Rotterdam Stroke Service

Background:To address issues related to suboptimal insight in outcomes, fragmentation, and increasing costs, stakeholders are experimenting with value-based payment (VBP) models, aiming to facilitate high-value integrated care. However, insight in how, why and under what circumstances such models can be successful is limited. Drawing upon realist evaluation principles, this study identifies context factors and associated mechanisms influencing the introduction of VBP in stroke care.Methods:Existing knowledge on context-mechanism relations impacting the introduction of VBP programs (in real-world settings) was summarized from literature. These relations were then tested, refined, and expanded based on a case study comprising interviews with representatives from organizations involved in the introduction of a VBP model for integrated stroke care in Rotterdam, the Netherlands.Results:Facilitating factors were pre-existing trust-based relations, shared dissatisfaction with the status quo, regulatory compatibility and simplicity of the payment contract, gradual introduction of down-side risk for providers, and involvement of a trusted third party for data management. Yet to be addressed barriers included friction between short- and long-term goals within and among organizations, unwillingness to forgo professional and organizational autonomy, discontinuity in resources, and limited access to real-time data for improving care delivery processes.Conclusions:Successful payment and delivery system reform require long-term commitment from all stakeholders stretching beyond the mere introduction of new models. Careful consideration of creating the ‘right’ contextual circumstances remains crucially important, which includes willingness among all involved providers to bear shared financial and clinical responsibility for the entire care chain, regardless of where care is provided.

PurposeMany healthcare organizations are looking for methods, such as Lean, to reduce their costs and increase the productivity of their professionals. The Lean method looks at every step in every process to assess if this step adds value for the customer or not. The aim of this study was to explore the value adding and non-value adding process steps in stroke patient admission in an integrated care stroke service in the Netherlands.Design/methodology/approachThis study focused on discharge of stroke patients from hospital acute treatment, and they were admitted for rehabilitation. According to the Grounded Theory, value stream mapping, organized interviews and expert meetings and coded was used. A configuration analysis was used to distinguish aggregates and configurations.FindingsThe most reported issues concerned in the paper are as follows: (1) insufficient internal logistics in the hospital, (2) miscommunication about medical readiness for discharge of the patient, (3) missing or delayed medical patient information, (4) overlapping discharge interviews, (5) unsafe transfer of sensitive information and (6) waiting lists and queuing up in rehabilitation facility.Originality/valueAt least six main areas of waste were identified in this stroke service, and they form the target for waste reducing activities. The results give insight in possible wastes in healthcare organizations and are therefore beneficial for other healthcare organizations which are planning to reduce wastes.

We studied the diagnostic value of recently introduced ELISA's for the determination of thrombin-antithrombin III (TAT) complexes, fibrin degradation products (FbDP), fibrinogen degradation products (FgDP) and total degradation products (TDP) for deep venous thrombosis (DVT) in plasma of 239 consecutive outpatients, suspected for DVT by their family doctor. DVT was confirmed by impedance plethysmography in 60 patients. Using the 95th percentile range of 42 healthy volunteers the sensitivity for the detection of DVT was: 37% for TAT, 95% for TDP, 92% for FbDP and 90% for FgDP. Specificity was: 88% for TAT, 16% for TDP, 20% for FbDP and 25% for FgDP. We conclude that these assays are of little value in the diagnosis of DVT in outpatients.

The settling velocity of mud flocs in the Elbe and Weser was measured by letting the floes settle in a tube. During the settling process, differential settling of mud flocs can increase the measured settling velocities appreciably. A correction procedure is suggested to counteract the effect of differential settling. In the Elbe, two zones with differing floc settling behaviour were found; in both zones the median settling velocity of mud flocs is proportional to the square of the concentration of suspended solid matter. Compared with the Elbe estuary, flocculation of suspended solids in the Weser estuary is slightly stronger. Flocs in estuaries are continuously destroyed and rebuilt within a time scale that is smaller than the time scale of vertical mixing. A vertical concentration profile is derived for suspended mud flocs.

Estuaries are unique water systems; they are the interface between fresh river water and saline coastal water. They have a high biological productivity, and are generally situated in densely populated areas, where often many pollution problems exist. To preserve the water resources in these systems, where complex interactions of physical, chemical and biological factors occur, decisions have to be made in the midst of many conflicting interests. There is a strong need in water quality management for a set of reliable numerical models, which are capable of predicting the consequences of such decisions. Transport models, which predict the transport of both dissolved and particulate constituents, are the basis of the water quality models.