DUCAT (Dutch inventory of invasive Coronary Atherosclerosis Treatments)

Het DUCAT (Dutch inventory of invasive Coronary Atherosclerosis Treatments) project had tot doel te bepalen hoe passend behandelbeslissingen (beleidsbeslissingen) zijn bij patiënten met vernauwing van een of meer kransslagaders rond het hart (coronairlijden). DUCAT bestond uit drie delen: a) bepaling van de passendheid van behandelindicaties door een panel van deskundigen, uitgaande van drie behandelvormen: coronaire-omleidingsoperatie (CABG), 'dotteren' (PTCA), en medicamenteuze of andere niet-invasieve therapie (conservatieve behandeling); b) toetsing van de beleidsbeslissingen in tien hartcentra in Nederland aan de paneloordelen; c) het volgen van de lotgevallen van patiënten met passende en niet-passende beleidsbeslissingen. Dat laatste is beperkt gebleven tot een periode van een jaar. Hoe kan men vaststellen of een indicatie voor een ingreep passend is of niet? Ideaal zou zijn als de wetenschappelijke literatuur geen twijfel toelaat over wat de beste benadering is, maar dat is niet zo. De literatuur biedt voor vele toepassingen van CABG en vooral PTCA onvoldoende zekerheid. Er moet daarom ook een beroep worden gedaan op de ervaring van deskundigen die de indicaties in de praktijk stellen. Een aanpak - maar zeker niet de enige - om die ervaring te laten meetellen is ontwikkeld door het Amerikaanse instituut RAND in samenwerking met de Universiteit van California in Los Angeles (UCLA). De RAND/UCLA methode houdt in dat vele modelpatiënten, en bijpassende indicaties voor behandeling, worden onderscheiden op basis van combinaties van klinische kenmerken. Deskundige leden van een panel geven, op grond van de literatuur en aanvullende medische inzichten, voor elk van die modelpatiënten aan of een behandelindicatie passend, onzeker of niet-passend is. DUCAT is het eerste onderzoek in Nederland waarin deze methode is toegepast. DUCAT kende een theorie- en een praktijkdeel. In het theoriedeel kwamen twee vragen aan de orde. Hoe passend waren volgens het DUCAT-panel de vele indicaties voor behandeling bij coronairlijden en welke klinische en niet-klinische factoren hadden invloed op de oordelen van het panel? Het panel koos bij bijna de helft van de modelpatiënten voor invasieve behandeling en bij ruim een op de vijf voor conservatieve therapie, terwijl het in de rest van de gevallen geen voorkeur had voor de ene of andere benadering. Het panel vond CABG-indicaties vaker passend dan PTCA-indicaties. Het baseerde zich daarbij vooral op medische overwegingen, zoals het actuele klinische beeld en vooral de ernst van de anatomische afwijkingen. Anatomische kenmerken wogen in de oordeelsvorming zwaarder dan andere karakteristieken, zoals medicatie en de uitslag van een inspanningsproef. DUCAT richtte zich op patiënten die in het hartcentrum werden besproken op initiatief van een verwijzend cardioloog waarbij de bespreking leidde tot een beleidsbeslissing. Onze primaire belangstelling ging uit naar 3647 mensen met anatomisch gedefinieerd significant coronairlijden. De desbetreffende DUCAT-populatie bestond in doorsnee uit niet al te jonge mannen en vrouwen van wie velen zich presenteerden met een uitgebreide geschiedenis of actuele uiting van risicofactoren, ziekteverschijnselen, vatafwijkingen en behandelingen, dus met ernstige pathologie. Dat gold niet over de hele linie. Opvallend was het grote aantal mensen met eenvatslijden. Bij verreweg de meeste patiënten met significant coronairlijden opteerden de interventieartsen voor invasieve behandeling (CABG of PTCA); bij 13 procent viel de keus op conservatieve therapie. CABG kr

Indications for coronary revascularisation: a Dutch perspective

OBJECTIVE: To assess the appropriateness of indications for coronary artery bypass graft (CABG) surgery and percutaneous transluminal coronary angioplasty (PTCA). METHODS: A modified Delphi group judgement process with input from a panel of six interventional cardiologists and six cardiopulmonary surgeons. There was one clinician from each of the 12 tertiary referral heart centres in The Netherlands. MAIN OUTCOME MEASURE: Ratings by panel members, on a 1 to 9 scale, of indications presented as a choice between two treatments (CABG v medical treatment, PTCA v medical treatment, and CABG v PTCA) for 1182 model cases. Each case represented a unique combination of clinical features in terms of symptoms, medical history, and results of tests. Ratings were analysed with respect to degree of agreement among panelists, degree of appropriateness of indications, and panel's preference for invasive or medical treatment. RESULTS: The panel agreed on 58.6% and disagreed on 3.2% of the indications. The panel opted for invasive treatment in 48.2% and medical treatment in 22.8%, and had no clear preference for either method in 29.0% of the cases. When compared with medical treatment, CABG was more often rated appropriate than PTCA: 35.4% v 21.6% (P < 0.001). Panel scores depended on severity of anatomical disease. For instance, for 51.5% of the model cases with one-vessel disease not including the proximal left anterior descending artery, the panel preferred medical treatment to invasive treatment, while the latter was preferred in 18% of the cases. In cases with type C lesions, the panel frequently rated PTCA as inappropriate. Panel scores were also affected by nonclinical factors. Cardiologists and surgeons rated the procedure of their own specialty higher than the alternative invasive intervention. CONCLUSIONS: The panel method yields logically consistent scores of the appropriateness of indications for carrying out medical procedures. It may be an aid in formulating clinical practice guidelines

Waiting for coronary revascularization: A comparison between New York State, the Netherlands and Sweden

Objective: To compare waiting times for percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass graft (CABG) surgery in New York State, the Netherlands and Sweden and to determine whether queuing adversely affects patients' health. Methods: We reviewed the medical records of 4487 chronic stable angina patients who underwent PTCA or CABG in one of 15 New York State hospitals (n = 1021) or were referred for PTCA or CABG to one of ten hospitals in the Netherlands (n = 1980) or to one of seven hospitals in Sweden (n = 1486). We measured the median waiting time between coronary angiography and PTCA or CABG. Results: The median waiting time for PTCA in New York was 13 days compared with 35 and 42 days, respectively, in the Netherlands and Sweden (P<0.001). For CABG, New York patients waited 17 days, while Dutch and Swedish patients waited 72 and 59 days, respectively (P< 0.001). The Swedish and Dutch waiting list mortality rate was 0.8% for CABG candidates and 0.15% for PTCA candidates. Conclusions: There were large variations in waiting time for coronary revascularization among these three sites. Patients waiting for CABG were at greatest risk of experiencing an adverse event. In both the Netherlands and Sweden, the capacity to perform coronary revascularization has been expanded since this study began. Further international cooperation may identify other areas where quality of care can be improved

European youth care sites serve different populations of adolescents with cannabis use disorder. Baseline and referral data from the INCANT trial

Background: MDFT (Multidimensional Family Therapy) is a family based outpatient treatment programme for adolescent problem behaviour. MDFT has been found effective in the USA in adolescent samples differing in severity and treatment delivery settings. On request of five governments (Belgium, France, Germany, the Netherlands, and Switzerland), MDFT has now been tested in the joint INCANT trial (International Cannabis Need of Treatment) for applicability in Western Europe. In each of the five countries, study participants were recruited from the local population of youth seeking or guided to treatment for, among other things, cannabis use disorder. There is little information in the literature if these populations are comparable between sites/countries or not. Therefore, we examined if the study samples enrolled in the five countries differed in baseline characteristics regarding demographics, clinical profile, and treatment delivery setting.Methods: INCANT was a multicentre phase III(b) randomized controlled trial with an open-label, parallel group design. It compared MDFT with treatment as usual (TAU) at and across sites in Berlin, Brussels, Geneva, The Hague and Paris.Participants of INCANT were adolescents of either sex, from 13 through 18 years of age, with a cannabis use disorder (dependence or abuse), and at least one parent willing to take part in the treatment. In total, 450 cases/families were randomized (concealed) into INCANT.Results: We collected data about adolescent and family demographics (age, gender, family composition, school, work, friends, and leisure time). In addition, we gathered data about problem behaviour (substance use, alcohol and cannabis use disorders, delinquency, psychiatric co-morbidity).There were no major differences on any of these measures between the treatment conditions (MDFT and TAU) for any of the sites. However, there were cross-site differences on many variables. Most of these could be explained by variations in treatment culture, as reflected by referral policy, i.e., participants' referral source. We distinguished 'self-determined' referral (common in Brussels and Paris) and referral with some authority-related 'external' coercion (common in Geneva and The Hague). The two referral types were more equally divided in Berlin. Many cross-site baseline differences disappeared when we took referral source into account, but not all.Conclusions: A multisite trial has the advantage of being efficient, but it also carries risks, the most important one being lack of equivalence between local study populations. Our site populations differed in many respects. This is not a problem for analyses and interpretations if the differences somehow can be accounted for. To a major extent, this appeared possible in INCANT. The most important factor underlying the cross-site variations in baseline characteristics was referral source. Correcting for referral source made most differences disappear. Therefore, we will use referral source as a covariate accounting for site differences in future INCANT outcome analyses

Multidimensional family therapy decreases the rate of externalising behavioural disorder symptoms in cannabis abusing adolescents: Outcomes of the INCANT trial

Background: US-based trials have shown that Multidimensional Family Therapy (MDFT) not only reduces substance abuse among adolescents, but also decreases mental and behavioural disorder symptoms, most notably externalising symptoms. In the INCANT trial, MDFT decreased the rate of cannabis dependence among Western European youth. We now focus on other INCANT outcomes, i.e., lessening of co-morbidity symptoms and improvement of family functioning.Methods: INCANT was a randomised controlled trial comparing MDFT with individual therapy (IP) at and across sites in Berlin, Brussels, Geneva, The Hague, and Paris. We recruited 450 boys and girls aged 13 up to 18 years with a cannabis use disorder, and their parent(s), and followed them for 12 months. Mental and behavioural characteristics (classified as 'externalising' or 'internalising') and family conflict and cohesion were assessed.Results: From intake through 12 months, MDFT and IP groups improved on all outcome measures. Models including treatment, site, and referral source showed that MDFT outperformed IP in reducing externalising symptoms.Adolescents were either self-referred to treatment (mostly on the initiative from people close to the teen) or referred under some measure of coercion by an external authority. These two groups reacted equally well to treatment.Conclusions: Both MDFT and IP reduced the rate of externalising and internalising symptoms and improved family functioning among adolescents with a cannabis use disorder. MDFT outperformed IP in decreasing the rate of externalising symptoms. Contrary to common beliefs among therapists in parts of Western Europe, the 'coerced' adolescents did at least as well in treatment as the self-referred adolescents.MDFT shows promise as a treatment for both substance use disorders and externalising symptoms