Redesigning cardiovascular healthcare: patient and professional perspectives on value

Cardiovascular healthcare is continuously evolving. Biochemical,-and surgical discoveries from past decades improved patient survival to outstanding heights. However, with an ever growing aging patient population and scarce resources, cardiovascular healthcare has to become more value-driven. Value Based Healthcare (VBHC) research is becoming increasingly important in that matter, which questions the relevance (i.e. value) of contemporary evidence-based interventions in relation to patients’ health status and personal preferences.It is difficult to obtain a comprehensive view of ‘valuable outcome’ for both patients and professionals as individual and subjective perspectives on the value of treatment are ever present. This thesis presents a methodological ‘toolbox’ to assess clinical cardiovascular care, unravel the ‘value of care’ for its stakeholders and develop it further in a meaningful way. Patients were assessed on a national level using claims data, which enables insight into care patterns and helps unravel if that which is perceived as valuable by the professional (i.e. guideline evidence), is truly applied in daily practice. Second, cardiovascular care on a local hospital level is qualitatively assessed via Human Factors (HF) science, a novelty in clinical research. In line with VBHC, it helps to understand how the patient and professional experience healthcare within a certain context.Alrijne Hospital Leiderdorp The Dutch Heart FoundationLUMC / Geneeskund

Non-ST-elevation myocardial infarction in the Netherlands: room for improvement!

Aim To analyse non-ST-elevation myocardial infarction (NSTEMI) care in the Netherlands and to identify modifiable factors to improve NSTEMI healthcare. Methods This retrospective cohort study analysed hospital and pharmacy claims data of all NSTEMI patients in the Netherlands in 2015. The effect of percutaneous coronary intervention (PCI) during hospitalisation on 1-year mortality was investigated in the subcohort alive 4 days after NSTEMI. The effect of medical treatment on 1-year mortality was assessed in the subcohort alive 30 days after NSTEMI. The effect of age, gender and co-morbidities was evaluated. PCI during hospitalisation was defined as PCI within 72x202f;h after NSTEMI and optimal medical treatment was defined as the combined use of an aspirin species, P2Y(12) inhibitor, statin, beta-blocker and angiotensin converting enzyme inhibitor/angiotensin II receptor blocker, started within 30 days after NSTEMI. Results Data from 17,997 NSTEMI patients (age 69.6 (SDx202f;= 12.8) years, 64% male) were analysed. Of the patients alive 4 days after NSTEMI, 43% had a PCI during hospitalisation and 1-year mortality was 10%. In the subcohort alive 30 days after NSTEMI, 47% of patients were receiving optimal medical treatment at 30 days and 1-year mortality was 7%. PCI during hospitalisation (odds ratio (OR) 0.42; 95% confidence interval (CI) 0.37-0.48) and optimal medical treatment (OR 0.59; 95% CI 0.51-0.67) were associated with a lower 1-year mortality. Conclusion In Dutch NSTEMI patients, use of PCI during hospitalisation and prescription of optimal medical treatment are modest. As both are independently associated with a lower 1-year mortality, this study provides direction on how to improve the quality of NSTEMI healthcare in the Netherlands.Cardiolog

To treat or not to treat: left ventricular thrombus in a patient with cerebral amyloid angiopathy: a case report

Background: Cerebral amyloid angiopathy (CAA) is an important cause of cognitive impairment and spontaneous lobar intracerebral haemorrhage in older individuals. When necessary, anticoagulant treatment in these patients comes with two dilemmas; significant intracerebral bleeding risk with treatment vs. high risk of embolic stroke with no treatment.Case summary: A 66-year-old female patient presented to the emergency clinic with a ST-elevation myocardial infarction. Her past medical history revealed cognitive problems associated with lobar cerebral microbleeds on magnetic resonance imaging suspect for probable CAA. A primary percutaneous coronary intervention of the left anterior descending artery with implantation of drug eluting stent was performed. Dual antiplatelet treatment was started initially. During hospitalization, an impaired left ventricular (LV) function was observed with an apical aneurysm. Six months after the initial event, LV function remained stable however a LV thrombus was observed. Apixaban 5 mg twice daily was started based on multidisciplinary consensus and on its efficacy and safety profile in patients with atrial fibrillation. Despite treatment, patient suffered a new ischaemic stroke probably from the LV thrombus, for which vitamin K antagonist treatment was initiated and Apixaban discontinued.Discussion: Evidence for LV thrombus treatment with direct oral anticoagulants in CAA patients is scarce, however feasible based on its efficacy and safety profile. For CAA patients, the cardinal role of both clinical and radiological characteristics in determining the risk-benefit ratio for anticoagulant initiation in this specific subset of patients, is crucial. The clinical course described highlights the therapeutical dilemma of coexisting CAA and the clinical challenge it creates.Keywords: Apixaban; Case report; Cerebral amyloid angiopathy; LV thrombus.Paroxysmal Cerebral Disorder

Teamwork and safety attitudes in complex aortic surgery at a Dutch hospital: cross-sectional survey study

AbstractBackground: Improving teamwork in surgery is a complex goal and difficult to achieve. Human factors questionnaires, such as the Safety Attitudes Questionnaire (SAQ), can help us understand medical teamwork and may assist in achieving this goal.Objective: This paper aimed to assess local team and safety culture in a cardiovascular surgery setting to understand how purposeful teamwork improvements can be reached.Methods: Two cardiovascular surgical teams performing complex aortic treatments were assessed: an endovascular-treatment team (ETT) and an open-treatment team (OTT). Both teams answered an online version of the SAQ Dutch Edition (SAQ-NL) consisting of 30 questions related to six different domains of safety: teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management, and working conditions. In addition, one open-ended question was posed to gain more insight into the completed questionnaires.Results: The SAQ-NL was completed by all 23 ETT members and all 13 OTT members. Team composition was comparable for both teams: 57% and 62% males, respectively, and 48% and 54% physicians, respectively. All participants worked for 10 years or more in health care. SAQ-NL mean scores were comparable between both teams, with important differences found between the physicians and nonphysicians of the ETT. Nonphysicians were less positive about the safety climate, job satisfaction, and working climate domains than were the physicians (PConclusions: Nonphysicians of a local team performing complex endovascular aortic aneurysm surgery perceived safety climate, job satisfaction, and working conditions less positively than did physicians from the same team. Open-ended questions suggested that this is related to a lack of adequate conjoined training, lack of adequate education, and lack of an adequate operating room. With added open-ended questions, the SAQ-NL appears to be an assessment tool that allows for developing strategies that are instrumental in improving quality of care.Keywords: SAQ; SAQ-NL; human factors; organizational culture; safety assessment; vascular surgery.</p

Age and gender differences in medical adherence after myocardial infarction: Women do not receive optimal treatment - The Netherlands claims database

Cardiolog

Effect of orthostatic hypotension on sustained attention in patients with autonomic failure

Paroxysmal Cerebral Disorder

Development of a patient-oriented hololens application to illustrate the function of medication after myocardial infarction

Aims: Statin treatment is one of the hallmarks of secondary prevention after myocardial infarction. Adherence to statins tends to be difficult and can be improved by patient education. Novel technologies such as mixed reality (MR) expand the possibilities to support this process. To assess if an MR medication-application supports patient education focused on function of statins after myocardial infarction. Methods and results: A human-centred design-approach was used to develop an MR statin tool for Microsoft HoloLens™. Twenty-two myocardial infarction patients were enrolled; 12 tested the application, 10 patients were controls. Clinical, demographic, and qualitative data were obtained. All patients performed a test on statin knowledge. To test if patients with a higher tendency to become involved in virtual environments affected test outcome in the intervention group, validated Presence- and Immersive Tendency Questionnaires (PQ and ITQ) were used. Twenty-two myocardial infarction patients (ST-elevation myocardial infarction, 18/22, 82%) completed the study. Ten out of 12 (83%) patients in the intervention group improved their statin knowledge by using the MR application (median 8 points, IQR 8). Test improvement was mainly the result of increased understanding of statin mechanisms in the body and secondary preventive effects. A high tendency to get involved and focused in virtual environments was moderately positive correlated with better test improvement (r = 0.57, P &lt; 0.05). The median post-test score in the control group was poor (median 6 points, IQR 4). Conclusions: An MR statin education application can be applied effectively in myocardial infarction patients to explain statin function and importance.Applied Ergonomics and Desig