How improving access times had unforeseen consequences:a case study in a Dutch hospital

Objectives To investigate the consequences of increasing capacity to reduce access times, and to explore how patient waiting times and use of physical capacity were influenced by variability. Design A retrospective case study that combines both primary and secondary data. Secondary data were retrieved from a hospital database to establish inflow and outflow of patients, utilisation of resources and available capacity, realised access times and the weekly number of new patients seen over 1 year. Primary data consisted of field notes, onsite visits and observations, and semistructured interviews. Setting A secondary care facility, that is, a rheumatology department, in a large Dutch hospital. Participants Analyses are based on secondary patient data from the hospital database, and the responses of the interviews with physicians, nurses and Lean Six Sigma project leaders. Results The study shows that artificial variability was increased by managerial decisions to add capacity and to allow an increased inflow of new patients. This, in turn, resulted in undesirable and significant fluctuations in access times. We argue that we witnessed a new multiplier effect that typifies the fluctuations. Conclusions Adding capacity resources to reduce access times might appear an obvious and effective solution. However, the outcomes were less straightforward than expected, and even led to new artificial variability. The study reveals a phenomenon that is specific to service environments, and especially healthcare, and has detrimental consequences for access times

How improving access times had unforeseen consequences: a case study in a Dutch hospital

OBJECTIVES: To investigate the consequences of increasing capacity to reduce access times, and to explore how patient waiting times and use of physical capacity were influenced by variability. DESIGN: A retrospective case study that combines both primary and secondary data. Secondary data were retrieved from a hospital database to establish inflow and outflow of patients, utilisation of resources and available capacity, realised acc

Reorganizing the Multidisciplinary Team Meetings in a Tertiary Centre for Gastro-Intestinal Oncology Adds Value to the Internal and Regional Care Pathways. A Mixed Method Evaluation

Introduction: The reorganisation of the structure of a Gastro-Intestinal Oncology Multidisciplinary Team Meeting (GIO-MDTM) in a tertiary centre with three care pathways is evaluated on added value. Methods: In a mixed method investigation, process indicators such as throughput times were analysed and stakeholders were interviewed regarding benefits and drawbacks of the reorganisation and current MDTM functioning. Results: For the hepatobiliary care pathway, the time to treatment plan increased, but the time to start treatment reduced significantly. The percentage of patients treated within the Dutch standard of 63 days increased for the three care pathways. From the interviews, three themes emerged: added value of MDTMs, focus on planning integrated care and awareness of possible improvements. Discussion: The importance of evaluating interventions in oncology care pathways is shown, including detecting unexpected drawbacks. The evaluation provides insight into complex dynamics of the care pathways and contributes with recommendations on functioning of an MDTM. Conclusions: Throughput times are only partly determined by oncology care pathway management, but have influence on the functioning of MDTMs. Process indicator information can help to reflect on integration of care in the region, resulting in an increase of patients treated within the Dutch standard

How improving access times had unforeseen consequences: a case study in a Dutch hospital

Objectives To investigate the consequences of increasing capacity to reduce access times, and to explore how patient waiting times and use of physical capacity were influenced by variability. Design A retrospective case study that combines both primary and secondary data. Secondary data were retrieved from a hospital database to establish inflow and outflow of patients, utilisation of resources and available capacity, realised access times and the weekly number of new patients seen over 1 year. Primary data consisted of field notes, onsite visits and observations, and semistructured interviews. Setting A secondary care facility, that is, a rheumatology department, in a large Dutch hospital. Participants Analyses are based on secondary patient data from the hospital database, and the responses of the interviews with physicians, nurses and Lean Six Sigma project leaders. Results The study shows that artificial variability was increased by managerial decisions to add capacity and to allow an increased inflow of new patients. This, in turn, resulted in undesirable and significant fluctuations in access times. We argue that we witnessed a new multiplier effect that typifies the fluctuations. Conclusions Adding capacity resources to reduce access times might appear an obvious and effective solution. However, the outcomes were less straightforward than expected, and even led to new artificial variability. The study reveals a phenomenon that is specific to service environments, and especially healthcare, and has detrimental consequences for access times

HIV-Präexpositionsprophylaxe-Versorgung in intersektoraler Zusammenarbeit

$\it Hintergrund$ Zur HIV("human immunodeficiency virus")-Präexpositionsprophylaxe (PrEP) wird am WIR – Walk In Ruhr – Zentrum für Sexuelle Gesundheit und Medizin ein innovatives Modellprojekt zur intersektoralen PrEP-Versorgung durchgeführt. $\it Forschungsziele$ Die vorliegende Studie beschreibt, wer mit der PrEP versorgt wurde und wie sich im Verlauf der PrEP-Einnahme das sexuelle Risikoverhalten änderte sowie welche sexuell übertragbaren Infektionen (STI) und unerwünschte Arzneimittelwirkungen auftraten. $\it Methoden$ In die Studie wurden bisher $\it N$ = 139 Probanden eingeschlossen, die zwischen 10/2017 und 12/2018 mit einer PrEP begonnen haben. Alle PrEP-Nutzer erhielten Fragebögen, zudem wurden Nebenwirkungen, HIV und andere STI mittels klinischer Laborwerte über einen Zeitraum von 13 Monaten erfasst. $\it Ergebnisse$ Die PrEP-Nutzer hatten ein durchschnittliches Alter von 38 Jahren, waren zu 98,6 % Männer, die Sex mit Männern (MSM) hatten, und zeichneten sich durch einen hohen Bildungsstatus und geringe Arbeitslosigkeit aus. Die durchschnittliche Partneranzahl pro Proband innerhalb der letzten 6 Monate stieg im Verlauf signifikant an, während die Kondomnutzung signifikant zurückging. Innerhalb der ersten 4 Monate nach PrEP-Beginn traten 44 STI bei 34 Patienten auf. Es wurde keine HIV-Infektion festgestellt. In den ersten 4 Wochen nach PrEP-Beginn zeigten sich bei 38,8 % der Probanden unerwünschte Arzneimittelwirkungen, hauptsächlich Symptome des Magen-Darm-Trakts. $\it Schlussfolgerung$ Die PrEP-Nutzer hatten einen guten Bildungsstatus und einen festen Arbeitsplatz bzw. eine Ausbildungsstelle. Das sexuelle Risikoverhalten nahm im Verlauf zu, verbunden mit einem gehäuften Auftreten von STI. Unerwünschte Arzneimittelwirkungen zeigten sich insbesondere zu Anfang der PrEP-Einnahme.$\it Background$ HIV pre-exposure prophylaxis (PrEP), a further opportunity to prevent HIV, is available at the WIR—Walk In Ruhr, Centre for Sexual Health and Medicine, as part of an innovative model project for intersectoral PrEP care. $\textit {Research objectives}$ The present study describes the collective of persons provided with PrEP and how PrEP use influences sexual risk behaviour, the incidence of sexually transmitted diseases (STD) and adverse drug reactions. $\it Methods$ A total of 139 men who started PrEP between 10/2017 and 12/2018 have been included in the study. During a period of 13 months of PrEP treatment, all PrEP users received questionnaires; side effects, HIV and other STI were also monitored via clinical laboratory examinations. $\it Results$ The participants’ average age was 38 years and 98.6% of them were men who had sex with men (MSM). Most of them had a high educational background; the unemployment rate was low. The average number of sexual partners within the last 6 months increased significantly, while the use of condoms decreased. In all, 44 STI were found in 34 participants within the first 4 months. No one was infected with HIV. Within the first 4 weeks of PrEP, 38.8% of the participants suffered from side effects, mainly gastrointestinal symptoms. $\it Conclusion$ Most of the participants were working in a job or a vocational training. The sexual risk behaviour increased in the course of using PrEP resulting in a high incidence of STD. Side effects appeared most frequently in the first few weeks after starting PrEP

Changes in the user profiles of HIV pre-exposure prophylaxis (PrEP) before and after PrEP reimbursement.

BACKGROUND: In Germany, oral HIV pre-exposure prophylaxis (PrEP) was licensed in 2016. Health insurances have been covering the costs since 09/2019. This study compares the sociodemographic profiles of PrEP users before and after PrEP re-imbursement. METHODS: Participants were recruited in a cross-sectoral sexual health centre in Germany. baseline data were compared for 139 vs 138 individuals starting PrEP from 10/2017-12/2018 (pre-reimbursement cohort) and 09/2019-3/2020; respectively. The pre-reimbursement cohort was further analysed with respect to sexual behaviour and incident sexually transmitted infections (STIs). RESULTS: There were no significant differences in the sociodemographic characteristics between the two cohorts. Almost all PrEP users were men-who-have-sex-with-men (MSM). Before reimbursement, fewer individuals used PrEP on a daily base, and more had used PrEP prior to enrolment. During follow-up (pre-reimbursement cohort), the number of sexual and condomless intercourse partners increased, so did the proportion engaging in Chemsex. Incidences of infections with C.trachomatis, N.gonorrhoeae, M.genitalium, and T.pallidum were 45.2; 36.8; 30.1; and 9.2, respectively, per 100 person-years. CONCLUSION: The goal to make PrEP available to a broader range of people with the covering of costs was only partially reached. Medically supervised use is important to detect and treat STIs

HIV pre-exposure prophylaxis during the SARS-CoV-2 pandemic

$\bf Aims:$ Since 2017, HIV pre-exposure prophylaxis (PrEP) care has been provided through an intersectoral collaboration at WIR (Walk-in-Ruhr, Center for Sexual Health and Medicine, Bochum, Germany). The aim of this study was to establish possible impact of COVID-restrictions on the sexual behavior of PrEP users in North Rhine-Westphalia. $\bf Methods:$ The current PrEP study collected data of individuals using PrEP, their sexual behavior and sexually transmitted infections (STIs) before (each quarter of year 2018) and during the COVID-19 pandemic (each quarter of year 2020). $\bf Results:$ During the first lockdown in Germany from mid-March until May 2020, PrEP-care appointments at WIR were postponed or canceled. Almost a third of PrEP users had discontinued their PrEP intake in the $2^{nd}$ quarter of 2020 due to alteration of their sexual behavior. The number of sexual partners decreased from a median of 14 partners in the previous 6 months in $1^{st}$ quarter of 2020, to 7 partners in $4^{th}$ quarter of 2020. Despite such a significant reduction in partner number during the pandemic in comparison to the pre-pandemic period, a steady rate of STIs was observed among PrEP users in 2020. \(\bf Conclusion:\9 The SARS-CoV-2-pandemic has impacted PrEP-using MSM in North Rhine-Westphalia with respect to their PrEP intake regimen and sexual behavior in 2020. Our study revealed a steady rate of STI among PrEP users even during the pandemic, thus highlighting the importance of ensuring appropriate HIV/STI prevention services in times of crisis