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In order to provide tailor-made care, governments are considering the implementation of output-pricing based on hospital case-mix measures, such as diagnosis related groups (DRG). The question is whether the current DRG classification system can provide a satisfactory prediction of the variance of costs in stroke patients and if not, in what way other variables may enhance this prediction. In this study, data from 731 stroke patients hospitalized at University Hospital Maastricht during 1996-1998 are used in the cost analysis. The DRG classification for this group uses information--in addition to the DRG classification operation or no operation--on the patient's age combined with discharge status. The results of regression analysis show that using DRGs, the variance explained in the costs amounts to 34%. Adding other variables to the DRGs, the variance explained increases to about 61%. Additional factors highly correlating with inpatient costs are the level of functioning after stroke, comorbidity, complications, and 'days of stay for non-medical reasons'. Costs decreased for stroke patients discharged during the latter part of the years studied, and if stroke patients happened to die during their hospital stay. The results do suggest that future implementation of output-pricing based on the DRG case-mix measures is feasible for stroke patients only if it is enhanced with information on complications and the level of functioning.

(i) To describe and analyse pelvic floor dysfunction symptoms in men referred to a Pelvic Care Centre (PCC). (ii) To describe the triage process of the same patients based on response to a first-contact interview.Triage started with a telephone interview using previously constructed questions, asking for six types of PF complaints during the preceding 6 months. If present, complaint severity was registered on a 0-10 scale. Next, these first-contact complaints were used to describe patient case mix profiles using cross-tabular analysis. Later on, at first PCC visit, an intake questionnaire regarding specific PF health problem(s) was filled out. This procedure contributed to a firm baseline characterization of the individual patient profile and a clinically valid allocation to structured, predefined assessment and treatment.From 2005 to 2013 985 first-time patients (mean age 58.2 years (SD 15.3) have been referred to the PCC. Most frequently mentioned complaints: voiding dysfunctions (73.9%), urinary incontinence (29.5%), sexual problems (16.6%), faecal incontinence (13.9%), constipation (9.6%), and prolapse (0.3%). A first appointment to a single specialist was determined in 805 (81.7%) patients, in 137 (13.9%) consultation of1 specialist. Data analysis revealed higher-order interactions between PF complaints, suggesting patient profile complexity and patient population heterogeneity.One out of seven PCC patients showed multifactorial problems, needing1 specialist. PF complaints either turned out to stand alone or cluster with others, or even to strengthen, weaken, nullify or inverse relationships. Neurourol. Urodynam. 35:487-491, 2016. © 2015 Wiley Periodicals, Inc.

Urinary incontinence (UI) is a very common problem, but existing guidelines on UI are not followed. To bring care in line with guidelines, we planned an intervention to involve nurse specialists on UI in primary care and assessed this in a randomised controlled trial. Alongside this intervention, we assessed consumer satisfaction among patients and general practitioners (GPs).Patients' satisfaction with the care provided by either nurse specialists (intervention group) or GPs (control group), respectively, was measured with a self-completed questionnaire. GPs' views on the involvement of nurse specialists were measured in a structured telephone interview.The patient satisfaction score on the care offered by nurse specialists was 8.4 (scale 1-10), vs. 6.7 for care-as-usual by GPs. Over 85% of patients would recommend nurse specialist care to their best friends and 77% of the GPs considered the role of the nurse specialist to be beneficial, giving it a mean score of 7.2.Although the sample was relatively small and the stability of the results only provisionally established, substituting UI care from GP to nurse specialist appears to be welcomed by both patients and GPs. Small changes like giving additional UI-specific information and devoting more attention to UI (which had been given little attention before) would provide a simple instrument to stimulate patients to change their behaviour in the right direction.

Urinary incontinence is a common problem, affecting quality of life and leading to high costs. There is doubt about the use of clinical practice guidelines on urinary incontinence in primary care.To assess adherence levels and reasons for (non)adherence to the Guideline on Urinary Incontinence of the Dutch College of General Practitioners. Design, setting and participants A postal survey among Dutch general practitioners (GPs).Adherence of GPs to the guideline.We analysed 264 questionnaires. Almost all GPs adhered to the guideline when diagnosing the type of urinary incontinence. A bladder diary is not often used (35%). Adherence to therapeutic procedures was only high for mild/moderate stress urinary incontinence: most GPs (82.6%) used adequate advice on bladder retraining and pelvic floor muscle training. One out of four GPs agreed that adhering to the guideline is difficult, mainly owing to lack of time, staff, diagnostic tools, competences to provide this care and low motivation of patients.Dutch GPs follow the guideline only partially: compliance with diagnostic advices is fairly good; compliance with treatment advices is low. Further research should focus on solutions how to support GPs to tackle major barriers to facilitate the adherence to guidelines (substitution of tasks to specialized nurses, reducing the threshold for referral and concentrating expertise in integrated continence care services).

Object. The aim of this study was to evaluate the long-term effects of unilateral pallidal stimulation on motor function in selected patients with advanced Parkinson disease (PD). Methods. The authors enrolled 26 patients with idiopathic PD in whom there was an asymmetric distribution of symptoms and, despite optimal pharmocological treatment, severe response fluctuations and/or dyskinesias. After the patient had received a local anesthetic agent, a quadripolar electrode (Medtronic model 3387) was implanted at the side opposite the side affected or, if both sides were affected, the side contralateral to the more affected side. No serious complications occurred. After 3 months, the total Unified PD Rating Scale (UPDRS) Part III score decreased by 50.7% while patients were in the off-medication state (from 26.5 ± 9.2 to 13.1 ± 6.1) and by 55.4% while they were in the on-medication state (from 10.6 ± 6.3 to 4.7 ± 4.4). Only during the on state was the contralateral effect clearly more pronounced. The UPDRS Part IVa score decreased by 75% (from 3.7 ± 2.5 to 0.9 ± 1.1) and the UPDRS Part IVb score by 54.7% (from 3.3 ± 1.3 to 1.5 ± 1.3). At long-term follow-up review (32.7 ± 10.7 months), there was an 8.3% increase in the UPDRS Part III score while patients were in the off state (from 26.5 ± 9.2 to 28.7 ± 7.6) and a 40.2% increase in this score while patients were in the on state (from 10.6 ± 6.3 to 14.9 ± 5.1). The UPDRS Part IVa score decreased by 28.1% (from 3.7 ± 2.5 to 2.7 ± 2.3) and the UPDRS Part IVb score increased by 3.5% (from 3.3 ± 1.3 to 3.4 ± 1.6). Conclusions. Based on these unsatisfactory results at long-term review, the authors conclude that unilateral pallidal stimulation is not an effective treatment option for patients with advanced PD.

To investigate the number of cells to be counted in cytocentrifuged bronchoalveolar lavage (BAL) fluid preparations in order to reach a reliable enumeration of each cell type.A total of 136 BAL fluid samples for patients with suspected pneumonia or interstitial lung disease were investigated. Differential cell counts were performed on May-Grünwald-Giemsa-stained cytocentrifuged preparations by 2 observers, each differentiating 500 cells. Reliability for the enumeration of each cell type was expressed as phi value, as calculated in generalizability theory.For polymorphonuclear neutrophils (PMNs), alveolar macrophages, lymphocytes and eosinophils, an acceptable phi value ofor = .95 was reached at a count of 300 cells by 1 observer. Mast cells reached a phi value of only .674 at a count of 500 cells by 1 observer, precluding a reliable count. At a count of 500 cells by 1 observer, squamous epithelial cells, bronchial epithelial cells and plasma cells displayed phi values of .868, .903 and .816, respectively.At a count of 300 cells, PMNs, alveolar macrophages, lymphocytes and eosinophils are reliably enumerated in cytocentrifuged BAL fluid samples.

Objective: Postoperative wound infections generally cause considerable extra morbidity, mortality and costs. As nowadays length of hospitalization shortens, post-discharge surveillance is important to get reliable information on the prevalence of postoperative wound infections. In this study, the prevalences of sternal wound (SWI) and donor site infections (DSI) during hospitalization as well as, 30 and 90 days after cardiac surgery were studied paying special attention to the contribution of post-discharge surveillance. Methods: A total of 1885 patients who underwent cardiac surgery were included in the study and were followed for the prevalence of SWI or DSI up to 90 days postoperatively. Infection data during hospitalization were collected using medical records, bacteriological results and systematic observations of infection control nurses. After discharge from the hospital, data were collected with the help of the out-patient clinic and the family physician. Results: After cardiac surgery, SWI and DSI were diagnosed in 4.7 and 1.5% of patients during hospitalization, in 6.8 and 4.6% at 30 days postoperatively, and in 9.0 and 7.3% of patients at 90 days postoperatively. Of the 90-days postoperative infections rates almost half of SWI and 80% of DSI were diagnosed post-discharge, a result predominantly achieved by the active participation of the family physicians. Conclusions: After 30 and 90 days follow-up of patients after cardiac surgery, additional sternal wound and donor site infections were diagnosed compared with the in-hospital infection rate. Post-discharge surveillance is essential for a reliable assessment of surgical wound infections.

In a survey on 26 clinical trials we have studied the reasons why some patients choose to participate in clinical trials while others decline. Interviews were held with 198 adult patients, just after they had been asked by the trial-clinician to participate. We interviewed patients who were asked to participate in a clinical trial, including those who decided not to participate. The theoretical guidelines to explain participation were based on an extended form of the Health Belief Model. Patients being asked to participate in a clinical trial decide by making a personal balance account. This comprises the physical and emotional added value patients hope to gain from the trial treatment compared to the non-trial treatment, minus the risks they expect in the trial and minus the extra time they expect the trial will take. The extent they feel physically threatened by their illness will also influence their decision. Furthermore, this personal balance account was found to depend on patient opinion about medical care and care-givers in general and on how patients regard their illness. Relatively long-term patients show a slightly different motivation to participate in a clinical trial than short-term patients. In line with the Health Belief Model, motivational beliefs on the relevance to reducing the threat to the patient's health condition ('values') and the evaluations of the clinical trial the patient is approached for ('expectancy'), are relevant in explaining patient behavior. Moreover, specific evaluative frames of reference are relevant in patients faced with the choice to participate or not. Suggestions are made to improve insight into patient motivation during the informed consent procedure of clinical trials.