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Table 2 Description of the cases

From: The implementation of change model adds value to value-based healthcare: a qualitative study

Case 1: A pre-incision checklist for cardiac surgery Case 2: Preoperative protein-enriched diet
The pre-incision checklist for cardiac surgery is an addition to the surgical safety checklist that was previously developed by the World Health Organization [27]. Items specific to cardiac surgery are added to the checklist and patients are divided into three risk categories: low, intermediate and high risk. Peri- or postoperative complications are identified with a focus on six main organ-specific topics: cardiac, pulmonary, renal, neurologic, inflammation and coagulation. The checklist is part of a greater project from an external hospital that identified this “best practice” based on insights into outcomes [28]. The checklist was identified based on differences in 120-day mortality rate among benchmarking hospitals. [1] This external project is expected to contribute positively to communication between various members of the operation team. This is expected to contribute to more risk awareness, structured consultation and a better culture [28]. Evidence has shown that the checklist contributes to significantly lower 120-day mortality rate compared to a group of patients who did not receive the checklist [29]. At the current research setting only questions from the pre-incision checklist were implemented. The goal of the intervention was to improve outcomes (120-day mortality rate). Elderly patients undergoing Surgical Aortic Valve Replacement (SAVR) or Transcatheter Aortic Valve Replacement (TAVR) receive a protein-enriched diet during a two-week period prior to the scheduled surgery. Offering a preoperative protein-enriched diet had a positive effect on health outcomes in cancer patients, patients with hip fracture undergoing surgery and patients with end-stage liver disease who needed to undergo transplantation [30,31,32,33]. In a study of non-cancer patients, malnutrition was most frequently identified in patients undergoing major vascular surgery [34]. The initiative was selected based on insights into outcomes and in-depth data and process analyses with the goal of optimizing preoperative preparation of older patients. The diet consists of familiar foods enriched with protein in order to reach the recommended protein intake for elderly people with an illness of 1.2–1.5 g/kg/d during and after hospitalization [35]. The goal is to increase protein intake by 45 g per day spread over meals during the day. Protein intake is measured with validated 24-h recall questionnaires. The protein-enriched diet is expected to contribute to higher protein intake, fewer postoperative complications and faster recovery. The effect of a preoperative protein-enriched diet for elderly patients undergoing aortic valve replacement is currently being evaluated.