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Table 1 Two examples of Appropriate Care trajectories

From: Collective constructions of ‘waste’: epistemic practices for disinvestment in the context of Dutch social health insurance

Phase Topic
Knee/Hip arthrosis Peripheral Artery Disease (PAD)
Screening The first topic selected for an Appropriate Care trajectory did not result from a screening, but was initiated by the Ministry of Health. Based on reports showing medical practice variations in diagnostic interventions and prosthesis placements in care for hip and knee arthrosis and PROMs reporting that 1 in 5 patients was not satisfied with the outcome of the treatment received for hip and knee arthrosis, the Ministry of Health suggested ‘care for patients with hip or knee arthrosis’ as the first topic for the Institute to research within the context of the Appropriate Car program. In 2015 the Institute published its Screening report of Diseases of the Circulatory System (ICD-10 IX100–199). The Institute selected 3 topics for further research: Implantable Cardioverter Defibrillators, Stable Angina Pectoris and Peripheral Artery Disease (PAD).
PAD was selected for 2 reasons:
1) PAD stage 24 (also known as Claudicatio Intermittens or ‘window-shoppers’ disease’) was marked by stakeholders as a topic that required the attention of the National Health Care Institute;
2) screening identified PAD as a topic for further research based on data on costs, volume and their growth.
In-depth analysis In-depth analysis showed that [28]:
1. Too many patients receive an X-ray, MRI, arthroscopy or puncture for diagnostics, while clinical guidelines state that these are only needed in exceptional cases. The Institute estimates that 90% of the diagnostics are not necessary.
2. In current clinical guidelines and in daily clinical practice little attention is paid to shared decision-making and stepped care, while this is thought to lead to a decrease in the number of surgical interventions and a more selective placement of prostheses. The Institute estimates that this could potentially lead to a reduction of prosthesis placement of 10% for knee prosthesis and 5% for hip prosthesis.
3. PROMs for placement of knee and hip prosthesis are available, but require further development and validation to provide insights into actual health outcomes and require further definitions of patient characteristics that are related with an unfavorable outcome of the prosthesis.
Actions for improvement:
• guideline compliance for the use of (imaging) diagnostics
• More selective placement of knee and hip prostheses
• Further development of PROMs
Estimated budget impact: 49 million euros
In-depth analysis showed that [29]:
1. Too many patients are referred to a vascular surgeon for diagnostics, while clinical guidelines indicate that ankle-brachial pressure index diagnostics can be performed under the responsibility of a GP.
2. 11,000 unnecessary duplex ultrasounds a year are carried out, while clinical guidelines state that duplex ultrasound should only be used if endovascular revascularisation (ER) or surgery are being considered
3. 75% of patients received no Supervised Exercise Therapy (SET) as first-line treatment and 20% of patients may undergo ER unnecessarily, while guidelines state that all new patients with PAD should get SET as first-line treatment.
Actions for improvement:
• Improved agreements between care professionals
• Provision of reliable patient information
• Development of quality information
• Inform GPs that diagnostics can be outsourced to a vascular laboratory without referral to a specialist
• All newly diagnosed patients receive SET as first-line treatment.
• Reimbursement of SET
• Aim to go from 35 to 11% of patients undergoing ER
Estimated budget impact: 30 million euros
Implementation The following concrete actions are implemented by field parties to improve the care for patients with knee/hip arthrosis:
• Offering of patient information on knee/hip arthrosis (and its treatment) on one central website (
• public availability of PROM
• revision of the GPs guideline on ‘non-traumatic knee problems’ (by the Dutch College of General Practitioners (NHG))
• development of the multidisciplinary guideline ‘conservative treatment of knee/hip arthrosis’ including transmural stepped care agreements (by Dutch Orthopedic Association (NOV))
• development of the guideline ‘Total Hip prosthesis’ (by NOV)
• Development of the guideline ‘Arthrosis Hip/Knee’ (by the Royal Dutch Society for Physical Therapy (KNGF))
These are a few examples of the concrete actions that are being implemented by field parties to improve care for patients with PAD:
• The organization of ankle-brachial pressure index diagnostics in primary care will be improved. Information will be made available for primary care professionals on the possibility of having these diagnostics carried out in primary care diagnostic centers and vascular laboratories. Accessibility of the latter will also be improved (by the NHG, the Netherlands Association of Surgeons (NVvH), together with the National Health Care Institute)
• Clear agreements will be made between primary care and hospital care about advice on diagnostics and treatment (NHG), the Netherlands Association for Vascular Surgery (NVVV), together with other relevant parties)
• Patient information must improve, e.g. by offering reliable patient information in a single location. (The Heart&Vascular Group, NHG, NVvH)
• Attention should be given to stepped-care, i.e., explaining properly why an operation is not the first choice (by all professionals).
• Et cetera
Monitoring Evaluation and monitoring of the implementation of improvements is planned for 2019. Evaluation and monitoring of the implementation of improvements is planned for 2020.