title: Improvement of hospital care for patients with non-Hodgkin's lymphoma: protocol for a cluster randomized controlled trial (PEARL study).
abstract: BACKGROUND
  Malignant lymphomas constitute a diverse group of cancers of lymphocytes. One well-known disease is Hodgkin's lymphoma; the others are classified as non-Hodgkin's lymphoma (NHL). NHLs are the most common hematologic neoplasms in adults worldwide, and in 2012 over 170,000 new cases were estimated in the United States and Europe.In previous studies, several practice gaps in hospital care for patients with NHL have been identified. To decrease this variation in care, the present study aims to perform a problem analysis in which barriers to and facilitators for optimal NHL care will be identified and, based on these findings, to develop (tailored) improvement strategies. Subsequently, we will assess the effectiveness, feasibility and costs of the improvement strategies.
  
  
  METHODS
  Barriers and facilitators will be explored using the literature, using interviews and questionnaires among physicians involved in NHL care, and patients diagnosed with NHL. The results will be used to develop a tailored improvement strategy. A cluster randomized controlled trial involving 19 Dutch hospitals will be conducted. Hospitals will be randomized to receive either an improvement strategy tailored to the barriers and facilitators found or, a standard strategy of audit and feedback.The effects of both strategies will be evaluated using previously developed quality indicators. Adherence to the indicators will be measured before and after the intervention period based on medical records from newly diagnosed NHL patients. To study the feasibility of both strategies, a process evaluation will be additionally performed. Data about exposure to the different elements of the strategies will be collected using questionnaires. Economic evaluation from a healthcare perspective will compare the two implementation strategies, where the costs of the implementation strategy and changes in healthcare consumption will be assessed.
  
  
  CONCLUSIONS
  The presence of variation in the use of diagnostic tests, treatment, and follow-up between different physicians in different hospitals in the Netherlands is important for patients. To reduce the existing variation in care, implementation of tailored interventions to improve NHL care is necessary.
  
  
  BACKGROUND
  This trial is registered at ClinicalTrial.gov as the PEARL study, registration number NCT01562509.
authors.affiliation: Scientific Institute for Quality of Healthcare IQ healthcare, Radboud University Nijmegen Medical Centre, PO box 9101, 6500 HB Nijmegen the Netherlands. J.Stienen@iq.umcn.nl
authors.forename: Jozette J C
authors.initials: JJ
authors.lastname: Stienen
authors.forename: Rosella P M G
authors.initials: RP
authors.lastname: Hermens
authors.forename: Lianne
authors.initials: L
authors.lastname: Wennekes
authors.forename: Saskia A M
authors.initials: SA
authors.lastname: van de Schans
authors.forename: Helena M
authors.initials: HM
authors.lastname: Dekker
authors.forename: Nicole M A
authors.initials: NM
authors.lastname: Blijlevens
authors.forename: Richard W M
authors.initials: RW
authors.lastname: van der Maazen
authors.forename: Eddy M M
authors.initials: EM
authors.lastname: Adang
authors.forename: Johan H J M
authors.initials: JH
authors.lastname: van Krieken
authors.forename: Petronella B
authors.initials: PB
authors.lastname: Ottevanger
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D016000:Cluster Analysis; D003365:Costs and Cost Analysis; D005240:Feasibility Studies; D019983:Guideline Adherence; D006760:Hospitalization; D006801:Humans; D008228:Lymphoma, Non-Hodgkin / Q000191:economics / Q000628:therapy*; D008875:Middle Aged; D009426:Netherlands; D017410:Practice Guidelines as Topic; D058996:Quality Improvement; D055815:Young Adult