Practical Application of Value‐Based Medicine in Chronic Pelvic Pain: A Qualitative Study

M.C.W., Y.E. and K.J.B.N. designed the protocol. M.C.W. and K.J.B.N. conducted the focus groups. M.C.W. and M.v.d.H did the data analysis. The final codes, categories and themes were discussed and defined with in the complete research group. M.C.W. wrote the drafts of the paper. K.J.B.N., SvdW, M.v.d.H, P.R.d.R., L.D., Y.E., K.C.P.V., and K.B.K. critically revised the drafts of the paper. All authors approved the final version of the paper and accept responsibility for the paper as published.

The Medical Review Ethics Committee region Arnhem‐Nijmegen determined that this study was exempt from the Medical Research Involving Human Subjects Act (file number: 2022‐13865). All participants gave oral consent for participating in this study.

A total of 23 participants engaged in the three NGT sessions. Two NGT sessions included in total nine female patients with CPPS (mean age 47 years, range 29–62 years). Some patients suffered of more than one etiology of CPPS, eight patients had myofascial‐related pain complaints, two patients had endometriosis, one patient had MESH‐related pain, one patient had pudendal neuralgia, and one patient had vulvodynia. For the first NGT session, two patients cancelled, resulting in a lower number of participants (five patients) of the NGT. To validate the outcomes of the first session, another NGT session with patients was conducted, and the outcomes were confirmed and practically similar to the first session. The session with healthcare providers consisted of 14 participants: two anesthesiologist‐pain specialists, one gynaecologist, one urologist, two nurse practitioners of urology, two pelvic floor physiotherapists, one psychologist, four administrational employees (gynaecology, urology and anaesthesiology) and one healthcare assistant. One of the anesthesiologist‐pain specialists was male, and all other healthcare providers were female. All sessions, with the healthcare providers and with the patients, were analysed separately, but codes, categories and themes overlapped between both stakeholder groups and followed the same structure. In total 17 categories were identified to improve the care pathway, which could be grouped in five themes. Five out of the 17 categories were mentioned only in the patients' sessions and one category was derived solely from the healthcare providers. The themes with the corresponding categories are presented by group in Appendix  3 . Tables  2 (patients) and  3 (healthcare providers) provide an overview of the key topics derived from the categories and themes. The five overarching key topics were: the structured start of the patient journey, the execution of the patient journey, the follow‐up after the patient journey, administration during the patient journey, and communication and education. These key topics and matching categories are specified in the following paragraphs. The key topics based on patient's perspectives. Planning and triage Preparations for the initial consultation Planning and triage Preparations for the initial consultation Clear and correct referrals Reduced waiting times and baseline questionnaires Clear and correct referrals Reduced waiting times and baseline questionnaires The healthcare practitioners and overview of the care pathway The components of the care pathway The organisation of the care pathway The composition of the multidisciplinary team The content of the multidisciplinary consultation The healthcare practitioners and overview of the care pathway The components of the care pathway The organisation of the care pathway The composition of the multidisciplinary team The content of the multidisciplinary consultation Lack of overview, urge for a case manager Standardised diagnostics, combined consultations Continuity of healthcare providers Adding specialisms for example, neurology, surgeons, gastroenterology and primary care The timing of the multidisciplinary consultation Lack of overview, urge for a case manager Standardised diagnostics, combined consultations Continuity of healthcare providers Adding specialisms for example, neurology, surgeons, gastroenterology and primary care The timing of the multidisciplinary consultation Care outside of the hospital Aftercare Care outside of the hospital Aftercare Aligned physiotherapists Communication with primary care, rehabilitation projects Aligned physiotherapists Communication with primary care, rehabilitation projects Reports in electronic medical records The electronic medical record Planning Reports in electronic medical records The electronic medical record Planning Clear reports Improved electronic medical record More adequate planning of patients Clear reports Improved electronic medical record More adequate planning of patients Information services Knowledge of CPPS Talking about pain Communication Patient interaction Information services Knowledge of CPPS Talking about pain Communication Patient interaction Education and availability of reliable information for patients Awareness and education on CPPS Importance of talking about pain Clear communication about expectations, diagnosis and therapy Shared decision making, feeling recognised in complaints Education and availability of reliable information for patients Awareness and education on CPPS Importance of talking about pain Clear communication about expectations, diagnosis and therapy Shared decision making, feeling recognised in complaints Note: The five key topics in the grey rows and their matching categories in the blank rows followed by brief explanation. The key topics based on healthcare provider's perspectives. Planning and triage Preparations for the initial consultation Planning and triage Preparations for the initial consultation Collaborative triage with all specialisms Reduced waiting times, questionnaires, collection of documentation from previous healthcare providers Collaborative triage with all specialisms Reduced waiting times, questionnaires, collection of documentation from previous healthcare providers The healthcare practitioners and overview of the care pathway The components of the care pathway The composition of the multidisciplinary team The content of the multidisciplinary consultation The healthcare practitioners and overview of the care pathway The components of the care pathway The composition of the multidisciplinary team The content of the multidisciplinary consultation Lack of overview, urge for a case manager Standardised diagnostics, combined consultations Adding specialisms for example, surgeons, gastroenterologists The timing of the multidisciplinary consultation Lack of overview, urge for a case manager Standardised diagnostics, combined consultations Adding specialisms for example, surgeons, gastroenterologists The timing of the multidisciplinary consultation Aftercare Aftercare Communication with primary care, rehabilitation projects Communication with primary care, rehabilitation projects The electronic medical record Healthcare costs Planning The electronic medical record Healthcare costs Planning Reduction in extensiveness of electronic medical records No adequate options to register for reimbursement Complexity of patient planning Reduction in extensiveness of electronic medical records No adequate options to register for reimbursement Complexity of patient planning Information services Communication Information services Communication Pain education, availability reliable information Improved communication between healthcare providers Pain education, availability reliable information Improved communication between healthcare providers Note: The five key topics in the grey rows and their matching categories in the blank rows followed by brief explanation. The matching categories for the theme ‘structured start of the patient journey’ were the ‘planning and triage’, and ‘preparations for the initial consultation’. Both categories were mentioned by both patients and healthcare providers, though there were slight differences in the suggested improvements mentioned in each group. The patients were primarily concerned with the planning of patients in general and referrals. They felt that referrals needed more explanation, as they often had referrals to several specialists without understanding the explicit details. The healthcare providers, on the other hand, were more concerned about the internal referrals and the resulting delays. They proposed a collaborative triage and planning system involving all relevant specialisms. In the category ‘preparation for the initial consultation’, both participant groups supported shorter waiting times and a mandatory questionnaire at the time of referral. Additionally, healthcare providers suggested improved data collection from previous healthcare providers. The theme ‘execution of the patient journey’ consisted of five categories derived from the patients and four from the healthcare providers. The overlapping categories were ‘the healthcare practitioners and overview of the care pathway’, ‘components of the care pathway’, ‘composition of the multidisciplinary team’, and ‘content of the multidisciplinary consultation’. An additional category for the patient group was ‘Organisation of the care pathway’. In this last mentioned category, they emphasised the importance of the flow in healthcare between patients and healthcare providers, but also between healthcare providers. In the second category ‘healthcare practitioners and overview of the care pathway’, both groups highlighted the lack of overview of the patient journey, and the absence of a case manager or a directing practitioner to provide more structure and overview. Furthermore, in the next category, ‘the composition of the multidisciplinary team’, some minor changes were recommended by both the patients and healthcare providers. The patients suggested adding, if indicated, a neurologist, an extra psychologist, a surgeon and a gastroenterologist, and an increased contribution of primary care healthcare providers. The healthcare providers recommended adding, a surgeon and a gastroenterologist if needed. Both groups had specific comments on the fourth category: ‘content of the MDC’. They suggested to change the timing of the MDC, to reduce waiting times until the MDC and to improve communication related to the MDC. This communication concerned the information in the letter to the general practitioner (GP) and pelvic floor physiotherapists about the treatment plan. This letter was often late or missing in case of the pelvic floor physiotherapists. In the final category, ‘components of the care pathway’, both groups stressed the importance of an initial multidisciplinary consultation, the importance of standardised diagnostics, and the importance of combined appointments at the same day with specialists. The latter helps to reduce hospital visits and delays in the patient journey. The categories belonging to the theme ‘follow‐up after the patient journey’ were ‘aftercare’ and ‘care outside the hospital’. In both groups, the category ‘aftercare’ emphasised the significance of the communication between primary care, secondary care, and pelvic floor physiotherapists, the significance of providing support in primary care, and the significance of rehabilitation projects. A key improvement proposed by both groups was the development of a rehabilitation programme supported by the Radboudumc. In accordance with the suggested improvements mentioned above, the patients advocated for changes in ‘the care outside the hospital’. They suggested more aligned physiotherapists and improved communication between the pharmacy and the healthcare providers. Four categories confirmed that improvements are needed regarding ‘the administration during the patient journey’. The categories were ‘electronic medical record’, ‘planning’, ‘healthcare costs’, and ‘reports in the electronic medical records’. The first and second category were emphasised by both groups and stressed the importance of the use of the electronic medical record (EMR) and the planning of patients. Patients mentioned that they would like to see improvements in the possibilities of the EMR, such as improved accessibility, more excess to results and information, and contact with healthcare providers. In contrast to the healthcare providers, who emphasised the reduction in the extensiveness of the EMR, and thereby a reduction in the time and effort to prepare consultations. In relation to the electronic medical records in the category ‘reports in the electronic medical records’, the patients suggested clearer reports of the consultations that they could read in the EMR after the consultation. The category ‘planning’ had a different perception between patients and healthcare providers. The healthcare providers noted the complexity of scheduling patients during the patient journey due to the limited capacity of healthcare providers. On the other hand, the patients criticised the lack of efficient scheduling; they often experienced long waiting times (weeks or months) for follow‐up appointment or needed to initiate the scheduling of appointments themselves. In the category ‘healthcare costs’, healthcare providers expressed their concerns about incomplete coverage of costs for CPPS due to insufficient registration options for diagnosis and treatment combinations. Compared to the previous themes, there was more diversity in the categories between the healthcare providers and the patients in this theme. Two categories overlapped and three additional categories were solely mentioned in the patient group. ‘Knowledge of CPPS’ emerged as a significant concern for patients, as they stated that awareness should be created among patients, GPs and healthcare providers in hospitals about CPPS in general and the existence of the multidisciplinary team in the Radboudumc. Furthermore, they addressed the importance of educating healthcare providers about CPPS. This aligns with the category ‘information services’, where both groups emphasised the importance of (pain) education, and the availability of reliable information on CPPS. For example, information of CPPS on the website of the Radboudumc should be accessible for patients and healthcare providers. Another relevant category linked to this theme is ‘talking about pain’. Patients highlighted the importance of talking about pain with healthcare providers, and specifically the lack of possibilities. Additionally, in the category ‘patient interaction’, the patient group emphasised the importance of establishing a positive relationship with healthcare providers, noting that shared decision making and feeling recognised in their complaints improved the relationship. Patients also suggested that adherence to agreements made in the treatment plan could enhance the relationship. The final category, identified by both groups, underscores the importance of ‘communication’. Patients preferred clear communication regarding expectations, diagnosis and treatment. Healthcare providers acknowledged the need for improvements in communication with GPs, pelvic floor physiotherapists and patients. Table  4 presents the key improvements identified for the CPPS care pathway as determined during the prioritisation in the ranking phase of the NGT sessions. The key recommendations for the CPPS care pathway. Note: Recommendations in the right column and in the left column the group that stated the recommendation. Abbreviations: CPPS, chronic pelvic pain syndrome; MDC, multidisciplinary consultation.

In this explorative qualitative study using the nominal group technique, our objective was to compile insights from both patients and healthcare providers on the individual components of the current CPPS patient journey to develop a CPPS care pathway. Information from patients and health care providers was collected in focus group sessions and structured into categories and themes. With use of the nominal group technique, this process led to key topics and recommendations for a to be developed CPPS care pathway. The most important recommendations include the earlier implementation of a multidisciplinary approach, adding a case manager and expanding the multidisciplinary team, establishing a collaborative triage process, updating questionnaires, enhancing communication, developing a rehabilitation programme, and reducing waiting times. The (inter)national guidelines advocate for a multidisciplinary approach for CPPS patients, though they do not specify the timing of its implementation within the patient journey [ 4 , 6 ]. The wish for an earlier implementation of a multidisciplinary approach aligns with the current literature [ 25 , 26 , 27 ]. In a review study, Stanos et al. conclude that chronic pain warrants a multidisciplinary and interdisciplinary approach from the start of the patient journey [ 25 ]. This, coupled with the support from the guidelines, supports the recommendation for early implementation of this approach. Furthermore, the recommendation to include a case manager is also supported by the literature [ 25 , 28 , 29 ]. Several papers highlight the value of a case manager. For example, in an ethnographic study, Aarhus et al. report the essential role of case managers in care pathways and their influence in the structure of a patient journey [ 28 ]. Additionally, both Figueiredo et al. and Stanos et al. emphasise the significant impact of a case manager in monitoring patients [ 25 , 29 ]. Concluding, a case manager could be of great value and is therefore recommended for inclusion in the CPPS care pathway. The next recommendation, expanding the multidisciplinary team, complements to the previous recommendations. The American College of Obstetricians and Gynecologist (ACOG) practice bulletin outlines the composition of a multidisciplinary team for CPPS [ 2 ]. This multidisciplinary team should ideally comprise a gynaecologist, psychologist, pain specialist and physical therapist. Collett et al. further suggest collaborating with a gastro‐enterologist, a urologist and an orthopaedic surgeon in addition to the core team [ 30 ]. However, Collett et al. also advise a personalised approach by prioritising the involved healthcare providers to prevent overwhelming patients with a voluminous group [ 30 ]. Associated with prior recommendations, is the improvement of communication: MgGowan et al. and Selfe et al. both demonstrate a positive correlation between effective communication and clinical outcomes [ 31 , 32 ]. MgGowan et al. even show the withdrawal of care due to poor consultations, emphasising the importance of listening carefully to patients and acknowledging their clinical situation [ 32 ]. This aligns with the recommendations from the patient groups in our study. The fifth recommendation, providing a collaborative triage to organise the appropriate care for CPPS patients is supported by the work of Azeredo et al. [ 33 ]. They describe the importance of an effective triage system for organising appropriate care for emergency patients [ 33 ]. In the context of CPPS care, this entails ensuring timely access to the right specialists. By introducing a collaborative triage system, where a multidisciplinary team of specialists (a gynaecologist, a urologist and an anesthesiologist) jointly assess the referrals, these delays in accessing appropriate care are prevented. The subsequent recommendation concerns the reduction of the waiting times. The current guidelines claim an improvement of the prognosis if a treatment is initiated promptly, so a reduction in the waiting times makes a significant impact on the outcome [ 4 , 6 ]. This could be achieved by implementing the aforementioned recommendations. Al Abbadey et al. emphasise the necessity for the next recommendation: ‘updating the questionnaires’ [ 34 ]. They present all different available questionnaires for CPPS and aimed to create a new overarching validated questionnaire to measure the impact of CPPS [ 34 ]. This demonstrates the need for an improved questionnaire that is useful for a baseline measurement and follow up in the CPPS care pathway. In our final recommendation, we advocate for the development of a rehabilitation programme. Multiple studies emphasise the relevance of a rehabilitation programme in chronic pain and specifically chronic pelvic pain [ 35 , 36 , 37 , 38 ]. A rehabilitation programme improves the quality of life of CPPS patients through its interdisciplinary and multidisciplinary approach [ 35 ]. Incorporating a rehabilitation programme would increase the quality of care to the CPPS care pathway. These recommendations contribute to optimalization of CPPS care pathways in healthcare centres, as illustrated in Figure  1 . Future research could focus on evaluating an updated version of the CPPS care pathway. Preferably in a quantitative study to adequately measure the improvements of quality of life of CPPS patients. Schematic overview of a possible CPPS care pathway based on the recommendations. Figure  1 presents a schematic care pathway for chronic pelvic pain based on the key recommendations of the stakeholders. The exact amount of contact might differ for patients. This study possesses several noteworthy strengths. This is the first study that carefully extracts the perspectives of patients and healthcare providers on a CPPS care pathway. Another strength is the involvement of multiple stakeholders, enabling us to produce a generalisable outcome. The use of the NGT method was convenient to structure the topics for the participants and ultimately to prioritise the recommendations for the CPPS care pathway. The NGT method ensures equal participation for each attendee in the sessions. However, certain limitations warrant acknowledgement. One limitation pertains to the therapeutic relationship between the moderator and some participants. Despite the fact that the researcher told the patients that their answers would not influence their treatment plan, it could have led to bias in their answers. Ideally, employing an external moderator would have mitigated this potential bias. Another limitation might be excluding male patients in the focus groups, however, female patients tend to be more complex compared to male patients. By using more complex patients for setting a standardised care pathway, we think it might be easy to adjust it to a male population. For our proposed schematic care pathway this means leaving out the gynaecologist in the patient journey for male patients. Another limitation concerns the ranking system, some participants deviated from the prescribed 5‐point system, either by grouping several items together or by marking less than five items as important in the final ranking. To overcome this limitation, we scored items as important in case at least three participants enlisted the items in their ranking. We did not prioritise between the items marked as important due to this lack of consistency in the ranking.

In our notice, this is the first qualitative study that provides an overview of the perspectives of patients and healthcare providers on a future improved CPPS care pathway. The perspectives led to important recommendations for elements that can be implemented. The key recommendations were the significance of an immediate multidisciplinary approach from the start of the patient journey. There seems an added value of a collaborative triage system, using updated the questionnaires, implementing a case manager and expanding the multidisciplinary team, improving communication, developing a rehabilitation programme, and reducing the waiting times.

Chronic Pelvic Pain Syndrome (CPPS) is characterised by pain in the pelvic area lasting for at least 3 months and is increasingly prevalent in all genders [ 1 , 2 , 3 , 4 , 5 , 6 , 7 ]. This condition is often accompanied with complaints of multiple organ systems in the lower pelvis. CPPS significantly affects patients' quality of life, particularly in terms of mental coping and sexual functioning [ 2 , 4 , 6 , 7 ]. Due to the complexity of CPPS and involvement of multiple organ systems, an inter‐ and multidisciplinary approach is recommended for both diagnostic and treatment strategies [ 4 , 6 , 8 , 9 , 10 , 11 , 12 ]. Currently, the care for CPPS is inefficient, involving a continues cycle of referrals, investigations, and treatments. Accurate diagnostics from the initial presentation can lead to effective treatment plans, potentially reducing the disruption to patients' lives. Clinical guidelines suggest that prompt initiation of treatment can improve prognosis [ 4 , 6 ]. To achieve this, complex conditions such as CPPS, may benefit from a value based health care approach by dedicated standardised care pathways [ 17 ]. A care pathway is a structured medical format that outlines patient's journey for a specific medical condition over a defined period, tailored to fit the majority of patients [ 11 , 13 , 14 , 15 ]. These care pathways are based on evidence‐based guidelines, best practice descriptions, clinical outcome data and patient experiences. Their goal is to improve the quality of care, patient's satisfaction and overall quality of life [ 14 , 16 ]. In chronic conditions (e.g., chronic obstructive pulmonary disease [COPD] and chronic knee pain), care pathways have already proven to improve clinical outcomes and be cost‐effective [ 16 , 17 , 18 , 19 ]. Since 2014, CPPS patients at our Dutch University Medical Center, have been managed in a multidisciplinary clinic. However, there is currently no standardised CPPS care pathway, what results in that every patient follows an individualised patient journey. For instance, the first referral can be addressed to either the gynaecologist, urologist or anesthesiologist‐pain specialist, with further referrals as needed. These internal referrals cause a delay in the patient journey and may not align with patient expectations, leading to frustration and dissatisfaction. Hence, there is a pressing need to develop a care pathway in line with national and international guidelines. The overall aim of this project is to develop a successful and evidence based CPPS care pathway based on the suggestions of stakeholders. Such an innovated care pathway may structure the patient journey and optimise the multidisciplinary approach. In this study, we perform a qualitative study with focus groups. The objective is to collect the perspectives of patients and healthcare providers on the individual components of the current CPPS patient journey and structure their recommendations.

The authors declare no conflicts of interest.

A qualitative study was performed using the nominal group technique (NGT). This technique consists of structured group sessions (2–14 participants), and explores a specific healthcare problem on a detailed level with input of every participant [ 20 , 21 , 22 ]. The goal was to provide recommendations for a CPPS care pathway, based on the perspectives of stakeholders on the individual components of the CPPS patient journey in small group discussions. The COREQ checklist was used for reporting this qualitative study [ 23 ]. Two groups of stakeholders were selected as participants in the NGT sessions: healthcare providers and patients. Participants were included if they were an involved healthcare provider regarding care for CPPS or if they were a patient with CPPS. Healthcare providers were included from different healthcare professions and specialties, and excluded if they were not actively working as professional. Patients were eligible if they were female and treated in our institution between 2019 and 2022, and they were excluded in case of incompetency of the Dutch language. Purposive sampling was done and patients that had different etiologies of CPPS (e.g., myofascial pain, neuropathy, endometriosis), that were satisfied/unsatisfied with their patient journey, patients that did/did not attend a multidisciplinary consultation, and completed/uncompleted their patient journey were selected. Participants were approached by telephone, email or face‐to‐face and they gave consent for participation of the NGT session. All participants were familiar with the current patient journey in our institution. The individual components of this journey are as follows: it starts with the referral, and then follows the diagnostic process. This consists of medical history taking, physical exams, and where deemed valuable, imaging (ultrasounds, CT‐scan or MRI‐scan) and/or electrodiagnostic tests. There are two multidisciplinary moments: the complete multidisciplinary team meets without the patient to discuss the patient journey and a meeting with the multidisciplinary team and the patient. The latter multidisciplinary meeting is called the multidisciplinary consultation (MDC) and the end result is a personalised treatment plan for each individual patient. The MDC consists of sessions with the psychologist, pelvic floor therapist and a nurse specialised in pain medicine and ends with a concluding session with the anesthesiologist‐pain specialist, gynaecologist and urologist to discuss the personalised treatment plan with the patient. There is a waiting time up till 9 months for the MDC due to a limited availability of the multidisciplinary team. The last component, the therapy, may be provided by multiple members of the team depending on the patient's the needs and indications. One of the multidisciplinary team members directs and coordinates the therapy. In case of a somatic abnormality this will be treated by the gynaecologist, urologist and/or pelvic floor physiotherapist. The anesthesiologist‐pain specialists manage the more complex pain interventions (e.g., caudal infiltration, pudendal nerve block) and medication (e.g., drugs for neuropathic pain). Standardised pain medication and local injections can also be administered by the gynaecologist or urologist. Some patients are referred to primary care for interventions (e.g., cognitive therapy, occupational therapy, physiotherapy or rehabilitation programmes). In 2022 and 2023, a total of three NGT sessions were conducted for the healthcare providers and the patients in the Radboud University Medical Center (Radboudumc) in a neutral office building. The NGT sessions consisted of five separate phases explained in Table  1 [ 20 , 21 ]. Two sessions were in 2022; one contained healthcare providers and the other patients. Data saturation was reached if no new ideas would come up during the round robin and afterwards during the discussing or clarification phase. To confirm data saturation, an extra NGT session with patients was conducted in 2023. All sessions were moderated by a female urogynecologist (KN, principal investigator), and a female PhD candidate (MW, study investigator) was present as an observer taking notes. Both were trained in qualitative research (focus group and interview studies). The nominal group technique. The research question was presented: ‘What are the perspectives of patients and healthcare providers on the individual components of the current patient journey for CPPS patients?’ The participants were asked to individually compose a list of positive and negative attributes regarding the care pathway. Abbreviations: CPPS, chronic pelvic pain syndrome; NGT, nominal group technique. The research team had developed a topic guide (Appendix  1 ) and a PowerPoint presentation to guide the NGT session (Appendix  2 ). The patients were in a therapeutic relationship with either KN or MW. Both researchers and patients stated that they felt free and independent to discuss the topic, and felt assured that the treatment of the patients was not compromised. The sessions with the patients were audiotaped after consent of the participants. The session with the healthcare providers was not audiotaped but extensive notes were made. The audiotaped sessions and notes were transcribed verbatim and analysed using ATLAS.ti (version 22.0.11). The transcripts were coded independently by two researchers (MW and MvdH) by conventional thematic content analysis [ 22 , 24 ]. The created codebooks were compared and discussed until consensus was reached. The codebook and suggested categories were debated in the research team (YE, KN and SvdW), and subsequently the categories were grouped in themes. Multiple peer group meetings with the research group led to overarching key topics from the themes and categories, and these key topics are presented in the results section. These key topics were selected based on the individual rankings of the patients and the healthcare providers in the last phase of the NGT session, and had to be mentioned by at least three participants. Due to inconsistency in the ranking of participants, the key topics marked as important were not prioritised. The key topics that were marked as important were formulated in recommendations and are presented at the end of the results section. The Medical Review Ethics Committee region Arnhem‐Nijmegen determined that this study was exempt from the Medical Research Involving Human Subjects Act (file number: 2022‐13865).

Supporting information.