Key Points Question What is the association of a multifaceted intervention aimed at changing the mindset of caregivers with the amount of unnecessary laboratory testing? Findings In this before-after quality improvement study conducted in the internal medicine departments of 4 large teaching hospitals in the Netherlands, the volume of laboratory tests ordered per patient contact was reduced in all 4 departments by 11.4% overall. In contrast, volume increased by 2.4% in 19 comparable hospitals in the Netherlands. Meaning The approach used in this study can be used as a framework for future projects aiming to reduce unnecessary laboratory diagnostic tests in routine clinical practice.

ObjectivesTo develop predictive models for blood culture (BC) outcomes in an emergency department (ED) setting.DesignRetrospective observational study.SettingED of a large teaching hospital in the Netherlands between 1 September 2018 and 24 June 2020.ParticipantsAdult patients from whom BCs were collected in the ED. Data of demographic information, vital signs, administered medications in the ED and laboratory and radiology results were extracted from the electronic health record, if available at the end of the ED visits.Main outcome measuresThe primary outcome was the performance of two models (logistic regression and gradient boosted trees) to predict bacteraemia in ED patients, defined as at least one true positive BC collected at the ED.ResultsIn 4885 out of 51 399 ED visits (9.5%), BCs were collected. In 598/4885 (12.2%) visits, at least one of the BCs was true positive. Both a gradient boosted tree model and a logistic regression model showed good performance in predicting BC results with area under curve of the receiver operating characteristics of 0.77 (95% CI 0.73 to 0.82) and 0.78 (95% CI 0.73 to 0.82) in the test sets, respectively. In the gradient boosted tree model, the optimal threshold would predict 69% of BCs in the test set to be negative, with a negative predictive value of over 94%.ConclusionsBoth models can accurately identify patients with low risk of bacteraemia at the ED in this single-centre setting and may be useful to reduce unnecessary BCs and associated healthcare costs. Further studies are necessary for validation and to investigate the potential clinical benefits and possible risks after implementation.

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BackgroundLittle is known about the development of chronic Q fever in occupational risk groups. The aim of this study was to perform long-term follow-up of Coxiella burnetii seropositive veterinarians and investigate the course of IgG phase I and phase II antibodies against C. burnetii antigens and to compare this course with that in patients previously diagnosed with acute Q fever.MethodsVeterinarians with IgG phase I ≥1:256 (immunofluorescence assay) that participated in a previous seroprevalence study were asked to provide a second blood sample three years later. IgG antibody profiles were compared to a group of acute Q fever patients who had IgG phase I ≥1:256 twelve months after diagnosis.ResultsIgG phase I was detected in all veterinarians (n = 76) and in 85% of Q fever patients (n = 98) after three years (p<0.001). IgG phase I ≥1:1,024, indicating possible chronic Q fever, was found in 36% of veterinarians and 12% of patients (OR 3.95, 95% CI: 1.84–8.49).ConclusionsIgG phase I persists among veterinarians presumably because of continuous exposure to C. burnetii during their work. Serological and clinical follow-up of occupationally exposed risk groups should be considered.

BackgroundThe identification of four Consensus Molecular Subtypes (CMS1–4) of colorectal cancer forms a new paradigm for the design and evaluation of subtype-directed therapeutic strategies. The most aggressive subtype - CMS4 - has the highest chance of disease recurrence. Novel adjuvant therapies for patients with CMS4 tumours are therefore urgently needed. CMS4 tumours are characterized by expression of mesenchymal and stem-like genes. Previous pre-clinical work has shown that targeting Platelet-Derived Growth Factor Receptors (PDGFRs) and the related KIT receptor with imatinib is potentially effective against mesenchymal-type colon cancer. In the present study we aim to provide proof for the concept that imatinib can reduce the aggressive phenotype of primary CMS4 colon cancer.MethodsTumour biopsies from patients with newly diagnosed stage I-III colon cancer will be analysed with a novel RT-qPCR test to pre-select patients with CMS4 tumours. Selected patients (n = 27) will receive treatment with imatinib (400 mg per day) starting two weeks prior to planned tumour resection. To assess treatment-induced changes in the aggressive CMS4 phenotype, RNA sequencing will be performed on pre- and post-treatment tissue samples.DiscussionThe development of effective adjuvant therapy for primary colon cancer is hindered by multiple factors. First, new drugs that may have value in the prevention of (early) distant recurrence are almost always first tested in patients with heavily pre-treated metastatic disease. Second, measuring on-target drug effects and biological consequences in tumour tissue is not commonly a part of the study design. Third, due to the lack of patient selection tools, clinical trials in the adjuvant setting require large patient populations. Finally, the evaluation of recurrence-prevention requires a long-term follow-up. In the ImPACCT trial these issues are addressed by including newly diagnosed pre-selected patients with CMS4 tumours prior to primary tumour resection, rather than non-selected patients with late-stage disease. By making use of the pre-operative window period, the biological effect of imatinib treatment on CMS4 tumours can be rapidly assessed. Delivering proof-of-concept for drug action in early stage disease should form the basis for the design of future trials with subtype-targeted therapies in colon cancer patients.Trial registrationClinicalTrials.gov: NCT02685046. Registration date: February 9, 2016.

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Objectives Inappropriate use of laboratory testing remains a challenging problem worldwide. Minimum retest intervals (MRI) are used to reduce inappropriate laboratory testing. However, their effectiveness and the usefulness in reducing inappropriate laboratory testing is still a matter of debate. The aim of this study was to evaluate the effectiveness of broadly implemented MRIs as a means of reducing inappropriate laboratory test requests. Methods We performed a retrospective study in a general care and teaching hospital in the Netherlands, where MRI alerts have been implemented as standard care since June 7th 2017. Clinical chemistry test orders in adult internal medicine patients placed between July 13th 2017 and December 31st 2019 were included. The primary outcome was the effectiveness of MRIs, expressed as percentages of tests ordered and barred as a result of MRIs. Results Of a total of 218,511 test requests, 4,159 (1.90%) got an MRI alert. These MRIs were overruled by physicians in 21.76% of the cases. As a result of implementing MRIs, 3,254 (1.49%) tests were barred. The financial savings for the department of internal medicine directly related to the included barred laboratory tests during this period were 11,880 euros on a total amount of 636,598 euros for all performed tests. Conclusions Only a small proportion of laboratory tests are barred after implementation of MRIs, with a limited impact on the annual costs. However, MRIs provide a continuous reminder to focus on appropriate testing and the effectiveness of MRIs is potentially higher than described in this study.

Background Inappropriate bed occupancy due to delayed hospital discharge affects both physical and psychological wellbeing in patients and can disrupt patient flow. The Dutch healthcare system is facing ongoing pressure, especially during the current COVID-19 pandemic, intensifying the need for optimal use of hospital beds. The aim of this study was to quantify inappropriate patient stays and describe the underlying reasons for the delays in discharge. Methods The Day of Care Survey (DoCS) is a validated tool used to gain information about appropriate and inappropriate bed occupancy in hospitals. Between February 2019 and January 2021, the DoCS survey was performed five times in three different hospitals within the region of Amsterdam, the Netherlands. All inpatients were screened, using standardized criteria, for their need for in-hospital care at the time of survey and reasons for discharge delay. Results A total of 782 inpatients were surveyed. Of these patients, 94 (12%) were planned for definite discharge that day. Of all other patients, 145 (21%, ranging from 14% to 35%) were without need for acute in-hospital care. In 74% (107/145) of patients, the reason for discharge delay was outside the hospital; most frequently due to a shortage of available places in care homes (26%, 37/145). The most frequent reason for discharge delay inside the hospital was patients awaiting a decision or review by the treating physician (14%, 20/145). Patients who did not meet criteria for hospital stay were, in general, older (median 75; IQR 65 to 84 years, and 67; IQR 55 to 75 years respectively, p&lt;0.001) and had spent more days in hospital (7; IQR 5 to 14 days and 3; IQR 1 to 8 days respectively, p&lt;0.001). Conclusion Approximately one in five admitted patients occupying hospital beds did not meet the criteria for acute in-hospital stay or care at the time of the survey. Most delays were related to issues outside the immediate control of the hospital. Improvement programs working with stakeholders focusing on the transfer from hospital to outside areas of care need to be further developed and may offer potential for the greatest gain. The Day of Care Survey can be a tool to periodically monitor changes and improvements in patient flow.