Evaluation of the introduction of a new treatment for the termination of pregnancy in The Netherlands

All hospital-based gynecologists in The Netherlands were sent a questionnaire on the termination of pregnancy with off-label drugs in the absence of treatment protocols. Response was received from 93.2% of the teaching hospitals and 87.9% of the non-teaching hospitals, thus representing practice of nearly all gynecologists working in The Netherlands. More than 40 different regimens were used for five different indications. Gynecologists embarked on a large number of different regimens of which a distressing number do not have any merits to be found in studies or guidelines illustrating that, without clear protocols or guidelines, the implementation of new medical treatments is potential haphazard and based on personal preference. Suboptimal treatment regimens will frustrate patients and doctors and deprive future patients from the most efficacious and patient friendly treatment regimes availabl

Using business process redesign to reduce wait times at a university hospital in the Netherlands

BACKGROUND: Business process redesign (BPR) has been applied to implement more customer-focused and cost-effective care. In 2002, two pilot projects to improve patient care processes for two specific patient groups were conducted at the Academic Medical Center, a 1,000-bed university hospital in Amsterdam. METHODS: The BPR consisted of process analysis, identification of bottlenecks and goals for redesign, selection of interventions, and evaluation of effects. After identifying and selecting interventions with the greatest expected benefits, changes were implemented and effects were evaluated. RESULTS: For gynecologic oncology patients, access time (from telephone call to first visit) was reduced from 14 days to <7 days, and the proportion of patients who completed all diagnostic examinations within 14 days increased from 49% to 83%. For dyspnea patients, access time was reduced to <6 days, and the number of visits was halved. DISCUSSION: Despite the fact that we applied the same approach in these two projects, the interventions turned out to be quite different. Whereas changes in communication and planning were sufficient to eliminate bottlenecks in the gynecologic oncology project, the dyspnea project required a radical redesign of processes. Experience since these projects suggests that process redesign may have only marginal impact when the greatest bottleneck occurs, as was the case for the two BPR projects, at the point of access to central diagnostic facilitie

Vulvar carcinoma - The price of less radical surgery

BACKGROUND. The objective of this study was to determine whether modifications in the treatment of patients with vulvar carcinoma influence the rates of recurrence and survival. METHODS. Between 1982 and 1997, 253 patients with T1 and T2 invasive squamous cell carcinoma of the vulva were treated by essentially the same team of gynecologic oncologists, and 168 patients (Group I) underwent radical vulvectomy with en bloc inguinofemoral lymphadenectomy. Standard therapy was changed in 1993, and 85 patients (Group II) underwent wide local excision with inguinofemoral lymphadenectomy through separate incisions. The rates of recurrence and survival were compared between both groups. RESULTS. In Group II, the overall recurrence rate (33.3%) within 4 years was increased compared with Group I (19.9%; P = 0.03). In Group II, 5 of 79 patients (6.3%) developed fatal groin or skin bridge recurrences compared with 2 of 159 patients (1.3%) in Group I (P = 0.029); this did not result in a difference in overall survival. In Group 11, 40 of 79 patients had tumor free margins measuring less than or equal to 8 mm, resulting in 9 local recurrences; whereas 39 of 79 patients had tumor free margins measuring > 8 mm, resulting in no local recurrences (P = 0.002). CONCLUSIONS. The current study showed that fatal recurrences in either the groin or the skin bridge were more frequent after wide local excision and inguinofemoral lymphadenectomy through separate incisions; however, probably due to lack of power, this did not result in shorter survival. In 40 of 79 patients, the histologic margins measured less than or equal to 8 mm, resulting in a high risk of local recurrences. Therefore, the authors recommend obtaining surgical margins of 2 cm for the local treatment of patients with vulvar carcinoma. (C) 2002 American Cancer Societ