Models for delivery and co-ordination of primary or secondary health care (or both) to older adults living in aged care facilities.

BACKGROUND: The number of older people is increasing worldwide and public expenditure on residential aged care facilities (ACFs) is expected to at least double, and possibly triple, by 2050. Co-ordinated and timely care in residential ACFs that reduces unnecessary hospital transfers may improve residents' health outcomes and increase satisfaction with care among ACF residents, their families and staff. These benefits may outweigh the resources needed to sustain the changes in care delivery and potentially lead to cost savings. Our systematic review comprehensively and systematically presents the available evidence of the effectiveness, safety and cost-effectiveness of alternative models of providing health care to ACF residents. OBJECTIVES: Main objective To assess the effectiveness and safety of alternative models of delivering primary or secondary health care (or both) to older adults living in ACFs. Secondary objective To assess the cost-effectiveness of the alternative models. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers (WHO ICTRP, ClinicalTrials.gov) on 26 October 2022, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA: We included individual and cluster-randomised trials, and cost/cost-effectiveness data collected alongside eligible effectiveness studies. Eligible study participants included older people who reside in an ACF as their place of permanent abode and healthcare professionals delivering or co-ordinating the delivery of healthcare at ACFs. Eligible interventions focused on either ways of delivering primary or secondary health care (or both) or ways of co-ordinating the delivery of this care. Eligible comparators included usual care or another model of care. Primary outcomes were emergency department visits, unplanned hospital admissions and adverse effects (defined as infections, falls and pressure ulcers). Secondary outcomes included adherence to clinical guideline-recommended care, health-related quality of life of residents, mortality, resource use, access to primary or specialist healthcare services, any hospital admissions, length of hospital stay, satisfaction with the health care by residents and their families, work-related satisfaction and work-related stress of ACF staff. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any alternative model of care versus usual care. MAIN RESULTS: We included 40 randomised trials (21,787 participants; three studies only reported number of beds) in this review. Included trials evaluated alternative models of care aimed at either all residents of the ACF (i.e. no specific health condition; 11 studies), ACF residents with mental health conditions or behavioural problems (12 studies), ACF residents with a specific condition (e.g. residents with pressure ulcers, 13 studies) or residents requiring a specific type of care (e.g. residents after hospital discharge, four studies). Most alternative models of care focused on 'co-ordination of care' (n = 31). Three alternative models of care focused on 'who provides care' and two focused on 'where care is provided' (i.e. care provided within ACF versus outside of ACF). Four models focused on the use of information and communication technology. Usual care, the comparator in all studies, was highly heterogeneous across studies and, in most cases, was poorly reported. Most of the included trials were susceptible to some form of bias; in particular, performance (89%), reporting (66%) and detection (42%) bias. Compared to usual care, alternative models of care may make little or no difference to the proportion of residents with at least one emergency department visit (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.84 to 1.20; 7 trials, 1276 participants; low-certainty evidence), but may reduce the proportion of residents with at least one unplanned hospital admission (RR 0.74, 95% CI 0.56 to 0.99, I2 = 53%; 8 trials, 1263 participants; low-certainty evidence). We are uncertain of the effect of alternative models of care on adverse events (proportion of residents with a fall: RR 1.15, 95% CI 0.83 to 1.60, I² = 74%; 3 trials, 1061 participants; very low-certainty evidence) and adherence to guideline-recommended care (proportion of residents receiving adequate antidepressant medication: RR 5.29, 95% CI 1.08 to 26.00; 1 study, 65 participants) as the certainty of the evidence is very low. Compared to usual care, alternative models of care may have little or no effect on the health-related quality of life of ACF residents (MD -0.016, 95% CI -0.036 to 0.004; I² = 23%; 12 studies, 4016 participants; low-certainty evidence) and probably make little or no difference to the number of deaths in residents of ACFs (RR 1.03, 95% CI 0.92 to 1.16, 24 trials, 3881 participants, moderate-certainty evidence). We did not pool the cost-effectiveness or cost data as the specific costs associated with the various alternative models of care were incomparable, both across models of care as well as across settings. Based on the findings of five economic evaluations (all interventions focused on co-ordination of care), we are uncertain of the cost-effectiveness of alternative models of care compared to usual care as the certainty of the evidence is very low. AUTHORS' CONCLUSIONS: Compared to usual care, alternative models of care may make little or no difference to the number of emergency department visits but may reduce unplanned hospital admissions. We are uncertain of the effect of alternative care models on adverse events (i.e. falls, pressure ulcers, infections) and adherence to guidelines compared to usual care, as the certainty of the evidence is very low. Alternative models of care may have little or no effect on health-related quality of life and probably have no effect on mortality of ACF residents compared to usual care. Importantly, we are uncertain of the cost-effectiveness of alternative models of care due to the limited, disparate data available.

Two sides of the same coin? Absolute income and perceived income inadequacy as social determinants of health.

BACKGROUND: Absolute income is commonly used in studies of health inequalities, however it does not reflect spending patterns, debts, or expectations. These aspects are reflected in measures concerning perceived income inadequacy. While health inequities by absolute income or perceived income inadequacy are well established, few studies have explored the interplay of absolute income and perceived income inadequacy in relation to health. METHODS: Multiple data sources were linked into a nationally representative dataset (n = 445,748) of Dutch adults (18 +). The association between absolute income, perceived income inadequacy and health (self-reported health, chronic disease and psychological distress) was tested using logistic and Poisson regressions, controlling for various potential confounders (demographics, education) and mastery. Interactions were tested to check the association between perceived income inadequacy and health for different absolute income groups. RESULTS: Perceived income inadequacy was reported at every absolute income group (with 42% of individuals in the lowest income group and 5% of individuals in the highest income group). Both absolute income and perceived income inadequacy were independently associated with health. The adjusted relative risk (RR) for lowest absolute income group is 1.11 (1.08-1.1.14) and 1.28 (1.24-1.32) for chronic disease and self-reported health respectively, and the Odds Ratio (OR) for psychological distress is 1.28 (1.16-1.42). For perceived income inadequacy the RR's were 1.41 (1.37-1.46) and 1.49 (1.44-1.54) and the OR for psychological distress is 3.14 (2.81-3.51). Mastery appeared to be an important mediator for the relationship between perceived income inadequacy, poor self-rated health and psychological distress. CONCLUSIONS: Absolute income and perceived income inadequacy reflect conceptually different aspects of income and are independently associated with health outcomes. Perceived income inadequacy may be accounted for in health inequality studies, alongside measures of absolute income. In policy-making, targeting perceived income inadequacy might have potential to reduce health inequalities.

Regional differences in healthcare costs further explained: The contribution of health, lifestyle, loneliness and mastery.

Healthcare costs in the Netherlands are rising and vary considerably among regions. Explaining regional differences in healthcare costs can help policymakers in targeting appropriate interventions in order to restrain costs. Factors usually taken into account when analyzing regional differences in healthcare costs are demographic structure and socioeconomic status (SES). However, health, lifestyle, loneliness and mastery have also been linked to healthcare costs. Therefore, this study analyzes the contribution of health, lifestyle factors (BMI, alcohol consumption, smoking and physical activity), loneliness, and mastery to regional differences in healthcare costs. Analyses are performed in a linked dataset (n = 334,721) from the Dutch Public Health Services, Statistics Netherlands, the National Institute for Public Health and the Environment (year 2016), and the healthcare claims database Vektis (year 2017) with Poisson and zero-inflated binomial regressions. Regional differences in general practitioner consult costs remain significant even after taking into account health, lifestyle, loneliness, and mastery. Regional differences in costs for mental, pharmaceutical, and specialized care are less pronounced and can be explained to a large extent. For total healthcare costs, regional differences are mostly explained through the factors included in this study. Hence, addressing lifestyle factors, loneliness and mastery can help policymakers in restraining healthcare costs. In this study, the region of Zuid-Limburg represents the reference region. Use compare regions for health and healthcare costs (Regiovergelijker gezondheid en zorgkosten) in order to select all other Dutch regions as reference region. Supplementary Information: The online version of this article (10.1007/s12508-022-00369-4) contains supplementary material, which is available to authorized users.

Exploring discordance between Health Literacy Questionnaire scores of people with RMDs and assessment by treating health professionals.

OBJECTIVES: We studied discordance between health literacy of people with rheumatic and musculoskeletal diseases (RMDs) and assessment of health literacy by their treating health professionals, and explored whether discordance is associated with the patients' socioeconomic background. METHODS: Patients with RA, spondyloarthritis (SpA) or gout from three Dutch outpatient rheumatology clinics completed the nine-domain Health Literacy Questionnaire (HLQ). Treating health professionals assessed their patients on each HLQ domain. Discordance per domain was defined as a ≥2-point difference on a 0-10 scale (except if both scores were below three or above seven), leading to three categories: 'negative discordance' (i.e. professional scored lower), 'probably the same' or 'positive discordance' (i.e. professional scored higher). We used multivariable multilevel multinomial regression models with patients clustered by health professionals to test associations with socioeconomic factors (age, gender, education level, migration background, employment, disability for work, living alone). RESULTS: We observed considerable discordance (21-40% of patients) across HLQ domains. Most discordance occurred for 'Critically appraising information' (40.5%, domain 5). Comparatively, positive discordance occurred more frequently. Negative discordance was more frequently and strongly associated with socioeconomic factors, specifically lower education level and non-Western migration background (for five HLQ domains). Associations between socioeconomic factors and positive discordance were less consistent. CONCLUSION: Frequent discordance between patients' scores and professionals' estimations indicates there may be hidden challenges in communication and care, which differ between socioeconomic groups. Successfully addressing patients' health literacy needs cannot solely depend on health professionals' estimations but will require measurement and dialogue. VIDEO ABSTRACT: A video abstract of this article can be found at https://www.youtube.com/watch?v=ggnB1rATdQ4.

Is Loneliness an Undervalued Pathway between Socio-Economic Disadvantage and Health?

Loneliness is a growing public health issue. It is more common in disadvantaged groups and has been associated with a range of poor health outcomes. Loneliness may also form an independent pathway between socio-economic disadvantage and poor health. Therefore, the aim of this study was to explore the contribution of loneliness to socio-economic health inequalities. These contributions were studied in a Dutch national sample (n = 445,748 adults (≥19 y.o.)) in Poisson and logistic regression models, controlling for age, gender, marital status, migration background, BMI, alcohol consumption, smoking, and physical activity. Loneliness explained 21% of socioeconomic health inequalities between the lowest and highest socio-economic groups in self-reported chronic disease prevalence, 27% in poorer self-rated health, and 51% in psychological distress. Subgroup analyses revealed that for young adults, loneliness had a larger contribution to socioeconomic gaps in self-rated health (37%) than in 80+-year-olds (16%). Our findings suggest that loneliness may be a social determinant of health, contributing to the socioeconomic health gap independently of well-documented factors such as lifestyles and demographics, in particular for young adults. Public health policies targeting socioeconomic health inequalities could benefit from integrating loneliness into their policies, especially for young adults.

Does Loneliness Have a Cost? A Population-Wide Study of the Association Between Loneliness and Healthcare Expenditure.

Objectives: Loneliness has been associated with unhealthy behavior, poorer health, and increased morbidity. However, the costs of loneliness are poorly understood. Methods: Multiple sources were combined into a dataset containing a nationally representative sample (n = 341,376) of Dutch adults (18+). The association between loneliness and total, general practitioner (GP), specialized, pharmaceutical, and mental healthcare expenditure was tested using Poisson and Zero-inflated negative binomial models, controlling for numerous potential confounders (i.e., demographic, socioeconomic, lifestyle-related factors, self-perceived health, and psychological distress), for four age groups. Results: Controlling for demographic, socioeconomic, and lifestyle-related factors, loneliness was indirectly (via poorer health) associated with higher expenditure in all categories. In fully adjusted models, it showed a direct association with higher expenditure for GP and mental healthcare (0.5 and 11.1%, respectively). The association with mental healthcare expenditure was stronger in younger than in older adults (for ages 19-40, the contribution of loneliness represented 61.8% of the overall association). Conclusion: Loneliness contributes to health expenditure both directly and indirectly, particularly in younger age groups. This implies a strong financial imperative to address this issue.

Prioritising models of healthcare service delivery for a more sustainable health system: a Delphi study of Australian health policy, clinical practice and management, academic and consumer stakeholders.

Objectives Healthcare expenditure is growing at an unsustainable rate in developed countries. A recent scoping review identified several alternative healthcare delivery models with the potential to improve health system sustainability. Our objective was to obtain input and consensus from an expert Delphi panel about which alternative models they considered most promising for increasing value in healthcare delivery in Australia and to contribute to shaping a research agenda in the field. Methods The panel first reviewed a list of 84 models obtained through the preceding scoping review and contributed additional ideas in an open round. In a subsequent scoring round, the panel rated the priority of each model in terms of its potential to improve health care sustainability in Australia. Consensus was assumed when ≥50% of the panel rated a model as (very) high priority (consensus on high priority) or as not a priority or low priority (consensus on low priority). Results Eighty-two of 149 invited participants (55%) representing all Australian states/territories and wide expertise completed round one; 71 completed round two. Consensus on high priority was achieved for 59 alternative models; 14 were rated as (very) high priority by ≥70% of the panel. Top priorities included improving medical service provision in aged care facilities, providing single-point-access multidisciplinary care for people with chronic conditions and providing tailored early discharge and hospital at home instead of in-patient care. No consensus was reached on 47 models, but no model was deemed low priority. Conclusions Input from an expert stakeholder panel identified healthcare delivery models not previously synthesised in systematic reviews that are a priority to investigate. Strong consensus exists among stakeholders regarding which models require the most urgent attention in terms of (cost-)effectiveness research. These findings contribute to shaping a research agenda on healthcare delivery models and where stakeholder engagement in Australia is likely to be high. What is known about the topic? Healthcare expenditure is growing at an unsustainable rate in high-income countries worldwide. A recent scoping review of systematic reviews identified a substantial body of evidence about the effects of a wide range of models of healthcare service delivery that can inform health system improvements. Given the large number of systematic reviews available on numerous models of care, a method for gaining consensus on the models of highest priority for implementation (where evidence demonstrates this will lead to beneficial effects and resource savings) or for further research (where evidence about effects is uncertain) in the Australian context is warranted. What does this paper add? This paper describes a method for reaching consensus on high-priority alternative models of service delivery in Australia. Stakeholders with leadership roles in health policy and government organisations, hospital and primary care networks, academic institutions and consumer advocacy organisations were asked to identify and rate alternative models based on their knowledge of the healthcare system. We reached consensus among ≥70% of stakeholders that improving medical care in residential aged care facilities, providing single-point-access multidisciplinary care for patients with a range of chronic conditions and providing early discharge and hospital at home instead of in-patient stay for people with a range of conditions are of highest priority for further investigation. What are the implications for practitioners? Decision makers seeking to optimise the efficiency and sustainability of healthcare service delivery in Australia could consider the alternative models rated as high priority by the expert stakeholder panel in this Delphi study. These models reflect the most promising alternatives for increasing value in the delivery of health care in Australia based on stakeholders' knowledge of the health system. Although they indicate areas where stakeholder engagement is likely to be high, further research is needed to demonstrate the effectiveness and cost-effectiveness of some of these models.

Addressing Health Literacy Needs in Rheumatology: Which Patient Health Literacy Profiles Need the Attention of Health Professionals?

OBJECTIVE: To identify and describe health literacy profiles of patients with rheumatic diseases and explore whether the identified health literacy profiles can be generalized to a broader rheumatology context. METHODS: Patients with rheumatoid arthritis, spondyloarthritis, and gout from 3 hospitals in different regions in The Netherlands completed the Health Literacy Questionnaire (HLQ). Hierarchical cluster analysis was used to identify patients' health literacy profiles based on 9 HLQ domains. A multinomial regression model with the identified health literacy profiles as the dependent variable was fitted to assess whether patients with a given disease type or attending a given hospital were more likely to belong to a specific profile. RESULTS: Among 895 participating patients, the lowest mean HLQ domain scores (indicating most difficulty) were found for "critical appraisal," "navigating the health system," and "finding good health information." The 10 identified profiles revealed substantial diversity in combinations of strengths and weaknesses. While 42% of patients scored moderate to high on all 9 domains (profiles 1 and 3), another 42% of patients (profiles 2, 4, 5, and 6) clearly struggled with 1 or several aspects of health literacy. Notably, 16% (profiles 7-10) exhibited difficulty across a majority of health literacy domains. The probability of belonging to one of the profiles was independent of the hospital where the patient was treated or the type of rheumatic disease. CONCLUSION: Ten distinct health literacy profiles were identified among patients with rheumatic diseases, independent of disease type and treating hospital. These profiles can be used to facilitate the development of health literacy interventions in rheumatology.

Role of clinical, functional and social factors in the association between multimorbidity and quality of life: Findings from the Survey of Health, Ageing and Retirement in Europe (SHARE).

OBJECTIVE: An increasing number of diseases is linked to deterioration of quality of life (QoL). Part of this association can be explained by socio-economic factors, which are most commonly accounted for. Our aim was to explore the potential contribution of other factors related to clinical burden, social interaction and functioning. METHODS: A cross-sectional analysis was conducted on wave 6 of the population-based Survey of Health, Ageing and Retirement in Europe (SHARE), among participants aged 50+ (n = 67 179). The Control, Autonomy, Self-Realization and Pleasure (CASP-12v1) questionnaire measured QoL. The association between number of diseases and QoL was tested in a mixed-effects linear regression model. The base model controlled for socio-economic characteristics. Factors of interest (symptoms, polypharmacy, unmet care needs, utilisation of care, social network, personal and financial help, loneliness and activities of daily living (ADL) with instrumental activities (IADL)) were added to the base model one at a time and tested for relevance (i.e. change in the ß-coefficient of the number of conditions of 15% or more). RESULTS: Symptoms, polypharmacy, loneliness and ADL/IADL appeared relevant and were retained in the final model. The association between number of conditions and QoL in the base model was -2.44 [95% CI: -2.72; -2.16], while this association was -0.76 [95%CI: -0.97; -0.54] after all relevant factors were included. CONCLUSION: Factors beyond the socio-economic circumstances play an important role in explaining the association between number of conditions and QoL. These factors should be considered to better estimate the impact of chronic diseases on QoL, and for improving patient care.

Identifying alternative models of healthcare service delivery to inform health system improvement: scoping review of systematic reviews.

OBJECTIVE: To describe available evidence from systematic reviews of alternative healthcare delivery arrangements relevant to high-income countries to inform decisions about healthcare system improvement. DESIGN: Scoping review of systematic reviews. DATA SOURCES: Systematic reviews of interventions indexed in Pretty Darn Quick-Evidence. ELIGIBILITY CRITERIA: All English language systematic reviews evaluating the effects of alternative delivery arrangements relevant to high-income countries, published between 1 January 2012 and 20 September 2017. Eligible reviews had to summarise evidence on at least one of the following outcomes: patient outcomes, quality of care, access and/or use of healthcare services, resource use, impacts on equity and/or social outcomes, healthcare provider outcomes or adverse effects. DATA EXTRACTION AND SYNTHESIS: Journal, publication year, number and design of primary studies, populations/health conditions represented and types of outcomes were extracted. RESULTS: Of 829 retrieved records, 531 reviews fulfilled our inclusion criteria. Almost all (93%) reviews reported on patient outcomes, while only about one-third included resource use as an outcome of interest. Just over a third (n=189, 36%) of reviews focused on alternative information and communications technology interventions (including 162 reviews on telehealth). About one-quarter (n=122, 23%) of reviews focused on alternative care coordination interventions. 15% (n=80) of reviews examined interventions involving changes to who provides care and how the healthcare workforce is managed. Few reviews investigated the effects of interventions involving changes to how and when care is delivered (n=47, 9%) or interventions addressing a goal-focused question (n=38, 7%). CONCLUSION: A substantial body of evidence about the effects of a wide range of delivery arrangements is available to inform health system improvements. The lack of economic evaluations in the majority of systematic reviews of delivery arrangements means that the value of many of these models is unknown. This scoping review identifies evidence gaps that would be usefully addressed by future research.

Patients with rheumatoid arthritis facing sick leave or work disability meet varying regulations: a study among rheumatologists and patients from 44 European countries.

OBJECTIVES: To describe and explore differences in formal regulations around sick leave and work disability (WD) for patients with rheumatoid arthritis (RA), as well as perceptions by rheumatologists and patients on the system's performance, across European countries. METHODS: We conducted three cross-sectional surveys in 50 European countries: one on work (re-)integration and social security (SS) system arrangements in case of sick leave and long-term WD due to RA (one rheumatologist per country), and two among approximately 15 rheumatologists and 15 patients per country on perceptions regarding SS arrangements on work participation. Differences in regulations and perceptions were compared across categories defined by gross domestic product (GDP), type of social welfare regime, European Union (EU) membership and country RA WD rates. RESULTS: Forty-four (88%) countries provided data on regulations, 33 (75%) on perceptions of rheumatologists (n=539) and 34 (77%) on perceptions of patients (n=719). While large variation was observed across all regulations across countries, no relationship was found between most of regulations or income compensation and GDP, type of SS system or rates of WD. Regarding perceptions, rheumatologists in high GDP and EU-member countries felt less confident in their role in the decision process towards WD (ß=-0.5 (95% CI -0.9 to -0.2) and ß=-0.5 (95% CI -1.0 to -0.1), respectively). The Scandinavian and Bismarckian system scored best on patients' and rheumatologists' perceptions of regulations and system performance. CONCLUSIONS: There is large heterogeneity in rules and regulations of SS systems across Europe in relation to WD of patients with RA, and it cannot be explained by existing welfare regimes, EU membership or country's wealth.

Assessing the role of criminality in neighbourhood safety feelings and self-reported health: results from a cross-sectional study in a Dutch municipality.

BACKGROUND: Neighbourhood safety has repeatedly been shown to be associated with the health and well-being of the residents. Criminality is often seen as one of the key factors affecting neighbourhood safety. However, the relationship between crime, fear of crime and feelings of safety remains underexplored. METHODS: Data on socio-demographic, health and safety perceptions was extracted from the Maastricht municipality survey (the Netherlands) (n = 9656 adults) and merged with data on official neighbourhood crime rates from the Police Registry. Pearson correlation coefficients and multilevel logistic regression models were computed to assess the association between aspects of objective and perceived criminality, individuals' feelings of safety and health. RESULTS: The correlation between the police recorded crime and residents' perceptions of the neighbourhood crime rates was weak (0.14-0.38), with the exception of violent crime (0.59), which indicates that other factors contribute to the perceptions of safety. In turn, the perception of higher rates of violent crime and more nuisance (on the scale 0-10) but not other types of crime or nuisance was positively associated with feeling unsafe (OR 1.27 [1.22;1.32] and 1.39 [1.33;1.46], respectively). Lower general feelings of safety at both the individual and neighbourhood level were consistently associated with worse self-rated health. Among different indicators of safety, the general feelings of safety had the most pronounced association with health, while subjective or objective measures of crime showed limited to no direct relationship with health. CONCLUSIONS: Public health policies targeting safety as a social determinant of health should consider prioritizing areas of violent crime and nuisance to improve general feelings of safety. Further research is needed to understand which factors aside from criminality are driving residents' feelings of safety.

Alternative service models for delivery of healthcare services in high-income countries: a scoping review of systematic reviews.

INTRODUCTION: Costs associated with the delivery of healthcare services are growing at an unsustainable rate. There is a need for health systems and healthcare providers to consider the economic impacts of the service models they deliver and to determine if alternative models may lead to improved efficiencies without compromising quality of care. The aim of this protocol is to describe a scoping review of the extent, range and nature of available synthesised research on alternative delivery arrangements for health systems relevant to high-income countries published in the last 5 years. DESIGN: We will perform a scoping review of systematic reviews of trials and economic studies of alternative delivery arrangements for health systems relevant to high-income countries published on 'Pretty Darn Quick' (PDQ)-Evidence between 1 January 2012 and 20 September 2017. All English language systematic reviews will be included. The Cochrane Effective Practice and Organisation of Care taxonomy of health system interventions will be used to categorise delivery arrangements according to: how and when care is delivered, where care is provided and changes to the healthcare environment, who provides care and how the healthcare workforce is managed, co-ordination of care and management of care processes and information and communication technology systems. This work is part of a 5-year Partnership Centre for Health System Sustainability aiming to investigate and create interventions to improve health-system-performance sustainability. ETHICS AND DISSEMINATION: No primary data will be collected, so ethical approval is not required. The study findings will be published and presented at relevant conferences.

Individual-level and country-level socioeconomic determinants of disease outcomes in SpA: multinational, cross-sectional study (ASAS-COMOSPA).

OBJECTIVE: To explore the independent contribution of individual-level and country level socioeconomic status (SES) determinants to disease activity and physical function in patients with spondyloarthritis (SpA). METHODS: Data from the cross-sectional, multinational (n=22 countries worldwide) COMOSPA (COMOrbidities in SpA) study were used. Contribution of individual SES factors (gender, education) and country of residence to Ankylosing Spondylitis Disease Activity Score (ASDAS) and Bath Ankylosing Spondylitis Functional Index (BASFI) was explored in multilevel regression models, adjusting for clinical and demographic confounders. Next, the additional effects of national macroeconomic indicators (gross domestic product [GDP], Human Development Index, healthcare expenditure and Gini index) were explored. The mediating role of uptake of biologic disease-modifying antirheumatic drugs between education or GDP and ASDAS was explored by testing indirect effects. RESULTS: In total, 3370 patients with SpA were included: 65% were male, with a mean age of 43 (SD 14), ASDAS of 2.0 (SD 1.1) and BASFI score of 3.1 (SD 2.7). In adjusted models, patients with low education and female patients had an OR of 1.7 (95% CI 1.3 to 2.2) and an OR of 1.7 (95% CI 1.4 to 2.0), respectively, of having ASDAS ≥2.1. They also reported slightly worse function. Large country differences were observed independent of individual SES and clinical confounders. Patients from less SES developed countries have worse ASDAS, while patterns for BASFI were insignificant. Uptake of biologicals did not mediate the relationship between individual-level or country-level SES and disease activity. CONCLUSIONS: Individual-level and country-level health inequalities exist also among patients with SpA. Women and lower educated persons had worse disease activity and somewhat worse physical function. While patients in less socioeconomically developed countries had higher disease activity, they reported similar physical function.

Socio-economic inequalities in occurrence and health care costs in rheumatic and musculoskeletal diseases: results from a Spanish population-based study including 1.9 million persons.

OBJECTIVES: To explore and compare the impact of socio-economic deprivation on the occurrence of the major rheumatic and musculoskeletal diseases (RMDs) and health care costs. METHODS: Data on diagnoses, socio-demographics and health care costs of the entire adult population of the Basque Country (Spain) was used. Area deprivation index included five categories (1 to 5 (most deprived)). Cost categories included primary and specialist care, emergency room, hospitalisations, and drug prescriptions. Twenty-nine RMDs were grouped into seven groups: Rheumatoid Arthritis, Spondyloarthritis, Crystal Arthropathies, Osteoarthritis, Soft Tissue Diseases, Connective Tissue Diseases, and Vasculitis. The relations between the deprivation and the occurrence of RMD and costs were explored in regression models adjusted for relevant confounders. RESULTS: Data from 1,923,156 adults were analysed. Mean age was 49.9 (SD18.4) years, 49% were males. Soft tissue diseases were the most prevalent RMD (5.5%, n=105,656), followed by osteoarthritis (2.2%, n=41,924). Socio-economic deprivation was associated with higher likelihood to have any of the 29 RMDs. The strongest socio-economic gradient was seen for the soft tissue diseases (OR 1.82 [95%CI 1.78;1.85], most vs. least deprived), followed by osteoarthritis (OR 1.59 [1.54;1.64]). Deprivation was also associated with higher costs across the majority of the conditions however patterns were more blurred, and inverse relationship was observed for connective tissue diseases, gout, hip osteoarthritis and undifferentiated (poly)arthritis. CONCLUSIONS: Socio-economic deprivation is associated with increased occurrence of all RMDs, and in most cases more deprived patients incur higher health care costs.

Equivalence in the Health Assessment Questionnaire (HAQ) across socio-demographic determinants: Analyses within QUEST-RA.

OBJECTIVES: To investigate potential bias in scores of the Health Assessment Questionnaire (HAQ) related to socio-demographic (SD) background of patients with rheumatoid arthritis (RA). METHODS: Data from the Quantitative Standard Monitoring of Rheumatoid Arthritis study (QUEST-RA), comprising 9022 patients were analysed. Physical function was assessed through 30 items of four HAQ versions: the HAQ-Disability scale, HAQ-II, modified HAQ and multi-dimensional HAQ (MD-HAQ). DIF was investigated using item response theory models implemented in a latent variable modelling framework. Models were equivalent to ordinal logistic regression models with HAQ score (item level) as outcome, the latent trait 'physical function' and individual SD factors (age, gender, education, and employment status) as predictors. Next, scores of composite HAQs were adjusted for DIF. To assess the impact of DIF on associations between SD factors and HAQs, multilevel mixed-effect linear regression models with individuals nested in country were estimated with DIF-adjusted or unadjusted HAQ as outcome. RESULTS: Relevant DIF (OR > 1.1 or <0.90) was found in several HAQ items primarily for age, gender and work status. Adjustment of composite HAQs for DIF resulted in small increases (Δ0.02-0.07); MD-HAQ best compensated for bias related to SD factors (Δ0.02). In regressions, all SD factors remained significantly related to DIF-adjusted HAQs, with differences in coefficients largest for gender (Δ0.02-0.07) but overall negligible. CONCLUSIONS: SD factors produce response bias in individual HAQ items but have little impact on composite HAQs. When interpreting HAQ across SD factors, MD-HAQ is preferred, but caution remains when comparing function across gender.

Deriving common comorbidity indices from the MedDRA classification and exploring their performance on key outcomes in patients with rheumatoid arthritis.

OBJECTIVE: To develop algorithms for calculating the Rheumatic Diseases Comorbidity Index (RDCI), Charlson-Deyo Index (CDI) and Functional Comorbidity Index (FCI) from the Medical Dictionary for Regulatory Activities (MedDRA), and to assess how these MedDRA-derived indices predict clinical outcomes, utility and health resource utilization (HRU). METHODS: Two independent researchers linked the preferred terms of the MedDRA classification into the conditions included in the RDCI, the CDI and the FCI. Next, using data from the Norwegian Register-DMARD study (a register of patients with inflammatory joint diseases treated with DMARDs), the explanatory value of these indices was studied in models adjusted for age, gender and DAS28. Model fit statistics were compared in generalized estimating equation (prediction of outcome over time) models using as outcomes: modified HAQ, HAQ, physical and mental component summary of SF-36, SF6D and non-RA related HRU. RESULTS: Among 4126 patients with RA [72% female, mean (s.d.) age 56 (14) years], median (interquartile range) of RDCI at baseline was 0.0 (1.0) [range 0-6], CDI 0.0 (0.0) [0-7] and FCI 0.0 (1.0) [0-6]. All the comorbidity indices were associated with each outcome, and differences in their performance were moderate. The RDCI and FCI performed better on clinical outcomes: modified HAQ and HAQ, hospitalization, physical and mental component summary, and SF6D. Any non-RA related HRU was best predicted by RDCI followed by CDI. CONCLUSION: An algorithm is now available to compute three commonly used comorbidity indices from MedDRA classification. Indices performed comparably well in predicting a variety of outcomes, with the CDI performing slightly worse when predicting outcomes reflecting functioning and health.

Impact of Chronic Diseases and Multimorbidity on Health and Health Care Costs: The Additional Role of Musculoskeletal Disorders.

OBJECTIVE: Chronic diseases are increasingly prevalent and often occur as multimorbidity. This study compares the impact of musculoskeletal disorders (MSKDs) on health and health care costs with other chronic diseases, and assesses the additional impact of MSKDs on these outcomes when occurring as part of multimorbidity. METHODS: A household survey in a random Dutch population sample (n = 8,904) yielded information on sociodemographics, presence of 9 physician-confirmed chronic diseases (i.e., musculoskeletal, migraine, diabetes mellitus, cardiovascular, cancer, respiratory, skin, mental, and gastrointestinal), physical component summary (PCS) and mental component summary (MCS) scores of the Short Form 12 health survey, and health care utilization. The independent influence of different diseases and the role of MSKDs with increasing number of morbidities on PCS/MCS and 3-month societal health care costs were explored through multivariable linear and zero-inflated negative binomial regressions, respectively. RESULTS: Twenty percent of all subjects and 56% of those with multimorbidity had an MSKD. MSKDs had the largest impact on PCS (ß = -8.37 [95% confidence interval (95% CI) -8.84, -7.89]) but no significant impact on MCS. When MSKDs occurred as part of multimorbidity, an amplification of the adverse effect on PCS but not on MCS was seen, irrespective of the number of comorbidities. MSKDs were responsible for a 2-fold increase in costs (Exp [ß] = 2.27 [95% CI 2.08, 2.51]), which was the second highest cost increase of all diseases (after cancer). Significant amplification of costs was seen when MSKDs co-occurred with mental diseases. CONCLUSION: MSKDs often co-occur with other chronic diseases. In the context of multimorbidity, presence of an MSKD amplifies the impact on physical health, and to a lesser extent on health care costs, but not on mental health.

Less educated and older patients have reduced access to biologic DMARDs even in a country with highly developed social welfare (Norway): results from Norwegian cohort study NOR-DMARD.

OBJECTIVE: To explore whether age, gender or education influence the time until initiation of the first bDMARD in patients with RA. METHODS: Data from the Norwegian Register of DMARDs collected between 2000 and 2012 were used. Only DMARD-naïve patients with RA starting their first conventional synthetic DMARD were included in the analyses. The start of the first bDMARD was the main outcome of interest. Cox regression analyses were used to explore the impact of education, age and gender on the start of a first bDMARD, adjusting for confounders, either at baseline or varying over time (time-varying model). RESULTS: Of 1946 eligible patients [mean (s.d.) age: 55 (14) years, 68% females], 368 (19%) received a bDMARD during follow-up (mean 2.6 years). In the baseline prediction model, older age [Hazard Ratio (HR) 0.97, 95% CI: 0.96, 0.98], lower education [HR = 0.76 and 0.68 for low and intermediate education levels vs college/university education, respectively (P = 0.01)] and female gender [only in the period 2000-03, HR = 0.61 (95% CI: 0.41, 0.91)] were associated with a lower hazard ratio to start a bDMARD. The time-varying model provided overall consistent results, but the effect of education was only relevant for older patients (>57 years) and became more pronounced by the end of the decade. CONCLUSIONS: Less educated and older patients have disadvantages with regard to access to costly treatments, even in a country with highly developed welfare like Norway. Females had lower access in the beginning of the 2000s, but access had improved by the end of the decade.