W.H. van Harten

Improving the efficiency of a chemotherapy day unit: Applying a business approach to oncology

AIM To improve the efficiency of a hospital-based chemotherapy day unit (CDU). METHODS The CDU was benchmarked with two other CDUs to identify their attainable performance levels for efficiency, and causes for differences. Furthermore, an in-depth analysis using a business approach, called lean thinking, was performed. An integrated set of interventions was implemented, among them a new planning system. The results were evaluated using pre- and post-measurements. RESULTS We observed 24% growth of treatments and bed utilisation, a 12% increase of staff member productivity and an 81% reduction of overtime. CONCLUSIONS The used method improved process design and led to increased efficiency and a more timely delivery of care. Thus, the business approaches, which were adapted for healthcare, were successfully applied. The method may serve as an example for other oncology settings with problems concerning waiting times, patient flow or lack of beds.

Prospective cost-effectiveness analysis of genomic profiling in breast cancer

BACKGROUND The cost-effectiveness of the 70-gene signature (70-GS) (MammaPrint®) has earlier been estimated using retrospective validation data. Based on the prospective 5-year survival data of the microarRAy-prognoSTics-in-breast-cancER (RASTER) study, the aim here was to evaluate the cost-effectiveness reflecting the actual use in clinical practice, including reality-based compliance rates. METHODS Costs and outcomes (quality-adjusted-life-years (QALYs)) were calculated in node-negative (N-) patients included in the RASTER study (n=427). Sensitivity and specificity of the 70-gene and Adjuvant! Online (AO) were based on 5-year distant-disease-free survival (DDFS). Subgroup analyses were performed for two groups for whom benefit of the 70-gene had earlier been reported: (1) ductal, oestrogen receptor-positive (ER+), tumour diameter 10-30 mm, grade II, age 40-70; (2) ductal, oestrogen receptor-positive, tumour diameter 5-30 mm, grade II/III and age 40-70. RESULTS Based on 5-year survival data, the cost-effectiveness of the 70-gene signature versus AO was prospectively confirmed. The total health care costs per patient were €26,786 for the 70-gene and €29,187 for AO. The quality adjusted life years yielded 12.49 and 11.88, respectively. The subgroups retrieved slightly higher life gains and higher costs, but all resulted finally in a favourable position for the 70-gene signature. CONCLUSIONS The use of the 70-gene signature, as judged appropriate by doctors and patients and supported by a low risk 70-gene signature as an oncological safe choice, was also found to be cost-effective.

Equipment-related incidents in the operating room: an analysis of occurrence, underlying causes and consequences for the clinical process

Background Equipment-related incidents in the operating room (OR) can affect quality of care. In this study, the authors determined the occurrence and effects on the care process in a large teaching hospital. Methods During a 4-week period, OR nurses reported equipment-related incidents during surgery procedures in both locations of the hospital. The incidents were reported using a separate form for each incident. A structured analysis (PRISMA) was used to analyse incidents that resulted in serious delays (>15 min). Results Forms were returned for 911 out of 1580 surgeries (57.7%). In total, 148 incidents were registered, relating to a total of 29 h and 45 min of extra work. In addition, 12 h and 9 min of operational delay was registered. Most incidents involved instruments (46%) or medical devices (28%). 68% occurred during surgery and 32% during the preparation phase. No direct physical harm was reported, although indirect harm, like longer anaesthesia, did occur and can be defined as an adverse event. 10% of the incidents led to a delay of over 15 min. For these incidents, ‘management decisions’ (eg, inventory capacity, planning procedure) was the most encountered root cause. Only six out of the 148 incidents found corresponded with the blame-free reporting database. Conclusions Equipment-related incidents occurred frequently in the involved hospital sites (up to 15.9%) and resulted in some extra work and additional minutes of delay per event. Management decisions have considerable influence on the occurrence of equipment-related incidents. There was serious under-reporting of incidents.

Effective cooperation influencing performance: a study in Dutch hospitals

OBJECTIVE This study focuses on cooperation between physicians and managers and aspects of that cooperation that can provide leads for interventions aimed at enhancing hospital performance. DESIGN We performed a qualitative study on cooperation between physicians and managers and the influence of that cooperation on hospital performance, and structured the resulting data according to the conditions of Allports theory on intergroup conflicts. SETTING General hospitals in the Netherlands. PARTICIPANTS Thirty physicians (surgical and internal) and managers (strategic, tactic and operational) working in five different hospitals. INTERVENTIONS In-depth interviews exploring the influence of cooperation between physicians and managers on hospital performance. MAIN OUTCOME MEASURES Respondents confirmed the complexity of the relationship between physicians and managers and the link between their cooperation and hospital performance. Mentioned aspects such as power and status differences, clarity in decision-making and personal click, are important in determining the effectiveness of the cooperation between physicians and managers. RESULTS Our study suggests that the effectiveness of cooperation between physicians and managers is related to the uptake of quality initiatives and hospital performance. CONCLUSIONS The complex relationship between physicians and managers can be referred to as an intergroup conflict situation. We combined Allports Contact theory conditions with aspects found in our study leading to the following facilitating conditions: address common goals; create interdependent tasks; arrange the support of authorities and respect the medical domain. They will enhance intra-hospital cooperation and therewith hospital performance.

Stereotypical images between physicians and managers in hospitals

PURPOSE The purpose of this paper is to apply the image theory to the hospital context in order to add a perspective into the known complex relationship between physicians and hospital managers. This insight can enrich current intervention schemes used in health care to facilitate organisational change. DESIGN/METHODOLOGY/APPROACH In this paper, the image theory of Alexander et al. on the known complex intergroup context of physicians and hospital managers is applied. The theory is operationalised in relative status, power, and goal incompatibility. FINDINGS The data show the three variables are highly relevant and representative. Hospital managers see physicians as higher in professional status and power, and having different goals. Physicians see hospital managers to have higher power, lower status, and different goals. The study validates the applicability of the image theory in the Dutch hospital context. This results in a questionnaire suitable for performing a quick scan on the strength and direction of intergroup stereotyping within hospital organisations. ORIGINALITY/VALUE Data from the questionnaire give the opportunity to have insight in the way physicians and hospital managers perceive each other. This insight helps to focus attention on bottlenecks and possibilities in enhancing the co-operation between physicians and hospital managers. Research on the relationship between physicians and hospital managers is scarce and mostly of a qualitative nature. This paper is executed in both qualitative and quantitative way, which enables us to empirically and statistically validate the data. The resulting questionnaire is applicable on an organisational intergroup level, while the focus in the extant literature is mostly on the interpersonal or intragroup level.

Evaluating patient care communication in integrated care settings: application of a mixed method approach in cerebral palsy programs

OBJECTIVE In this study, we evaluated patient care communication in the integrated care setting of children with cerebral palsy in three Dutch regions in order to identify relevant communication gaps experienced by both parents and involved professionals. DESIGN A three-step mixed method approach was used starting with a questionnaire to identify communication links in which parents experienced gaps. In subsequent in-depth interviews with parents and focus group meetings with professionals underlying factors were evaluated. RESULTS In total, 197 parents completed the questionnaire (response 67%); 6% scored negative on parent-professional communication, whereas 17% scored negative on inter-professional communication, especially between the rehabilitation physician and primary care physiotherapy (16%) and (special) education/day care (15%). In-depth interviews among a subset of 20 parents revealed various sources of dissatisfaction such as lack of cooperation and patient centeredness, inappropriate amount of information exchange and professional use of parents as messenger of information. Focus group meetings revealed that professionals recognized these gaps. They attributed them to capacity problems, lack of interdisciplinary guidelines and clear definition of roles, but also a certain hesitance for contact due to unfamiliarity with involved professionals in the care network. CONCLUSIONS Parents particularly identified gaps in inter-professional communication between (rehabilitation) hospitals and primary care settings. Involved professionals recognized these gaps and primarily attributed them to organizational factors. Improvement initiatives should focus on these factors as well as facilitation of low-threshold contact across the patients care network.

The impact of organisational external peer review on colorectal cancer treatment and survival in the Netherlands

Background:Organisational external peer review was introduced in 1994 in the Netherlands to improve multidisciplinary cancer care. We examined the clinical impact of this programme on colorectal cancer care.Methods:Patients with primary colorectal cancer were included from 23 participating hospitals and 7 controls. Hospitals from the intervention group were dichotomised by their implementation proportion (IP) of the recommendations from each peer review (high IP vs low IP). Outcome measures were the introduction of new multidisciplinary therapies and survival.Results:In total, 45 705 patients were included (1990–2010). Patients from intervention hospitals more frequently received adjuvant chemotherapy for stage III colon cancer. T2–3/M0 rectal cancer patients from hospitals with a high IP had a higher chance of receiving preoperative radiotherapy (OR 1.31, 95% CI 1.11–1.55) compared with the controls and low IP group (OR 0.75, 95% CI 0.63–0.88). There were no differences in the use of preoperative chemoradiation for T4/M0 rectal cancer. Survival was slightly higher in colon cancer patients from intervention hospitals but unrelated to the phase of the programme in which the hospital was at the time of diagnosis.Conclusions:Some positive effects of external peer review on cancer care were found, but the results need to be interpreted cautiously due to the ambiguity of the outcomes and possible confounding factors.

Selecting indicators for international benchmarking of radiotherapy centres.

Introduction: Benchmarking can be used to improve hospital performance. It is however not easy to develop a concise and meaningful set of indicators on aspects related to operations management. We developed an indicator set for managers and evaluated its use in an international benchmark of radiotherapy centres. The indicator set assessed the efficiency, patient-centeredness and timeliness of the services delivered. Methods: We identified possible indicators from literature and professionals. Stakeholders’ feedback helped to produce a shortlist of indicators. For this indicator set, data were obtained in a pilot that included four European radiotherapy centres. With these data, the indicators were evaluated on definition clarity, data availability, reliability and discriminative value. Results: Literature produced a gross list of 81 indicators. Based on stakeholder feedback, 33 indicators were selected and evaluated in the benchmark. Six negatively evaluated indicators were adapted, together with eight positively evaluated indicators 14 indicators seemed feasible. Examples of indicators concerned utilisation, waiting times, patient satisfaction and risk analysis. Conclusions: This study provides a pragmatic indicator development process for international benchmarks on operations management. The presented indicators showed to be feasible for use in international benchmarking of radiotherapy centres. The pilot identified attainable performance levels and provided leads for improvements

Scenario drafting for early technology assessment of next generation sequencing in clinical oncology

BackgroundNext Generation Sequencing (NGS) is expected to lift molecular diagnostics in clinical oncology to the next level. It enables simultaneous identification of mutations in a patient tumor, after which targeted therapy may be assigned. This approach could improve patient survival and/or assist in controlling healthcare costs by offering expensive treatment to only those likely to benefit. However, NGS has yet to make its way into the clinic. Health Technology Assessment can support the adoption and implementation of a novel technology, but at this early stage many of the required variables are still unknown.MethodsScenario drafting and expert elicitation via a questionnaire were used to identify factors that may act as a barrier or facilitate adoption of NGS-based molecular diagnostics. Attention was paid to predominantly elicit quantitative answers, allowing their use in future modelling of cost-effectiveness.ResultsAdequately informing patients and physicians, the latters’ opinion on clinical utility and underlying evidence as well as presenting sequencing results within a relevant timeframe may act as pivotal facilitators. Reimbursement for NGS-based testing and accompanying therapies (both general and in case of off-label prescription) was found to be a potential barrier. Competition on the market and demonstrating clinical utility may also be challenging. Importantly, numerous quantitative values for variables related to each of these potential barriers/facilitators, such as such as desired panel characteristics, willingness to pay or the expected number of targets identified per person, were also elicited.ConclusionsWe have identified several factors that may either pose a barrier or facilitate the adoption of NGS in the clinic. We believe acting upon these findings, for instance by organizing educational events, advocating new ways of evidence generation and steering towards the most cost-effective solution, will accelerate the route from bench-to-bedside. Moreover, due to the methodology of expert elicitation, this study provides parameters that can be incorporated in future cost-effectiveness modeling to steer the development of NGS gene panels towards the most optimal direction.

PCN 149 - Early cost-effectiveness modeling for tumor infiltrating lymphocytes (TIL-)treatment versus ipilimumab in metastatic melanoma patients

Objectives: Metastatic melanoma has a poor prognosis with 10 year survival being 50% and expected survival rates of 25%-42% versus 45% (1yr) and 23,5% (2yr) for Ipilimumab. TIL is highly personalized, however complex and requests substantial upfront investments from the hospital in expensive lab-equipment, staff expertise and training, as well as extremely tight hospital logistics. Therefore, an early health economic modelling study, supporting a Coverage with Evidence Development (CED) program, was performed. Methods: We used a Markov decision model to estimate the expected costs and outcomes (quality adjusted life years; QALYs) for TIL versus Ipilimumab in metastatic melanoma patients from a societal perspective over a life long time horizon. Three mutually exclusive health states (stable disease, progressive disease and death) were modelled, divided in first and second line treatment. Technical failures and non-compliance were incorporated to reflect the dynamic nature of the technology. To inform further research prioritization, Value of Information (VOI) analysis was performed. Results: TIL is expected to yield more QALYs compared to Ipilimumab (0.99 vs 0.52 respectively) at lower total costs (€83,588 vs €87,834 respectively). Based on current information TIL has a probability of 88% for being cost effective at a cost/QALY threshold of €30,000. Expected Value of Perfect Information (EVPI) amounted to €1,2 million. Partial EVPI (EVPPI) was highest for survival data (€550,000). Expected Value of Sample information was estimated €355,000 for an optimal sample size of n=50. Conclusions: TIL is expected to improve QALYs compared to Ipilimumab at lower incremental cost and has the highest probability of being cost-effective. To reduce decision uncertainty, a future clinical trial to investigate survival seems most valuable, and should preferably be undertaken as part of a CED program.