (visit-operation) are analyzed with a univariate and multivariate linear regression analysis. Separate analysis was done for visit-operation for academic and non-academic hospitals and for screening compared to non-screening patients.In 2014 there was an increase of 1469 (15%) patients compared to 2013. In 2015 this increase consisted of 1168 (11%) patients compared to 2014. In 2014 and 2015, 1359 (12%) and 3111 (26%) patients were referred to the surgeon through screening, respectively. The median waiting time of biopsy-operation significantly decreased (ß: 0.94, 95%BI) over the years 2014-2015 compared to 2011-2013. In non-academic hospitals, the waiting time visit-operation also decreased significantly (ß: 0.89, 95%BI 0.87-0.90) over the years 2014-2015 compared to 2011-2013. No difference was found in waiting times between patients referred to the surgeon through screening compared to non-screening.There is a clear increase in volume since the introduction of the colorectal cancer screening programme without an increase in waiting time until surgery.