Variation in practice and outcomes after inguinal hernia repair: a nationwide observational study.

BACKGROUND: Inguinal hernia repair has often been used as a showcase to illustrate practice variation in surgery. This study determined the degree of hospital variation in proportion of patients with an inguinal hernia undergoing operative repair and the effect of this variation on clinical outcomes. METHODS: A nationwide, longitudinal, database study was performed in all hospitals in the Netherlands between 2013 and 2015. Patients with inguinal hernias were collected from the Diagnosis-Related-Group (DRG) database. The case-mix adjusted operation rate in patients with a new DRG determines the observed variation. Hospital variation in case-mix adjusted inguinal hernia repair-rates was calculated per year. Clinical outcomes after surgery were compared between hospitals with high and low adjusted operation-rates. RESULTS: In total, 95,637 patients were included. The overall operation rate was 71.6%. In 2013-2015, the case-mix adjusted performance of inguinal hernia repairs in hospitals with high rates was 1.6-1.9 times higher than in hospitals with low rates. Moreover, in hospitals with high adjusted rates of inguinal hernia repair the time to surgery was shorter, more laparoscopic procedures were performed, less emergency department visits were recorded post-operatively, while more emergency department visits were recorded when patients were treated conservatively compared to hospitals with low adjusted operation rates. CONCLUSION: Hospital variation in inguinal hernia repair in the Netherlands is modest, operation-rates vary by less than two-fold, and variation is stable over time. Hernia repair in hospitals with high adjusted rates of inguinal hernia repair are associated with improved outcomes.

Hospital Variation in Cholecystectomies in The Netherlands: A Nationwide Observational Study.

BACKGROUND: Practice variation generally raises concerns about the quality of care. This study determined the longitudinal degree of hospital variation in proportion of patients with gallstone disease undergoing cholecystectomy, while adjusted for case-mix, and the effect on clinical outcomes. METHODS: A nationwide, longitudinal, database study was performed in all hospitals in the Netherlands in 2013-2015. Patients with gallstone disease were collected from the diagnosis-related group database. Hospital variation in case-mix-adjusted cholecystectomy rates was calculated per year. Clinical outcomes after cholecystectomy were compared between hospitals in the lowest/highest 20th percentile of the distribution of adjusted cholecystectomy rates in all 3 subsequent years. RESULTS: In total, 96,673 patients with gallstones were included. The cholecystectomy rate was 73.6%. In 2013-2015, the case-mix-adjusted performance of cholecystectomies was in hospitals with high rates 1.5-1.6 times higher than in hospitals with low rates. Hospitals with a high adjusted cholecystectomy rate had a higher laparoscopy rate, shorter time to surgery, and less emergency department visits after a cholecystectomy compared to hospitals with a low-adjusted cholecystectomy rate. CONCLUSION: Hospital variation in cholecystectomies in the Netherlands is modest, cholecystectomy rates varies by <2-fold, and variation is stable over time. Cholecystectomies in hospitals with high adjusted cholecystectomy rates are associated with improved outcomes.

Impact of evidence-based guidelines on healthcare utilisation and costs for disc related sciatica in the Netherlands: a population-based, cross-sectional study.

OBJECTIVE: The aim of this study was to assess the impact of high-quality evidence supporting surgical treatment of lumbar disc herniation (LDH) on healthcare practice in the Netherlands by examining changes in healthcare utilisation, including the timing of surgery, and the healthcare costs for patients with LDH. DESIGN: A retrospective, cross-sectional study was performed using population-based, longitudinal data obtained from the Dutch Healthcare Authority (2007-2020) and NIVEL's primary care (2012-2020) administrative databases. SETTING: The study was conducted within the healthcare system of the Netherlands. PARTICIPANTS: We included adults (≥18 years) who visited a Dutch hospital or a general practitioner (GP) for lumbar degenerative disc disease. Patients with LDH were identified based on registered diagnosis code, type of surgery (discectomy) and age (<56 years). MAIN OUTCOME MEASURES: The primary outcome measure was the difference in the annual number of LDH procedures following the publication of evidence-based guidelines in 2009 (comparing the periods 2007-2009 to 2017-2019). Secondary outcome measures focused on the timing of surgery and associated healthcare costs. To validate the outcomes, secondary outcomes also include the number of discectomies and the number of procedures in the younger age group (discectomies, laminectomies, and fusion surgery). RESULTS: The number of patients suffering from LDH increased from 55 581 to 68 997 (+24%) between 2007 and 2019. A decrease was observed in the annual number of LDH procedures (-18%), in the number of discectomies (-22%) and in the number of procedures for patients aged <56 years (-18%). This resulted in lower healthcare costs by €10.5 million annually. In 2012, 31% of all patients <56 years had surgery before 12 weeks from diagnosis at the GP, whereas 20% did in 2019. CONCLUSIONS: Healthcare utilisation for LDH changed tremendously in the Netherlands between 2007 and 2020 and seemed to be associated with the publication and implementation of evidence-based guidelines. The observed decrease in the number of procedures has been accompanied by a corresponding reduction in healthcare costs. These findings underscore the importance of adhering to evidence-based guidelines to optimise the management of patients with LDH.

Neural evidence of the allophonic mode of speech perception in adults with dyslexia.

OBJECTIVE: A growing body of evidence suggests that individuals with dyslexia perceive speech using allophonic rather than phonemic units and are thus sensitive to phonetic variations that are actually irrelevant in the ambient language. This study investigated speech perception difficulties in adults with dyslexia using behavioural and neural measurements with stimuli along a place-of-articulation continuum with well-defined allophonic boundaries. Adults without dyslexia served as control participants. METHODS: Categorical perception of a /bə - də/ place-of-articulation continuum was evaluated using both identification and discrimination tasks. In addition to these behavioural measures, mismatch negativity (MMN) was recorded for stimuli that came from either similar or different phoneme categories. RESULTS: The adults with dyslexia exhibited less consistent labelling than controls, but no heightened sensitivity to allophonic contrasts was observed at the behavioural level. Neural measurements revealed that stimuli from different phoneme categories elicited MMNs in both the adults with dyslexia and controls, whereas stimuli from the same category elicited an MMN in the adults with dyslexia only. CONCLUSION: The finding that adults with dyslexia have heightened sensitivity to allophonic contrasts in the form of neural activation supports the allophonic explanation of dyslexia. SIGNIFICANCE: Sensitivity to allophonic contrasts may be a valuable marker for dyslexia.

Aberrant N400 responses to phonological overlap during rhyme judgements in children at risk for dyslexia.

It is widely accepted that dyslexia is associated with difficulties in phonological awareness and that rhyme awareness in young children can predict later reading success. However, little is known regarding the underlying phonological mechanisms of rhyme awareness in dyslexia, as rhyme awareness is typically assessed using explicit behavioural measures that represent only the endpoint of processing and often lack phonological distracters. We examined event-related potentials (ERPs) in response to auditory word pairs that differed in phonological overlap during a rhyme judgement task given to 6-year-old beginning readers who were at risk for dyslexia (n=30) and typical-reading age-matched controls (n=29). ERPs were recorded in response to word pairs with various types of phonological overlap, including rhyming (e.g., wall-ball), non-rhyming overlapping (e.g., bell-ball) and non-rhyming unrelated (e.g., sock-ball) word pairs. Both groups of participants exhibited N400 responses for basic rhyme judgements vs. unrelated targets. In the typical-reading controls, the neural responses also differed between the rhyming targets and the non-rhyming overlapping targets, whereas neural responses to these targets were similar in the group of children at risk for dyslexia, indicating difficulties in their ability to process similar-sounding, non-rhyming targets. These findings suggest that typical-reading children solve the rhyme judgement task using a more analytical approach, whereas children who are at risk for dyslexia base their judgments on a comparison of overall sound similarity.

Deviant neural processing of phonotactic probabilities in adults with dyslexia.

During language acquisition in the first year of life, children become sensitive to phonotactic probabilities such as the likelihood of speech sound occurrences in the ambient language. Because this sensitivity is acquired at an early age, the extent to which the neural system that underlies speech processing in adults is tuned to these phonological regularities can reflect difficulties in processing language-specific phonological regularities that can persist into adulthood. Here, we examined the neural processing of phonotactic probabilities in 18 adults with dyslexia and 18 non-dyslexic controls using mismatch negativity, a pre-attentive neurophysiological response. Stimuli that differed in phonotactic probability elicited similar mismatch negativity responses among the adults with dyslexia, whereas the controls responded more strongly to stimuli with a high phonotactic probability than to stimuli with a low phonotactic probability, suggesting that controls - but not adults with dyslexia - are sensitive to the phonological regularities of the ambient language. These findings suggest that the underlying neural system in adults with dyslexia is not properly tuned to language-specific phonological regularities, which may partially account for the phonological deficits that are often reported in dyslexic individuals.