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In the Netherlands, a large variation in organization of compression therapy exists for patients with deep venous thrombosis (DVT) and chronic venous disease (CVD). The IDEAL-DVT study conducted earlier showed that for patients with deep venous thrombosis (DVT), an individualized therapy with elastic compression stockings (ECS) was non-inferior to a standardized treatment duration of 24 months in preventing post-thrombotic syndrome. This approach could save at least 30 million euro per treatment episode. However, this approach is not yet implemented in the entire country. Furthermore, the implementation of assistive devices to apply and remove the ECS, and initial compression therapy types prescribed are variable. This thesis identified 19 targets for improvement to optimize the organization of ECS therapy in The Netherlands based on three studies performed: a Functional Resonance Analysis Method (FRAM), a Realist Evaluation and a modified Delphi analysis. Consensus was reached regarding these statements among national stakeholders and patients. Three main targets for improvement were identified: 1) optimizing initial compression therapy to remain self-reliance, 2) early consultation of an occupational therapist to train the patient how to use an assistive device, and 3) a tailored duration of elastic compression stocking therapy. A budget impact analysis showed that the improvements resulted in considerable cost savings within three years after implementation for two of the three regions included in this study. Finally, an interdisciplinary cross-domain protocol was developed targeting treatment decisions, communication, and roles and responsibilities regarding the process.

ObjectivesElastic compression stocking (ECS) therapy is an important treatment for patients with deep venous thrombosis (DVT) and chronic venous insufficiency (CVI). This study aimed to provide insight into the structure and variability of the ECS therapy process, its effects on outcomes, and to elicit improvement themes from a multiple stakeholder perspective.DesignThirty semi-structured interviews with professionals and patients were performed. The essential functions for the process of ECS therapy were extracted to create two work-as-done models using the Functional Resonance Analysis Method (FRAM). These findings were used to guide discussion between stakeholders to identify improvement themes.SettingTwo regions in the Netherlands, region Limburg and region North-Holland, including an academic hospital and a general hospital and their catchment region.ParticipantsThe interviewees were purposely recruited and included 25 healthcare professionals (ie, general practitioners, internists, dermatologists, nurses, doctor’s assistants, occupational therapists, home care nurses and medical stocking suppliers) and 5 patients with DVT or CVI.ResultsTwo FRAM models were created (one for each region). The variability of the functions and their effect on outcomes, as well as interdependencies between functions, were identified. These were presented in stakeholder meetings to identify the structure of the process and designated variable and uniform parts of the process and its outcomes. Ultimately, six improvement themes were identified: dissemination of knowledge of the entire process; optimising and standardising initial compression therapy; optimising timing to contact the medical stocking supplier (when oedema has disappeared); improving the implementation of assistive devices; harmonising follow-up duration for patients with CVI; personalising follow-up and treatment duration in patients with DVT.ConclusionsThis study provided a detailed understanding of how ECS therapy is delivered in daily practice by describing major functions and variability in performances and elicited six improvement themes from a multistakeholder perspective.

Background The cesarean section (CS) rate has increased over recent decades with poor guideline adherence as a possible cause. The objective of this study was to explore barriers and facilitators for delivering optimal care as described in clinical practice guidelines. Methods Key recommendations from evidence-based guidelines were used as a base to explore barriers and facilitators for delivering optimal CS care in The Netherlands. Both focus group and telephone interviews among 29 different obstetrical professionals were performed. Transcripts from the interviews were analysed. Barriers and facilitators were identified and categorised in six domains according to the framework developed by Grol: the guideline recommendations (I), the professional (II), the patient (III), the social context (IV), the organizational context (V) and the financial/legislation context (VI). Results Most barriers were found in the professional and organizational domain. Barriers mentioned by healthcare professionals were disagreement with specific guideline recommendations, and hesitation to allow women to be part of the decision making process. Other barriers are lack of adequately trained personal staff, lack of collaboration between professionals, and lack of technical equipment. Conclusions Clear facilitators and barriers for guideline adherence were identified in all domains. Several barriers may be addressed by using decision aids on mode of birth or prediction models to individualise care in women in whom both planned vaginal birth and CS are equal options. In women with an intended vaginal birth, adequate staffing and the availability of both fetal blood sampling and epidural analgesia are important. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1416-3) contains supplementary material, which is available to authorized users.