Herziening van de geneesmiddelendistributie in het Sophia Kinderziekenhuis (Academisch Ziekenhuis Rotterdam)

Doelstelling: In het Sophia Kinderziekenhuis is onderzoek verricht ter optimalisering van het geneesmiddelendistributiesysteem. De geneesmiddelendistributie verloopt momenteel op sommige afdelingen via verpleegkundigen en op andere via apothekersassistenten in depotheken. Methoden: De beoordeling van beide distributiesystemen vond plaats aan de hand van de kwaliteitsindicatoren klantgerichtheid, effectiviteit en doelmatigheid. De klantgerichtheid is in kaart gebracht met behulp van interviews. Het vóórkomen van distributiefouten en microbiologische contaminatie zijn beschouwd als effectiviteitsmaten. De doelmatigheid is bepaald met een rekenmodel waarbij het geneesmiddelengebruik is gemeten en tijdmetingen en kostenberekeningen zijn uitgevoerd. Met behulp van het rekenmodel is een aantal alternatieve distributievormen doorgerekend. Resultaten: De geneesmiddeldistributie via depotheken is de meest optimale distributievorm binnen het kinderziekenhuis. De geneesmiddelenbereiding door apothekersassistenten komt tegemoet aan de toenemende complexiteit van medicatiebehoeften in een academisch kinderziekenhuis. Bij het bereiden treedt minder contaminatie op. Bovendien blijkt de depotheek het doelmatigste distributiesysteem te zijn. De nadelen van het systeem van depotheken in de huidige vorm betreffen voornamelijk de inefficiëntie van het registratiesysteem. Daarnaast vindt te weinig sturing plaats op integratie met het primaire proces. Discussie: Automatisering zal de inefficiëntie van het administratieve deel binnen het distributietraject via depotheken grotendeels wegnemen. Daarnaast wordt het management geadviseerd om aandacht te besteden aan meer afstemming met het primaire proces. Op langere termijn verdient uitbreiding van het depotheeksysteem de voorkeur, waarbij rekening zal moeten worden gehouden met zekere randvoorwaarden (bijvoorbeeld omtrent ruimten en ARBO-eisen). Het rekenmodel is onder bepaalde voorwaarden geschikt om ook buiten het Sophia te worden toegepast

Kwaliteit en kosten in instellingen voor klinische zorg. Eindrapportage van de toepassing van een kwaliteitsmodel in 5 Nederlandse zorginstellingen 1999-2002

In dit rapport wordt verslag gedaan van de bruikbaarheid en toepasbaarheid van het kwaliteitskostenmodel in de praktijk. Het verslag bestaat uit 2 delen: 1) Externe verslagen over het verloop en de resultaten binnen de kwaliteitsprojecten in de zorginstellingen door de projectteams. 2) Een procesevaluatie met name gericht op de toepassing en het gebruik van kwaliteitskosten bij de uitvoering van de kwaliteitsprojecten. Algemeen blijkt het kwaliteitskostenmodel in de praktijk uitvoerbaar: met behulp van kwaliteitskosteninformatie kunnen knelpunten binnen het zorgproces aangewezen worden en kunnen prioriteiten voor verbetering worden gesteld. De toepasbaarheid van de kwaliteitskosteninformatie voor de besluitvorming binnen de kwaliteitsprojecten is nog beperkt. Hierbij spelen zowel een aantal interne als externe factoren een rol die belemmerend werken: 1) Betrokkenen zijn niet kosten-minded ingesteld, waardoor terughoudend wordt omgegaan met kostenargumenten. 2) Kostenargumenten als zodanig blijken niet direct bruikbaar als motiverend argument om draagvlak te krijgen voor kwaliteitsverbeteringen. 3) Het ontbreekt binnen de zorginstellingen veelal aan een ‘outcome’-gerichtheid die de basis vormt van de werking van het kwaliteitskostenmodel. 4) De huidige Functiegerichte Budgettering biedt weinig prikkels om vermijdbare kosten binnen het zorgproces te doen dalen of om te komen tot omzetvergroting. In het algemeen gaat de aandacht vooral uit naar mogelijkheden voor financiële besparingen (beïnvloeding op geldstromen). De mogelijke economische besparingen vragen om topdown ondersteuning en sturing vanuit het management. Daarnaast vraagt de toepassing van de methode expertise om consequenties van financiële en economische kosten in te passen in beleidsbeslissingen binnen de zorginstellingen

Quality of Life in adults who stutter

Abstract: Although persistent developmental stuttering is known to affect daily living, just how great the impact is remains unclear. Furthermore, little is known about the underlying mechanisms which lead to a diminished quality of life (QoL). The primary objective of this study is to explore to what extent QoL is impaired in adults who stutter (AWS). In addition, this study aims to identify determinants of QoL in AWS by testing relationships between stuttering severity, coping, functioning and QoL and by testing for differences in variable scores between two AWS subgroups: receiving therapy versus not receiving therapy. A total of 91 AWS filled in several questionnaires to assess their stuttering severity, daily functioning, coping style and QoL. The QoL instruments used were the Health Utility Index 3 (HUI3) and the EuroQoL EQ-5D and EQ-VAS. The results indicated that moderate to severe stuttering has a negative impact on overall quality of life; HUI3 derived QoL values varied from .91 (for mild stuttering) to .73 (for severe stuttering). The domains of functioning that were predominantly affected were the individual’s speech, emotion, cognition and pain as measured by the HUI3 and daily activities and anxiety/depression as measured by the EQ-5D. AWS in the therapy group rated their stuttering as more severe and recorded more problems on the HUI3 speech domain than AWS in the non-therapy group. The EQ-VAS was the only instrument that showed a significant difference in overall QoL between groups. Finally, it was found that the relationship between stuttering severity and QoL was influenced by the individual’s coping style (emotion-oriented and task-oriented). These findings highlight the need for further research into stuttering in relation to QoL, and for a broader perspective on the diagnosis and treatment of stuttering, which would take into consideration quality of life and its determinants

Cost-effectiveness of the 'Walcheren Integrated Care Model' intervention for community-dwelling frail elderly

Background.: An important aim of integrated care for frail elderly is to generate more cost-effective health care. However, empirical research on the cost-effectiveness of integrated care for community-dwelling frail elderly is limited. Objective.: This study reports on the cost-effectiveness of the Walcheren Integrated Care Model (WICM) after 1

Let's go back to work: survival analysis on the return-to-work after depression

Absence from work due to mental disorders is substantial. Additionally, long-term absence from work is associated with a reduced probability of return-to-work (RTW). Major depressive disorder (MDD) is a prevalent condition in Dutch occupational health care settings. An early estimate of the prognosis regarding RTW in patients with MDD could serve both as a point of departure for the identification of high-risk cases and as an instrument to monitor the course of the disorder and of RTW. In the current study, we aimed to assess the added value of health-related quality of life (HRQoL) and severity of depression to predict the time to RTW

Probabilistic markov model estimating cost effectiveness of methylphenidate osmotic-release oral system versus immediate-release methylphenidate in children and adolescents: Which information is needed?

Background: Incidence of attention deficit hyperactivity disorder (ADHD) in children and adolescents has been increasing. The disorder results in high societal costs. Policymakers increasingly use health economic evaluations to inform decisions on competing treatments of ADHD. Yet, health economic evaluations of first-choice medication of ADHD in children and adolescents are scarce and generally do not include broader societal effects. Objectives: This study presents a probabilistic model and analysis of methylphenidate osmotic-release oral system (OROS) versus methylphenidate immediate-release (IR). We investigate and include relevant societal aspects in the analysis so as to provide cost-effectiveness estimates based on a broad societal perspective. Methods: We enhanced an existing Markov model and determined the cost effectiveness of OROS versus IR for children and adolescents responding suboptimally to treatment with IR. Enhancements included screening of a broad literature base, updated utilit

Employment and associated impact on quality of life in people diagnosed with schizophrenia

A systematic review was conducted to assess the employment rate of people with schizophrenia. Additionally, information from the selected studies concerning factors associated with employment and health-related quality of life (HRQoL) was examined. Employment rates ranged from 4% to 50.4%. The studies differed considerably in design, patient settings, and methods of recruitment. The most frequently reported factors associated with employment were negative and cognitive symptoms, age of onset, and duration and course of the disease. Individual characteristics associated with unemployment were older age, lower education, and sex (female). Additionally, environmental factors, eg, the availability of welfare benefits and vocational support programs, seemed to play a role. Generally, being employed was positively associated with HRQoL. However, the causal direction of this association remained unclear, as studies on the bidirectional relationship between employment and HRQoL were lacking

A cost of illness and equality of life study in patients with B-cell chronic lymphocytic leukemia (CLL) in the Netherlands

During the last decade the management of CLL was subject to progressive changes in diagnostic and prognostic procedures as well as the development of new alternative treatments. The aim of this study was to assess management, costs, quality of life and survival of CLL patients in daily practice. This information is becoming more important for reimbursement decsions, as new expensive drugs are only reimbursed when the incremental cost-effectiveness ratio lies within existing thresholds. Cost-effectiveness ratios are preferably calculated both in daily practice (or real world) setting and a clinical trial setting

Predicting ongoing pregnancy chances after IVF and ICSI: A national prospective study

Background: The Dutch IVF guideline suggests triage of patients for IVF based on diagnostic category, duration of infertility and female age. There is no evidence for the effectiveness of these criteria. We evaluated the predictive value of patient characteristics that are used in the Dutch IVF guideline and developed a model that predicts the IVF ongoing pregnancy chance within 12 months. Methods: In a national prospective cohort study, pregnancy chances after IVF and ICSI treatment were assessed. Couples eligible for IVF or ICSI were followed during 12 months, using the databases of 11 IVF centres and 20 transport IVF clinics. Kaplan-Meier analysis was performed to estimate the cumulative probability of an ongoing pregnancy, and Cox regression was used for assessing the effects of predictors of pregnancy. Results: 4928 couples starting IVF/ICSI treatment were prospectively followed. On average, couples had 1.8 cycles in 12 months for both IVF and ICSI. The 1-year probability of ongoing pregnancy was 44.8% (95% CI 42.1-47.5%). ICSI for severe oligospermia had a significantly higher ongoing pregnancy rate than IVF indicated treatments, with a multivariate Hazard ratio (HR) of 1.22 (95% CI 1.07-1.39). The success rates were comparable for all diagnostic categories of IVF. The highest success rate is at age 30, with a slight decline towards younger women and women up to 35 and a sharp drop after 35. Primary subfertility with a HR of 0.90 (95% CI 0.83-0.99) and duration of subfertility with a HR of 0.97 (95% CI 0.95-0.99) per year significantly affected the pregnancy chance. Conclusions: The most important predictors of the pregnancy chance after IVF and ICSI are women's age and ICSI. The diagnostic category is of no consequence. Duration of subfertility and pregnancy history are of limited prognostic value

Developing a decision tool to identify patients with personality disorders in need of highly specialized care

Abstract Background Current guidelines recommend referral to highly specialized care for patients with severe personality disorders. However, criteria for allocation to highly specialized care are not clearly defined. The aim of the present study was to develop a decision tool that can support clinicians to identify patients with a personality disorder in need of highly specialized care. Methods Steps taken to develop a decision tool were a literature search, concept mapping, a meeting with experts and a validation study. Results The concept mapping method resulted in six criteria for the decision tool. The model used in concept mapping provided a good fit (stress value = 0.30) and reasonable reliability (ρ = 0.49). The bridging values were low, indicating homogeneity. The decision tool was subsequently validated by enrolling 368 patients from seven centers. A multilevel model with a Receiver Operating Characteristic Curve (ROC) was applied. In this way, an easily implementable decision tool with relatively high sensitivity (0.74) and specificity (0.69) was developed. Conclusions A decision tool to identify patients with personality disorders for highly specialized care was developed using advanced methods to combine the input of experts with currently available scientific knowledge. The tool appeared to be able to accurately identify this group of patients. Clinicians can use this decision tool to identify patients who are in need of highly specialized treatment