Influences of hospital information systems, indicator data collection and computation on reported Dutch hospital performance indicator scores

Background: For health care performance indicators (PIs) to be reliable, data underlying the PIs are required to be complete, accurate, consistent and reproducible. Given the lack of regulation of the data-systems used in the Netherlands, and the self-report based indicator scores, one would expect heterogeneity with respect to the data collection and the ways indicators are computed. This might affect the reliability and plausibility of the nationally reported scores. Methods. We aimed to investigate the extent to which local hospital data collection and indicator computation strategies differ and how this affects the plausibility of self-reported indicator scores, using survey results of 42 hospitals and data of the Dutch national quality database. Results: The data collection and indicator computation strategies of the hospitals were substantially heterogenic. Moreover, the Hip and Knee replacement PI scores can be regarded as largely implausible, which was, to a great extent, related to a limited (computerized) data registry. In contrast, Breast Cancer PI scores were more plausible, despite the incomplete data registry and limited data access. This might be explained by the role of the regional cancer centers that collect most of the indicator data for the national cancer registry, in a standardized manner. Hospitals can use cancer registry indicator scores to report to the government, instead of their own locally collected indicator scores. Conclusions: Indicator developers, users and the scientific field need to focus more on the underlying (heterogenic) ways of data collection and conditional data infrastructures. Countries that have a liberal software market and are aiming to implement a self-report based performance indicator system to obtain health care transparency, should secure the accuracy and precision of the heath care data from which the PIs are calculated. Moreover, ongoing research and development of PIs and profound insight in the clinical practice of data registration is warranted

Testing the construct validity of hospital care quality indicators: a case study on hip replacement

BACKGROUND: Quality indicators are increasingly used to measure the quality of care and compare quality across hospitals. In the Netherlands over the past few years numerous hospital quality indicators have been developed and reported. Dutch indicators are mainly based on expert consensus and face validity and little is known about their construct validity. Therefore, we aim to study the construct validity of a set of national hospital quality indicators for hip replacements.METHODS: We used the scores of 100 Dutch hospitals on national hospital quality indicators looking at care delivered over a two year period. We assessed construct validity by relating structure, process and outcome indicators using chi-square statistics, bootstrapped Spearman correlations, and independent sample t-tests. We studied indicators that are expected to associate as they measure the same clinical construct.RESULT: Among the 28 hypothesized correlations, three associations were significant in the direction hypothesized. Hospitals with low scores on wound infections had high scores on scheduling postoperative appointments (p-value = 0.001) and high scores on not transfusing homologous blood (correlation coefficient = -0.28; p-value = 0.05). Hospitals with high scores on scheduling complication meetings, also had high scores on providing thrombosis prophylaxis (correlation coefficient = 0.21; p-value = 0.04).CONCLUSION: Despite the face validity of hospital quality indicators for hip replacement, construct validity seems to be limited. Although the individual indicators might be valid and actionable, drawing overall conclusions based on the whole indicator set should be done carefully, as construct validity could not be established. The factors that may explain the lack of construct validity are poor data quality, no adjustment for case-mix and statistical uncertainty

Colorectal liver metastases: Surgery versus thermal ablation (COLLISION) - a phase III single-blind prospective randomized controlled trial

Background: Radiofrequency ablation (RFA) and microwave ablation (MWA) are widely accepted techniques to eliminate small unresectable colorectal liver metastases (CRLM). Although previous studies labelled thermal ablation inferior to surgical resection, the apparent selection bias when comparing patients with unresectable disease to surgical candidates, the superior safety profile, and the competitive overall survival results for the more recent reports mandate the setup of a randomized controlled trial. The objective of the COLLISION trial is to prove non-inferiority of thermal ablation compared to hepatic resection in patients with at least one resectable and ablatable CRLM and no extrahepatic disease. Methods: In this two-arm, single-blind multi-center phase-III clinical trial, six hundred and eighteen patients with at least one CRLM (≤3cm) will be included to undergo either surgical resection or thermal ablation of appointed target lesion(s) (≤3cm). Primary endpoint is OS (overall survival, intention-to-treat analysis). Main secondary endpoints are overall disease-free survival (DFS), time to progression (TTP), time to local progression (TTLP), primary and assisted technique efficacy (PTE, ATE), procedural morbidity and mortality, length of hospital stay, assessment of pain and quality of life (QoL), cost-effectiveness ratio (ICER) and quality-adjusted life years (QALY). Discussion: If thermal ablation proves to be non-inferior in treating lesions ≤3cm, a switch in treatment-method may lead to a reduction of the post-procedural morbidity and mortality, length of hospital stay and incremental costs without compromising oncological outcome for patients with CRLM. Trial registration:NCT03088150 , January 11th 2017

Touching upon tactile processing: Output dependent somatosensory functions in the brain

When a fly lands on your hand, one is both able to identify the exact location on the skin of the hand (perceptual recognition), as well as to hit the fly with the other hand (action). The research reported in this thesis aimed to study whether the processing of tactile information depends on the type of response one performs on it (action or perceptual recognition). Furthermore we were interested in the relationship between lower-level and higher-order somatosensory (tactile and kinaesthetic) processes and whether this relationship can be modulated by the required response. Using various experimental paradigms in healthy participants and stroke patients we were able to ascertain that higher order stored somatosensory knowledge influences bottom-up perception in several ways. We observed that these influences were most salient when bottom-up information was processed in order to consciously identify or recognize the tactile information. On the contrary, the processing of information for the computation of a goal directed motor response was less affected by higher-order processes. An important test that can account for such conclusion was provided by comparing the performances of two stroke patients, revealing a classical double dissociation. That is, one patient performed relatively well when programming a motor response directed towards a touched location on his hand, but was impaired when indicating this location on a drawing of a hand which requires stored knowledge about general body characteristics. In contrast, a second patient showed the reverse pattern of results (impaired motor response with intact perceptual recognition). This suggests a relative independence of tactile processing that underlies action and perception. Further support for the assumption that influences of higher-order somatosensory information are most pronounced in perceptual tasks is provided by a study on tactile imagery. Here we found that participants were able to use higher-order knowledge about the tactile world to imagine tactile information such as provided by a key ring. Also, this mental image influenced subsequently presented real tactile information (such as a short tap on the fingers), suggesting that the processing of real and imagined stimuli (partly) overlaps. This finding might be relevant for future investigation of the rehabilitation of tactile disorders. In sum, although the studies in this thesis show that tactile information is processed differently when it is used for the programming and control of an action as compared to when it is used for conscious recognition, this does not entail that these systems operate without communication. It could therefore be that the processing of somatosensory input may be better explained in terms of complex interactions between the two tasks. These interactions need to be specified in more detail and future studies should be aimed at exploring them

Integration of tactile input across fingers in a patient with finger agnosia.

Finger agnosia has been described as an inability to explicitly individuate between the fingers, which is possibly due to fused neural representations of these fingers. Hence, are patients with finger agnosia unable to keep tactile information perceived over several fingers separate? Here, we tested a finger agnosic patient (GO) on two tasks that measured the ability to keep tactile information simultaneously perceived by individual fingers separate. In experiment 1 GO performed a haptic search task, in which a target (the absence of a protruded line) needed to be identified among distracters (protruded lines). The lines were presented simultaneously to the fingertips of both hands. Similarly to the controls, her reaction time decreased when her fingers were aligned as compared to when her fingers were stretched and in an unaligned position. This suggests that she can keep tactile input from different fingers separate. In experiment two, GO was required to judge the position of a target tactile stimulus to the index finger, relatively to a reference tactile stimulus to the middle finger, both in fingers uncrossed and crossed position. GO was able to indicate the relative position of the target stimulus as well as healthy controls, which indicates that she was able to keep tactile information perceived by two neighbouring fingers separate. Interestingly, GO performed better as compared to the healthy controls in the finger crossed condition. Together, these results suggest the GO is able to implicitly distinguish between tactile information perceived by multiple fingers. We therefore conclude that finger agnosia is not caused by minor disruptions of low-level somatosensory processing. These findings further underpin the idea of a selective impaired higher order body representation restricted to the fingers as underlying cause of finger agnosia