Ron Hendrix

Why business modeling is crucial in the development of eHealth technologies

The impact and uptake of information and communication technologies that support health care are rather low. Current frameworks for eHealth development suffer from a lack of fitting infrastructures, inability to find funding, complications with scalability, and uncertainties regarding effectiveness and sustainability. These issues can be addressed by defining a better implementation strategy early in the development of eHealth technologies. A business model, and thus business modeling, help to determine such an implementation strategy by involving all important stakeholders in a value-driven dialogue on what the technology should accomplish. This idea also seems promising to eHealth, as it can contribute to the whole development of eHealth technology. We therefore suggest that business modeling can be used as an effective approach to supporting holistic development of eHealth technologies. The contribution of business modeling is elaborated in this paper through a literature review that covers the latest business model research, concepts from the latest eHealth and persuasive technology research, evaluation and insights from our prior eHealth research, as well as the review conducted in the first paper of this series. Business modeling focuses on generating a collaborative effort of value cocreation in which all stakeholders reflect on the value needs of the others. The resulting business model acts as the basis for implementation. The development of eHealth technology should focus more on the context by emphasizing what this technology should contribute in practice to the needs of all involved stakeholders. Incorporating the idea of business modeling helps to cocreate and formulate a set of critical success factors that will influence the sustainability and effectiveness of eHealth technology.

Clinical predictors of bacterial involvement in exacerbations of chronic obstructive pulmonary disease.

BACKGROUND The wide use of antibiotics for treatment of exacerbations of chronic obstructive pulmonary disease (COPD) lacks evidence. The efficacy is debatable, and bacterial involvement in exacerbation is difficult to verify. The aim of this prospective study was to identify factors that can help to estimate the probability that a microorganism is involved in exacerbation of COPD and, therefore, predict the success of antibiotic treatment. METHODS Clinical data and sputum samples were obtained from 116 patients during exacerbation of COPD. Bacterial infection was defined by the abundant presence of >or=1 potential pathological microorganism in relation to the normal flora in sputum. RESULTS Of 116 exacerbations, 22 (19%) had bacterial involvement. The combination of a negative result of a sputum Gram stain, a relevant nonclinical decrease in lung function (compared with baseline measurements), and occurrence of <2 exacerbations in the previous year were 100% predictive of a nonbacterial origin of the exacerbation. The presence of all 3 of these clinical characteristics yielded a positive predictive value of 67% for a bacterial exacerbation. CONCLUSIONS Patients presenting with an exacerbation who have a negative result of sputum Gram stain, do not have a clinically relevant decrease in lung function, and have experienced <2 exacerbations of COPD in the previous year do not require antibiotic treatment [corrected]. A treatment protocol taking into account these variables might lead to a 5%-24% reduction in unnecessary treatment with antibiotics, depending on actual prescription rates.

Host-pathogen interaction during pneumococcal infection in patients with chronic obstructive pulmonary disease

ABSTRACT Acute exacerbation is a frequent complication of chronic obstructive pulmonary disease (COPD). Recent studies suggested a role for bacteria such as Streptococcus pneumoniae in the development of acute exacerbation. For this study, we investigated the following in COPD patients: (i) the epidemiology of pneumococcal colonization and infection, (ii) the effect of pneumococcal colonization on the development of exacerbation, and (iii) the immunological response against S. pneumoniae. We cultured sputa of 269 COPD patients during a stable state and during exacerbation of COPD and characterized 115 pneumococcal isolates by use of serotyping. Moreover, we studied serum immunoglobulin G (IgG) antibody titers, antibody avidities, and functional antibody titers against the seven conjugate vaccine serotypes in these patients. Colonization with only pneumococci (monocultures) increased the risk of exacerbation, with a hazard ratio of 2.93 (95% confidence interval, 1.41 to 6.07). The most prevalent pneumococcal serotypes found were serotypes 19F, 3, 14, 9L/N/V, 23A/B, and 11. We calculated the theoretical coverage for the 7- and 11-valent pneumococcal vaccines to be 60 and 73%, respectively. All patients had detectable IgG levels against the seven conjugate vaccine serotypes. These antibody titers were significantly lower than those in vaccinated healthy adults. Finally, on average, a 2.5-fold rise in serotype-specific and functional antibodies in S. pneumoniae-positive sputum cultures was observed during exacerbation. Our data indicate that pneumococcal colonization in COPD patients is frequently caused by vaccine serotype strains. Moreover, pneumococcal colonization is a risk factor for exacerbation of COPD. Finally, our findings demonstrate that COPD patients are able to mount a significant immune response to pneumococcal infection. COPD patients may therefore benefit from pneumococcal vaccination.

The role of atypical respiratory pathogens in exacerbations of chronic obstructive pulmonary disease

The aetiology of acute exacerbations of chronic obstructive pulmonary disease (COPD) is heterogeneous and still under discussion. Serological studies have suggested that Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella pneumophila may play a role in acute exacerbations of COPD. The presence of these atypical pathogens in sputum samples was investigated in patients with stable COPD and with acute exacerbations of COPD using real-time PCR. The present study was part of a randomised, double-blind, single-centre study and a total of 248 sputum samples from 104 COPD patients were included. In total, 122 samples obtained during stable disease (stable-state sputa) and 126 samples obtained during acute exacerbations of COPD (exacerbation sputa) were tested. Of the 122 stable-state sputa, all samples were negative for M. pneumoniae and C. pneumoniae DNA, whereas one sample was positive for Legionella non-pneumophila DNA. Of the 126 exacerbation sputa, all samples were negative for M. pneumoniae and C. pneumoniae DNA, whereas one sample was positive for Legionella non-pneumophila DNA. The possible relationship between the presence of atypical pathogens and the aetiology of acute exacerbations in chronic obstructive pulmonary disease was investigated in patients with stable disease and in those with acute exacerbations using real-time PCR. No indication was found of a role for Legionella spp., Chlamydia pneumoniae or Mycoplasma pneumoniae in stable, moderately severe chronic obstructive pulmonary disease and in its exacerbations.

Detection of New Methicillin-Resistant Staphylococcus aureus Strains That Carry a Novel Genetic Homologue and Important Virulence Determinants

ABSTRACT In this study, 18 methicillin-resistant Staphylococcus aureus (MRSA) isolates harboring staphylococcal cassette chromosome mec (SCCmec) type XI, recovered in the Dutch-German Euregio, were characterized by DNA microarrays. In contrast to previous data, we found two MRSA strains of different clonal lineages possessing SCCmec XI that carried important virulence determinants. The worrisome emergence of such toxigenic MRSA strains raises concerns that MRSA strains with enhanced virulence potential and impaired detectability by standard molecular assays may spread in Europe.

Financial evaluations of antibiotic stewardship programs—a systematic review

Introduction: There is an increasing awareness to counteract problems due to incorrect antimicrobial use. Interventions that are implemented are often part of an Antimicrobial Stewardship Program (ASPs). Studies publishing results from these interventions are increasing, including reports on the economical effects of ASPs. This review will look at the economical sections of these studies and the methods that were used. Methods: A systematic review was performed of articles found in the PubMed and EMBASE databases published from 2000 until November 2014. Included studies found were scored for various aspects and the quality of the papers was assessed following an appropriate check list (CHEC criteria list). Results: 1233 studies were found, of which 149 were read completely. Ninety-nine were included in the final review. Of these studies, 57 only mentioned the costs associated with the antimicrobial medication. Others also included operational costs (n = 23), costs for hospital stay (n = 18), and/or other costs (n = 19). Nine studies were further assessed for their quality. These studies scored between 2 and 14 out of a potential total score of 19. Conclusions: This review gives an extensive overview of the current financial evaluation of ASPs and the quality of these economical studies. We show that there is still major potential to improve financial evaluations of ASPs. Studies do not use similar nor consistent methods or outcome measures, making it impossible draw sound conclusions and compare different studies. Finally, we make some recommendations for the future.

A multi-center blinded study on the efficiency of phenotypic screening methods to detect glycopeptide intermediately susceptible Staphylococcus aureus (GISA) and heterogeneous GISA (h-GISA).

BackgroundsTo determine the true incidence of hGISA/GISA and its consequent clinical impact, methods must be defined that will reliably and reproducibly discriminate these resistant phenotypes from vancomycin susceptible S. aureus (VSSA).MethodsThis study assessed and compared the ability of eight Dutch laboratories under blinded conditions to discriminate VSSA from hGISA/GISA phenotypes and the intra- and inter-laboratory reproducibility of agar screening plates and the Etest method. A total of 25 blinded and unique strains (10 VSSA, 9 hGISA and 6 GISA) were categorized by the PAP-AUC method and PFGE typed to eliminate clonal duplication. All strains were deliberately added in quadruplets to evaluate intra-laboratory variability and reproducibility of the methods. Strains were tested using three agar screening methods, Brain Heart Infusion agar (BHI) + 6 μg/ml vancomycin, Mueller Hinton agar (MH) + 5 μg/ml vancomycin and MH + 5 μg/ml teicoplanin) and the Etest macromethod using a 2 McFarland inoculum.Results and DiscussionThe ability to detect the hGISA/GISA phenotypes varied significantly between methods and phenotypes. BHI vancomycin and MH vancomycin agar screens lacked the ability to detect hGISA. The MH teicoplanin agar screen was more sensitive but still inferior to Etest that had a sensitivity of 98.5% and 99.5%, for hGISA and GISA, respectively. Intra- and inter-laboratory reproducibility varied between methods with poorest performance seen with BHI vancomycin.ConclusionThis is the first multi-center blinded study to be undertaken evaluating various methods to detect GISA and hGISA. These data showed that the ability of clinical laboratories to detect GISA and hGISA varied considerably, and that screening plates with vancomycin have a poor performance in detecting hGISA.

Participatory eHealth development to support nurses in antimicrobial stewardship

BackgroundAntimicrobial resistance poses a threat to patient safety worldwide. To stop antimicrobial resistance, Antimicrobial Stewardship Programs (ASPs; programs for optimizing antimicrobial use), need to be implemented. Within these programs, nurses are important actors, as they put antimicrobial treatment into effect. To optimally support nurses in ASPs, they should have access to information that supports them in their preparation, administration and monitoring tasks. In addition, it should help them to detect possible risks or adverse events associated with antimicrobial therapy. In this formative study, we investigate how nurses’ can be supported in ASPs by means of an eHealth intervention that targets their information needs.MethodsWe applied a participatory development approach that involves iterative cycles in which health care workers, mostly nurses, participate. Focus groups, observations, prototype evaluations (via a card sort task and a scenario-based information searching task) and interviews are done with stakeholders (nurses, managers, pharmacist, and microbiologist) on two pulmonary wards of a 1000-bed teaching hospital.ResultsTo perform the complex antimicrobial-related tasks well, nurses need to consult various information sources on a myriad of occasions. In addition, the current information infrastructure is unsupportive of ASP-related tasks, mainly because information is not structured to match nurse tasks, is hard to find, out of date, and insufficiently supportive of awareness. Based our findings, we created a concept for a nurse information application. We attuned the application’s functionality, content, and structure to nurse work practice and tasks.ConclusionsBy applying a participatory development approach, we showed that task support is a basic need for nurses. Participatory development proved useful regarding several aspects. First, it allows for combining bottom-up needs (nurses’) and top-down legislations (medical protocols). Second, it enabled us to fragmentise and analyse tasks and to reduce and translate extensive information into task-oriented content. Third, this facilitated a tailored application to support awareness and enhance patient safety. Finally, the involvement of stakeholders created commitment and ownership, and helped to weigh needs from multiple perspectives.

Legionella pneumophila pneumonia in a pregnant woman treated with anti-TNF-α antibodies for Crohn's disease: A case report

Anti-TNF-α antibodies are widely used. The indications for their usage are still increasing. With their emerging use, their infectious complications are seen more often. We describe the first case of a pneumonia with Legionella pneumophila in a pregnant women with Crohns disease, during treatment with anti-TNF-α antibodies. She was treated with erythromycin and made a full recovery.

Reduction of the nosocomial meticillin-resistant Staphylococcus aureus incidence density by a region-wide search and follow-strategy in forty German hospitals of the EUREGIO, 2009 to 2011

Meticillin-resistant Staphylococcus aureus (MRSA) disseminates between hospitals serving one patient catchment area. Successful prevention and control requires concerted efforts and regional surveillance. Forty hospitals located in the German EUREGIO have established a network for combating MRSA. In 2007 they agreed upon a synchronised strategy for screening of risk patients and a standard for transmissionbased precautions (search and follow). The same year, the hospitals started synchronised MRSA prevention and annually reporting MRSA-data to the public health authorities. The median rate of screening cultures per 100 patients admitted increased from 4.38 in 2007 to 34.4 in 2011 (p<0.0001). Between 2007 and 2011, the overall incidence density of MRSA (0.87 MRSA cases/1,000 patient days vs 1.54; p<0.0001) increased significantly. In contrast, both the incidence density of nosocomial MRSA cases (0.13 nosocomial MRSA cases/1,000 patient days in 2009 vs 0.08 in 2011; p=0.0084) and the MRSA-days-associated nosocomial MRSA rate (5.51 nosocomial MRSA cases/1,000 MRSA days in 2009 vs 3.80 in 2011; p=0.0437) decreased significantly after the second year of the project. We documented adherence to the regional screening strategy resulting in improved detection of MRSA carriers at admission. Subsequently, after two years the nosocomial MRSA-incidence density was reduced. Regional surveillance data, annually provided as benchmarking to the regional hospitals and public health authorities, indicated successful prevention.