Multimorbidity status and annual healthcare expenditures of rheumatoid arthritis patients: a Dutch hospital-centered versus population-based comparison.

The prevalence of multimorbidity among rheumatoid arthritis (RA) patients is increasing and associated with worse outcomes. Therefore, management of multimorbid patients requires a multidisciplinary approach. However, healthcare systems consist of mono-disciplinary subsystems, which limits collaboration across subsystems. To study the importance of a multidisciplinary, integrated approach, associations between expenditures and multimorbidity are assessed in real-life data. Retrospective data on RA patients from a Dutch single-hospital are analyzed and compared to the Dutch RA population data. The Elixhauser index is used to measure the multimorbidity prevalence. Regression analyses were conducted to derive the relationship between multimorbidity, healthcare costs and self-reported quality of life (e.g. EQ-5D). When analyzing the impact of multimorbidity within RA patients in context of a single-hospital context, multimorbidity is only partially captured: 13% prevalence versus 24% of the Dutch population. Multimorbidity is associated with higher care expenditures. Depending on the type of multimorbidity, expenditures are €43-€5821 higher in a single-hospital and from €2259-€9648 in population data. Finally, medication use associated with chronic diseases and self-reported aspects of well-being are associated with similar increases in healthcare expenditures as multimorbidity based on hospital care. Within RA, a single-hospital approach underestimates the association between multimorbidity and healthcare expenditures as 43% of healthcare utilization and expenditures are missed. To overcome a single-provider perspective in healthcare and efficiently coordinate multimorbid patients, besides providing holistic care, professionals also need to use data providing comprehensive pictures of patients.

Differences in Treatment Patterns and Outcomes of Acute Myocardial Infarction for Low- and High-Income Patients in 6 Countries.

Importance: Differences in the organization and financing of health systems may produce more or less equitable outcomes for advantaged vs disadvantaged populations. We compared treatments and outcomes of older high- and low-income patients across 6 countries. Objective: To determine whether treatment patterns and outcomes for patients presenting with acute myocardial infarction differ for low- vs high-income individuals across 6 countries. Design, Setting, and Participants: Serial cross-sectional cohort study of all adults aged 66 years or older hospitalized with acute myocardial infarction from 2013 through 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. Exposures: Being in the top and bottom quintile of income within and across countries. Main Outcomes and Measures: Thirty-day and 1-year mortality; secondary outcomes included rates of cardiac catheterization and revascularization, length of stay, and readmission rates. Results: We studied 289 376 patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and 843 046 hospitalized with non-STEMI (NSTEMI). Adjusted 30-day mortality generally was 1 to 3 percentage points lower for high-income patients. For instance, 30-day mortality among patients admitted with STEMI in the Netherlands was 10.2% for those with high income vs 13.1% for those with low income (difference, -2.8 percentage points [95% CI, -4.1 to -1.5]). One-year mortality differences for STEMI were even larger than 30-day mortality, with the highest difference in Israel (16.2% vs 25.3%; difference, -9.1 percentage points [95% CI, -16.7 to -1.6]). In all countries, rates of cardiac catheterization and percutaneous coronary intervention were higher among high- vs low-income populations, with absolute differences ranging from 1 to 6 percentage points (eg, 73.6% vs 67.4%; difference, 6.1 percentage points [95% CI, 1.2 to 11.0] for percutaneous intervention in England for STEMI). Rates of coronary artery bypass graft surgery for patients with STEMI in low- vs high-income strata were similar but for NSTEMI were generally 1 to 2 percentage points higher among high-income patients (eg, 12.5% vs 11.0% in the US; difference, 1.5 percentage points [95% CI, 1.3 to 1.8 ]). Thirty-day readmission rates generally also were 1 to 3 percentage points lower and hospital length of stay generally was 0.2 to 0.5 days shorter for high-income patients. Conclusions and Relevance: High-income individuals had substantially better survival and were more likely to receive lifesaving revascularization and had shorter hospital lengths of stay and fewer readmissions across almost all countries. Our results suggest that income-based disparities were present even in countries with universal health insurance and robust social safety net systems.

Well-being right before and after a permanent nursing home admission.

Permanent nursing home (NH) admissions are a frequent and major life event aimed at maintaining quality of life in old age. Yet, insights into the impact of a NH admission on well-being are scarce and inconclusive. We evaluate the effect of a NH admission on domains of well-being among those who are admitted using event study methodology for cross-sections combined with inverse probability weighting. We apply this doubly robust approach to Dutch survey data on well-being linked to extensive administrative data on NH admissions, health, and socio-economic status. We find that a NH admission leads to a temporary increase in loneliness, the risk of anxiety and depression, and a loss of control over one's life. However, these scores revert to pre-admission levels after 6 months. These findings may contribute to better-informed individual-level and policy decisions about potential NH entry and aging in place policies.

The effects of supported housing for individuals with mental disorders.

Societies face the challenge of providing appropriate arrangements for individuals who need living support due to their mental disorders. We estimate the effects of eligibility to the Dutch supported housing program (Beschermd Wonen), which offers a structured living environment in the community as an intermediate alternative to independent housing and inpatient care. For this, we use exogenous variation in eligibility based on conditionally random assignment of applications to assessors, and the universe of applications to supported housing in the Netherlands, linked to rich administrative data. Supported housing eligibility increases the probability of moving into supported housing and decreases the use of home care, resulting in higher total care expenditures. This increase is primarily due to the costs of supported housing, but potentially also higher consumption of curative mental health care. Supported housing eligibility reduces the total personal income and income from work. Findings do also suggest lower participation in the labor market by the individuals granted eligibility, but the labor participation of their parents increases in the long-run. Our study highlights the trade-offs of access to supported housing for those at the margin of eligibility, informing the design of long-term mental health care systems around the world.

Minimising population health loss in times of scarce surgical capacity: a modelling study for surgical procedures performed in nonacademic hospitals.

BACKGROUND: The burden of the COVID-19 pandemic resulted in a reduction of available health care capacity for regular care. To guide prioritisation of semielective surgery in times of scarcity, we previously developed a decision model to quantify the expected health loss due to delay of surgery, in an academic hospital setting. The aim of this study is to validate our decision model in a nonacademic setting and include additional elective surgical procedures. METHODS: In this study, we used the previously published three-state cohort state-transition model, to evaluate the health effects of surgery postponement for 28 surgical procedures commonly performed in nonacademic hospitals. Scientific literature and national registries yielded nearly all input parameters, except for the quality of life (QoL) estimates which were obtained from experts using the Delphi method. Two expert panels, one from a single nonacademic hospital and one from different nonacademic hospitals in the Netherlands, were invited to estimate QoL weights. We compared estimated model results (disability adjusted life years (DALY)/month of surgical delay) based on the QoL estimates from the two panels by calculating the mean difference and the correlation between the ranks of the different surgical procedures. The eventual model was based on the combined QoL estimates from both panels. RESULTS: Pacemaker implantation was associated with the most DALY/month of surgical delay (0.054 DALY/month, 95% CI: 0.025-0.103) and hemithyreoidectomy with the least DALY/month (0.006 DALY/month, 95% CI: 0.002-0.009). The overall mean difference of QoL estimates between the two panels was 0.005 (95% CI -0.014-0.004). The correlation between ranks was 0.983 (p < 0.001). CONCLUSIONS: Our study provides an overview of incurred health loss due to surgical delay for surgeries frequently performed in nonacademic hospitals. The quality of life estimates currently used in our model are robust and validate towards a different group of experts. These results enrich our earlier published results on academic surgeries and contribute to prioritising a more complete set of surgeries.

Health Care Use and Out-of-pocket Spending by Persons With Dementia Differ Between Europe and the United States.

BACKGROUND: Persons with dementia need much care, but what care is used and how the burden of financing is divided between persons with dementia, caregivers, and public programs may differ between countries. OBJECTIVE: The objective of this study was to compare how health care use and out-of-pocket (OOP) spending associated with dementia differ between the United States and Europe, with and without controlling for background characteristics. RESEARCH DESIGN: We use prospectively collected survey data from the United States-based Health and Retirement Study (n=48,877) and the Survey of Health, Ageing, and Retirement in Europe (n=98,971) including all adults over the age of 70 years. Dementia status is imputed using a validated algorithm. After first reporting the observed differences in care use, we analyze how care use is associated with dementia using multivariate regressions, controlling for other health conditions and background characteristics. RESULTS: Persons with dementia in the United States use 50% less formal home care per year than persons living with dementia in Europe [mean (SD)=236.8 h (1047.4) vs. 463.3 h (1371.2)], but use more nursing home care [75.1 d (131.4) vs. 45.5 d (119.4)). Dementia is associated with higher OOP spending in the United States than Europe [4406 USD (95% confidence interval, 3914-4899) vs. 246 USD (73-418)-2017 price levels]. CONCLUSIONS: Health care use and OOP spending differ between Europe and the United States. The far greater reliance on nursing home care in the United States likely causes much higher expenditures for people with dementia and insurance programs alike.

Eligibility or use? Disentangling the sources of horizontal inequity in home care receipt in the Netherlands.

We study horizontal inequity in home care use in the Netherlands, where a social insurance scheme aims to allocate long-term care according to care needs. Whether the system reaches its goal depends not only on whether eligible individuals have equal access to care but also on whether entitlements for care reflect needs, irrespective of socioeconomic status and other characteristics. We assess and decompose total inequity into inequity in (i) entitlements for home care and (ii) the conversion of these entitlements into actual use. This distinction is original and important, because inequity calls for different policy responses depending on the stage at which it arises. Linking survey and administrative data on the 65 and older, we find higher income elderly to receive less home care than poorer elderly with similar needs. Although lower income elderly tend to make greater use of their entitlements, need-standardized entitlements are similar across income, education, and wealth levels. However, both use and entitlements vary by origin and place of residence. The Dutch need assessment seems effective at restricting socioeconomic inequity in home care use but may not fully prevent inequity along other dimensions. Low financial barriers and universal eligibility rules may help achieve equity in access but are not sufficient conditions.

Equal long-term care for equal needs with universal and comprehensive coverage? An assessment using Dutch administrative data.

The Netherlands is one of the few countries that offer generous universal public coverage of long-term care (LTC). Does this ensure that the Dutch elderly with similar care needs receive similar LTC, irrespective of their income? In contrast with previous studies of inequity in care use that relied on a statistically derived variable of needs, our paper exploits a readily available, administrative measure of LTC needs stemming from the eligibility assessment organized by the Dutch LTC assessment agency. Using exhaustive administrative register data on 616,934 individuals aged 60 and older eligible for public LTC, we find a substantial pro-poor concentration of LTC use that is only partially explained by poorer individuals' greater needs. Among those eligible for institutional care, higher-income individuals are more likely to use-less costly-home care. This pattern may be explained by differences in preferences, but also by their higher copayments for nursing homes and by greater feasibility of home-based LTC arrangements for richer elderly. At face value, our findings suggest that the Dutch LTC insurance "overshoots" its target to ensure that LTC is accessible to poorer elderly. Yet, the implications depend on the origins of the difference and one's normative stance.

A cost-effectiveness threshold based on the marginal returns of cardiovascular hospital spending.

Traditionally, threshold levels of cost-effectiveness have been derived from willingness-to-pay studies, indicating the consumption value of health (v-thresholds). However, it has been argued that v-thresholds need to be supplemented by so-called k-thresholds, which are based on the marginal returns to health care. The objective of this research is to estimate a k-threshold based on the marginal returns to cardiovascular disease (CVD) hospital care in the Netherlands. To estimate a k-threshold for hospital care on CVD, we proceed in two steps: First, we estimate the impact of hospital spending on mortality using a Bayesian regression modelling framework, using data on CVD mortality and CVD hospital spending by age and gender for the period 1994-2010. Second, we use life tables in combination with quality of life data to convert these estimates into a k-threshold expressed in euros per quality-adjusted life year gained. Our base case estimate resulted in an estimate of 41,000 per quality-adjusted life year gained. In our sensitivity analyses, we illustrated how the incorporation of prior evidence into the estimation pushes estimates downwards. We conclude that our base case estimate of the k-threshold may serve as a benchmark value for decision making in the Netherlands as well as for future research regarding k-thresholds.

Explaining declining rates of institutional LTC use in the Netherlands: a decomposition approach.

The use of long-term care (LTC) is changing rapidly. In the Netherlands, rates of institutional LTC use are falling, whereas homecare use is growing. Are these changes attributable to declining disability rates, or has LTC use given disability changed? And have institutionalization rates fallen regardless of disability level, or has LTC use become better tailored to needs? We answer these questions by explaining trends in LTC use for the Dutch 65+ population in the period 2000-2008 using a nonlinear variant of the Oaxaca-Blinder decomposition. We find that changes in LTC use are not due to shifts in the disability distribution but can almost entirely be traced back to changes in the way the system treats disability. Elderly with mild disability are more likely to be treated at home than before, whereas severely disabled individuals continue to receive institutional LTC. As a result, LTC use has become better tailored to the needs for such care. This finding suggests that policies that promote LTC in the community rather than in institutions can effectively mitigate the consequences of population aging on LTC spending.

Going formal or informal, who cares? The influence of public long-term care insurance.

International differences in long-term care (LTC) use are well documented, but not well understood. Using comparable data from two countries with universal public LTC insurance, the Netherlands and Germany, we examine how institutional differences relate to differences in the choice for informal and formal LTC. Although the overall LTC utilization rate is similar in both countries, use of formal care is more prevalent in the Netherlands and informal care use in Germany. Decomposition of the between-country differences in formal and informal LTC use reveals that these differences are not chiefly the result of differences in population characteristics but mainly derive from differences in the effects of these characteristics that are associated with between-country institutional differences. These findings demonstrate that system features such as eligibility rules and coverage generosity and, indirectly, social preferences can influence the choice between formal and informal care. Less comprehensive coverage also has equity implications: for the poor, access to formal LTC is more difficult in Germany than in the Netherlands.

Variation in Excess Mortality Across Nursing Homes in the Netherlands During the COVID-19 Pandemic.

OBJECTIVES: Nursing home residents constituted a vulnerable population during the COVID-19 pandemic, and half of all cause-attributed COVID-19 deaths occurred within nursing homes. Yet, given the low life expectancy of nursing home residents, it is unclear to what extent COVID-19 mortality increased overall mortality within this population. Moreover, there might have been differences between nursing homes in their ability to protect residents against excess mortality. This article estimates the number of excess deaths among Dutch nursing home residents during the pandemic, the variation in excess deaths across nursing homes, and its relationship with nursing home characteristics. DESIGN: Retrospective, use of administrative register data. SETTING AND PARTICIPANTS: All residents (N = 194,432) of Dutch nursing homes (n = 1463) in 2016-2021. METHODS: We estimated the difference between actual and predicted mortality, pooled at the nursing home level, which provided an estimate of nursing home-specific excess mortality corrected for resident case-mix differences. We show the variation in excess mortality across nursing homes and relate this to nursing home characteristics. RESULTS: In 2020 and 2021, the mortality probability among nursing home residents was 4.0 and 1.6 per 100 residents higher than expected. There was considerable variation in excess deaths across nursing homes, even after correcting for differences in resident case mix and regional factors. This variation was substantially larger than prepandemic mortality and was in 2020 related to prepandemic spending on external personnel and satisfaction with the building, and in 2021 to prepandemic staff absenteeism. CONCLUSIONS AND IMPLICATIONS: The variation in excess mortality across nursing homes was considerable during the COVID-19 pandemic, and larger compared with prepandemic years. The association of excess mortality with the quality of the building and spending on external personnel indicates the importance of considering differences across nursing home providers when designing policies and guidelines related to pandemic preparedness.

Sex-Based Disparities in Acute Myocardial Infarction Treatment Patterns and Outcomes in Older Adults Hospitalized Across 6 High-Income Countries: An Analysis From the International Health Systems Research Collaborative.

BACKGROUND: Sex differences in acute myocardial infarction treatment and outcomes are well documented, but it is unclear whether differences are consistent across countries. The objective of this study was to investigate the epidemiology, use of interventional procedures, and outcomes for older females and males hospitalized with ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation myocardial infarction (NSTEMI) in 6 diverse countries. METHODS: We conducted a serial cross-sectional cohort study of 1 508 205 adults aged ≥66 years hospitalized with STEMI and NSTEMI between 2011 and 2018 in the United States, Canada, England, the Netherlands, Taiwan, and Israel using administrative data. We compared females and males within each country with respect to age-standardized hospitalization rates, rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery within 90 days of hospitalization, and 30-day age- and comorbidity-adjusted mortality. RESULTS: Hospitalization rates for STEMI and NSTEMI decreased between 2011 and 2018 in all countries, although the hospitalization rate ratio (rate in males/rate in females) increased in virtually all countries (eg, US STEMI ratio, 1.58:1 in 2011 and 1.73:1 in 2018; Israel NSTEMI ratio, 1.71:1 in 2011 and 2.11:1 in 2018). Rates of cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery were lower for females than males for STEMI in all countries and years (eg, US cardiac catheterization in 2018, 88.6% for females versus 91.5% for males; Israel percutaneous coronary intervention in 2018, 76.7% for females versus 84.8% for males) with similar findings for NSTEMI. Adjusted mortality for STEMI in 2018 was higher for females than males in 5 countries (the United States, Canada, the Netherlands, Israel, and Taiwan) but lower for females than males in 5 countries for NSTEMI. CONCLUSIONS: We observed a larger decline in acute myocardial infarction hospitalizations for females than males between 2011 and 2018. Females were less likely to receive cardiac interventions and had higher mortality after STEMI. Sex disparities seem to transcend borders, raising questions about the underlying causes and remedies.

The Thrust Plate Prosthesis: long-term clinical and radiological results.

The Thrust Plate Prosthesis is a femoral implant designed for total hip arthroplasty, based on the principles of physiologic loading of the metaphysis of the proximal femur, and preserving the bone stock. This study presents the long-term clinical and radiological results of 34 patients with 36 Thrust Plate Prostheses. In a retrospective analysis, we investigated the reoperation-free survival as well as the clinical and radiological results. Mean age at operation was 51 +/- 6.4 years. Mean follow-up length was 11.9 +/- 1.6 years. Reoperation-free survival was 88.9%. Four (11.1%) reoperations were performed, in three patients due to aseptic loosening and in one patient because of a fracture distal to the lateral plate. Three of the reoperations were performed between 12 and 32 months postoperatively. The major complaint was pain at the lateral side of the hip (44%). Radiolucencies did not exceed 1 mm, but 35% of the hips showed resorption of the cortex directly under the thrust plate, together with cancellous bone hypertrophy at the calcar, noted in 97%. Because of the relatively high reoperation-free survival and favourable radiological results, the Thrust Plate Prosthesis appears as a possible alternative to stemmed total hip arthroplasty, especially in relatively young patients.

Measuring Nursing Home Performance Using Administrative Data.

To improve the quality of nursing home care, reliable estimates of outcomes are essential. Obtaining such estimates requires optimal use of limited data, especially for small homes. We analyze the variation in mortality and hospital admissions across nursing homes in the Netherlands during the years 2010-2013. We use administrative data on all nursing home clients. We apply mixed-effects survival models, empirical Bayes estimation, and machine-learning techniques to optimally use the available longitudinal data. We find large differences in both outcomes across nursing homes, yet the estimates are surrounded by substantial uncertainty. We find no correlation between performance on mortality and avoidable hospital admissions, suggesting that these are related to different aspects of quality. Hence, caution is needed when evaluating the performance of individual nursing homes, especially when the number of outcome indicators is limited.

Informal Care Costs According to Age and Proximity to Death to Support Cost-Effectiveness Analyses.

BACKGROUND: Costs of informal care are ignored in many cost-effectiveness analyses (CEAs) conducted from a societal perspective; however, these costs are relevant for lifesaving interventions targeted at the older population. In this study, we estimated informal care costs by age and proximity to death across European regions and showed how these estimates can be included in CEAs. METHODS: We estimated informal care costs by age and proximity to death using generalised linear mixed-effects models. For this, we selected deceased singles from the Survey of Health, Ageing and Retirement, which we grouped by four European regions. We combined the estimates of informal care costs with life tables to illustrate the impact of including informal care costs on the incremental cost-effectiveness ratio (ICER) of a hypothetical intervention that prevents a death at different ages. RESULTS: Informal care use, and hence informal care costs, increase when approaching death and with increasing age. The impact of including informal care costs on the ICER varies between €200 and €17,700 per quality-adjusted life-year gained. The impact increases with age and is stronger for women and in southern European countries. CONCLUSION: Our estimates of informal care costs facilitate including informal care costs in CEAs of life-extending healthcare interventions. Including these costs may influence decisions as it leads to reranking of life-extending interventions compared with interventions improving quality of life.

Acute hospital use in older adults following the 2015 Dutch reform of long-term care: an interrupted time series analysis.

BACKGROUND: In 2015, the Dutch government implemented a long-term care (LTC) reform primarily designed to promote older adults to age-in-place. Increased proportions of older adults living in the community might have resulted in more and longer acute hospitalisations. The aims of this study were to evaluate whether the Dutch 2015 LTC reform was associated with immediate and longitudinal increases in the monthly rate of acute clinical hospitalisation and monthly average hospital length of stay (LOS) in adults aged 65 years or older. METHODS: In this interrupted time series analysis of national hospital data (2009-18), we evaluated the association of the Dutch 2015 LTC reform with the monthly rate of acute clinical hospitalisation and monthly average LOS for older adults (aged ≥65 years). Patient-level episodic hospital data were provided by Dutch Hospital Data. Records were included that were defined as an acute clinical hospital admission for which a medical specialist decided treatment was necessary within 24 h. The analysis controlled for population growth (Dutch population data was provided by Statistics Netherlands) and seasonality, and calculated adjusted incident rate ratios (IRR). FINDINGS: Before the 2015 LTC reform, the rate of acute monthly hospitalisation was increasing (IRR 1·002 [95% CI 1·001-1·002]). A positive average reform effect was observed (1·116 [1·070-1·165]), accompanied by a negative change in trend (0·997 [0·996-0·998]) that resulted in a decreasing trend over the post-reform period (0·998 [0·998-0·999]). The pre-reform trend of LOS was decreasing (0·998 [0·997-0·998]), and the 2015 reform exhibited a positive change in trend (1·002 [1·002-1·003]) that resulted in a stabilisation of LOS in the post-reform period (0·999 [0·999-1·000]). INTERPRETATION: Our findings suggest that the increase in the rate of acute hospitalisation after the reform implementation was temporary, whereas the increase in LOS post-reform appeared to last longer than expected. These results have the potential to inform policy makers about effects of ageing-in-place LTC strategies on health and curative care. FUNDING: The Netherlands Organization for Health Research and Development, the Yale Claude Pepper Center, and the National Center for Advancing Translational Sciences, National Institutes of Health. TRANSLATION: For the Dutch translation of the abstract see Supplementary Materials section.

Patient-reported outcome and experience measures for quality improvement in pregnancy and childbirth care: a retrospective cohort study.

BACKGROUND: Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) can highlight issues that remain unnoticed when using standard clinical quality indicators. However, estimations of the potential power of measuring PROMs and PREMs to identify unrecognised areas suitable for quality improvement are often limited by a lack of reliable real-world data. Here, we report on how the indicator set for PROMs and PREMs that was recently developed by the International Consortium for Health Outcome Measures can change perspectives on quality assessment in women receiving care for pregnancy and childbirth. METHODS: PROMs and PREMs were captured 6 months after childbirth via an online survey in a single academic maternity unit in the Netherlands between 2018 and 2019. Indicators of abnormality were scored using predefined cut-off values established by a national consensus group. We used regression analysis to identify associations between PROMs, PREMs and healthcare use, and further stratified data to explore the distribution of indicators among relevant patient subgroups. RESULTS: Of 2775 questionnaires, 645 were completed and linked to medical health records. Despite only 5% of women reporting overall dissatisfaction with care, suboptimal scores were often found; in birth experience for 32% of the population, and 42% who experienced painful sexual intercourse. Subgroup analysis further revealed associations with relevant indicators of quality of care; inadequate pain relief among women with preterm birth (OR 8.8), pain with sexual intercourse among women undergoing vaginal assisted delivery (OR 2.2) and women living in a deprived area had problematic birth experiences (coefficient -3.2). CONCLUSION: Use of PROMs and PREMs in pregnancy and childbirth care provides new insights on quality of care, resulting in potentially actionable targets for improvement not normally identified with standard clinical quality indicators. Implementation strategies and follow-up are needed to act on these findings.

Variation in care for patients presenting with hip fracture in six high-income countries: A cross-sectional cohort study.

BACKGROUND: Hip fractures are costly and common in older adults, but there is limited understanding of how treatment patterns and outcomes might differ between countries. METHODS: We performed a retrospective serial cross-sectional cohort study of adults aged ≥66 years hospitalized with hip fracture between 2011 and 2018 in the US, Canada, England, the Netherlands, Taiwan, and Israel using population-representative administrative data. We examined mortality, hip fracture treatment approaches (total hip arthroplasty [THA], hemiarthroplasty [HA], internal fixation [IF], and nonoperative), and health system performance measures, including hospital length of stay (LOS), 30-day readmission rates, and time-to-surgery. RESULTS: The total number of hip fracture admissions between 2011 and 2018 ranged from 23,941 in Israel to 1,219,696 in the US. In 2018, 30-day mortality varied from 3% (16% at 1 year) in Taiwan to 10% (27%) in the Netherlands. With regards to processes of care, the proportion of hip fractures treated with HA (range 23%-45%) and THA (0.2%-10%) differed widely across countries. For example, in 2018, THA was used to treat approximately 9% of patients in England and Israel but less than 1% in Taiwan. Overall, IF was the most common surgery performed in all countries (40%-60% of patients). IF was used in approximately 60% of patients in the US and Israel, but only 40% in England. In 2018, rates of nonoperative management ranged from 5% of patients in Taiwan to nearly 10% in England. Mean hospital LOS in 2018 ranged from 6.4 days (US) to 18.7 days (England). The 30-day readmission rate in 2018 ranged from 8% (in Canada and the Netherlands) to nearly 18% in England. The mean days to surgery in 2018 ranged from 0.5 days (Israel) to 1.6 days (Canada). CONCLUSIONS: We observed substantial between-country variation in mortality, surgical approaches, and health system performance measures. These findings underscore the need for further research to inform evidence-based surgical approaches.

TNF blockade requires 1,25(OH)2D3 to control human Th17-mediated synovial inflammation.

OBJECTIVES: T helper 17 (Th17) cells from patients with early rheumatoid arthritis (RA) induce a proinflammatory feedback loop upon RA synovial fibroblast (RASF) interaction, including autocrine interleukin (IL)-17A production. A major challenge in medicine is how to control the pathogenic Th17 cell activity in human inflammatory autoimmune diseases. The objective of this study was to examine whether tumour necrosis factor (TNF) blockade and/or 1,25-dihydroxyvitamin D(3) (1,25(OH)(2)D(3)) controls Th17-mediated synovial inflammation. METHODS: Peripheral CD4+CD45RO+CCR6+ Th17 cells of patients with early RA, Th17-RASF cocultures and synovial biopsy specimens were cultured with or without 1,25(OH)(2)D(3) and/or TNFα blockade. Intracellular cytokine expression was detected by flow cytometry. Cytokine and matrix metalloprotease (MMP) production was determined by ELISA. RESULTS: The authors show that the 1,25(OH)(2)D(3), but not TNFα blockade, significantly suppressed autocrine IL-17A production in Th17-RASF and synovial biopsy cultures. Combining 1,25(OH)(2)D(3) and TNFα blockade had a significant additive effect compared with single treatment in controlling synovial inflammation, indicated by a further reduction in IL-6, IL-8, MMP-1 and MMP-3 in Th17-RASF cocultures and IL-6 and IL-8 expression in cultures of RA synovial tissue. CONCLUSIONS: These data show that TNF blockade does not suppress IL-17A and IL-22, which can be overcome by 1,25(OH)(2)D(3). The combination of neutralising TNF activity and 1,25(OH)(2)D(3) controls human Th17 activity and additively inhibits synovial inflammation. This indicates more valuable therapeutic potential of activation of Vitamin D receptor signalling over current TNF neutralisation strategies in patients with RA and potentially other Th17-mediated inflammatory diseases.