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Background: This observational study investigates the role of value-based healthcare (VBHC) principles in executive decision-making in Dutch hospitals. Methods: A total of 379 questionnaires were sent to executives in 69 Dutch hospitals. The survey included questions prioritizing VBHC and other elements in decision-making and the weight and frequency at which each VBHC element was considered. Results: Responses were received from 82.6% of hospitals (57/69) and 26.9% of executives (102/379). 'Clinical outcomes' and 'costs' were most often considered in decision-making whereas 'integration of care delivery across separate facilities' and 'bundled payments' were considered the least. VBHC was reported as being considered in decision-making 8 out of 10 times and was given a median score of 8 out of 10. Members of the board of directors placed a higher priority on 'clinical outcomes', 'internal politics', 'the ambition of healthcare professionals' and 'integrating care delivery across separate facilities' and perceived that they include these elements more frequently than other direct colleagues. Conclusion: This study reveals that, although VBHC is generally considered in managerial decision-making, 'clinical outcomes' and 'costs' predominantly have priority. Action must be taken to ensure executives implement all VBHC elements in decision-making to maximize the effects of VBHC. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study is to assess the effects on procedural, 30-day, and 1‑year all-cause mortality by a newly introduced quality improvement strategy in patients after transcatheter aortic valve replacement (TAVR). Methods: In October 2015, a coherent set of quality improving interventions with respect to patient geriatric screening, general diagnostic examination and safety of the procedure was implemented at a single centre in the Netherlands. Patients undergoing TAVR in 2013–2018 were included for retrospective analysis. Mortality was assessed in the pre-quality improvement strategy cohort (January 2013 to October 2015; cohort A) and in the post-quality improvement strategy cohort (November 2015 to December 2018; cohort B). Logistic regression analysis was used to estimate the influence of patient and procedural characteristics on the results of the quality improvement strategy in terms of procedural, 30-day, and 1‑year all-cause mortality. Results: In total, 806 patients were analysed with 274 patients in cohort A and 532 patients in cohort B. After introduction of the quality improvement strategy, procedural (4.4% to 1.3%, p < 0.01), 30-day (8.4% to 2.7%, p < 0.01) and 1‑year (16.4% to 8.5%, p < 0.01) all-cause mortality significantly decreased. Multivariate regression analysis showed that the quality improvement strategy also significantly reduced 30-day (odds ratio [OR] 0.19, 95% confidence interval [CI] 0.09–0.42) and 1‑year (OR 0.38, 95% CI 0.24–0.61) all-cause mortality if corrected for patient characteristics. Conclusion: Structural meetings on evaluation of outcomes highlight potential areas for improvement and subsequent outcome-based quality improvement initiatives can result in lower procedural, 30-day, and 1‑year all-cause mortality. [ABSTRACT FROM AUTHOR]

Value-based healthcare has been introduced in 2006. Ten years later, this concept is adopted by a growing number of healthcare organizations. However, little is known about the practical implementation of value-based healthcare within hospitals. While working on the implementation of value-based healthcare in Dutch heart care, physicians are confronted with three main challenges that still need to be addressed to make value-based healthcare successful. First, it will require a shift in our thinking to actually use outcomes as drivers for quality improvement instead of as end points in scientific studies. Secondly, it will require tools for linking outcomes to quality of care processes enabling quicker and continuous improvement cycles. Finally, platforms are needed where benchmarking on outcomes is connected to an open learning and sharing environment where physicians can discuss good care delivery practices. [ABSTRACT FROM AUTHOR]

Background: Clinical quality registries (CQR) aid in measuring, collecting and monitoring outcome data but it is still unknown how these data are used by hospitals to improve the quality of care. This study assessed the current state of outcome-based quality improvement in the Netherlands in 2022 based on data from multiple disease areas and CQRs; cardiothoracic surgery (Netherlands Heart Registration [NHR]), cardiology (NHR), nephrology, (Nefrovision), intensive care (National Intensive Care Evaluation [NICE]), and orthopaedic surgery (Dutch Arthroplasty Register [LROI])., Methods & Results: The Health Outcomes Management Evaluation (HOME) model was used to assess the current state of outcome-based quality improvement. A questionnaire with 36 questions was sent to healthcare departments of the six disease areas in participating hospitals within five quality registrations in the Netherlands. In total, 124 responses were received; 20 within cardiology, 12 within cardiothoracic surgery, 30 within nephrology, 35 within intensive care and 27 within orthopaedic surgery. Results showed outcome measures were actively used to improve the quality of care, several improvement initiatives were implemented, but outcomes were not always monitored regularly. Results differed between hospitals, but differences were limited between disease areas., Conclusion: The current state of outcome-based quality improvement in all five disease areas is that outcome measures were consequently employed and used on a frequent basis aiming to achieve quality improvement in healthcare. Results can be improved by structurally embedding the entire improvement cycle into the organisation., (© 2024. The Author(s).)

This study examines, from a legal standpoint, the conditions under which patient data may be shared and processed by clinical quality registries in the Netherlands and investigates the potential impact of the proposed changes of the Healthcare Quality, Complaints and Disputes Act (WKKGZ) on these practices. Healthcare providers in the Netherlands may share patient data with clinical quality registries to measure and improve care quality, provided they have explicit patient consent or a legal basis. While there is general consensus within the field, legal ambiguity remains regarding processing data without explicit consent. Proposed changes to the WKKGZ would create an explicit legal basis for clinical quality registries to collect and process patient data without explicit consent, aiming to improve to improve the quality of care for the greater public interest.

Background and Aims: This study aimed to evaluate clinical outcomes in patients developing post-operative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) and characterize variations in oral anticoagulation (OAC) use, benefits, and complications., Methods: A systematic search identified studies on new-onset POAF after CABG and OAC initiation. Outcomes included risks of thromboembolic events, bleeding, and mortality. Furthermore, a meta-analysis was conducted on these outcomes, stratified by the use or non-use of OAC., Results: The identified studies were all non-randomized. Among 1 698 307 CABG patients, POAF incidence ranged from 7.9% to 37.6%. Of all POAF patients, 15.5% received OAC. Within 30 days, thromboembolic events occurred at rates of 1.0% (POAF: 0.3%; non-POAF: 0.8%) with 2.0% mortality (POAF: 1.0%; non-POAF: 0.5%). Bleeding rates were 1.1% for POAF patients and 2.7% for non-POAF patients. Over a median of 4.6 years, POAF patients had 1.73 thromboembolic events, 3.39 mortality, and 2.00 bleeding events per 100 person-years; non-POAF patients had 1.14, 2.19, and 1.60, respectively. No significant differences in thromboembolic risks [effect size -0.11 (-0.36 to 0.13)] and mortality [effect size -0.07 (-0.21 to 0.07)] were observed between OAC users and non-users. However, OAC use was associated with higher bleeding risk [effect size 0.32 (0.06-0.58)]., Conclusions: In multiple timeframes following CABG, the incidence of complications in patients who develop POAF is low. The use of OAC in patients with POAF after CABG is associated with increased bleeding risk., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Type I and type II diabetes mellitus (DM) patients have a higher prevalence of cardiovascular diseases, as well as a higher mortality risk of cardiovascular diseases and interventions. This study provides an update on the impact of DM on clinical outcomes, including mortality, complications and reinterventions, using data on percutaneous and surgical cardiac interventions in the Netherlands., Methods: This is a retrospective, nearby nationwide study using real-world observational data registered by the Netherlands Heart Registration (NHR) between 2015 and 2020. Patients treated for combined or isolated coronary artery disease (CAD) and aortic valve disease (AVD) were studied. Bivariate analyses and multivariate logistic regression models were used to evaluate the association between DM and clinical outcomes both unadjusted and adjusted for baseline characteristics., Results: 241,360 patients underwent the following interventions; percutaneous coronary intervention(N = 177,556), coronary artery bypass grafting(N = 39,069), transcatheter aortic valve implantation(N = 11,819), aortic valve replacement(N = 8,028) and combined CABG and AVR(N = 4,888). The incidence of DM type I and II was 21.1%, 26.7%, 17.8%, 27.6% and 27% respectively. For all procedures, there are statistically significant differences between patients living with and without diabetes, adjusted for baseline characteristics, at the expense of patients with diabetes for 30-days mortality after PCI (OR = 1.68; p <.001); 120-days mortality after CABG (OR = 1.35; p <.001), AVR (OR = 1.5; p <.03) and CABG + AVR (OR = 1.42; p =.02); and 1-year mortality after CABG (OR = 1.43; p <.001), TAVI (OR = 1.21; p =.01) and PCI (OR = 1.68; p <.001)., Conclusion: Patients with DM remain to have unfavourable outcomes compared to nondiabetic patients which calls for a critical reappraisal of existing care pathways aimed at diabetic patients within the cardiovascular field., (© 2024. The Author(s).)

Aims: Heart failure (HF) registries provide valuable insights into patient management and quality of care. However, healthcare professionals face challenges due to the administrative burden of participation in registries. This study aims to evaluate the impact of education through an engagement toolkit on HF nurse practitioners' participation rate and data completeness in a national registry: the Netherlands Heart Registration-Heart Failure (NHR-HF) registry., Methods and Results: Engage-HF is an observational study (intervention at the HF nurse level) with a pretest-posttest design within the participating hospitals. Between December 2022 and April 2024, 28 HF nurse practitioners from 12 hospitals will participate in a 24-week educational programme using the Engage-HF engagement toolkit. The main interaction platform in this toolkit is a gamified smartphone-based educational application called BrightBirds. The complete toolkit includes this educational application with weekly challenges, interactive posters, pop-ups, and alert messages, and a follow-up call at Week 4. The primary endpoints are the NHR-HF participation rates and data completeness at 1 and 6 months after using the toolkit. Additionally, we will analyse the experience of participants with the toolkit concerning their HF registry and knowledge of ESC 2021 HF guidelines., Conclusion: The Engage-HF study is the first to explore the impact of education through a gamified engagement toolkit to boost participation rates in a HF registry (NHR-HF) and test participant knowledge of the ESC 2021 HF guidelines. This innovative approach addresses challenges in the rollout of healthcare registries and the implementation of guidelines by providing a contemporary support base and a time-efficient method for education., Competing Interests: Conflict of interest: J.S. received payment for lectures/presentations/consultancy outside the scope of the submitted work from Boehringer Ingelheim, Daiichi Sankyo, AstraZeneca, General Electric, and Novo Nordisk. R.M.A.v.d.B. received an independent research grant and speaker fees from Abbott to the institute outside the scope of the submitted work. J.J.B. received an independent research grant for ISS from Abbott to the institute and has had speaker engagement or advisory boards in the past 5 years with AstraZeneca, Abbott, Boehringer Ingelheim, Bayer, Daiichi Sankyo, Novartis, and Vifor. L.M.H. received a grant from the Dutch Heart Foundation (2020T058), Netherlands CardioVascular Research Initiative (CVON; 2020B008), and a Vifor Pharma investigator-initiated grant. Furthermore, he received speaker/consultancy fees from Novartis, Boehringer Ingelheim, Daiichi Sankyo, Vifor Pharma, AstraZeneca, Bayer, MSD, Abbott, and Quin, all not related to this work. J.W.C.B. received speaker fees from Abbott, AstraZeneca, Boehringer Ingelheim, and Novartis. R.v.K. received speaker fees from Novartis and Bayer. F.W.A. and D.v.V., as a representative of the Heart4Data consortium, received funding from the Dutch Heart Foundation and ZonMw (2021-B2015) to the institute as a part of the funding for this study. C.E.E.v.O.-H. is a board member of NVVC, audit committee in FMS, and ESC Heart Academy Alumni. R.P. received grants from NovoNordisk to the institution outside the scope of this study., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

This paper presents an overview of the development of an integrated patient-centred cardiac care registry spanning the initial 5 years (September 2017 to December 2022). The Netherlands Heart Registration facilitates registration committees in which mandated cardiologists and cardiothoracic surgeons structurally evaluate quality of care using real-world data. With consistent attendance rates exceeding 60%, a valuable network is supported. Over time, the completeness level of the registry has increased. Presently, four out of six quality registries show over 95% completeness in variables that are part of the quality policies of cardiology and cardiothoracic surgery societies. Notably, 93% of the centres voluntarily report outcomes related to open heart surgery and (trans)catheter interventions publicly. Moreover, outcomes after implantable cardioverter-defibrillator and pacemaker procedures are transparently reported by 26 centres. Multiple innovation projects have been initiated by the committees, signalling a shift from publishing outcomes transparently to collaborative efforts in sharing healthcare processes and investigating improvement initiatives. The next steps will focus on the entire pathway of cardiac care for a specific medical condition instead of focusing solely on the outcomes of the procedures. This redirection of focus to a comprehensive assessment of the patient pathway in cardiac care ultimately aims to optimise outcomes for all patients., (© 2024. The Author(s).)

Objectives: The aim of this study was to describe trends and outcomes for patients undergoing surgical aortic valve replacement (SAVR) in the Netherlands., Methods: The Netherlands Heart Registration database was used to report the number and outcomes of isolated, primary SAVR procedures performed from 2007 to 2018 in adult patients., Results: A total of 17 142 procedures were included, of which 77.9% were performed using a biological prosthesis and 21.0% with a mechanical prosthesis. Median logistic EuroSCORE I decreased from 4.6 [interquartile range (IQR) 2.4-7.7] to 4.0 (IQR 2.6-6.0). The 120-day mortality decreased from 3.3% in 2007 to 0.7% in 2018. The median duration of follow-up was 76 months (IQR 53-111). Ten-year survival, when adjusted for age, EuroSCORE I and body surface area, was 72.4%, and adjusted 10-year freedom from reinvervention was 98.1%. Additional analysis for patients under the age of 60 showed no difference between patients treated with a biological or mechanical prosthesis in adjusted 10-year survival, 89.7% vs 91.9±%, respectively (P = 0.25), but a significant difference in adjusted 10-year freedom from reintervention, 90.0±% vs 95.9%, respectively (P < 0.01)., Conclusions: Between 2007 and 2018, age and risk profile of patients undergoing SAVR decreased, especially for patients treated with a biological prosthesis. The 120-day mortality decreased over time. Patients undergoing SAVR nowadays have a risk of 120-day mortality of <1% and 10-year freedom from valve-related reintervention of >95%., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Introduction: Atrial fibrillation often necessitates catheter ablation when antiarrhythmic drug therapy fails. Single-shot technologies using thermal energy, such as cryoballoon ablation, are commonly used, but pulsed field ablation (PFA), an innovative non-thermal ablation technique, is a potential alternative. This retrospective observational study aimed to compare the safety and efficacy of cryoballoon ablation and PFA in patients undergoing their first pulmonary vein isolation (PVI) procedure for atrial fibrillation treatment., Methods: We utilised real-world data from patients who underwent PVI using cryoballoon ablation or PFA. The primary outcome encompassed procedural complications, including phrenic nerve palsy, cardiac tamponade, thromboembolic complications, bleeding complications and mortality. Secondary outcomes were procedural characteristics including procedure duration, length of hospital admission, and re-do ablation rates within 6 months., Results: A total of 1714 procedures were analysed: 1241 in the cryoballoon group and 473 in the PFA group. Gender distribution (p = 0.03) and estimated glomerular filtration rate (p = 0.01) differed significantly. With regard to the primary outcome, the cryoballoon group demonstrated a higher incidence of phrenic nerve palsy compared with the PFA group (15 vs 0; p = 0.02). The procedure duration was shorter in the PFA group, even after adjusting for baseline characteristics (95.0 vs 74.0 min; p < 0.001). After adjustment for baseline characteristics, admission duration differed between the groups as well (p = 0.04)., Conclusion: The study results supported the safety and efficacy of PFA over cryoballoon ablation for PVI, highlighting advantages such as shorter procedure duration and absence of phrenic nerve palsy., (© 2024. The Author(s).)

Randomised clinical trials (RCTs) are vital for medical progress. Unfortunately, 'traditional' RCTs are expensive and inherently slow. Moreover, their generalisability has been questioned. There is considerable overlap in routine health care data (RHCD) and trial-specific data. Therefore, integration of RHCD in an RCT has great potential, as it would reduce the effort and costs required to collect data, thereby overcoming some of the major downsides of a traditional RCT. However, use of RHCD comes with other challenges, such as privacy issues, as well as technical and practical barriers. Here, we give a current overview of related initiatives on national cardiovascular registries (Netherlands Heart Registration, Heart4Data), showcasing the interrelationships between and the relevance of the different registries for the practicing physician. We then discuss the benefits and limitations of RHCD use in the setting of a pragmatic RCT from a cardiovascular perspective, illustrated by a case study in heart failure., (© 2024. The Author(s).)

Objective: Prehospital risk stratification and triage are currently not performed in patients suspected of non-ST-segment elevation acute coronary syndrome (NSTE-ACS). This may lead to prolonged time to revascularisation, increased duration of hospital admission and higher healthcare costs. The preHEART score (prehospital history, ECG, age, risk factors and point-of-care troponin score) can be used by emergency medical services (EMS) personnel for prehospital risk stratification and triage decisions in patients with NSTE-ACS. The aim of the current study was to evaluate the effect of prehospital risk stratification and direct transfer to a percutaneous coronary intervention (PCI) centre, based on the preHEART score, on time to final invasive diagnostics or culprit revascularisation., Methods: Prospective, multicentre, two-cohort study in patients with suspected NSTE-ACS. The first cohort is observational (standard care), while the second (interventional) cohort includes patients who are stratified for direct transfer to either a PCI or a non-PCI centre based on their preHEART score. Risk stratification and triage are performed by EMS personnel. The primary endpoint of the study is time from first medical contact until final invasive diagnostics or revascularisation. Secondary endpoints are time from first medical contact until intracoronary angiography (ICA), duration of hospital admission, number of invasive diagnostics, number of inter-hospital transfers and major adverse cardiac events at 7 and 30 days., Results: A total of 1069 patients were included. In the interventional cohort (n=577), time between final invasive diagnostics or revascularisation (42 (17-101) hours vs 20 (5-44) hours, p<0.001) and length of hospital admission (3 (2-5) days vs 2 (1-4) days, p=0.007) were shorter than in the observational cohort (n=492). In patients with NSTE-ACS in need for ICA or revascularisation, healthcare costs were reduced in the interventional cohort (€5599 (2978-9625) vs €4899 (2278-5947), p=0.02)., Conclusion: Prehospital risk stratification and direct transfer to a PCI centre, based on the preHEART score, reduces time from first medical contact to final invasive diagnostics and revascularisation, reduces duration of hospital admission and decreases healthcare costs in patients with NSTE-ACS in need for ICA or revascularisation., Trial Registration: NCT05243485., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: Current heart failure (HF) guidelines recommend to prescribe four drug classes in patients with HF with reduced ejection fraction (HFrEF). A clear challenge exists to adequately implement guideline-directed medical therapy (GDMT) regarding the sequencing of drugs and timely reaching target dose. It is largely unknown how the paradigm shift from a serial and sequential approach for drug therapy to early parallel application of the four drug classes will be executed in daily clinical practice, as well as the reason clinicians may not adhere to new guidelines. We present the design and rationale for the real-world TITRATE-HF study, which aims to assess sequencing strategies for GDMT initiation, dose titration patterns (order and speed), intolerance for GDMT, barriers for implementation, and long-term outcomes in patients with de novo, chronic, and worsening HF., Methods and Results: A total of 4000 patients with HFrEF, HF with mildly reduced ejection fraction, and HF with improved ejection fraction will be enrolled in >40 Dutch centres with a follow-up of at least 3 years. Data collection will include demographics, physical examination and vital parameters, electrocardiogram, laboratory measurements, echocardiogram, medication, and quality of life. Detailed information on titration steps will be collected for the four GDMT drug classes. Information will include date, primary reason for change, and potential intolerances. The primary clinical endpoints are HF-related hospitalizations, HF-related urgent visits with a need for intravenous diuretics, all-cause mortality, and cardiovascular mortality., Conclusions: TITRATE-HF is a real-world multicentre longitudinal registry that will provide unique information on contemporary GDMT implementation, sequencing strategies (order and speed), and prognosis in de novo, worsening, and chronic HF patients., (© 2023 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of European Society of Cardiology.)

Objectives: This study evaluates clinical outcomes after implementing a liberal post-dilatation strategy during PCI., Background: Post-dilatation after percutaneous coronary intervention (PCI) is performed to achieve optimal stent expansion and reduce complications. However, its prognostic effects are unclear and conflicting., Methods: This study is a pre-post-intervention analysis of two cohorts, before (2015-2017) and after (2018-2020) implementation of a liberal post-dilatation strategy. The primary end point consisted of major adverse cardiovascular events (MACE) at 30 days. Secondary end points consisted of the individual components of the primary end point as well as 1 year mortality and target vessel revascularization., Results: A total of 10,153 patients were included: 5,383 in the pre-cohort and 4,770 in the post-cohort. The 30-day MACE was 5.00% in the pre-cohort and 4.09% in the post-cohort (p = 0.008; OR 0.75 (CI 0.61-0.93)). There was a significant difference between the pre- and post-cohort in 30-day mortality, respectively, 2.91% and 2.25% (p = .01; OR 0.70 (CI 0.53-0.93)), and MI at 30 days, 1.17% versus 0.59% (p = .003; OR 0.49 (CI 0.31-0.78)). At 1 year, there was a significant difference in mortality between the pre-cohort, 5.84%, and post-cohort, 5.19% (p = .02; OR 0.79 (CI 0.66-0.96))., Conclusions: A liberal post-dilatation strategy after PCI was associated with a significant decrease in 30-day MACE, 30-day MI, 30-day mortality, and 1-year mortality. Future studies are warranted to validate the causality between post-dilatation and improvement of clinical outcomes., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to declare., (Copyright © 2023 Hellenic Society of Cardiology. Published by Elsevier B.V. All rights reserved.)

Evidence on the potential for value-based payment models to improve quality of care and ensure more efficient outcomes is limited and mixed. We aim to identify the factors that enhance or inhibit the design, implementation, and application of these models through a systematic literature review. We used the PRISMA guidelines. The facilitating and inhibiting factors were divided into subcategories according to a theoretical framework. We included 143 publications, each reporting multiple factors. Facilitators on objectives and strategies, such as realistic/achievable targets, are reported in 56 studies. Barriers regarding dedicated time and resources (e.g., an excessive amount of time for improvements to manifest) are reported in 25 studies. Consensus within the network regarding objectives and strategies, trust, and good coordination is essential. Health care staff needs to be kept motivated, well-informed, and actively involved. In addition, stakeholders should manage expectations regarding when results are expected to be achieved.

Background and Objective: Routine outcome monitoring is becoming standard in care evaluations, but costs are still underrepresented in these efforts. The primary aim of this study was therefore to assess if patient-relevant cost drivers can be used alongside clinical outcomes to evaluate an improvement project and to provide insight into (remaining) areas for improvement., Methods: Data from patients who underwent transcatheter aortic valve implantation (TAVI) between 2013 and 2018 at a single center in the Netherlands were used. A quality improvement strategy was implemented in October 2015, and pre- (A) and post-quality improvement cohorts (B) were distinguished. For each cohort, clinical outcomes, quality of life (QoL), and cost drivers were collected from the national cardiac registry and hospital registration data. The most appropriate cost drivers in TAVI care were selected from hospital registration data using a novel stepwise approach with an expert panel of physicians, managers, and patient representatives. A radar chart was used to visualize the clinical outcomes, QoL and the selected costs drivers., Results: We included 81 patients in cohort A and 136 patients in cohort B. All-cause mortality at 30 days was borderline significantly lower in cohort B than in cohort A (1.5% vs 7.4%, P = .055). QoL improved after TAVI for both cohorts. The stepwise approach resulted in 21 patient-relevant cost drivers. Costs for pre-procedural outpatient clinic visits (€535, interquartile range [IQR] = 321-675, vs €650, IQR = 512-890, P < .001), costs for the procedure (€1354, IQR = 1236-1686, vs €1474, IQR = 1372-1620, P < .001), and imaging during admission (€318, IQR = 174-441, vs €329, IQR = 267-682, P = .002) were significantly lower in cohort B than in cohort A. Possible improvement potential was seen in 30-day pacemaker implantation and 120-day readmission., Conclusion: A selection of patient-relevant cost drivers is a valuable addition to clinical outcomes for use in evaluation of improvement projects and identification of room for further improvement., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

The introduction of dedicated tools for pacing and defibrillator lead extraction has resulted in relatively high success and low complication rates. The confidence this elicits has broadened the indications from device infections to non-functional or redundant leads and the latter make up an increasing share of extraction procedures. Proponents of extracting these leads point to the higher complication burden of lead extraction in patients with longstanding abandoned leads when compared one-to-one with extraction when these leads become redundant. However, this does not translate into better patient outcomes on a population level: complications are rare with properly abandoned leads and thus most patients will never be subjected to an extraction procedure and the ensuing complications. Therefore, not extracting redundant leads minimises the risk for the patients and avoids many expensive procedures., (© 2023. The Author(s).)

Background: The differences in outcomes and process parameters for NSTEMI patients who are directly admitted to an intervention centre and patients who are first admitted to a general centre are largely unknown., Hypothesis: There are differences in process indicators, but not for clinical outcomes, for NSTEMI who are directly admitted to an intervention centre and patients who are first admitted to a general centre., Methods: We aim to compare process indicators, costs and clinical outcomes of non-ST-segment elevation myocardial infarction (NSTEMI) patients stratified by center of first presentation and revascularisation strategy. Hospital claim data from patients admitted with a NSTEMI between 2017 and 2019 were used for this study. Included patients were stratified by center of admission (intervention vs. general center) and subdivided by revascularisation strategy (PCI, CABG, or no revascularisation [noRevasc]). The primary outcome was length of hospital stay. Secondary outcomes included: duration between admission and diagnostic angiography and revascularisation, number of intracoronary procedures, clinical outcomes at 30 days (MACE: all-cause mortality, recurrent myocardial infarction and cardiac readmission) and total costs (accumulation of costs for hospital claims and interhospital ambulance rides)., Results: A total of 9641 NSTEMI events (9167 unique patients) were analyzed of which 5399 patients (56%) were admitted at an intervention center and 4242 patients to a general center. Duration of hospitalization was significantly shorter at direct presentation at an intervention centre for all study groups (5 days [2-11] vs. 7 days [4-12], p < 0.001). For PCI, direct presentation at an intervention center yielded shorter time to diagnostic angiography (1 day [0-2] vs. 1 day [1-2], p < 0.01) and revascularisation (1 day [0-3] vs. 4 days [1-7], p < 0.001) and less intracoronary procedures per patient (2 [1-2] vs. 2 [2-2], p < 0.001). For CABG, time to revascularisation was shorter (8 days [5-12] vs. 10 days [7-14], p < 0.001). Total costs were significantly lower in case of direct presentation in an intervention center for all treatment groups €10.211 (8750-18.192) versus €13.741 (11.588-19.381), p < 0.001) while MACE was similar 11.8% versus 12.4%, p = 0.344)., Conclusion: NSTEMI patients who were directly presented to an intervention center account for shorter duration of hospitalization, less time to revascularisation, less interhospital transfers, less intracoronary procedures and lower costs compared to patients who present at a general center., (© 2023 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Background: In this study, the prognostic value of AF-related quality of life (AFEQT) at baseline on Major Adverse Cardiovascular Events (MACE) and improvement of perceived symptoms (EHRA) was assessed. Furthermore, the relationship between QoL and AF-related hospitalizations was assessed., Methods: A cohort of AF-patients diagnosed between November 2014 and October 2019 in four hospitals embedded within the Netherlands Heart Network were prospectively followed for 12 months. MACE was defined as stroke, myocardial infarction, heart failure and/or mortality. Subsequently, MACE, EHRA score improvement and AF-related hospitalizations between baseline and 12 months of follow-up were recorded., Results: In total, 970 AF-patients were available for analysis. In analyses with patients with complete information on the confounder subset 36/687 (5.2%) AF-patients developed MACE, 190/432 (44.0%) improved in EHRA score and 189/510(37.1%) were hospitalized during 12 months of follow-up. Patients with a low AFEQT score at baseline more often developed MACE (OR(95%CI): 2.42(1.16-5.06)), more often improved in EHRA score (OR(95%CI): 4.55(2.45-8.44) and were more often hospitalized (OR(95%CI): 4.04(2.22-7.01)) during 12 months post diagnosis, compared to patients with a high AFEQT score at baseline., Conclusions: AF-patients with a lower quality of life at diagnosis more often develop MACE, more often improve on their symptoms and also were more often hospitalized, compared to AF-patients with a higher quality of life. This study highlights that the integration of patient-reported outcomes, such as quality of life, has the potential to be used as a prognostic indicator of the expected disease course for AF., (© 2023. The Author(s).)

Worldwide, quality registries for cardiovascular diseases enable the use of real-world data to monitor and improve the quality of cardiac care. In the Netherlands Heart Registration (NHR), cardiologists and cardiothoracic surgeons register baseline, procedural and outcome data across all invasive cardiac interventional, electrophysiological and surgical procedures. This paper provides insight into the governance and processes as organised by the NHR in collaboration with the hospitals. To clarify the processes, examples are given from the percutaneous coronary intervention and coronary artery bypass grafting registries. Physicians who are mandated by their hospital to instruct the NHR to process their data are united in registration committees. The committees determine standard sets of variables and periodically discuss the completeness and quality of data and patient-relevant outcomes. In the case of significant variation in outcomes, processes of healthcare delivery are discussed and good practices are shared in a non-competitive and safe setting. To create new insights for further improvement in patient-relevant outcomes, quality projects are initiated on, for example, multivessel disease treatment, cardiogenic shock and diagnostic intracoronary procedures. Moreover, possibilities are explored to expand the quality registries through additional relevant indicators, such as resource use before and after the procedure, by enriching NHR data with other existing data resources., (© 2022. The Author(s).)

Aims: Patient-reported outcome measures (PROMs) to assess health-related quality of life (HRQoL) are increasingly used to guide decision-making in cardiovascular care. However, many of the existing PROMs are developed with limited patient involvement and overlook personal health preferences. We aim to develop a cardiovascular disease (CVD)-specific patient-centred preference-based PROM to assess and monitor HRQoL in CVD patients., Methods and Results: A mixed-methods study consisting of several phases was conducted to identify important health items: (i) a scoping literature review, (ii) first- and second-round expert group meetings, (iii) interviews with CVD patients, and (iv) an online survey asking CVD patients to indicate from a large set those health items that are considered the most important. The literature review, expert group meetings, and patient interviews resulted in a list of 55 items potentially important to CVD patients. In total, 666 CVD patients responded to the survey. The following nine items were considered the most important by CVD patients: mobility, activities, self-reliance, fatigue, shortness of breath, chest pain, palpitations, anxiety/worrying, and sexual limitations. An electronic preference-based PROM consisting of these nine items was developed within a cloud-based environment for clinical implementation., Conclusion: Nine items considered the most important for health by CVD patients were identified and included in a new preference-based patient-centred PROM. This new CVD-specific PROM can be easily implemented using the electronic application and has the potential to improve quality of care for CVD patients., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: A group of heart centres in the Netherlands have been at the forefront internationally to implement the principles of value-based healthcare. This study aims to give an up-to-date assessment of outcome-based quality improvement in 2020 at a national level in Dutch heart care., Methods and Results: Physicians and healthcare professionals for each participating hospital filled out a questionnaire with 26 detailed questions on quality improvement and organization of care. In total, 20 hospitals participated; 11 heart centres with thoracic surgery and 9 without thoracic surgery. Results show that outcome reports are actively used within the heart centres to support quality improvement initiatives. In 50% of the centres, apart from physicians, also nurses and hospital management are involved. For 60% of the heart centres, outcome measurement is embedded in strategy and annual plans. The stage of development of supporting IT infrastructure (outcome measurement in the Electronic Health Record and dashboards) is very diverse. A wide range of different learning strategies supports outcome-based quality improvement., Conclusion: Health outcomes have become a relevant element in quality improvement and organization of Dutch heart centres. Earlier research shows that in 2012-2016 heart centres focused mainly on measuring outcomes. Now in 2020, heart centres are more able to actually use the acquired insights based on these measurements to initiate improvement projects. The diversity in how this is done indicates that this field is still strongly developing and shows potential for heart centres to share best practices in the implementation of value-based healthcare., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Heart failure (HF) is a major health concern, which accounts for 1-2% of all hospital admissions. Nevertheless, there remains a knowledge gap concerning which interventions contribute to effective prevention of HF (re)hospitalization. Therefore, this umbrella review aims to systematically review meta-analyses that examined the effectiveness of interventions in reducing HF-related (re)hospitalization in HFrEF patients. An electronic literature search was performed in PubMed, Web of Science, PsycInfo, Cochrane Reviews, CINAHL, and Medline to identify eligible studies published in the English language in the past 10 years. Primarily, to synthesize the meta-analyzed data, a best-evidence synthesis was used in which meta-analyses were classified based on level of validity. Secondarily, all unique RCTS were extracted from the meta-analyses and examined. A total of 44 meta-analyses were included which encompassed 186 unique RCTs. Strong or moderate evidence suggested that catheter ablation, cardiac resynchronization therapy, cardiac rehabilitation, telemonitoring, and RAAS inhibitors could reduce (re)hospitalization. Additionally, limited evidence suggested that multidisciplinary clinic or self-management promotion programs, beta-blockers, statins, and mitral valve therapy could reduce HF hospitalization. No, or conflicting evidence was found for the effects of cell therapy or anticoagulation. This umbrella review highlights different levels of evidence regarding the effectiveness of several interventions in reducing HF-related (re)hospitalization in HFrEF patients. It could guide future guideline development in optimizing care pathways for heart failure patients., (© 2022. The Author(s).)

Background: Health care utilization after coronary artery bypass graft (CABG) surgery is high and is partly of an unplanned nature. eHealth applications have been proposed to reduce care consumption, which involve and assist patients in their recovery. In this way, health care expenses could be reduced and quality of care could be improved., Objective: The aim of this study was to evaluate if an eHealth program can reduce unplanned health care utilization and improve mental and physical health in the first 6 weeks after CABG surgery., Methods: A single-blind randomized controlled trial was performed, in which patients scheduled for nonacute CABG surgery were included from a single center in the Netherlands between February 2020 and October 2021. Participants in the intervention group had, alongside standard care, access to an eHealth program consisting of online education videos and video consultations developed in conjunction with the Dutch Heart Foundation. The control group received standard care. The primary outcome was the volume and costs of a composite of unplanned health care utilization, including emergency department visits, outpatient clinic visits, rehospitalization, patient-initiated telephone consultations, and visits to a general practitioner, measured using the Medical Technology Assessment Medical Consumption Questionnaire. Patient-reported anxiety and recovery were also assessed. Intention-to-treat and "users-only" analyses were used., Results: During the study period, 280 patients were enrolled and randomly allocated at a 1:1 ratio to the intervention or control group. The intention-to-treat analysis consisted of 136 and 135 patients in the intervention and control group, respectively. At 6 weeks, the primary endpoint had occurred in 43 of 136 (31.6%) patients in the intervention group and in 61 of 135 (45.2%) patients in the control group (hazard ratio 0.56, 95% CI 0.34-0.92). Recovery was faster in the intervention group, whereas anxiety was similar between study groups. "Users-only" analysis yielded similar results., Conclusions: An eHealth strategy comprising educational videos and video consultations can reduce unplanned health care utilization and can aid in faster patient-reported recovery in patients following CABG surgery., Trial Registration: Netherlands Trial Registry NL8510; https://trialsearch.who.int/Trial2.aspx?TrialID=NL8510., International Registered Report Identifier (irrid): RR2-10.1007/s12471-020-01508-9., (©Gijs van Steenbergen, Dennis van Veghel, Dideke van Lieshout, Merel Sperwer, Joost ter Woorst, Lukas Dekker. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 26.08.2022.)

Background: Patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) are currently transported and admitted to the nearest emergency department (ED) for risk stratification, diagnostic workup and treatment. Although such patients with NSTE-ACS can benefit from direct transfer to a PCI center for early invasive treatment, no reliable prehospital triage tools are available. Recently, the PreHEART score has been validated in the PreHEART study for prehospital triage of patients with suspected NSTE-ACS., Methods: The primary objective of the TRIAGE-ACS study, a prospective cohort study, is to determine whether prehospital triage using the PreHEART score can significantly reduce time from first medical contact to final diagnostics and revascularization in patients in need of coronary revascularization. The first cohort (control cohort; n = 500) is observatory and is used as a reference group for the second cohort. In the second cohort (interventional cohort; n = 500) patients are stratified in the ambulance for direct transfer to either a PCI or a non-PCI center, based on the PreHEART score. These two cohorts will be compared with each other. In total, 1000 patients will be included. Follow-up for endpoints will be performed by reviewing the medical record after 30 days, 1 year, and 2 years., Conclusion: The TRIAGE-ACS study is the first prospective study to investigate the impact of prehospital triage using the PreHEART score on time to final invasive diagnostics and treatment in patients with NSTE-ACS in need of revascularization by transferring high risk patients directly to a PCI center and patients at a low risk of having an NSTE-ACS to a non-PCI center. Such triage strategy could potentially result in optimization of regional care for all ACS patients., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: In this study, the relationship between AF-related quality of life (AFEQT) at baseline in AF-patients and the improvement on perceived symptoms and general state of health (EHRA, European Heart Rhythm Association score) at 12 months was assessed across predefined age categories., Methods: Between November 2014 and October 2019 patients diagnosed with AF de novo in four hospitals embedded within the Netherlands Heart Network were prospectively followed for 12 months. These AF-patients were categorized into quartiles based on their AFEQT score at diagnosis and EHRA score was measured at diagnosis and 12 months of follow-up. Stratified analyses were performed using age categories (<65 vs. ≥65 years; <75 vs. ≥75 years)., Results: In total, 203/483 (42.0%) AF-patients improved in EHRA score after 12 months of follow-up. AF-patients in the lowest AFEQT quartile were more likely to improve, compared to patients in the highest AFEQT quartile (OR [95%CI]:4.73 [2.63-8.50]). Furthermore, patients ≥65 years and patients <75 years at diagnosis with lower AFEQT scores at baseline were most likely to improve in EHRA score after 12 months, compared to similarly aged patients with higher AFEQT scores at baseline., Conclusion: The present study indicates that AF-patients with a lower quality of life at diagnosis were most likely to improve their EHRA score after 12 months. This effect was most prominent in patients ≥65 years of age and patients <75 years of age, compared to patients >65 and ≥75 years, respectively. Future research should focus on further defining characteristics of these age groups to enable the implementation of age-tailored treatment., Competing Interests: All authors declare no conflicts of interest. The sponsors of the Netherlands Heart Network were not in any way involved in the design, conduct, analysis, or writing of this manuscript., (© 2022 The Authors. Journal of Arrhythmia published by John Wiley & Sons Australia, Ltd on behalf of the Japanese Heart Rhythm Society.)

Background: Minimal evidence is available of the reduction in healthcare utilization of remote care in ICD patients over a longer period of follow-up., Objectives: This study compared healthcare utilization up to 3 year follow-up in implantable cardioverter-defibrillator (ICD) patients with remote care compared to conventional care., Methods: We conducted a retrospective cohort study of patients who received a single or dual-chamber ICD or cardiac resynchronization therapy-defibrillator (CRT-D) between 2016 and 2018. Patients with remote care and patients were compared with patients with received conventional care (control group). The primary endpoint was a composite of cardiac follow-up visits, ICD follow-up visits, telephone consultations, emergency department (ED) visits and hospital admissions and was defined as total healthcare utilization. The secondary endpoints were the individual care activities and one-year all-cause mortality., Results: A total of 497 patients were included in the study, of which 299 patients were allocated to the remote care and 198 patients to the control group. Mean follow-up was 815 ± 279 days. Remote care was associated with a significantly lower rate of adjusted total healthcare utilization in comparison to the control group that sustained for 3 subsequent follow-up years (IRR = 0.78, 95% CI [0.67 to 0.92], p < .01). One-year all-cause mortality was similar between the remote care and control group (respectively 3.0% vs. 5.5%, p = .29)., Conclusions: Compared to the standard follow-up of in-office care, a remote care program was associated with a sustained lower rate of planned and unplanned healthcare utilization up to 3 subsequent years after ICD/CRT-D implantation., (© 2021 Wiley Periodicals LLC.)

Introduction: eHealth interventions have the potential to improve the quality of healthcare and reduce costs. However, to implement eHealth interventions successfully instruments are needed to facilitate this process. This study aims to develop an eHealth implementation guideline for implementation of eHealth interventions in daily practice., Methods: In June and July 2019 a literature research was conducted and, subsequently, a two-round Delphi study including 13 international eHealth experts in the field of healthcare, ICT & technology, and research was performed. Within the Delphi study, experts scored specific determinants using an online survey. Based on mean scores and interquartile ranges (IQRs) in the online survey, consensus between the experts was assessed., Results: A total of five domains (i.e., Technology, Acceptance, Financing, Organizational, and Legislation & Policy) with 24 corresponding determinants were assessed by the experts. After the second Delphi round, consensus was achieved on the five domains and 23 determinants (mean scores ≥ 8; IQR ≤ 2). Only for the determinant 'Evidence-Based Medicine' was no consensus reached (mean score < 8; IQR = 2). Based on the 23 determinants, the eHealth implementation guideline is developed for eHealth implementations in healthcare in order to increase their effectiveness., Conclusion: The eHealth implementation guideline developed in this study may help healthcare providers/researchers assess the determinants of successful eHealth intervention prior to the implementation of the eHealth program.