Reoperation-requiring postoperative intracranial haemorrhage after posterior fossa craniotomy: Retrospective case-series.

Introduction: Studies report rates of treatment-requiring postoperative intracranial haemorrhage after craniotomy around 1-2%, but do not distinguish between supratentorial and posterior fossa operations. Reports about intracranial haemorrhages' temporal occurrence show conflicting results. Recommendations for duration of postoperative monitoring vary. Research question: To determine the rate, temporal pattern and clinical presentation of reoperation-requiring postoperative intracranial posterior fossa haemorrhage. Material and methods: This retrospective case-series identified cases operated with posterior fossa craniotomy or craniectomy between January 1, 2007 and December 31, 2021 by an electronic search in the patient administrative database, and collected data about patient- and treatment-characteristics, postoperative monitoring, and the occurrence of haemorrhagic and other serious postoperative complications. Results: We included 62 (n = 34, 55% women) cases with mean age 48 (interquartile range 50) years operated for tumours (n = 34, 55%), Chiari malformations (n = 18, 29%), ischemic stroke (n = 6, 10%) and other lesions (n = 3, 5%). One (2%) 66-year-old woman who was a daily smoker operated with decompressive craniectomy and infarct resection, developed a reoperation-requiring postoperative intracranial haemorrhage after 25.5 h. In four (6%) cases, other serious complications requiring reoperation or transfer from the post anaesthesia care unit or regular bed wards to the intensive care unit occurred after 0.5, 6, 9 and 54 h, respectively. Discussion and conclusion: Treatment-requiring postoperative intracranial haemorrhage and other serious complications after posterior fossa craniotomies occur over a wide timespan and are difficult to capture with a standardized postoperative monitoring time. This indicates that the duration of monitoring should be individualized based on assessment of risk factors.

Stable glioma incidence and increased patient survival over the past two decades in Norway: a nationwide registry-based cohort study.

BACKGROUND: Surveillance of incidence and survival of central nervous system tumors is essential to monitor disease burden and epidemiological changes, and to allocate health care resources. Here, we describe glioma incidence and survival trends by histopathology group, age, and sex in the Norwegian population. MATERIAL AND METHODS: We included patients with a histologically verified glioma reported to the Cancer Registry of Norway from 2002 to 2021 (N = 7,048). Population size and expected mortality were obtained from Statistics Norway. Cases were followed from diagnosis until death, emigration, or 31 December 2022, whichever came first. We calculated age-standardized incidence rates (ASIR) per 100,000 person-years and age-standardized relative survival (RS).  Results: The ASIR for histologically verified gliomas was 7.4 (95% CI: 7.3-7.6) and was higher for males (8.8; 95% CI: 8.5-9.1) than females (6.1; 95% CI: 5.9-6.4). Overall incidence was stable over time. Glioblastoma was the most frequent tumor entity (ASIR = 4.2; 95% CI: 4.1-4.4). Overall, glioma patients had a 1-year RS of 63.6% (95% CI: 62.5-64.8%), and a 5-year RS of 32.8% (95% CI: 31.6-33.9%). Females had slightly better survival than males. For most entities, 1- and 5-year RS improved over time (5-year RS for all gliomas 29.0% (2006) and 33.1% (2021), p < 0.001). Across all tumor types, the RS declined with increasing age at diagnosis. INTERPRETATION: The incidence of gliomas has been stable while patient survival has increased over the past 20 years in Norway. As gliomas represent a heterogeneous group of primary CNS tumors, regular reporting from cancer registries at the histopathology group level is important to monitor disease burden and allocate health care resources in a population.

Patient Characteristics Associated With Worsening of Neck Pain-Related Disability After Surgery for Degenerative Cervical Myelopathy: A Nationwide Study of 1508 Patients.

BACKGROUND AND OBJECTIVES: Functional status, pain, and quality of life usually improve after surgery for degenerative cervical myelopathy (DCM), but a subset of patients report worsening. The objective was to define cutoff values for worsening on the Neck Disability Index (NDI) and identify prognostic factors associated with worsening of pain-related disability 12 months after DCM surgery. METHODS: In this prognostic study based on prospectively collected data from the Norwegian Registry for Spine Surgery, the NDI was the primary outcome. Receiver operating characteristics curve analyses were used to obtain cutoff values, using the global perceived effect scale as an external anchor. Univariable and multivariable analyses were performed using mixed logistic regression to evaluate the relationship between potential prognostic factors and the NDI. RESULTS: Among the 1508 patients undergoing surgery for myelopathy, 1248 (82.7%) were followed for either 3 or 12 months. Of these, 317 (25.4%) were classified to belong to the worsening group according to the mean NDI percentage change cutoff of 3.3. Multivariable analyses showed that smoking (odds ratio [OR] 3.4: 95% CI 1.2-9.5: P < .001), low educational level (OR 2.5: 95% CI 1.0-6.5: P < .001), and American Society of Anesthesiologists grade >II (OR 2.2: 95% CI 0.7-5.6: P = .004) were associated with worsening. Patients with more severe neck pain (OR 0.8: 95% CI 0.7-1.0: P = .003) and arm pain (OR 0.8: 95% CI 0.7-1.0; P = .007) at baseline were less likely to report worsening. CONCLUSION: We defined a cutoff value of 3.3 for worsening after DCM surgery using the mean NDI percentage change. The independent prognostic factors associated with worsening of pain-related disability were smoking, low educational level, and American Society of Anesthesiologists grade >II. Patients with more severe neck and arm pain at baseline were less likely to report worsening at 12 months.

Diagnostic accuracy of anti-3-[18F]-FACBC PET/MRI in gliomas.

PURPOSE: The primary aim was to evaluate whether anti-3-[18F]FACBC PET combined with conventional MRI correlated better with histomolecular diagnosis (reference standard) than MRI alone in glioma diagnostics. The ability of anti-3-[18F]FACBC to differentiate between molecular and histopathological entities in gliomas was also evaluated. METHODS: In this prospective study, patients with suspected primary or recurrent gliomas were recruited from two sites in Norway and examined with PET/MRI prior to surgery. Anti-3-[18F]FACBC uptake (TBRpeak) was compared to histomolecular features in 36 patients. PET results were then added to clinical MRI readings (performed by two neuroradiologists, blinded for histomolecular results and PET data) to assess the predicted tumor characteristics with and without PET. RESULTS: Histomolecular analyses revealed two CNS WHO grade 1, nine grade 2, eight grade 3, and 17 grade 4 gliomas. All tumors were visible on MRI FLAIR. The sensitivity of contrast-enhanced MRI and anti-3-[18F]FACBC PET was 61% (95%CI [45, 77]) and 72% (95%CI [58, 87]), respectively, in the detection of gliomas. Median TBRpeak was 7.1 (range: 1.4-19.2) for PET positive tumors. All CNS WHO grade 1 pilocytic astrocytomas/gangliogliomas, grade 3 oligodendrogliomas, and grade 4 glioblastomas/astrocytomas were PET positive, while 25% of grade 2-3 astrocytomas and 56% of grade 2-3 oligodendrogliomas were PET positive. Generally, TBRpeak increased with malignancy grade for diffuse gliomas. A significant difference in PET uptake between CNS WHO grade 2 and 4 gliomas (p < 0.001) and between grade 3 and 4 gliomas (p = 0.002) was observed. Diffuse IDH wildtype gliomas had significantly higher TBRpeak compared to IDH1/2 mutated gliomas (p < 0.001). Adding anti-3-[18F]FACBC PET to MRI improved the accuracy of predicted glioma grades, types, and IDH status, and yielded 13.9 and 16.7 percentage point improvement in the overall diagnoses for both readers, respectively. CONCLUSION: Anti-3-[18F]FACBC PET demonstrated high uptake in the majority of gliomas, especially in IDH wildtype gliomas, and improved the accuracy of preoperatively predicted glioma diagnoses. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT04111588, URL: https://clinicaltrials.gov/study/NCT04111588.

Reducing unwarranted variation: can a 'clinical dashboard' be helpful for hospital executive boards and top-level leaders?

BACKGROUND/AIM: In the past decades, there has been an increasing focus on defining, identifying and reducing unwarranted variation in clinical practice. There have been several attempts to monitor and reduce unwarranted variation, but the experience so far is that these initiatives have failed to reach their goals. In this article, we present the initial process of developing a safety, quality and utilisation rate dashboard ('clinical dashboard') based on a selection of data routinely reported to executive boards and top-level leaders in Norwegian specialist healthcare. METHODS: We used a modified version of Wennberg's categorisation of healthcare delivery to develop the dashboard, focusing on variation in (1) effective care and patient safety and (2) preference-sensitive and supply-sensitive care. RESULTS: Effective care and patient safety are monitored with outcome measures such as 30-day mortality after hospital admission and 5-year cancer survival, whereas utilisation rates for procedures selected on cost and volume are used to follow variations in preference-sensitive and supply-sensitive care. CONCLUSION: We argue that selecting quality indicators of patient safety, quality and utilisation rates and presenting them in a dashboard may help executive hospital boards and top-level leaders to focus on unwarranted variation.

The Norwegian registry for spine surgery (NORspine): cohort profile.

PURPOSE: To review and describe the development, methods and cohort of the lumbosacral part of the Norwegian registry for spine surgery (NORspine). METHODS: NORspine was established in 2007. It is government funded, covers all providers and captures consecutive cases undergoing operations for degenerative disorders. Patients' participation is voluntary and requires informed consent. A set of baseline-, process- and outcome-variables (3 and 12 months) recommended by the International Consortium for Health Outcome Measurement is reported by surgeons and patients. The main outcome is the Oswestry disability index (ODI) at 12 months. RESULTS: We show satisfactory data quality assessed by completeness, timeliness, accuracy, relevance and comparability. The coverage rate has been 100% since 2016 and the capture rate has increased to 74% in 2021. The cohort consists of 60,647 (47.6% women) cases with mean age 55.7 years, registered during the years 2007 through 2021. The proportions > 70 years and with an American Society of Anaesthesiologists' Physical Classification System (ASA) score > II has increased gradually to 26.1% and 19.3%, respectively. Mean ODI at baseline was 43.0 (standard deviation 17.3). Most cases were operated with decompression for disc herniation (n = 26,557, 43.8%) or spinal stenosis (n = 26,545, 43.8%), and 7417 (12.2%) with additional or primary fusion. The response rate at 12 months follow-up was 71.6%. CONCLUSION: NORspine is a well-designed population-based comprehensive national clinical quality registry. The register's methods ensure appropriate data for quality surveillance and improvement, and research.

Prospects of returning to work after lumbar spine surgery for patients considering disability pension: a nationwide study based on data from the Norwegian Registry for Spine Surgery.

OBJECTIVES: To assess the odds for not returning to work (non-RTW) 1 year after treatment among patients who had applied for or were planning to apply for disability pension (DP-applicant) prior to an operation for degenerative disorders of the lumbar spine. METHODS: This population-based cohort study from the Norwegian Registry for Spine surgery included 26 688 cases operated for degenerative disorders of the lumbar spine from 2009 to 2020. The primary outcome was RTW (yes/no). Secondary patient-reported outcome measures (PROMs) were the Oswestry Disability Index, Numeric Rating Scales for back and leg pain, EuroQoL five-dimension and the Global Perceived Effect Scale. Logistic regression analysis was used to investigate associations between being a DP-applicant prior to surgery (exposure), possible confounders (modifiers) at baseline and RTW 12 months after surgery (outcome). RESULTS: The RTW ratio for DP-applicants was 23.1% (having applied: 26.5%, planning to apply 21.1%), compared with 78.6% among non-applicants. All secondary PROMs were more favourable among non-applicants. After adjusting for all significant confounders (low expectations and pessimism related to working capability, not feeling wanted by the employer and physically demanding work), DP-applicants with under 12 months preoperative sick leave had 3.8 (95% CI 1.8 to 8.0) higher odds than non-applicants for non-RTW 12 months after surgery. The subgroup having applied for disability pension had the strongest impact on this association. CONCLUSION: Less than a quarter of the DP-applicants returned to work 12 months after surgery. This association remained strong, also when adjusted for the confounders as well as other covariates related RTW.

Impact of the number of previous lumbar operations on patient-reported outcomes after surgery for lumbar spinal stenosis or lumbar disc herniation.

Repeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort. This is a population-based study from the Norwegian Registry for Spine surgery (NORspine). We included 26,723 consecutive cases operated for lumbar spinal stenosis or lumbar disc herniation from January 2007 to December 2018. The primary outcome was the Oswestry Disability Index (ODI), presented as the proportions reaching a patient-acceptable symptom state (PASS; defined as an ODI raw score ≤ 22) and ODI raw and change scores at 12-month follow-up. Secondary outcomes were the Global Perceived Effect scale, the numerical rating scale for pain, the EuroQoL five-dimensions health questionnaire, occurrence of perioperative complications and wound infections, and working capability. Binary logistic regression analysis was conducted to examine how the number of previous operations influenced the odds of not reaching a PASS. The proportion reaching a PASS decreased from 66.0% (95% confidence interval (CI) 65.4 to 66.7) in cases with no previous operation to 22.0% (95% CI 15.2 to 30.3) in cases with four or more previous operations (p < 0.001). The odds of not reaching a PASS were 2.1 (95% CI 1.9 to 2.2) in cases with one previous operation, 2.6 (95% CI 2.3 to 3.0) in cases with two, 4.4 (95% CI 3.4 to 5.5) in cases with three, and 6.9 (95% CI 4.5 to 10.5) in cases with four or more previous operations. The ODI raw and change scores and the secondary outcomes showed similar trends. We found a dose-response relationship between increasing number of previous operations and inferior outcomes among patients operated for degenerative conditions in the lumbar spine. This information should be considered in the shared decision-making process prior to elective spine surgery.

Clinical outcomes after surgery for cervical radiculopathy performed in public and private hospitals : a nationwide relative effectiveness study.

AIMS: The number of patients undergoing surgery for degenerative cervical radiculopathy has increased. In many countries, public hospitals have limited capacity. This has resulted in long waiting times for elective treatment and a need for supplementary private healthcare. It is uncertain whether the management of patients and the outcome of treatment are equivalent in public and private hospitals. The aim of this study was to compare the management and patient-reported outcomes among patients who underwent surgery for degenerative cervical radiculopathy in public and private hospitals in Norway, and to assess whether the effectiveness of the treatment was equivalent. METHODS: This was a comparative study using prospectively collected data from the Norwegian Registry for Spine Surgery. A total of 4,750 consecutive patients who underwent surgery for degenerative cervical radiculopathy and were followed for 12 months were included. Case-mix adjustment between those managed in public and private hospitals was performed using propensity score matching. The primary outcome measure was the change in the Neck Disability Index (NDI) between baseline and 12 months postoperatively. A mean difference in improvement of the NDI score between public and private hospitals of ≤ 15 points was considered equivalent. Secondary outcome measures were a numerical rating scale for neck and arm pain and the EuroQol five-dimension three-level health questionnaire. The duration of surgery, length of hospital stay, and complications were also recorded. RESULTS: The mean improvement from baseline to 12 months postoperatively of patients who underwent surgery in public and private hospitals was equivalent, both in the unmatched cohort (mean NDI difference between groups 3.9 points (95% confidence interval (CI) 2.2 to 5.6); p < 0.001) and in the matched cohort (4.0 points (95% CI 2.3 to 5.7); p < 0.001). Secondary outcomes showed similar results. The duration of surgery and length of hospital stay were significantly longer in public hospitals. Those treated in private hospitals reported significantly fewer complications in the unmatched cohort, but not in the matched cohort. CONCLUSION: The clinical effectiveness of surgery for degenerative cervical radiculopathy performed in public and private hospitals was equivalent 12 months after surgery.Cite this article: Bone Joint J 2023;105-B(1):64-71.

[Glioblastoma in adults]. / Glioblastom hos voksne.

Glioblastoma is the most common form of primary brain cancer in adults, and the disease has a serious prognosis. Although great progress has been made in molecular characteristics, no major breakthroughs in treatment have been achieved for many years. In this article we present a clinical review of current diagnostics and treatment, as well as the challenges and opportunities inherent in developing improved and more personalised treatment.

Non-respondents do not bias outcome assessment after cervical spine surgery: a multicenter observational study from the Norwegian registry for spine surgery (NORspine).

BACKGROUND: The Norwegian registry for spine surgery (NORspine) is a national clinical quality registry which has recorded more than 10,000 operations for degenerative conditions of the cervical spine since 2012. Registries are large observational cohorts, at risk for attrition bias. We therefore aimed to examine whether clinical outcomes differed between respondents and non-respondents to standardized questionnaire-based 12-month follow-up. METHODS: All eight public and private providers of cervical spine surgery in Norway report to NORspine. We included 334 consecutive patients who were registered with surgical treatment of degenerative conditions in the cervical spine in 2018 and did a retrospective analysis of prospectively collected register data and data on non-respondents' outcomes collected by telephone interviews. The primary outcome measure was patient-reported change in arm pain assessed with the numeric rating scale (NRS). Secondary outcome measures were change in neck pain assessed with the NRS, change in health-related quality of life assessed with EuroQol 5 Dimensions (EQ-5D), and patients' perceived benefit of the operation assessed by the Global Perceived Effect (GPE) scale. RESULTS: At baseline, there were few and small differences between the 238 (71.3%) respondents and the 96 (28.7%) non-respondents. We reached 76 (79.2%) non-respondents by telephone, and 63 (65.6%) consented to an interview. There was no statistically significant difference between groups in change in NRS score for arm pain (3.26 (95% CI 2.84 to 3.69) points for respondents and 2.77 (1.92 to 3.63) points for telephone interviewees) or any of the secondary outcome measures. CONCLUSIONS: The results indicate that patients lost to follow-up were missing at random. Analyses of outcomes based on data from respondents can be considered representative for the complete register cohort, if patient characteristics associated with attrition are controlled for.

Decompressive hemicraniectomy for space-occupying brain infarction: Nationwide population-based registry study.

OBJECTIVE: We analyzed data from the Norwegian Stroke Registry (NSR) to study access to and outcomes of decompressive hemicraniectomy for brain infarction in a nationwide routine clinical setting. We also discretionary assessed whether the outcomes were comparable with those achieved in randomized controlled trials (RCTs), and whether the use was in accordance with guidelines. METHODS: The NSR is a nationwide (population 5.3 million) clinical quality registry. We included all stroke-cases operated in 2017 through 2019, and retrieved data on baseline characteristics, treatment and functional outcome after three months (dichotomized modified Rankin Scale score; favorable (0-3) or unfavorable (4-6)). Crude treatment rates and the expected proportion of patients transferred from a local hospital to a stroke-center for the operation were estimated, based on the total population's distribution of residency. RESULTS: The 68 cases were 17 (25%) women and 51 (75%) men with a median National Institute of Health Stroke Scale (NIHSS) score on admission of 14.0 (inter-quartile range (IQR) 11.0) and a median time from onset to hemicraniectomy of 34.3 (IQR 40.9) hours. The crude treatment rate varied between regions from 0.29 to 1.40 operations per 100,000 population per year, and the proportion transferred from a local hospital (50%) was lower than expected (68%). A favorable outcome was achieved in 20/52 (38.5%) cases. CONCLUSIONS: The findings indicate gender- and geographic-inequalities in access. Among operated cases, outcomes were comparable with those reported from RCTs, and the use in accordance with recommendations in the current guidelines from the American Stroke Association.

Geographical variation in orthopedic procedures in Norway: Cross-sectional population-based study.

BACKGROUND: Standardized surgery rates for common orthopedic procedures vary across geographical areas in Norway. We explored whether area-level factors related to demand and supply in publicly funded healthcare are associated with geographical variation in surgery rates for six common orthopedic procedures. METHODS: The present study is a cross-sectional population-based study of hospital referral areas in Norway. We included adult admissions for arthroscopy for degenerative knee disease, arthroplasty for osteoarthritis of the knee and hip, surgical treatment for hip fracture, and decompression with/without fusion for lumbar disk herniation and lumbar spinal stenosis in 2012-2016. Variation in age and sex standardized rates was estimated using extremal quotients, coefficients of variation, and systematic components of variation (SCV). Associations between surgery rates and the socioeconomic factors urbanity, unemployment, low-income, high level of education, mortality, and number of surgeons and hospitals were explored with linear regression analyses. RESULTS: Knee arthroscopy showed highest level of variation (SCV 10.3) and decreased in numbers. Variation was considerable for spine surgery (SCV 3.8-4.9), moderate to low for arthroplasty procedures (SCV 0.8-2.6), and small for hip fracture surgery (SCV 0.2). Higher rates of knee arthroscopy were associated with more orthopedic surgeons (adjusted coefficient 24.8, 95% confidence interval (CI): 2.7-47.0), and less urban population (adjusted coefficient -13.3, 95% CI: -25.4 to -1.2). Higher spine surgery rates were associated with more hospitals (adjusted coefficient 22.4, 95% CI: 4.6-40.2), more urban population (adjusted coefficient 2.1, 95% CI: 0.4-3.8), and lower mortality (adjusted coefficient -192.6, 95% CI: -384.2 to -1.1). Rates for arthroplasty and hip fracture surgery were not associated with supply/demand factors included. CONCLUSIONS: Arthroscopy for degenerative knee disease decreased in line with guidelines, but showed high variation of surgery rates. Socioeconomic factors included in this study did not explain geographical variation in orthopedic surgery.

A nationwide study of patients operated for cervical degenerative disorders in public and private hospitals.

During the last decades, there has been an increase in the rate of surgery for degenerative disorders of the cervical spine and in the use of supplementary private health insurance. Still, there is limited knowledge about the differences in characteristics of patients operated in public and private hospitals. Therefore, we aimed at comparing sociodemographic-, clinical- and patient management data on patients operated for degenerative cervical radiculopathy and degenerative cervical myelopathy in public and private hospitals in Norway. This was a cross-sectional study on patients in the Norwegian Registry for Spine Surgery operated for degenerative cervical radiculopathy and degenerative cervical myelopathy between January 2012 and December 2020. At admission for surgery, we assessed disability by the following patient reported outcome measures (PROMs): neck disability index (NDI), EuroQol-5D (EQ-5D) and numerical rating scales for neck pain (NRS-NP) and arm pain (NRS-AP). Among 9161 patients, 7344 (80.2%) procedures were performed in public hospitals and 1817 (19.8%) in private hospitals. Mean age was 52.1 years in public hospitals and 49.7 years in private hospitals (P < 0.001). More women were operated in public hospitals (47.9%) than in private hospitals (31.6%) (P < 0.001). A larger proportion of patients in private hospitals had high education (≥ 4 years of college or university) (42.9% vs 35.6%, P < 0.001). Patients in public hospitals had worse disease-specific health problems than those in private hospitals: unadjusted NDI mean difference was 5.2 (95% CI 4.4 - 6.0; P < 0.001) and adjusted NDI mean difference was 3.4 (95% CI 2.5 - 4.2; P < 0.001), and they also had longer duration of symptoms (P < 0.001). Duration of surgery (mean difference 29 minutes, 95% CI 27.1 - 30.7; P < 0.001) and length of hospital stay (mean difference 2 days, 95% CI 2.3 - 2.4; P < 0.001) were longer in public hospitals. In conclusion, patients operated for degenerative cervical spine in private hospitals were healthier, younger, better educated and more often men. They also had less and shorter duration of symptoms and seemed to be managed more efficiently. Our findings indicate that access to cervical spine surgery in private hospitals could be skewed in favour of patients with higher socioeconomic status.

Cervical spine surgery in the Northern Norway Regional Health Authority area in 2014-18. / Nakkekirurgi i Helse Nord 2014­18.

BACKGROUND: Knowledge about the variation in treatment rates is needed to assess whether the access to health services is equitable. The objective of this study was to investigate the rates of surgical treatment of degenerative cervical spine disease in Norway and the Northern Norway Regional Health Authority area and the local coverage in the Northern Norway Regional Health Authority area, and to assess the activity in the region. MATERIAL AND METHOD: We included cervical spine procedures recorded in the Norwegian Patient Registry from the years 2014-18 and estimated age-standardised treatment rates for Norway, the health regions and health trusts in Northern Norway Regional Health Authority. We estimated the local coverage as the proportion of patients resident in the Northern Norway Regional Health Authority area who had undergone surgery at the University Hospital of North Norway in Tromsø. RESULTS: The treatment rate remained stable at an average of 29.6 surgical procedures per 100 000 inhabitants (aged 18-105) per year. The rate for residents in the Northern Norway Regional Health Authority area was 23.0 procedures per 100 000 inhabitants per year (78 % of the national average). The rates in Finnmark and the areas of residence served by the University Hospital of North Norway were close to the national average. Residents in the Nordland and Helgeland areas had lower rates in each year of the study period, with an average of 16.6 and 18.1 procedures per 100 000 inhabitants per year respectively. This corresponds to 56 % and 61 % of the national average. Local coverage in the Northern Norway Regional Health Authority area increased from 69 % in 2014 to 91 % in 2018. INTERPRETATION: The treatment rate for degenerative cervical spine disease was lower in the Northern Norway Regional Health Authority area than in the rest of Norway. For this to be compensated and the local coverage to be increased to 100 %, we have estimated that the activity needs to be increased by approximately 35 surgical procedures per year.

Obesity Does Not Protect From Subarachnoid Hemorrhage: Pooled Analyses of 3 Large Prospective Nordic Cohorts.

BACKGROUND: Several population-based cohort studies have related higher body mass index (BMI) to a decreased risk of subarachnoid hemorrhage (SAH). The main objective of our study was to investigate whether the previously reported inverse association can be explained by modifying effects of the most important risk factors of SAH-smoking and hypertension. METHODS: We conducted a collaborative study of three prospective population-based Nordic cohorts by combining comprehensive baseline data from 211 972 adult participants collected between 1972 and 2012, with follow-up until the end of 2018. Primarily, we compared the risk of SAH between three BMI categories: (1) low (BMI<22.5), (2) moderate (BMI: 22.5-29.9), and (3) high (BMI≥30) BMI and evaluated the modifying effects of smoking and hypertension on the associations. RESULTS: We identified 831 SAH events (mean age 62 years, 55% women) during the total follow-up of 4.7 million person-years. Compared with the moderate BMI category, persons with low BMI had an elevated risk for SAH (adjusted hazard ratio [HR], 1.30 [1.09-1.55]), whereas no significant risk difference was found in high BMI category (HR, 0.91 [0.73-1.13]). However, we only found the increased risk of low BMI in smokers (HR, 1.49 [1.19-1.88]) and in hypertensive men (HR, 1.72 [1.18-2.50]), but not in nonsmokers (HR, 1.02 [0.76-1.37]) or in men with normal blood pressure values (HR, 0.98 [0.63-1.54]; interaction HRs, 1.68 [1.18-2.41], P=0.004 between low BMI and smoking and 1.76 [0.98-3.13], P=0.06 between low BMI and hypertension in men). CONCLUSIONS: Smoking and hypertension appear to explain, at least partly, the previously reported inverse association between BMI and the risk of SAH. Therefore, the independent role of BMI in the risk of SAH is likely modest.

A prognostic model for failure and worsening after lumbar microdiscectomy: a multicenter study from the Norwegian Registry for Spine Surgery.

OBJECTIVE: To develop a prognostic model for failure and worsening 1 year after surgery for lumbar disc herniation. METHODS: This multicenter cohort study included 11,081 patients operated with lumbar microdiscectomy, registered at the Norwegian Registry for Spine Surgery. Follow-up was 1 year. Uni- and multivariate logistic regression analyses were used to assess potential prognostic factors for previously defined cut-offs for failure and worsening on the Oswestry Disability Index scores 12 months after surgery. Since the cut-offs for failure and worsening are different for patients with low, moderate, and high baseline ODI scores, the multivariate analyses were run separately for these subgroups. Data were split into a training (70%) and a validation set (30%). The model was developed in the training set and tested in the validation set. A prediction (%) of an outcome was calculated for each patient in a risk matrix. RESULTS: The prognostic model produced six risk matrices based on three baseline ODI ranges (low, medium, and high) and two outcomes (failure and worsening), each containing 7 to 11 prognostic factors. Model discrimination and calibration were acceptable. The estimated preoperative probabilities ranged from 3 to 94% for failure and from 1 to 72% for worsening in our validation cohort. CONCLUSION: We developed a prognostic model for failure and worsening 12 months after surgery for lumbar disc herniation. The model showed acceptable calibration and discrimination, and could be useful in assisting physicians and patients in clinical decision-making process prior to surgery.

Treatment rates for lumbar spine surgery in Norway and Northern Norway Regional Health Authority 2014-18. / Behandlingsrater for ryggkirurgi i Norge og Helse Nord 2014­18.

BACKGROUND: The objective of this study was to investigate whether the service provision for lumbar spine surgery within the Northern Norway Regional Health Authority area complies with the distribution of functions that has been decided for the hospitals in the region, and whether there are any geographical variations in service provision. We therefore studied the treatment rates in Norway as a whole and in the Northern Norway Regional Health Authority area, and assessed the activity in the region. MATERIAL AND METHOD: We included lumbar spine procedures in the Norwegian Patient Registry from the years 2014-2018 in a retrospective analysis and estimated treatment rates standardised by sex and age for Norway as a whole, the health regions and the health enterprises in Northern Norway Regional Health Authority. We estimated the local coverage as the proportion of patients who had undergone surgery in a hospital within their own area of residence. RESULTS: The treatment rate for lumbar spine surgery in Norway amounted to approximately 120 procedures per 100 000 inhabitants per year for the entire period. The number of spine procedures nationwide increased from 5 995 in 2014 to 6 494 in 2018 because of a general population growth. The treatment rates for fractures and simple spine procedures were approximately identical throughout Norway, but the rate for complex spine procedures among residents within the area of Northern Norway Regional Health Authority amounted to 57 % of the national average. Local coverage within the Northern Norway Regional Health Authority area increased from 60 % to 84 % during the period. The local hospital functions for simple spine procedures at Nordland and Helgeland hospitals (approximately 30 %) and the regional function for complex spine surgery at the University Hospital of North Norway (55 %) had a low degree of local coverage. INTERPRETATION: The treatment rate for complex spine procedures and the local coverage for all surgical procedures for degenerative lumbar spine disease were lower within the Northern Norway Regional Health Authority area than in the country as a whole. For this to be compensated in this region, we have estimated that the activity needs to be increased by approximately 170 procedures per year.

Associations between utilization rates and patients' health: a study of spine surgery and patient-reported outcomes (EQ-5D and ODI).

BACKGROUND: A vast body of literature has documented regional variations in healthcare utilization rates. The extent to which such variations are "unwarranted" critically depends on whether there are corresponding variations in patients' needs. Using a unique medical registry, the current paper investigated any associations between utilization rates and patients' needs, as measured by two patient-reported outcome measures (PROMs). METHODS: This observational panel study merged patient-level data from the Norwegian Patient Registry (NPR), Statistics Norway, and the Norwegian Registry for Spine Surgery (NORspine) for individuals who received surgery for degenerative lumbar spine disorders in 2010-2015. NPR consists of hospital administration data. NORspine includes two PROMs: the generic health-related quality of life instrument EQ-5D and the disease-specific, health-related quality of life instrument Oswestry Disability Index (ODI). Measurements were assessed at baseline and at 3 and 12 months post-surgery and included a wide range of patient characteristics. Our case sample included 15,810 individuals. We analyzed all data using generalized estimating equations. RESULTS: Our results show that as treatment rates increase, patients have better health at baseline. Furthermore, increased treatment rates are associated with smaller health gain. CONCLUSION: The correlation between treatment rates and patients health indicate the presence of unwarranted variation in treatment rates for lumbar spine disorders.

DIAGNOSTIC IMAGING AND IONIZING RADIATION EXPOSURE IN A LEVEL 1 TRAUMA CENTRE POPULATION MET WITH TRAUMA TEAM ACTIVATION: A ONE-YEAR PATIENT RECORD AUDIT.

This audit describes ionizing and non-ionizing diagnostic imaging at a regional trauma centre. All 144 patients (males 79.2%, median age 31 years) met with trauma team activation from 1 January 2015 to 31 December 2015 were included. We used data from electronic health records to identify all diagnostic imaging and report radiation exposure as dose area product (DAP) for conventional radiography (X-ray) and dose length product (DLP) and effective dose for CT. During hospitalization, 134 (93.1%) underwent X-ray, 122 (84.7%) CT, 92 (63.9%) focused assessment with sonography for trauma (FAST), 14 (9.7%) ultrasound (FAST excluded) and 32 (22.2%) magnetic resonance imaging. One hundred and sixteen (80.5%) underwent CT examinations during trauma admissions, and 73 of 144 (50.7%) standardized whole body CT (SWBCT). DAP values were below national reference levels. Median DLP and effective dose were 2396 mGycm and 20.42 mSv for all CT examinations, and 2461 mGycm (national diagnostic reference level 2400) and 22.29 mSv for a SWBCT.