Publications by authors named "Luk Bruyneel"

66 Publications

Second victims among baccalaureate nursing students in the aftermath of a patient safety incident: An exploratory cross-sectional study.

J Prof Nurs 2021 Jul-Aug;37(4):765-770. Epub 2021 Apr 29.

Department of Public Health and Primary Care - Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Belgium; Department of Quality Management, University Hospitals Leuven, Belgium.

Background: A patient safety incident (PSI) is considered to have an impact on nursing students. Healthcare professionals often feel personally responsible for the unexpected patient outcome and feel as though they have failed their patient. In this way they may become second victims of the incident. Little is known about possible initiatives from hospitals or teaching institutions regarding the support of their students involved in a PSI.

Aim: The study aims to examine the prevalence, symptoms and support in the aftermath of a PSI in baccalaureate nursing students.

Methods: A cross-sectional study in four teaching institutions for baccalaureate education across eleven campuses in Belgium. Students completed an online survey between February 2018 and March 2018.

Results: About one in three (38.4%) students were involved in a PSI during their clinical experience. Of these, 84.7% experienced second victim symptoms. Most common symptoms were hypervigilance (65.7%), stress (42.5%) and doubting knowledge and skills (40.6%). Besides negative effects, the PSI also led to a more positive attitude. Students expect most support and room for open discussion from staff nurses (80.8%).

Conclusion: Nursing students may already become second victims during their education. PSIs have a major impact on their performance and personal life. Students have the right for a decent treatment, respect, understanding and compassion, support, transparency and the opportunity to contribute to improving procedures. Teaching institutions should therefore bear the responsibility to prepare students of the probability of the occurrence of PSIs during their clinical experience.
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http://dx.doi.org/10.1016/j.profnurs.2021.04.010DOI Listing
July 2021

Timeliness of administration of amoxicillin-clavulanic acid and meropenem in a large tertiary care centre.

Int J Clin Pharm 2021 Jun 17. Epub 2021 Jun 17.

Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.

Background For amoxicillin-clavulanic acid and meropenem to be effective, concentrations must exceed the minimum inhibitory concentration of infecting pathogens. Objective To retrospectively evaluate time windows between both scheduled prescription and administration and reconstitution-preparation and end of administration of intravenous amoxicillin-clavulanic acid and meropenem prescriptions. Setting 37 hospital wards at a tertiary hospital, Belgium. Method All adult hospital stays with at least one amoxicillin-clavulanic acid or meropenem administration in 2018 were reviewed. Time windows were deemed acceptable if < 30 min between prescription and administration and < 90 or < 150 min between reconstitution-preparation and end of administration for amoxicillin-clavulanic acid and meropenem, respectively. Main outcome measure Time windows between prescription and administration and between reconstitution-preparation and administration. Results For 50 273 administered prescriptions, both time windows were acceptable in 53.7% of first dose and 56.4% of follow-up dose administrations. 43.7% of first doses did not respect the time window between reconstitution-preparation and administration (2.8%) or between prescription and administration (40.9%). These discrepancies equalled 11.1% and 26.3% for follow-up doses, respectively. Large variation across hospital wards was observed. After the first five consecutive administrations, 93.1% of patients had not received their antibiotics within the time windows allowed. The most striking predictor of timely administration with respect to both prescription and reconstitution-preparation time was prescription synchronisation with nursing administration rounds. Conclusion For amoxicillin-clavulanic acid and meropenem, timeliness of reconstitution-preparation and administration was appropriate in approximately half of administrations. Evaluating and safeguarding the timeliness of antibiotic administration should be considered an important aspect of antibiotic stewardship.
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http://dx.doi.org/10.1007/s11096-021-01297-0DOI Listing
June 2021

Is a hospital quality policy based on a triad of accreditation, public reporting and inspection evidence-based? A narrative review.

Int J Qual Health Care 2021 May;33(2)

Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Kapucijnenvoer 35, 3rd floor, box 3001, Leuven, Vlaams-Brabant 3000, Belgium.

Background: Since 2009, hospital quality policy in Flanders, Belgium, is built around a quality-of-care triad, which encompasses accreditation, public reporting (PR) and inspection. Policy makers are currently reflecting on the added value of this triad.

Methods: We performed a narrative review of the literature published between 2009 and 2020 to examine the evidence base of the impact accreditation, PR and inspection, both individually and combined, has on patient processes and outcomes. The following patient outcomes were examined: mortality, length of stay, readmissions, patient satisfaction, adverse outcomes, failure to rescue, adherence to process measures and risk aversion. The impact of accreditation, PR and inspection on these outcomes was evaluated as either positive, neutral (i.e. no impact observed or mixed results reported) or negative.

Objectives: To assess the current evidence base on the impact of accreditation, PR and inspection on patient processes and outcomes.

Results: We identified 69 studies, of which 40 were on accreditation, 24 on PR, three on inspection and two on accreditation and PR concomitantly. Identified studies reported primarily low-level evidence (level IV, n = 53) and were heterogeneous in terms of implemented programmes and patient populations (often narrow in PR research). Overall, a neutral categorization was determined in 30 articles for accreditation, 23 for PR and four for inspection. Ten of these recounted mixed results. For accreditation, a high number (n = 12) of positive research on adherence to process measures was discovered.

Conclusion: The individual impact of accreditation, PR and inspection, the core of Flemish hospital quality, was found to be limited on patient outcomes. Future studies should investigate the combined effect of multiple quality improvement strategies.
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http://dx.doi.org/10.1093/intqhc/mzab085DOI Listing
May 2021

A multicenter propensity score matched analysis in 73,843 patients of an association of nutritional risk with mortality, length of stay and readmission rates.

Am J Clin Nutr 2021 Sep;114(3):1123-1130

Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium.

Background: The reported prevalences and effects of nutritional risk vary widely in the literature because of both methodological differences (e.g., screening tools and statistical analyses) and different patient populations.

Objective: In this study the authors analyzed in-hospital mortality, 30-d mortality, readmission within 4 mo, and justified length of stay (jLoS) (determined by governmental assessment to justify financial compensation) in hospitalized patients nutritionally at risk compared with hospitalized patients not at risk.

Design: This was a multicenter retrospective cohort study in 6 Belgian hospitals among inpatients in 2018. Propensity score matching was applied, including comorbidity score and exact matching for hospital, age group, sex, type of admission, living situation, and medical specialty.

Results: In total, 73,843 of 85,677 patients were screened at admission, with 16,141 found to have nutritional risk (prevalence of 21.9%). Oncology patients had the highest risk prevalence of 38.3%, whereas patients receiving plastic or reconstructive surgery had a prevalence of 5.2%. Patients nutritionally at risk had higher odds of dying in the hospital (5.1% compared with 3.3%; OR: 1.56; 95% CI: 1.37, 1.76), dying within 30 d of admission (6.8% compared with 4.3%; OR: 1.62; 95% CI: 1.45, 1.81) and being readmitted within 4 mo after discharge (35.5% compared with 32.9%; OR: 1.12; 95% CI: 1.07, 1.18). These differences were consistent across hospitals. The association between being nutritionally at risk and jLoS was ambiguous.

Conclusions: One out of 5 patients included in this study was nutritionally at risk. Using propensity score matching, higher odds of in-hospital mortality, readmission, and 30-d mortality were observed. In contrast to oft-reported increased length of stay with poor nutrition, propensity matched data for jLoS suggested that this association was less pronounced in this cohort.
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http://dx.doi.org/10.1093/ajcn/nqab135DOI Listing
September 2021

Peer support by interprofessional health care providers in aftermath of patient safety incidents: A cross-sectional study.

J Nurs Manag 2021 Apr 24. Epub 2021 Apr 24.

Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium.

Aim: To investigate the health care professionals' preferences pertaining to support in the aftermath of patient safety incidents and potential variation thereof depending on the degree of harm.

Background: Peer support systems are available to support health care professionals in the aftermath of patient safety incidents. It is unclear which type of support is best offered by whom.

Methods: A cross-sectional study in 32 Dutch hospitals.

Results: In total, 2,362 nurses and 1,404 doctors indicated they were involved in patient safety incidents at any time during their career (86%). Less than 10% of health care providers had spoken with professional support, and less than 20% admitted a need to do so. They used different support. A higher degree of harm related to higher odds of desiring support. Respondents mainly wanted to understand what happened and how it can be prevented.

Conclusion: The desired support of health care professionals in the aftermath of patient safety incidents depends on the level of harm.

Implication For Nursing Management: Health care professionals seem to mostly rely on persons they are close with, and they mainly desire information related to the aftermath of patient safety incidents. This should be taken into account when support programmes are set up.
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http://dx.doi.org/10.1111/jonm.13345DOI Listing
April 2021

A 15-Year Follow-up Retrospective Study on 959 Spine Surgeries: What Can We Learn From Real-world Data?

Clin Spine Surg 2021 Feb 5. Epub 2021 Feb 5.

Department of Neurosurgery, Jessa Hospital Neurosurgery Study & Training Center Virga Jesse Faculty of Medicine and Life Science, Hasselt University, Hasselt Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium.

Study Design: This was a retrospective study.

Objective: The aim of this study was to investigate the patient flow and need for additional surgery after first-time lower back surgery. Next, we analyzed the patients who developed chronic low back pain (LBP) and were treated with spinal cord stimulation.

Summary Of Background Data: LBP has a lifetime prevalence of 84% and imposes a high economic burden. Treatment is focused on preventing chronic pain. Research has shown the efficacy of treatment options. However, less is known about who benefits the most from which therapy and when they should be positioned in the treatment algorithm.

Methods: In this retrospective study, data of all patients who underwent first-time surgery from 2000 to 2004 were included. After 10-15 years, patients were contacted about their quality of life (QoL) (EuroQoL-5 Dimension) and life and heath perception (EuroQoL Visual Analogue Scale).

Results: In all, 959 patients underwent surgery at the lower back area. Follow-up time ranged from 13 to 17 years; 225 patients (23.5%) underwent a second surgery. In total, 20 patients (2.1%) developed chronic neuropathic back pain and received spinal cord stimulation therapy. Ten years postsurgery, 438 (45.7%) patients completed the QoL and LBP questionnaires. The health-related QoL and health situation were significantly lower in patients with multiple surgeries (P<0.001).

Conclusions: The study results indicate that large data sets, with multiple outcome measurements and long-term follow-up are necessary to improve our knowledge and to optimize the therapeutic pathway. In that way, we might learn how to select a patient for the right treatment or treatments at the right moment and shorten the circulation in our health care system.
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http://dx.doi.org/10.1097/BSD.0000000000001134DOI Listing
February 2021

COVID-19 is having a destructive impact on health-care workers' mental well-being.

Int J Qual Health Care 2021 Feb;33(1)

Department of Adult Psychiatry, KU Leuven-University of Leuven, Herestraat 49, 3000 Leuven, Belgium.

Background: The coronavirus disease 2019 (COVID-19) may aggravate workplace conditions that impact health-care workers' mental health. However, it can also place other stresses on workers outside of their work. This study determines the effect of COVID-19 on symptoms of negative and positive mental health and the workforce's experience with various sources of support. Effect modification by demographic variables was also studied.

Methods: A cross-sectional survey study, conducted between 2 April and 4 May 2020 (two waves), led to a convenience sample of 4509 health-care workers in Flanders (Belgium), including paramedics (40.6%), nurses (33.4%), doctors (13.4%) and management staff (12.2%). About three in four were employed in university and acute hospitals (29.6%), primary care practices (25.7%), residential care centers (21.3%) or care sites for disabled and mental health care. In each of the two waves, participants were asked how frequently (on a scale of 0-10) they experienced positive and negative mental health symptoms during normal circumstances and during last week, referred to as before and during COVID-19, respectively. These symptoms were stress, hypervigilance, fatigue, difficulty sleeping, unable to relax, fear, irregular lifestyle, flashback, difficulty concentrating, feeling unhappy and dejected, failing to recognize their own emotional response, doubting knowledge and skills and feeling uncomfortable within the team. Associations between COVID-19 and mental health symptoms were estimated by cumulative logit models and reported as odds ratios. The needed support was our secondary outcome and was reported as the degree to which health-care workers relied on sources of support and how they experienced them.

Results: All symptoms were significantly more pronounced during versus before COVID-19. For hypervigilance, there was a 12-fold odds (odds ratio 12.24, 95% confidence interval 11.11-13.49) during versus before COVID-19. Positive professional symptoms such as the feeling that one can make a difference were less frequently experienced. The association between COVID-19 and mental health was generally strongest for the age group 30-49 years, females, nurses and residential care centers. Health-care workers reported to rely on support from relatives and peers. A considerable proportion, respectively, 18 and 27%, reported the need for professional guidance from psychologists and more support from their leadership.

Conclusions: The toll of the crisis has been heavy on health-care workers. Those who carry leadership positions at an organizational or system level should take this opportunity to develop targeted strategies to mitigate key stressors of health-care workers' mental well-being.
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http://dx.doi.org/10.1093/intqhc/mzaa158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7799030PMC
February 2021

Six years of measuring patient experiences in Belgium: Limited improvement and lack of association with improvement strategies.

PLoS One 2020 3;15(11):e0241408. Epub 2020 Nov 3.

Leuven Institute for Healthcare Policy, KU Leuven-University of Leuven, Leuven, Flanders, Belgium.

Objective: To examine trends in patient experiences in the period 2014-2019, describe improvement strategies implemented by hospitals in the same period, and study associations between patient experiences and implemented strategies.

Design: Multi-center retrospective region-wide observational design.

Setting: Flanders, Belgium.

Participants: 44 out of 46 Flemish acute-care hospitals publicly reporting patient experiences via the Flemish Patient Survey (FPS).

Main Outcome Measure(s): Primary outcomes were the two global FPS ratings: percentage of patients rating the hospital 9 or 10 and percentage of patients definitely recommending the hospital. Secondary outcomes were the average top-box score percentages for each of the 8 remaining dimensions of the FPS.

Results: Between 2014 and 2019, there was a significant improvement in patients scoring the hospital 9 or 10 (56% to 61%) and patients definitely recommending (67% to 70%) the hospital. Significant increases in patient experiences over time were also observed in other dimensions, except for the dimension discharge. Hospital key informants reported various improvement strategies related to patient experiences with care and the FPS. Feedback to nursing wards (n = 44, 100%) and clinicians (n = 39, 89%) were most common. Overall, most improvement strategies were not or only weakly associated with patient experience ratings in 2019 and changes in ratings over time. Still, positive associations were discovered between the strategies 'nursing ward interventions' and 'hospital wide education' and recommendation of the hospital.

Conclusions: Patient experiences have improved modestly in Flemish acute-care hospitals. Hospitals report to have invested in patient experience improvement strategies but positive associations between such strategies and FPS scores are weak, although there is potential in further exploring nursing ward interventions and hospital wide education. Hospitals should continue their efforts to improve the patient's experience, but with a more targeted approach, taking the lessons learned on the efficacy of strategies into consideration.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241408PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7608918PMC
December 2020

Interventions to prevent or reduce rationing or missed nursing care: A scoping review.

J Adv Nurs 2021 Feb 22;77(2):550-564. Epub 2020 Oct 22.

Department of Medical Science, University Udine, Udine, Italy.

Aims: To collate and synthesize published research on interventions developed and tested to prevent or reduce the rates of rationed or missed nursing care in healthcare institutions.

Background: Rationed and missed nursing care has been widely studied, including its predictors and associations with patient and nurse outcomes.

Design: Scoping review.

Data Sources: We searched for eligible studies, published between 1980-2019, in six electronic databases.

Review Methods: Researchers independently screened the abstracts of the retrieved studies using the inclusion and exclusion criteria. The decision of whether or not to include any given study was consensus-based.

Results: The search yielded 1,815 records, of which 13 were included. Three studies reported structural interventions, namely increased nurse staffing and improved nursing teamwork, both resulted in significant reductions in the rates of rationed or missed nursing care. The remaining 10 studies reported on process interventions: four concerned reminders (via technology or designated persons) and seven described interventions to change or optimize the relevant care processes. All 10 process interventions contributed to significant reductions in the rates of missed nursing care.

Conclusions: The results of the scoping review indicate that specific interventions can positively influence the performance of a selected nursing care activity, for example fall prevention. There is no evidence of a global reduction of rationed and missed nursing care through these interventions.

Impact: Clinicians, managers and researchers can use the results for adapting and implementing interventions to reduce rationed and missed nursing care.
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http://dx.doi.org/10.1111/jan.14596DOI Listing
February 2021

A novel tool to predict functional outcomes after robot-assisted radical prostatectomy and the value of additional surgery for incontinence.

BJU Int 2021 05 1;127(5):575-584. Epub 2020 Oct 1.

Department of Urology, University Hospitals Leuven, Leuven, Belgium.

Objectives: To develop and validate a model to predict 12-month continence status after robot-assisted radical prostatectomy (RARP) from preoperative and 3-month postoperative data; this model could help in informing patients on their individualised risk of urinary incontinence (UI) after RP in order to choose the best treatment option.

Patients And Methods: Data on 9421 patients in 25 Belgian centres were prospectively collected (2009-2016) in a compulsory regional database. The primary outcome was the prediction of continence status, using the International Consultation on Incontinence Urinary Incontinence Short Form (ICIQ-UI-SF) at 12-months after RARP. Linear regression shrinkage was used to assess the association between preoperative 3-month postoperative characteristics and 12-month continence status. This association was visualised using nomograms and an online tool.

Results: At 12 months, the mean (sd) score of the ICIQ-UI-SF questionnaire was 4.3 (4.7), threefold higher than the mean preoperative score of 1.4. For the preoperative model, high European Association of Urology risk classification for biochemical recurrence (estimate [Est.] 0.606, se 0.165), postoperative radiotherapy (Est. 1.563, se 0.641), lower preoperative European Organisation for Research and Treatment of Cancer quality of life questionnaire 30-item core (EORCT QLQ-C30)/quality of life (QoL) score (Est. -0.011, se 0.003), higher preoperative ICIQ-UI-SF score (Est 0.214, se 0.018), and older age (Est. 0.058, se 0.009), were associated with a higher 12-month ICIQ-UI-SF score. For the 3-month model, higher preoperative ICIQ-UI-SF score (Est. 0.083, se 0.014), older age (Est. 0.024, se 0.007), lower 3-month EORCT QLQ-C30/QoL score (Est. -0.010, se 0.002) and higher 3-month ICIQ-UI-SF score (Est. 0.562, se 0.009) were associated with a higher 12-month ICIQ-UI-SF score.

Conclusions: Our models set the stage for a more accurate counselling of patients. In particular, our preoperative model assesses the risk of UI according to preoperative and early postoperative variables. Our postoperative model can identify patients who most likely would not benefit from conservative treatment and should be counselled on continence surgery.
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http://dx.doi.org/10.1111/bju.15242DOI Listing
May 2021

Safe nurse staffing policies for hospitals in England, Ireland, California, Victoria and Queensland: A discussion paper.

Health Policy 2020 10 27;124(10):1064-1073. Epub 2020 Aug 27.

KU Leuven-University of Leuven, Institute for Healthcare Policy, 3000, Leuven, Belgium. Electronic address:

Objective: The association between higher registered nurses (RN) staffing (educational level and number) and better patient and nurse outcomes is well-documented. This discussion paper aims to provide an overview of safe staffing policies in various high-income countries to identify reform trends in response to recurring nurse workforce challenges.

Methods: Based on a scan of the literature five cases were selected: England (UK), Ireland, California (USA), Victoria and Queensland (Australia). Information was gathered via a review of the grey and peer-reviewed literature. Country experts were consulted for additional information and to review country reports.

Results: The focus of safe staffing policies varies: increasing transparency about staffing decisions (England), matching actual and required staffing levels based on patient acuity measurement (Ireland), mandated patient-to-nurse ratios at the level of the nurse (California) or the ward (Victoria, Queensland). Calibration of the number of patients by the number of nurses varies across cases. Nevertheless, positive effects on the nursing workforce (increased bedside staffing) and staff well-being (increased job satisfaction) have been consistently documented. The impact on patient outcomes is promising but less well evidenced.

Conclusion: Countries will have to set safe staffing policies to tackle challenges such as the ageing population and workforce shortages. Various approaches may prove effective, but need to be accompanied by a comprehensive policy that enhances bedside nurse staffing in an evidence-based, objective and transparent way.
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http://dx.doi.org/10.1016/j.healthpol.2020.08.003DOI Listing
October 2020

Mangomoments - preconditions and impact on patients and families, healthcare professionals and organisations: a multi-method study in Flemish hospitals.

BMJ Open 2020 08 6;10(8):e034543. Epub 2020 Aug 6.

Leuven Institute for Healthcare Policy - Department of Public Health, KU Leuven - University of Leuven, Leuven, Belgium

Objective: Understanding how small unexpected acts or gestures by healthcare professionals, known as Mangomoments, are translated into practice, what their preconditions are and what their impact is on patients and families, healthcare professionals and organisations.

Design: A multi-method design was used based on four phases: (1) A (media)campaign to collect Mangomoment stories (n=1045), of which 94% (n=983) were defined as Mangomoments; (2) Semi-structured interviews (n=120); (3) Focus group interviews (n=3); and (4) A consensus meeting.

Setting: Respondents from a hospital and primary care setting.

Participants: Patients, family, healthcare professionals, managers, researchers and a policymaker participated.

Results: Mangomoments are mainly classified in the dimensions 'Respect for values, preferences and needs' and 'Emotional support'. Differences in importance of the dimensions were found between healthcare professionals, oncological patients and family and non-oncological patients and family. The results of the interviews, focus groups and consensus meeting were visualised by the Mangomoment model. It identifies several preconditions on the level of patients, healthcare professionals and leadership. For each of these preconditions a catalyst was identified to increase the prevalence of Mangomoments. In general, Mangomoments improved the patient and family experience and facilitated adherence to therapy and led to a positive perception on the healing process. Positive effects for professionals include personal accomplishment and anti-burnout, joy in work and a positive team atmosphere. This led to positive resonance by a relationship of trust between the patient and the healthcare professionals, feelings of tolerance during negative experiences and open communication and a safe climate. Overall, patients and healthcare workers concluded that Mangomoments led to loyalty to the healthcare organisation.

Conclusion: Mangomoments do not only have a positive impact on patient and family but also on the healthcare professional. Leadership should shape several preconditions and catalysts which can lead to positive resonance and loyalty of patients and professionals.
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http://dx.doi.org/10.1136/bmjopen-2019-034543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7412612PMC
August 2020

Predicting patient nurse-level intensity for a subsequent shift in the intensive care unit: A single-centre prospective observational study.

Int J Nurs Stud 2020 Sep 2;109:103657. Epub 2020 Jun 2.

Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Kapucijnenvoer 35, 3000 Leuven; Belgium & Quality Improvement Department, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium. Electronic address:

Background: A dynamic optimized nurse staffing model for the Intensive Care Unit (ICU), requires a tool for monitoring nurse-level intensity with validated cut-offs to identify patients requiring 1:1, 2:1 or 3:1 patient-to-nurse ratios.

Objectives: We aimed to determine the Nursing Activities Score (NAS) cut-off values which can best distinguish between high, average and lower nurse-level intensity as unanimously perceived by care providers, and to evaluate whether these NAS cut-offs allow to predict nurse-level intensity in the next shift or the same shift the next day.

Design: A prospective observational study.

Setting: 9 ICUs in a Belgian tertiary care center.

Participants: All 3295 patients admitted between March 20, 2013, and September 12, 2013 were included. NAS was quantified at the end of each shift using automatically derived and manually entered care information. Additionally, 412 nurses, 24 nurse managers and 37 physicians rated perceived nurse-level intensity.

Methods: We first assessed concordance between nurses', nurse managers' and physicians' perceptions of lower (3:1 patient-to-nurse ratio), average (2:1 patient-to-nurse ratio) and high (1:1 patient-to-nurse ratio) nurse-level intensity. Next, receiver operating characteristic (ROC) analysis was applied to determine the NAS cut-offs that best distinguish between different levels of perceived intensity for cases with concordant opinions. Last, logistic regression analysis was applied to estimate the ability of these NAS cut-offs to predict low and high perceived intensity during the next shift and during the same shift the next day.

Results: Nurses', nurse managers' and physicians' perceptions were concordant in 57.1% (n = 4693) of cases, mostly concerning lower or average intensity. Optimal NAS cut-offs for lower and high intensity patients equaled 52.7% and 69.8%, respectively. The lower intensity NAS cut-off showed 74.0% accuracy to predict lower intensity in the next shift and 75.9% accuracy to predict lower intensity for the same shift the next day. The high intensity NAS cut-off showed 67.9% accuracy to predict high intensity in the next shift and 72.0% accuracy to predict high intensity for the same shift the next day.

Conclusions: NAS cut-offs could contribute considerably in predicting patient nurse-level intensity, and thus patient-to-nurse staffing ratios, in the next shift or day. Identification or prediction of high intensity, nevertheless, appears most complex and requires further study. Future studies need to account for the many confounding variables which complicate nurse staffing planning.
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http://dx.doi.org/10.1016/j.ijnurstu.2020.103657DOI Listing
September 2020

Effects of implementing a care pathway for colorectal cancer surgery in ten European hospitals: an international multicenter pre-post-test study.

Updates Surg 2020 Mar 28;72(1):61-71. Epub 2020 Jan 28.

Leuven Institute for Healthcare Policy, KU Leuven, Kapucijnenvoer 35/3, 3000, Louvain, Belgium.

Adherence to evidence-based recommendations is variable and generally low. This is also followed in colorectal surgery, despite the availability of the ERAS protocol. The aim of the study was to evaluate the effect of implementing a care pathway for perioperative care in colorectal cancer surgery on outcomes and protocol adherence. So, we performed an international pre-test-post-test multicenter study, performed in ten hospitals in four European countries. The measures used included length of stay, morbidity and mortality, and documentation and adherence on intervention and patient level. Unadjusted pre-test-post-test differences were analyzed following an analysis adjusted for patient-mix variables. Importance-performance analysis was used to map the relationship between importance and performance of individual interventions. In total, 381 patients were included. Length of stay decreased from 12.6 to 10.7 days (p = 0.0230). Time to normal diet and walking also decreased significantly. Protocol adherence improved from 56 to 62% (p < 0.00001). Adherence to individual interventions remained highly variable. Importance-performance analysis showed 30 interventions were scored as important, of which 19 had an adherence < 70%, showing priorities for improvement. Across hospitals, change in protocol adherence ranged from a 13% decrease to a 22% increase. Implementing a care pathway for colorectal cancer surgery reduced length of stay, time to normal diet and walking. Documentation and protocol adherence improved after implementing the care pathway. However, not in all participating hospitals protocol adherence improved. Only in 25% of patients, protocol adherence of ≥ 70% was achieved, suggesting a large group is at risk for underuse. Importance-performance analysis showed which interventions are important, but have low adherence, prioritizing improvement efforts.
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http://dx.doi.org/10.1007/s13304-020-00706-9DOI Listing
March 2020

Effect of an intervention on the congruence of nurses' and patients' perceptions of patient-centred care: A pre-test post-test study.

J Eval Clin Pract 2020 Dec 10;26(6):1648-1656. Epub 2020 Jan 10.

Department of Public Health & Primary Care, Institute for Healthcare Policy, KU Leuven-University of Leuven, Leuven, Belgium.

Aims And Objectives: To evaluate measurement invariance of the Individualized Care Scale (ICS) across patients and nurses, and assess the degree of congruence in nurses' and patients' perceptions on patient-centredness and the impact of an intervention there on.

Methods: A pre-post intervention study design with an expert by experience intervention was conducted in 2016 to 2017. Nurses (n = 138) and patients (n = 199) of two hospital departments in Belgium were surveyed. Patient-centredness was measured using the ICS (ICS-Nurse and ICS-Patient). Measurement invariance was evaluated by conducting multiple-group confirmatory factor analysis. Unpaired t tests and difference in difference analysis were used to evaluate the degree of congruence in nurses' and patients' perceptions on patient-centredness and assess pre-post changes in nurses' and patients' scores, respectively. SQUIRE guidelines were followed to report the study.

Results: There was no evidence of measurement non-invariance. Nurses perceived the individuality of care more positively than patients both before and after the implementation of the intervention. Pre-post changes in nurses' and patients' scores were not statistically significant.

Conclusion: There is a significant gap between the perceptions of nurses and patients regarding the support and provision of individual care: nurses consider provided care as more individualized than patients do. To orient nurses' perspectives more towards their patients' perspective, multicomponent interventions are needed. Researchers and hospital managers may use the ICS to evaluate interventions that have the ability to close the gap in nurses' and patients' perceptions of patient-centredness. Embedding experts by experience in the professionals' team has the potential to foster patient-centredness but needs to focus on patients and nurses equally.
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http://dx.doi.org/10.1111/jep.13348DOI Listing
December 2020

Translating Data From an Electronic Prescribing and Medicines Administration System Into Knowledge: Application to Doctor-Nurse Time Discrepancy in Antibiotic Ordering and Administration.

Med Care 2020 01;58(1):83-89

Department of Quality Improvement, University Hospitals Leuven.

Background: Electronic Prescribing and Medicines Administration (EPMA) systems are being widely implemented to facilitate medication safety improvement. However, translating the resulting big data into actionable knowledge has received relatively little attention.

Objective: The objective of this study was to use routinely collected EPMA data in the study of exact time discrepancy between physicians' order and nurses' administration of systemic antibiotics. We evaluated first and follow-up dose administration and dose intervals and examined multifactorial determinants in ordering and administration explaining potential discrepancy.

Methods: We conducted an observational study of electronic health records for all medical patient stays with antibiotic treatment from January to June 2018 (n=4392) in a large Belgian tertiary care hospital. Using an EPMA system with Barcode Medication Administration, we calculated time discrepancy between order and administration of first doses (n=6233), follow-up doses (n=87 960), and dose intervals. Multiple logistic regression analysis estimated the association between time discrepancy and various determinants in ordering and administration.

Results: Time discrepancy between physician order and nurse administration was <30 minutes for 48.7% of first doses and 61.7% of follow-up doses, with large variation across primary diagnoses. Greater dose intervals, oral versus intravenous administration, and order diversion from regular nurse administration rounds showed strongest association with less timely administration.

Conclusions: EPMA systems show huge potential to generate actionable knowledge. Concerning antibiotic treatment, having physicians' orders coincide with regular nurse administration rounds whenever clinically appropriate, further taking contextual factors into account, could potentially improve antibiotic administration timeliness.
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http://dx.doi.org/10.1097/MLR.0000000000001222DOI Listing
January 2020

Power Distance and Physician-Nurse Collegial Relations Across 14 European Countries: National Culture is Not Merely a Nuisance Factor in International Comparative Research.

J Nurs Scholarsh 2019 Nov 19;51(6):708-716. Epub 2019 Sep 19.

Full Professor, KU Leuven-University of Leuven, Institute for Healthcare Policy, Leuven, Belgium.

Purpose: This study illustrates the huge untapped potential of quantifying the impact of culture in making meaningful comparisons across groups. Our focus is on cross-national differences in nurses' reports of their relations with physicians, and how the measurement of this complex construct and the evaluation of true differences are related to dimensions of national culture.

Design: We examine across 14 European countries the association between indices of national culture from the seminal work of Hofstede and 39,435 nurses' ratings of their relations with physicians. Multilevel confirmatory factor analysis was used to evaluate strong factorial invariance across countries and to examine the influence of power distance and masculinity.

Findings: There was wide variation across countries in nurses' reports of their relations with physicians. Strong factorial invariance was shown for a one-factor model, which confirmed that across countries the seven survey items measure a common factor of physician-nurse relations. This model showed no country bias for any of the seven survey items, which suggests that differences across countries reflect true differences. These true differences were significantly associated with variation in country values of power distance, which showed a significant negative correlation with physician-nurse relations.

Conclusions: Continuously pursuing a better understanding of characteristics that impact the studied indicators, such as national culture, is elementary to better understand the construct under study. In this application, country values of power distance negatively impacted nurse-reported relations with physicians, which strongly varied across countries.

Clinical Relevance: Better nurse-reported relations between nurses and physicians link to higher nurse job satisfaction, lower emotional exhaustion, better nurse-perceived quality of care, and lower patient mortality. The Practice Environment Scale of the Nursing Work Index is an excellent instrument to characterize variation in working relations between nurses and physicians as well as physicians' professional posture towards nurses.
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http://dx.doi.org/10.1111/jnu.12514DOI Listing
November 2019

Standardised mortality ratios as a user-friendly performance metric and trigger for quality improvement in a Flemish hospital network: multicentre retrospective study.

BMJ Open 2019 09 8;9(9):e029857. Epub 2019 Sep 8.

Leuven Insititute for Healthcare Policy, KU Leuven, Leuven, Belgium.

Objective: To illustrate the development and use of standardised mortality rates (SMRs) as a trigger for quality improvement in a network of 27 hospitals.

Design: This research was a retrospective observational study. The primary outcome was in-hospital mortality. SMRs were calculated for All Patient Refined-Diagnosis-Related Groups (APR-DRGs) that reflect 80% of the Flemish hospital network mortality. Hospital mortality was modelled using logistic regression. The metrics were communicated to the member hospitals using a custom-made R-Shiny web application showing results at the level of the hospital, patient groups and individual patients. Experiences with the metric and strategies for improvement were shared in chief medical officer meetings organised by the Flemish hospital network.

Setting: 27 Belgian hospitals.

Participants: 1 198 717 hospital admissions for registration years 2009-2016.

Results: Patient gender, age, comorbidity as well as admission source and type were important predictors of mortality. Altogether the SMR models had a C-statistic of 88%, indicating good discriminatory capability. Seven out of ten APR-DRGs with the highest percentage of hospitals statistically significantly deviating from the benchmark involved malignancy. The custom-built web application and the trusted environment of the Flemish hospital network created an interoperable strategy to get to work with SMR findings. Use of the web application increased over time, with peaks before and after key discussion meetings within the Flemish hospital network. A concomitant reduction in crude mortality for the selected APR-DRGs from 6.7% in 2009 to 5.9% in 2016 was observed.

Conclusions: This study reported on the phased approach for introducing SMR reporting to trigger quality improvement. Prerequisites for the successful use of quality metrics in hospital benchmarks are a collaborative approach based on trust among the participants and a reporting platform that allows stakeholders to interpret and analyse the results at multiple levels.
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http://dx.doi.org/10.1136/bmjopen-2019-029857DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6738686PMC
September 2019

Impact of care pathway implementation on interprofessional teamwork: An international cluster randomized controlled trial.

J Interprof Care 2019 Aug 7:1-9. Epub 2019 Aug 7.

a Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care, KU Leuven - University of Leuven , Leuven , Belgium.

This study evaluates whether the implementation of an in-hospital care pathway (CP) improves interprofessional teamwork across countries and tests whether improved communications ("relational coordination") is the mechanism of action. A hospital-based cluster randomized controlled trial in Ireland, Belgium, Italy, and Portugal was performed. Fifty-six interprofessional teams caring for patients admitted with an exacerbation of chronic obstructive pulmonary disease or for patients with a proximal femur fracture were included and randomly assigned to an intervention group (31 teams and 567 team members), where a CP was implemented, and a control group (25 teams and 417 team members) representing usual care. Multilevel regression and mediation analysis were applied. First, although no significant effect was found on our primary outcome relational coordination, our CP significantly improved several team inputs, team processes (team climate for innovation) and team output (the level of organized care, level of competence) indicators. Second, our team process indicator of team climate for innovation partially mediated the association between CP implementation and team output indicator of better level of organized care. In conclusion, a CP sets in motion various mechanisms that improve some but not all aspects of interprofessional teamwork. Relational coordination does not appear to be the mechanism by which team outputs are enhanced.
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http://dx.doi.org/10.1080/13561820.2019.1634016DOI Listing
August 2019

Prolonged mental health sequelae among doctors and nurses involved in patient safety incidents with formal complaints and lawsuits.

Eur J Public Health 2020 08;30(4):777-779

Leuven Institute for Healthcare Policy, KU Leuven--University of Leuven, Leuven, Belgium.

We evaluated the presence of prolonged mental health sequelae in the aftermath of a patient safety incident and the impact of a formal complaint or lawsuit on these mental health sequelae in 19 hospitals and 2635 nurses and doctors. Of 2635 respondents, 983 (37.3%) reported a complaint and 190 (7.2%) reported a lawsuit. In both doctors and nurses prolonged mental health sequelae reflecting a stressor-related disorder were highly prevalent, each well over 20% overall. They were consistently more prevalent in case of a formal complaint or lawsuit. Lawsuits showed 2-, 3- and 4-fold increases in prevalence of mental health sequelae.
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http://dx.doi.org/10.1093/eurpub/ckz138DOI Listing
August 2020

Duration of second victim symptoms in the aftermath of a patient safety incident and association with the level of patient harm: a cross-sectional study in the Netherlands.

BMJ Open 2019 07 9;9(7):e029923. Epub 2019 Jul 9.

Tjongerschans Hospital, Heerenveen, The Netherlands.

Objectives: To describe healthcare providers' symptoms evoked by patient safety incidents (PSIs), the duration of these symptoms and the association with the degree of patient harm caused by the incident.

Design: Cross-sectional survey.

Setting: 32 Dutch hospitals that participate in the 'Peer Support Collaborative'.

Participants: 4369 healthcare providers (1619 doctors and 2750 nurses) involved in a PSI at any time during their career.

Interventions: All doctors and nurses working in direct patient care in the 32 participating hospitals were invited via email to participate in an online survey.

Primary And Secondary Outcome Measures: Prevalence of symptoms, symptom duration and its relationship with the degree of patient harm.

Results: In total 4369 respondents were involved in a PSI and completely filled in the questionnaire. Of these, 462 reported having been involved in a PSI with permanent harm or death during the last 6 months. This had a personal, professional impact as well as impact on effective teamwork requirements. The impact of a PSI increased when the degree of patient harm was more severe. The most common symptom was hypervigilance (53.0%). The three most common symptoms related to teamwork were having doubts about knowledge and skill (27.0%), feeling unable to provide quality care (15.6%) and feeling uncomfortable within the team (15.5%). PSI with permanent harm or death was related to eightfold higher likelihood of provider-related symptoms lasting for more than 1 month and ninefold lasting longer than 6 months compared with symptoms reported when the PSI caused no harm.

Conclusion: The impact of PSI remains an underestimated problem. The higher the degree of harm, the longer the symptoms last. Future studies should evaluate how these data can be integrated in evidence-based support systems.
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http://dx.doi.org/10.1136/bmjopen-2019-029923DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6624045PMC
July 2019

Supervised teaching and feedback improve physiotherapists' reporting of the International Classification of Functioning, Disability and Health in physiotherapeutic electronic patient records: A proof-of-concept randomized controlled trial.

J Eval Clin Pract 2020 Feb 20;26(1):357-363. Epub 2019 Jun 20.

Department of Quality Management, University Hospitals Leuven, Leuven, Belgium.

Rationale, Aims, And Objectives: The International Classification of Functioning, Disability and Health (ICF) is a landmark for physiotherapy to describe the full spectrum of human functioning, but ICF patient record completion could improve. In this study, we examine the effect of supervised teaching and personalized feedback on physiotherapists' completion and reporting of ICF in electronic patient records.

Method: In this proof-of-concept randomized controlled trial, the intervention group (10 physiotherapists) received supervised teaching and four rounds of personalized feedback on reporting of ICF components in electronic patient records. In the intervention group, review on patient record completion (n = 670 records) was performed at baseline, after teaching, after each of four feedback rounds, and at long-term follow-up. In the control group (five physiotherapists), which received no supervised teaching nor personalized feedback, review (n = 140 records) was performed at baseline, after the third feedback round of the intervention group, and at follow-up.

Results: After the third round of feedback (95% vs 72% completion; β, 2.68; 95% CI, 0.62-4.74), patient record completion was significantly higher in the intervention group. This was also true for following ICF components: "activity" (93% versus 64% completion; β, 3.03; 95% CI, 1.52-4.54), "participation" (50% versus 14% completion; β, 3.67; 95% CI, 1.79-5.55), and "personal factors" (35% versus 20% completion; β, 2.10; 95% CI, 0.63-3.57). These statistically significant and clinically relevant effects persisted at long-term follow-up. For "environmental factors," effects after the third round of feedback (75% vs 30% completion; β, 1.88; 95% CI, 0.63-3.13) disappeared at follow-up. Reporting of "body functions and structures" improved similarly across groups.

Conclusions: Supervised teaching and personalized feedback are active ingredients of an intervention to improve reporting of ICF components in physiotherapeutic patient records.
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http://dx.doi.org/10.1111/jep.13212DOI Listing
February 2020

Assessing vaccine hesitancy in the UK population using a generalized vaccine hesitancy survey instrument.

Vaccine 2019 04 30;37(18):2494-2501. Epub 2019 Mar 30.

Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom; Centre for Infectious Diseases, National Institute for Public Health and the Environment, Antonie van Leeuwenhoeklaan 9, 3721 MA Bilthoven, the Netherlands.

Background: In many regions of the world, vaccine hesitancy has become an important concern to public health. A key part of any effective solution to it is to gain an in-depth understanding of the problem: its scope, who holds hesitant views and for which reasons.

Methods: We adapt the original 10-item Vaccine Hesitancy Scale (VHS), which targets parental attitudes, to a more generic version that captures general attitudes to vaccination. We use this adapted VHS in a sample of 1402 British citizens, selected from a large online panel (N > 1,000,000) based on quota for age, gender, educational attainment and region (response rate 43%). The existence of VHS subscales is evaluated via exploratory and confirmatory factor analysis. We describe the extent of vaccine hesitancy in the sample, and use simple and multiple regression analysis to examine associations between respondent characteristics and vaccine hesitancy.

Results: Despite ambiguities in defining hesitancy, we found that a substantial part of our sample held hesitant views about vaccination, particularly for those items reflecting aversion to risks of side effects. Four percent responded in a hesitant way to all ten items and ninety to at least one of the ten items. In line with recent studies in other populations, we identified two subscales within the VHS: lack of confidence in the need for vaccines and aversion to the risk of side effects. We found significant associations between hesitancy and various respondent characteristics but the predictive power of these associations remained limited.

Conclusion: Our study suggests that whereas a substantial percentage of the British population is vaccine hesitant, these views are not clustered in typical demographic features. The small but important adaptation of the VHS to target general attitudes seems to result in highly similar psychometric characteristics as the original scale that exclusively targets parents. We provide suggestions for further validation of the VHS.
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http://dx.doi.org/10.1016/j.vaccine.2019.03.041DOI Listing
April 2019

Contribution of HCAHPS Specific Care Experiences to Global Ratings Varies Across 7 Countries: What Can be Learned for Reporting These Global Ratings?

Med Care 2019 11;57(11):e65-e72

Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven, Leuven, Belgium.

Background: Given the increased international interest in improvement strategies for patient experiences with care, it is important to understand whether the same specific care experiences affect global ratings across countries. Moreover, reporting of these global ratings currently substantially varies in both research and public reporting.

Objectives: The objectives of this study were to examine the differential magnitude of associations between Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) specific care experiences and global ratings, and to explore implications for reporting these global ratings.

Methods: HCAHPS data were collected from 11,289 patients across 7 European countries. We studied the association between 11 experience items and 2 global ratings (0-10 hospital rating, hospital recommendation) using multilevel ordered logistic regression analysis. Using interaction terms, we examined consistency of these associations across countries. Assuming homogeneous use and interpretations of response categories of these specific experiences across patients within and between countries, we investigated what the associations between specific experiences and global ratings imply for reporting global ratings across countries.

Results: All specific experiences were associated with both global ratings. "Being talked to about care after leaving the hospital" showed the strongest association. There were relatively little differential effects across countries. A reporting strategy with different cutpoints across countries might provide a more equitable comparison of global ratings.

Conclusions: Our findings highlight a differential contribution of HCAHPS specific experiences to overall ratings across countries. Research and public reporting may consider examining in more detail within and across populations global rating cutpoints that represent the same true level of positive patient experiences.
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http://dx.doi.org/10.1097/MLR.0000000000001077DOI Listing
November 2019

Better hospital context increases success of care pathway implementation on achieving greater teamwork: a multicenter study on STEMI care.

Int J Qual Health Care 2019 Jul;31(6):442-448

Leuven Institute for Healthcare Policy, University of Leuven, Leuven, Belgium.

Objective: To evaluate whether hospital context influences the effect of care pathway implementation on teamwork processes and output in STEMI care.

Design: A multicenter pre-post intervention study.

Setting: Eleven acute hospitals.

Participants: Cardiologists-in-chief, nurse managers, quality staff, quality managers and program managers reported on hospital context. Teamwork was rated by professional groups (medical doctors, nurses, allied health professionals, other) in the following departments: emergency room, catheterization lab, coronary care unit, cardiology ward and rehabilitation.

Intervention: Care pathway covering in-hospital care from emergency services to rehabilitation.

Main Outcome Measures: Hospital context was measured by the five dimensions of the Model for Understanding Success in Quality: microsystem, quality improvement team, quality improvement support, high-level organization, external environment. Teamwork process measures reflected teamwork between professional groups within departments and teamwork between departments. Teamwork output was measured through the level of organized care. Two-level regression analysis accounted for clustering of respondents within hospitals and assessed the influence of hospital context on the impact of care pathway implementation on teamwork.

Results: Care pathway implementation significantly improved teamwork processes both between professional groups (P < 0.001) and between departments (P < 0.001). Teamwork output also improved (P < 0.001). The effect of care pathway implementation on teamwork was more pronounced when the quality improvement team and quality improvement support and capacity were more positively reported on.

Conclusions: Hospitals can leverage the effect of quality improvement interventions such as care pathways by evaluating and improving aspects of hospital context.
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http://dx.doi.org/10.1093/intqhc/mzy197DOI Listing
July 2019

Care Pathway Effect on In-Hospital Care for ST-Elevation Myocardial Infarction.

Cardiology 2018 10;140(3):163-174. Epub 2018 Aug 10.

Leuven Institute for Healthcare Policy, University of Leuven, Leuven, Belgium.

Objectives: To study the care pathway effect on the percentage of patients with ST-elevation myocardial infarction -(STEMI) receiving timely coronary reperfusion and the percentage of STEMI patients receiving optimal secondary prevention.

Methods: A care pathway was implemented by the Collaborative Model for Achieving Breakthrough Improvement. One pre-intervention and 2 post-intervention audits included all adult STEMI patients admitted within 24 h after onset and eligible for reperfusion. Adjusted (hospital random intercepts and controls for transfer and out-of-office admission) differences in composite outcomes were analyzed by a multilevel logistic regression.

Results: Significant improvements in intervals between the first medical contact (FMC) to percutaneous coronary intervention (PCI) and between the door to PCI were shown between post-intervention audit II and post-intervention audit I. Secondary prevention significantly deteriorated at post-intervention audit I but improved significantly between both post-intervention audits. Six out of nine outcomes were significantly poorer in the case of transfer. The interval from FMC to PCI was significantly poorer for patients admitted during out-of-office hours.

Conclusions: After care pathway implementation, composite outcomes improved for in-hospital STEMI care. Collaborative efforts exploited heterogeneity in performance between hospitals. Iterative and incremental care pathway implementation maximized performance improvement.
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http://dx.doi.org/10.1159/000488932DOI Listing
May 2019

Minimal impact of a care pathway for geriatric hip fracture patients.

Injury 2018 Aug 4;49(8):1581-1586. Epub 2018 Jun 4.

Leuven Institute for Healthcare Policy, Department of Public Health and Primary Care, KU Leuven - University of Leuven, Belgium; Department of Quality Management, University Hospitals Leuven, Belgium. Electronic address:

Background: Adherence to guidelines for patients with proximal femur fracture is suboptimal.

Objective: To evaluate the effect of a care pathway for the in-hospital management of older geriatric hip fracture patients on adherence to guidelines and patient outcomes.

Design: The European Quality of Care Pathways study is a cluster randomized controlled trial.

Setting: 26 hospitals in Belgium, Italy and Portugal.

Subjects: Older adults with a proximal femur fracture (n = 514 patients) were included.

Methods: Hospitals treating older adults (>65) with a proximal femur fracture were randomly assigned to an intervention group, i.e. implementation of a care pathway, or control group, i.e. usual care. Thirteen patient outcomes and 24 process indicators regarding in-hospital management, as well as three not-recommended care activities were measured. Adjusted and unadjusted regression analyses were conducted using intention-to-treat procedures.

Results: In the intervention group 301 patients in 15 hospitals were included, and in the control group 213 patients in 11 hospitals. Sixty-five percent of the patients were older than 80 years. The implementation of this care pathway had no significant impact on the thirteen patient outcomes. The preoperative management improved significantly. Eighteen of 24 process indicators improved, but only two improved significantly. Only for a few teams a geriatrician was an integral member of the treatment team.

Discussion: Implementation of a care pathway improved compliance to evidence, but no significant effect on patient outcomes was found. The impact of the collaboration between surgeons and geriatricians on adherence to guidelines and patient outcomes should be studied.

Trial Registration: ClinicalTrials.gov: NCT00962910.
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http://dx.doi.org/10.1016/j.injury.2018.06.005DOI Listing
August 2018

Recommended care received by geriatric hip fracture patients: where are we now and where are we heading?

Arch Orthop Trauma Surg 2018 Aug 27;138(8):1077-1087. Epub 2018 Apr 27.

Department of Public Health and Primary Care, KU Leuven-University of Leuven, Kapucijnenvoer 35/7001, 3000, Leuven, Belgium.

Introduction: Despite the availability of clinical guidelines on the prevention and treatment of geriatric hip fractures, the percentage of recommended care received by patients is low. We conducted an importance-performance analysis for prioritizing interventions to improve the in-hospital management of these patients.

Materials And Methods: A secondary data analysis was conducted on the in-hospital treatment of 540 geriatric hip fracture patients in 34 hospitals in Belgium, Italy, and Portugal. First, we assessed the level of expert consensus on the process indicators composing international guidelines on hip fracture treatment. Second, guideline adherence on in-hospital care was evaluated within and across hospitals. Third, an importance-performance analysis was conducted, linking expert consensus to guideline adherence.

Results: Level of expert consensus was high (above 75%) for 12 of 22 process indicators identified from the literature. There is large between and within hospital variation in guideline adherence for these indicators and for none of the 540 patients were all 22 process indicators adhered to. Importance-performance analysis demonstrated that three indicators that had a high level of expert consensus also had a high level of adherence (above 80%). Nine indicators, most of which have been previously linked to patient outcomes, had a high level of expert consensus but a consistently low level of adherence across hospitals and are identified as priority areas for improvement.

Conclusions: Guideline adherence for the treatment of geriatric hip fracture patients is remarkably suboptimal. Importance-performance analysis is a useful strategic approach to assist practitioners and healthcare managers to improve the quality of care.
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http://dx.doi.org/10.1007/s00402-018-2939-4DOI Listing
August 2018

Multilevel moderated mediation model with ordinal outcome.

Stat Med 2018 05 20;37(10):1650-1670. Epub 2018 Feb 20.

Leuven Institute for Healthcare Policy, University of Leuven, Leuven, Belgium.

Although increasingly complex models have been proposed in mediation literature, there is no model nor software that incorporates the multiple possible generalizations of the simple mediation model jointly. We propose a flexible moderated mediation model allowing for (1) a hierarchical structure of clustered data, (2) more and possibly correlated mediators, and (3) an ordinal outcome. The motivating data set is obtained from a European study in nursing research. Patients' willingness to recommend their treating hospital was recorded in an ordinal way. The research question is whether such recommendation directly depends on system-level features in the organization of nursing care, or whether these associations are mediated by 2 measurements of nursing care left undone and possibly moderated by nurse education. We have developed a Bayesian approach and accompanying program that takes all the above generalizations into account.
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http://dx.doi.org/10.1002/sim.7605DOI Listing
May 2018
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