Disparities in Coronavirus Disease 2019 Mortality by Country of Birth in Stockholm, Sweden: A Total-Population-Based Cohort Study.

Preliminary evidence points to higher morbidity and mortality from coronavirus disease 2019 (COVID-19) in certain racial and ethnic groups, but population-based studies using microlevel data are lacking so far. We used register-based cohort data including all adults living in Stockholm, Sweden, between January 31, 2020 (the date of the first confirmed case of COVID-19) and May 4, 2020 (n = 1,778,670) to conduct Poisson regression analyses with region/country of birth as the exposure and underlying cause of COVID-19 death as the outcome, estimating relative risks and 95% confidence intervals. Migrants from Middle Eastern countries (relative risk (RR) = 3.2, 95% confidence interval (CI): 2.6, 3.8), Africa (RR = 3.0, 95% CI: 2.2, 4.3), and non-Sweden Nordic countries (RR = 1.5, 95% CI: 1.2, 1.8) had higher mortality from COVID-19 than persons born in Sweden. Especially high mortality risks from COVID-19 were found among persons born in Somalia, Lebanon, Syria, Turkey, Iran, and Iraq. Socioeconomic status, number of working-age household members, and neighborhood population density attenuated up to half of the increased COVID-19 mortality risks among the foreign-born. Disadvantaged socioeconomic and living conditions may increase infection rates in migrants and contribute to their higher risk of COVID-19 mortality.

Disparities in Children's Family Experiences by Mother's Socioeconomic Status: The Case of Finland.

A well-known argument claims that socioeconomic differentials in children's family structures have become increasingly important in shaping child outcomes and the resources available to children in developed societies. One assumption is that differentials are comparatively small in Nordic welfare states. Our study examines how children's experiences of family structures and family dynamics vary by their mother's educational attainment in Finland. Based on register data on the childbearing and union histories of women in Finland born from 1969 onwards, we provide life-table estimates of children's (N = 64,162) experiences of family dissolution, family formation, and family structure from ages 0-15 years, stratified by mother's education level at the child's birth. We find huge socioeconomic disparities in children's experiences of family structures and transitions. Compared to children of highly educated mothers, children of mothers with low levels of education are almost twice as likely to be born in cohabitation and four times as likely to be born to a lone mother. They are also much more likely to experience further changes in family structure-particularly parental separation. On average, children of low-educated mothers spend just half of their childhood years living with both their parents, whereas those of high-educated mothers spend four-fifths of their childhood with both parents. The sociodemographic inequalities among children in Nordic welfare states clearly deserve more scholarly attention.

A cost comparison of unicompartmental and total knee arthroplasty.

BACKGROUND: Unicompartmental knee arthroplasty (UKA) is an alternative to total knee arthroplasty (TKA) in appropriately selected patients. There is a paucity of data comparing hospital resource utilization and costs for UKA versus TKA. METHODS: We retrospectively reviewed 128 patients who underwent UKA or TKA for osteoarthritis by a single surgeon in the 2011 Fiscal Year. Sixty-four patients in each group were matched based on sex, age, race, body mass index, Charlson Comorbidity Index, and insurance type. Clinical data were obtained from medical records while costs were obtained from hospital billing. Bivariate analyses were used to compare outcomes. RESULTS: Both anesthesia and operative time (minutes) were significantly shorter for patients undergoing UKA (125.7 vs. 156.4; p<0.001, and 81.4 vs. 112.2; p<0.001). UKA patients required fewer transfusions (0% vs. 11.0%; p=0.007) and had a shorter hospital stay (2.2 vs. 3.8days; p<0.001). 96% of UKAs were discharged home compared with 75% of TKAs (p<0.001). Hospital direct costs were lower for UKA ($7893 vs. $11,156; p<0.001) as were total costs (hospital direct costs plus overhead; $11,397 vs. $16,243; p<0.001). Supply costs and implant costs were similarly lower for UKA ($701 vs. $781; p<0.001, and $3448 vs. $5006; p<0.001). CONCLUSION: Our data suggest that UKA provides a cost-effective alternative to TKA in appropriately selected patients. As the number of patients with end-stage arthritis of the knee requiring surgical care continues to rise, the costs of caring for these patients must be considered. LEVEL OF EVIDENCE: Level III, case control study.

A perioperative cost analysis comparing single-level minimally invasive and open transforaminal lumbar interbody fusion.

BACKGROUND CONTEXT: Emerging literature suggests superior clinical short- and long-term outcomes of MIS (minimally invasive surgery) TLIFs (transforaminal lumbar interbody fusion) versus open fusions. Few studies to date have analyzed the cost differences between the two techniques and their relationship to acute clinical outcomes. PURPOSE: The purpose of the study was to determine the differences in hospitalization costs and payments for patients treated with primary single-level MIS versus open TLIF. The impact of clinical outcomes and their contribution to financial differences was explored as well. STUDY DESIGN/SETTING: This study was a nonrandomized, nonblinded prospective review. PATIENT SAMPLE: Sixty-six consecutive patients undergoing a single-level TLIF (open/MIS) were analyzed (33 open, 33 MIS). Patients in either cohort (MIS/open) were matched based on race, sex, age, smoking status, medical comorbidities (Charlson Comorbidity index), payer, and diagnosis. Every patient in the study had a diagnosis of either degenerative disc disease or spondylolisthesis and stenosis. OUTCOME MEASURES: Operative time (minutes), length of stay (LOS, days), estimated blood loss (EBL, mL), anesthesia time (minutes), Visual Analog Scale (VAS) scores, and hospital cost/payment amount were assessed. METHODS: The MIS and open TLIF groups were compared based on clinical outcomes measures and hospital cost/payment data using SPSS version 20.0 for statistical analysis. The two groups were compared using bivariate chi-squared analysis. Mann-Whitney tests were used for non-normal distributed data. Effect size estimate was calculated with the Cohen d statistic and the r statistic with a 95% confidence interval. RESULTS: Average surgical time was shorter for the MIS than the open TLIF group (115.8 minutes vs. 186.0 minutes respectively; p=.001). Length of stay was also reduced for the MIS versus the open group (2.3 days vs. 2.9 days, respectively; p=.018). Average anesthesia time and EBL were also lower in the MIS group (p<.001). VAS scores decreased for both groups, although these scores were significantly lower for the MIS group (p<.001). Financial analysis demonstrated lower total hospital direct costs (blood, imaging, implant, laboratory, pharmacy, physical therapy/occupational therapy/speech, room and board) in the MIS versus the open group ($19,512 vs. $23,550, p<.001). Implant costs were similar (p=.686) in both groups, although these accounted for about two-thirds of the hospital direct costs in the MIS cohort ($13,764) and half of these costs ($13,778) in the open group. Hospital payments were $6,248 higher for open TLIF patients compared with the MIS group (p=.267). CONCLUSIONS: MIS TLIF technique demonstrated significant reductions of operative time, LOS, anesthesia time, VAS scores, and EBL compared with the open technique. This reduction in perioperative parameters translated into lower total hospital costs over a 60-day perioperative period. Although hospital reimbursements appear higher in the open group over the MIS group, shorter surgical times and LOS days in the MIS technique provide opportunities for hospitals to reduce utilization of resources and to increase surgical case volume.

Socioeconomic differences in the unemployment and fertility nexus: Evidence from Denmark and Germany.

Studies that have investigated the role of unemployment in childbearing decisions have often shown no or only barely significant results. We argue that many of these "non-findings" may be attributed to a neglect of group-specific differences in behavior. In this study, we examine how the association of unemployment and fertility varies by socio-demographic subgroups using data from the German Socio-Economic Panel (GSOEP) and from Danish population registers. We find that male unemployment is related to a postponement of first and second childbearing in both countries. The role of female unemployment is less clear at these two parities. Both male and female unemployment is positively correlated with third birth risks. More importantly, our results show that there are strong educational gradients in the unemployment and fertility nexus, and that the relationship between unemployment and fertility varies by socioeconomic group. Fertility tends to be lower during periods of unemployment among highly educated women and men, but not among their less educated counterparts.

Comparative effectiveness evidence from the spine patient outcomes research trial: surgical versus nonoperative care for spinal stenosis, degenerative spondylolisthesis, and intervertebral disc herniation.

STUDY DESIGN: Cost-effectiveness analysis of a randomized plus observational cohort trial. OBJECTIVE: Analyze cost-effectiveness of Spine Patient Outcomes Research Trial data over 4 years comparing surgery with nonoperative care for three common diagnoses: spinal stenosis (SPS), degenerative spondylolisthesis (DS), and intervertebral disc herniation (IDH). SUMMARY OF BACKGROUND DATA: Spine surgery rates continue to rise in the United States, but the safety and economic value of these procedures remain uncertain. METHODS: Patients with image-confirmed diagnoses were followed in randomized or observational cohorts with data on resource use, productivity, and EuroQol EQ-5D health state values measured at 6 weeks, 3, 6, 12, 24, 36, and 48 months. For each diagnosis, cost per quality-adjusted life year (QALY) gained in 2004 US dollars was estimated for surgery relative to nonoperative care using a societal perspective, with costs and QALYs discounted at 3% per year. RESULTS: Surgery was performed initially or during the 4-year follow-up among 414 of 634 (65.3%) SPS, 391 of 601 (65.1%) DS, and 789 of 1192 (66.2%) IDH patients. Surgery improved health, with persistent QALY differences observed through 4 years (SPS QALY gain 0.22; 95% confidence interval, CI: 0.15, 0.34; DS QALY gain 0.34, 95% CI: 0.30, 0.47; and IDH QALY gain 0.34, 95% CI: 0.31, 0.38). Costs per QALY gained decreased for SPS from $77,600 at 2 years to $59,400 (95% CI: $37,059, $125,162) at 4 years, for DS from $115,600 to $64,300 per QALY (95% CI: $32,864, $83,117), and for IDH from $34,355 to $20,600 per QALY (95% CI: $4,539, $33,088). CONCLUSION: Comparative effectiveness evidence for clearly defined diagnostic groups from Spine Patient Outcomes Research Trial shows good value for surgery compared with nonoperative care over 4 years.

Chronic low back pain: a heterogeneous condition with challenges for an evidence-based approach.

"Chronic" low back pain (LBP), defined as present for 3 or more months, has become a major socioeconomic problem insufficiently addressed by five major entities largely working in isolation from one another - procedural based specialties, strength based rehabilitation, cognitive behavioral therapy, pain management and manipulative care. As direct and indirect costs continue to rise, many authors have systematically evaluated the body of evidence in an effort to demonstrate the effectiveness (or lack thereof) for various diagnostic and therapeutic interventions. The objective of this Spine Focus issue is not to replicate previous work in this area. Rather, our expert panel has chosen a set of potentially controversial topics for more in-depth study and discussion. A recurring theme is that chronic LBP is a heterogeneous condition, and this affects the way it is diagnosed, classified, treated, and studied. The efficacy of some treatments may be appreciated only through a better understanding of heterogeneity of treatment effects (i.e., identification of clinically relevant subgroups with differing responses to the same treatment). Current clinical guidelines and payer policies for LBP are systematically compared for consistency and quality. Novel approaches for data gathering, such as national spine registries, may offer a preferable approach to gain meaningful data and direct us towards a "results-based medicine." This approach would require more high-quality studies, more consistent recording for various phenotypes and exploration of studies on genetic epidemiologic undertones to guide us in the emerging era of "results based medicine."

Surgical treatment of spinal stenosis with and without degenerative spondylolisthesis: cost-effectiveness after 2 years.

BACKGROUND: The SPORT (Spine Patient Outcomes Research Trial) reported favorable surgery outcomes over 2 years among patients with stenosis with and without degenerative spondylolisthesis, but the economic value of these surgeries is uncertain. OBJECTIVE: To assess the short-term cost-effectiveness of spine surgery relative to nonoperative care for stenosis alone and for stenosis with spondylolisthesis. DESIGN: Prospective cohort study. DATA SOURCES: Resource utilization, productivity, and EuroQol EQ-5D score measured at 6 weeks and at 3, 6, 12, and 24 months after treatment among SPORT participants. TARGET POPULATION: Patients with image-confirmed spinal stenosis, with and without degenerative spondylolisthesis. TIME HORIZON: 2 years. PERSPECTIVE: Societal. INTERVENTION: Nonoperative care or surgery (primarily decompressive laminectomy for stenosis and decompressive laminectomy with fusion for stenosis associated with degenerative spondylolisthesis). OUTCOME MEASURES: Cost per quality-adjusted life-year (QALY) gained. RESULTS OF BASE-CASE ANALYSIS: Among 634 patients with stenosis, 394 (62%) had surgery, most often decompressive laminectomy (320 of 394 [81%]). Stenosis surgeries improved health to a greater extent than nonoperative care (QALY gain, 0.17 [95% CI, 0.12 to 0.22]) at a cost of $77,600 (CI, $49,600 to $120,000) per QALY gained. Among 601 patients with degenerative spondylolisthesis, 368 (61%) had surgery, most including fusion (344 of 368 [93%]) and most with instrumentation (269 of 344 [78%]). Degenerative spondylolisthesis surgeries significantly improved health versus nonoperative care (QALY gain, 0.23 [CI, 0.19 to 0.27]), at a cost of $115,600 (CI, $90,800 to $144,900) per QALY gained. RESULT OF SENSITIVITY ANALYSIS: Surgery cost markedly affected the value of surgery. LIMITATION: The study used self-reported utilization data, 2-year time horizon, and as-treated analysis to address treatment nonadherence among randomly assigned participants. CONCLUSION: The economic value of spinal stenosis surgery at 2 years compares favorably with many health interventions. Degenerative spondylolisthesis surgery is not highly cost-effective over 2 years but could show value over a longer time horizon.

The cost effectiveness of surgical versus nonoperative treatment for lumbar disc herniation over two years: evidence from the Spine Patient Outcomes Research Trial (SPORT).

STUDY DESIGN: Spine Patient Outcomes Research Trial observational and randomized cohort participants with a confirmed diagnosis of intervertebral disc herniation (IDH) who received either usual nonoperative care and/or standard open discectomy were followed from baseline at 6 weeks, 3, 6, 12, and 24 months at 13 spine clinics in 11 US states. OBJECTIVE: To evaluate the cost-effectiveness of surgery relative to nonoperative care among patients with a confirmed diagnosis of lumbar IDH. SUMMARY OF BACKGROUND DATA: The cost-effectiveness of surgery as a treatment for conditions associated with low back and leg symptoms remains poorly understood. METHODS: Incremental cost-effectiveness ratio, reported as discounted cost per quality adjusted life year (QALY) gained in 2004 US dollars based on EuroQol EQ-5D health state values with US scoring, and information on resource utilization and time away from work. RESULTS: Among 775 patients who underwent surgery and 416 who were treated nonoperatively, the mean difference in QALYs over 2 years was 0.21 (95% CI: 0.16-0.25) in favor of surgery. Surgery was more costly than nonoperative care; the mean difference in total cost was $14,137(95% CI: $11,737-16,770). The cost per QALY gained for surgery relative to nonoperative care was $69,403 (95% CI: $49,523-94,999) using general adult surgery costs and $34,355 (95% CI: $20,419-52,512) using Medicare population surgery costs. CONCLUSION: Surgery for IDH was moderately cost-effective when evaluated over 2 years. The estimated economic value of surgery varied considerably according to the method used for assigning surgical costs.

Settlement size and fertility in the Nordic countries.

While the variation in childbearing patterns across countries and between socio-economic groups within a country has been studied in detail, less is known about the differences in fertility patterns across settlements within a country. Using aggregate and individual-level register data, we examine fertility variation across settlements in Denmark, Finland, Norway, and Sweden. We observe a significant variation in fertility level by settlement size in all four of these Nordic countries - the larger the settlement, the lower the fertility. Second, the variation in fertility level has decreased over time, but significant differences in fertility between settlements of different size persist. Third, the timing of childbearing also varies across settlements - the larger the settlement, the later the peak of fertility. Fourth, our analysis of parity-specific fertility in Sweden shows that the major socio-economic characteristics of women account for only a small portion of fertility variation across settlements.

Are back supports plus education more effective than education alone in promoting recovery from low back pain?: Results from a randomized clinical trial.

STUDY DESIGN: Randomized clinical trial. OBJECTIVES: To evaluate the effectiveness of a back support plus education versus education alone in promoting recovery from a work-related low back disorder (WR-LBD) while simultaneously considering personal, health, and occupational factors and the impact of occupational factors on recovery. SUMMARY OF BACKGROUND DATA: No randomized studies of active industrial workers with low back disorders exist regarding the effectiveness of back supports plus education. METHODS: A total of 433 actively employed hourly union workers who had a recent diagnosis of a WR-LBD: 1) those who wore a specially designed back support plus received education on back health; and 2) those who received education on back health only. Demographic, health, medical, and occupational factors were obtained through interview or abstraction of computer files; individual ergonomic exposures were measured with a lumbar motion monitor. Outcomes evaluated over a 12-month period included: self-reported measures of back pain, back pain disability level, physical health, mental health, and administrative measures of recurrence, lost work time, and medical care utilization. RESULTS: There was no difference between the study groups with respect to mental or physical health, low back pain, back pain disability, neurogenic symptoms, lost work time, likelihood of recurrence of an episode of a back disorder, or other administrative measures of healthcare utilization or lost work time. However, significant decreases in low back pain, low back pain disability, neurogenic symptoms, and an increase in physical health were observed over the 12 months of observation in both study groups. The only occupational variable found to influence was plant group whereby service parts operations workers in the back support plus education group experienced a lower likelihood of WR-LBD recurrence. CONCLUSION: Although there was no overall effect on self-reported recovery or administrative measures or lost work time between the study groups, a back support plus health education may have some value in preventing recurrent WR-LBD in industrial workers who work in psychosocial environments and perform manual material handling tasks similar to those found in parts distribution centers.

What is different about workers' compensation patients? Socioeconomic predictors of baseline disability status among patients with lumbar radiculopathy.

STUDY DESIGN: Combined analysis of 2 prospective clinical studies. OBJECTIVE: To identify socioeconomic characteristics associated with workers' compensation in patients with an intervertebral disc herniation (IDH) or spinal stenosis (SpS). SUMMARY OF BACKGROUND DATA: Few studies have compared socioeconomic differences between those receiving or not receiving workers' compensation with the same underlying clinical conditions. METHODS: Patients were identified from the Spine Patient Outcomes Research Trial (SPORT) and the National Spine Network (NSN) practice-based outcomes study. Patients with IDH and SpS within NSN were identified satisfying SPORT eligibility criteria. Information on disability and work status at baseline evaluation was used to categorize patients into 3 groups: workers' compensation, other disability compensation, or work-eligible controls. Enrollment rates of patients with disability in a clinical efficacy trial (SPORT) and practice-based network (NSN) were compared. Independent socioeconomic predictors of baseline workers' compensation status were identified in multivariate logistic regression models controlling for clinical condition, study cohort, and initial treatment designation. RESULTS: Among 3759 eligible patients (1480 in SPORT and 2279 in NSN), 564 (15%) were receiving workers' compensation, 317 (8%) were receiving other disability compensation, and 2878 (77%) were controls. Patients receiving workers' compensation were less common in SPORT than NSN (9.2% vs. 18.8%, P < 0.001), but patients receiving other disability compensation were similarly represented (8.9% vs. 7.7%, P = 0.19). In univariate analyses, many socioeconomic characteristics significantly differed according to baseline workers' compensation status. In multiple logistic regression analyses, gender, educational level, work characteristics, legal action, and expectations about ability to work without surgery were independently associated with receiving workers' compensation. CONCLUSION: Clinical trials involving conditions commonly seen in patients with workers' compensation may need special efforts to ensure adequate representation. Socioeconomic characteristics markedly differed between patients receiving and not receiving workers' compensation. Identifying the independent effects of workers' compensation on outcomes will require controlling for these baseline characteristics and other clinical features associated with disability status.

Bone ingrowth through porous titanium granulate around a femoral stem: histological assessment in a six-month canine hemiarthroplasty model.

The procedure of using of porous titanium granules for cementless fixation of a hip replacement femoral stem was studied in a hemiarthroplasty model in 10 canines for 6 months. A vibrating instrument was used to facilitate both the delivery and distribution of the irregularly shaped porous titanium granules into the femoral canal as well as the subsequent insertion of a titanium alloy stem into the intramedullary bed of granules. Histological examination revealed lamellar bone formation through the mantle of porous titanium granules in continuity with the surrounding cortex resulting in the formation of an integrated mantle of bone and titanium granulate around the prosthesis.

Technology assessment: approach and reimbursement.

STUDY DESIGN: Review of technology assessment process for novel spine patient care. OBJECTIVE: To discuss the issues surrounding the introduction of novel technologies for spine patient care. SUMMARY OF BACKGROUND DATA: The parties involved in the technology development and assessment process include clinicians, researchers, academic institutions, governmental organizations, and private health care payors. METHODS: Description of the responsibilities and processes of various parties involved in technology assessment. RESULTS: The process for introduction of novel spine technologies is complex and will become more efficient as each party involved increases its understanding of the roles played by all the others. CONCLUSIONS: The technology assessment process involves clinicians, researchers, governmental agencies, and private payors. All must work in concert for the efficient introduction of safe, efficacious, reasonable, and cost-effective novel treatments for spine patients.

Gendering family composition: sex preferences for children and childbearing behavior in the Nordic countries.

It has been argued that a society's gender system may influence parents' sex preferences for children. If this is true, one should expect to find no evidence of such preferences in countries with a high level of gender equality. In this article, we exploit data from population registers from Denmark, Finland, Norway, and Sweden to examine continuities and changes in parental sex preferences in the Nordic countries during the past three to four decades. First, we do not observe an effect of the sex of the first born child on second-birth risks. Second, we detect a distinct preference for at least one child of each sex among parents of two children. For third births, Danish, Norwegian, and Swedish parents seem to develop a preference for having a daughter, while Finns exhibit a significant preference for having a son. These findings show that modernization and more equal opportunities for women and men do not necessarily lead to parental gender indifference. On the contrary, they may even result in new sex preferences.

Labour-market status and first-time parenthood: the experience of immigrant women in Sweden, 1981-97.

This paper investigates the impact of labour-market attachment on first births of foreign-born women in Sweden. The study uses a longitudinal, register-based dataset consisting of the entire population of immigrants from ten nations and a 5-per-cent random sample of natives. The effects of earned income are evident, with increased income levels increasing the probability of becoming a mother for all observed nationalities. The effects of various forms of participation and non-participation in the labour force do not vary greatly between immigrants and the Swedish-born. Among all subgroups, we find a higher propensity to begin childbearing among those who are established in the labour market. Contrary to popular belief, receiving welfare benefits clearly reduces first-birth intensity for immigrants but not for natives. The similarity in patterns across widely different national groups supports the notion that various institutional factors affecting all subgroups are crucial in influencing childbearing behaviour.