N. F. de Keizer

Teledermatology applied following patient selection by general practitioners in daily practice improves efficiency and quality of care at lower cost.

Background  Teledermatology, the application of telemedicine in the field of dermatology, has similar accuracy and reliability as physical dermatology. Teledermatology has been widely used in daily practice in the Netherlands since 2005 and is fully reimbursed.

Maturity of teledermatology evaluation research: a systematic literature review

Background  There is a growing interest in teledermatology in todays clinical practice, but the maturity of the evaluation research of this technology is still unclear.

Reliability and accuracy of Sequential Organ Failure Assessment (SOFA) scoring

Objective:The Sequential Organ Failure Assessment (SOFA) score was developed to quantify the severity of patients’ illness, based on the degree of organ dysfunction. This study aimed to evaluate the accuracy and the reliability of SOFA scoring. Design:Prospective study. Setting:Adult intensive care unit (ICU) in a tertiary academic center. Subjects:Thirty randomly selected patient cases and 20 ICU physicians. Measurements and Main Results:Each physician scored 15 patient cases. The intraclass correlation coefficient was .889 for the total SOFA score. The weighted kappa values were moderate (0.552) for the central nervous system, good (0.634) for the respiratory system, and almost perfect (>0.8) for the other organ systems. To assess accuracy, the physicians’ scores were compared with a gold standard based on consensus of two experts. The total SOFA score was correct in 53% (n = 158) of the cases. The mean of the absolute deviations of the recorded total SOFA scores from the gold standard total SOFA scores was 0.82. Common causes of errors were inattention, calculation errors, and misinterpretation of scoring rules. Conclusions:The results of this study indicate that the reliability and the accuracy of SOFA scoring among physicians are good. We advise implementation of additional measures to further improve reliability and accuracy of SOFA scoring.

Control charts in healthcare quality improvement. A systematic review on adherence to methodological criteria

OBJECTIVES Use of Shewhart control charts in quality improvement (QI) initiatives is increasing. These charts are typically used in one or more phases of the Plan Do Study Act (PDSA) cycle to monitor summaries of process and outcome data, abstracted from clinical information systems, over time. We summarize methodological criteria of Shewhart control charts and investigate adherence of published QI studies to these criteria. METHODS We searched Medline, Embase and CINAHL for studies using Shewhart control charts in QI processes in direct patient care. We extracted methodological criteria for Shewhart control charts, and for the use of these charts in PDSA cycles, from textbooks and methodological literature. RESULTS We included 34 studies, presenting 64 control charts of which 40 control charts plotted two phases of the PDSA cycle. The criterion to use 10-35 data points in a control chart was least adhered to (48.4% non-adherence). Other criteria were: transformation of the data in case of a skewed distribution (43.7% non adherence), when comparing data from two phases of the PDSA cycle the Plan phase (the first phase) needs to be stable (40.0% non-adherence), using a maximum of four different rules to detect special cause variation (14.1% non-adherence), and setting control limits at three standard deviations from the mean (all control charts adhered). CONCLUSION There is room for improvement with regard to the methodological construction of Shewhart control charts used in QI processes. Higher adherence to all methodological criteria will decrease the risk of incorrect conclusions about the process being monitored.

A usability evaluation of a SNOMED CT based compositional interface terminology for intensive care

OBJECTIVE To evaluate the usability of a large compositional interface terminology based on SNOMED CT and the terminology application for registration of the reasons for intensive care admission in a Patient Data Management System. DESIGN Observational study with user-based usability evaluations before and 3 months after the system was implemented and routinely used. MEASUREMENTS Usability was defined by five aspects: effectiveness, efficiency, learnability, overall user satisfaction, and experienced usability problems. Qualitative (the Think-Aloud user testing method) and quantitative (the System Usability Scale questionnaire and Time-on-Task analyses) methods were used to examine these usability aspects. RESULTS The results of the evaluation study revealed that the usability of the interface terminology fell short (SUS scores before and after implementation of 47.2 out of 100 and 37.5 respectively out of 100). The qualitative measurements revealed a high number (n=35) of distinct usability problems, leading to ineffective and inefficient registration of reasons for admission. The effectiveness and efficiency of the system did not change over time. About 14% (n=5) of the revealed usability problems were related to the terminology content based on SNOMED CT, while the remaining 86% (n=30) was related to the terminology application. The problems related to the terminology content were more severe than the problems related to the terminology application. CONCLUSIONS This study provides a detailed insight into how clinicians interact with a controlled compositional terminology through a terminology application. The extensiveness, complexity of the hierarchy, and the language usage of an interface terminology are defining for its usability. Carefully crafted domain-specific subsets and a well-designed terminology application are needed to facilitate the use of a complex compositional interface terminology based on SNOMED CT.

An evaluation of patient data management systems in dutch intensive care

Objective: To assess the agreement between the functions of seven configurations of Patient Data Management Systems (PDMS) and the Dutch specifications prepared by the users prior to use.Design: An observational descriptive study with hospital visits of seven configurations of five different PDMS systems including three commercial systems and two locally developed systems.Setting: Seven Dutch level I intensive care units in university and teaching hospitals.Measurements and results: A substantial disagreement was found between the Dutch specifications and the actual functions of the PDMS configurations tested. Between the PDMS configurations, major differences in key features, including “automated charting”, “information and care planning”, and “management information”, were observed. Automated charting is adequately supported by the three commercial systems. All configurations tested had limited functions supporting care planning. In none of the configurations tested was the required function present to support unit management with reports on resource utilisation and outcome performance. The automatic calculation of prognostic scores was either absent or incorrect. The implementation, the (continuous) configuration and the training required a substantial investment in costs and human resources.Conclusion: Today, none of the PDMSs tested satisfy the Dutch specifications. This can be explained by technical impossibilities of the systems and shortcomings in the actual configuration or in the unit organisation. The PDMS might become a valuable tool in improving the quality of ICU practice, but full implementation of these systems according to the specifications still has a long way to go.

STARE-HI – Statement on Reporting of Evaluation Studies in Health Informatics: Explanation and Elaboration

BACKGROUND Improving the quality of reporting of evaluation studies in health informatics is an important requirement towards the vision of evidence-based health informatics. The STARE-HI - Statement on Reporting of Evaluation Studies in health informatics, published in 2009, provides guidelines on the elements to be contained in an evaluation study report. OBJECTIVES To elaborate on and provide a rationale for the principles of STARE-HI and to guide authors and readers of evaluation studies in health informatics by providing explanatory examples of reporting. METHODS A group of methodologists, researchers and editors prepared the present elaboration of the STARE-HI statement and selected examples from the literature. RESULTS The 35 STARE-HI items to be addressed in evaluation papers describing health informatics interventions are discussed one by one and each is extended with examples and elaborations. CONCLUSION The STARE-HI statement and this elaboration document should be helpful resources to improve reporting of both quantitative and qualitative evaluation studies. Evaluation manuscripts adhering to the principles will enable readers of such papers to better place the studies in a proper context and judge their validity and generalizability, and thus in turn optimize the exploitation of the evidence contained therein. LIMITATIONS This paper is based on experiences of a group of editors, reviewers, authors of systematic reviews and readers of the scientific literature. The applicability of the details of these principles has to evolve as a function of their use in practice.

The relation between TISS and real paediatric ICU costs: a case study with generalizable methodology

Objective: To determine the quantitative relation between the Therapeutic Intervention Scoring System (TISS) in combination with other relevant clinical variables and the real costs of (paediatric) intensive care. Design: A prospective, observational study. Setting: A Ten-bed paediatric intensive care unit in a university childrens hospital. Patients and participants: In a 17-months registration period we collected patient- and treatment-related data for all 611 consecutive admissions. A 21-day calibration period was used to collect detailed data to calculate the real costs of 33 consecutive admissions, in addition to the same data as in the registration period. Measurements and results: We used the Multi Moment Measurement method to measure time spent by nurses and physicians and medication used in the 21-day calibration period. The calibration period data set with explanatory variables including TISS was used to build a regression model to estimate nurse and physician time, which were converted to personnel costs, and to estimate medication costs. The regression models built from the calibration period were subsequently used to estimate the total costs per day and per admission in different patient groups in the registration period. Conclusion: It was feasible to calculate total direct medical costs based on a limited number of readily available clinical variables related to patient characteristics and treatment, of which TISS was the most important determinant. The proposed methods provide further tools for assessment of (paediatric) intensive care unit performance.

Outcomes of intensive care unit admissions after elective cancer surgery.

BACKGROUND Postoperative care for major elective cancer surgery is frequently provided on the Intensive Care Unit (ICU). OBJECTIVE To analyze the characteristics and outcome of patients after ICU admission following elective surgery for different cancer diagnoses. METHODS We analyzed all ICU admissions following elective cancer surgery in the Netherlands collected in the National Intensive Care Evaluation registry between January 2007 and January 2012. RESULTS 28,973 patients (9.0% of all ICU admissions; 40% female) were admitted to the ICU after elective cancer surgery. Of these admissions 77% were planned; in 23% of cases the decision for ICU admission was made during or directly after surgery. The most frequent malignancies were colorectal cancer (25.6%), lung cancer (18.5%) and tumors of the central nervous system (14.3%). Mechanical ventilation was necessary in 24.8% of all patients, most frequently after surgery for esophageal (62.5%) and head and neck cancer (50.2%); 20.7% of patients were treated with vasopressors in the acute postoperative phase, in particular after surgery for esophageal cancer (41.8%). The median length of stay on the ICU was 0.9 days (interquartile ranges [IQR] 0.8-1.5); surgery for esophageal cancer was associated with the longest ICU length of stay (median 2.0 days) with the largest variation (IQR 1.0-4.8 days). ICU mortality was 1.4%; surgery for gastrointestinal cancer was associated with the highest ICU mortality (colorectal cancer 2.2%, pancreatico-cholangiocarcinoma 2.0%). CONCLUSION Elective cancer surgery represents a significant part of all ICU admissions, with a short length of stay and low mortality.

The added value that increasing levels of diagnostic information provide in prognostic models to estimate hospital mortality for adult intensive care patients.

Objective: To investigate in a systematic, reproducible way the potential of adding increasing levels of diagnostic information to prognostic models for estimating hospital mortality. Design: Prospective cohort study. Setting: Thirty UK intensive care units (ICUs) participating in the ICNARC Case Mix Programme. Patients: Eight thousand fifty-seven admissions to UK ICUs. Measurements and results: Logistic regression analysis incorporating APACHE II score, admission type and increasing levels of diagnostic information was used to develop models to estimate hospital mortality for intensive care patients. The 53 UK APACHE II diagnostic categories were substituted with data from a hierarchical, five-tiered (type of condition required surgery or not, body system, anatomical site, physiological/pathological process, condition) coding method, the ICNARC Coding Method. The inter-rater reliability using the ICNARC Coding Method to code reasons for admission was good (k = 0.70). All new models had good discrimination (AUC = 0.79–0.81) and similar or better calibration compared with the UK APACHE II model (Hosmer-Lemeshow goodness-of-fit H = 18.03 to H = 26.77 for new models versus H = 63.51 for UK APACHE II model). Conclusion: The UK APACHE II model can be simplified by extending the admission type and substituting the 53 UK APACHE II diagnostic categories with nine body systems, without losing discriminative power or calibration.