Both underuse as well as overuse of medical services is associated with poor outcomes in healthcare. Underuse includes the failure to use effective medical interventions, where overuse refers to... Show moreBoth underuse as well as overuse of medical services is associated with poor outcomes in healthcare. Underuse includes the failure to use effective medical interventions, where overuse refers to providing low value medical services. This could be described as services that are more likely to cause harm, waste resources or could lead to unnecessary healthcare costs. To improve quality of care and to create a sustainable healthcare system, it is essential to prevent underuse of effective medical care and to reduce the use of low value care by implementation and de-implementation initiatives. Implementation can be described as the planned process to introduce or to improve the use of medical interventions with the aim that those medical interventions are given a structural place within care practice. In de-implementation, the use of low value medical interventions is reduced or stopped on a structural basis in a planned process. The aim of this thesis was to extend the knowledge on effective strategies for de-implementation of low value care and the implementation of underused medical services in orthopedic surgery as well as in nursing practice. Show less
Noorduyn, J.C.A.; Graaf, V.A. van de; Willigenburg, N.W.; Scholten-Peeters, G.G.M.; Mol, B.W.; Heymans, M.W.; ... ; ESCAPE Res Grp 2022
Purpose Marker-by-treatment analyses are promising new methods in internal medicine, but have not yet been implemented in orthopaedics. With this analysis, specific cut-off points may be obtained,... Show morePurpose Marker-by-treatment analyses are promising new methods in internal medicine, but have not yet been implemented in orthopaedics. With this analysis, specific cut-off points may be obtained, that can potentially identify whether meniscal surgery or physical therapy is the superior intervention for an individual patient. This study aimed to introduce a novel approach in orthopaedic research to identify relevant treatment selection markers that affect treatment outcome following meniscal surgery or physical therapy in patients with degenerative meniscal tears. Methods Data were analysed from the ESCAPE trial, which assessed the treatment of patients over 45 years old with a degenerative meniscal tear. The treatment outcome of interest was a clinically relevant improvement on the International Knee Documentation Committee Subjective Knee Form at 3, 12, and 24 months follow-up. Logistic regression models were developed to predict the outcome using baseline characteristics (markers), the treatment (meniscal surgery or physical therapy), and a marker-by-treatment interaction term. Interactions with p < 0.10 were considered as potential treatment selection markers and used these to develop predictiveness curves which provide thresholds to identify marker-based differences in clinical outcomes between the two treatments. Results Potential treatment selection markers included general physical health, pain during activities, knee function, BMI, and age. While some marker-based thresholds could be identified at 3, 12, and 24 months follow-up, none of the baseline characteristics were consistent markers at all three follow-up times. Conclusion This novel in-depth analysis did not result in clear clinical subgroups of patients who are substantially more likely to benefit from either surgery or physical therapy. However, this study may serve as an exemplar for other orthopaedic trials to investigate the heterogeneity in treatment effect. It will help clinicians to quantify the additional benefit of one treatment over another at an individual level, based on the patient's baseline characteristics. Show less
Background Surgery on extraforaminal lumbar disc herniation (ELDH) is a commonly performed procedure. Operating on this type of herniation is known to come with more difficulties than on the... Show moreBackground Surgery on extraforaminal lumbar disc herniation (ELDH) is a commonly performed procedure. Operating on this type of herniation is known to come with more difficulties than on the frequently seen paramedian lumbar disc herniation (PLDH). However, no comparative data are available on the effectiveness and safety of this operation. We sought out to compare clinical outcomes at 1 year following surgery for ELDH and PLDH. Methods Data were collected through the Norwegian Registry for Spine Surgery (NORspine). The primary outcome measure was change at 1 year in the Oswestry Disability Index (ODI). Secondary outcome measures were quality of life measured with EuroQol 5 dimensions (EQ-5D); and numeric rating scales (NRSs). Results Data of a total of 1750 patients were evaluated in this study, including 72 ELDH patients (4.1%). One year after surgery, there were no differences in any of the patient reported outcome measurements (PROMs) between the two groups. PLDH and ELDH patients experienced similar changes in ODI (- 30.92 vs. - 34.00, P = 0.325); EQ-5D (0.50 vs. 0.51, P = 0.859); NRS back (- 3.69 vs. - 3.83, P = 0.745); and NRS leg (- 4.69 vs. - 4.46, P = 0.607) after 1 year. The proportion of patients achieving a clinical success (defined as an ODI score of less than 20 points) at 1 year was similar in both groups (61.5% vs. 52.7%, P = 0.204). Conclusions Patients operated for ELDH reported similar improvement after 1 year compared with patients operated for PLDH. Show less
Varady, N.H.; Chandawarkar, A.A.; Kernkamp, W.A.; Gans, I. 2019
This thesis described the stepwise development and execution of a de-implementation strategy to reduce the use of the low-value blood salvage techniques and preoperative treatment with... Show moreThis thesis described the stepwise development and execution of a de-implementation strategy to reduce the use of the low-value blood salvage techniques and preoperative treatment with erythropoietin in primary elective hip and knee arthroplasty. The implementation model of Grol was used to develop de-implementation goals, to identify barriers that hinder de-implementation, to develop a de-implementation strategy and to execute and evaluate the developed de-implementation strategy. The intention of de-implementing low-value patient blood-management techniques was to reduce costs and improve the quality of healthcare. However, this thesis showed that a tailored de-implementation strategy is not necessarily successful. When evaluating the effects we found that in the group of hospitals that were exposed to the de-implementation strategy the reduction in blood salvage techniques and erythropoietin was comparable to the control group hospitals. We did found that the reduction in blood salvage techniques was associated with the increased use of local analgesic infiltration and the use of tranexamic acid, an antifibrinolytic drug to prevent excessive blood loss. We found that the substitution of low-value care might contribute to de-implementation of this low-value care. In future de-implementation efforts this can be used to improve the results. Show less
In this thesis first we show that patients after total hip replacement are more satisfied than patients after total knee replacement (TKR). The indication to perform TKR is important. We studied... Show moreIn this thesis first we show that patients after total hip replacement are more satisfied than patients after total knee replacement (TKR). The indication to perform TKR is important. We studied the reason for orthopedic surgeons to recommend TKR. It seemed that the radiological osteoarthritis and age were most important. We compared Dutch orthopedic surgeons with those from other countries. Also we studied how well the oldest old patients (85+) perform with or without total joint replacement. In part 2 of the thesis more technical issues are addressed. A RCT studying the effect of fibrin sealant on postoperative knee function. No beneficial effect could be shown for the fibrin sealant. A Cochrane review and meta-analysis studying whether to sacrifice or retain the posterior cruciate ligament in TKR. It seemed there was no clinical difference between the two. Finally a RCT studying two different kinds of warming blankets applied during total joint replacement showed no evident difference between the two. Show less
