Practice variation in surgical treatment for lumbar degenerative disc disease: exploring regional and hospital factors influencing surgical rates.

The presence of significant, unwarranted variation in treatment suggests that clinical decision making also depends on where patients live instead of what they need and prefer. Historically, high practice variation in surgical treatment for lumbar degenerative disc disease (LDDD) has been documented. This study aimed to investigate current regional variation in surgical treatment for sciatica resulting from LDDD. We conducted a retrospective, cross-sectional analysis of all Dutch adults (>18 years) between 2016 and 2019. Demographic data from Statistics Netherlands were merged with a nationwide claims database, covering over 99% of the population. Inclusion criteria comprised LDDD diagnosis codes and relevant surgical codes. Practice variation was assessed at the level of postal code areas and hospital service areas (HSAs). Multivariable logistic regression analysis was employed to identify variables associated with surgical treatment. Among the 119,148 hospital visitors with LDDD, 14,840 underwent surgical treatment. Practice variation for laminectomies and discectomies showed less than two-fold variation in both postal code and HSAs. However, instrumented fusion surgery demonstrated a five-fold variation in postal code areas and three-fold variation in HSAs. Predictors of receiving surgical treatment included opioid prescription and patient referral status. Gender differences were observed, with males more likely to undergo laminectomy or discectomy, and females more likely to receive instrumented fusion surgery. Our study revealed low variation rates for discectomies and laminectomies, while indicating a high variation rate for instrumented fusion surgery in LDDD patients. High-quality research is needed on the extent of guideline implementation and its influence on practice variation.

Practice Variation Research in Degenerative Lumbar Disc Surgery: A Literature Review on Design Characteristics and Outcomes.

STUDY DESIGN: Literature review. OBJECTIVE: To describe whether practice variation studies on surgery in patients with lumbar degenerative disc disease used adequate study methodology to identify unwarranted variation, and to inform quality improvement in clinical practice. Secondary aim was to describe whether variation changed over time. METHODS: Literature databases were searched up to May 4th, 2021. To define whether study design was appropriate to identify unwarranted variation, we extracted data on level of aggregation, study population, and case-mix correction. To define whether studies were appropriate to achieve quality improvement, data were extracted on outcomes, explanatory variables, description of scientific basis, and given recommendations. Spearman's rho was used to determine the association between the Extreme Quotient (EQ) and year of publication. RESULTS: We identified 34 articles published between 1990 and 2020. Twenty-six articles (76%) defined the diagnosis. Prior surgery cases were excluded or adjusted for in 5 articles (15%). Twenty-three articles (68%) adjusted for case-mix. Variation in outcomes was analyzed in 7 articles (21%). Fourteen articles (41%) identified explanatory variables. Twenty-six articles (76%) described the evidence on effectiveness. Recommendations for clinical practice were given in 9 articles (26%). Extreme Quotients ranged between 1-fold and 15-fold variation and did not show a significant change over time (rho= -.33, P= .09). CONCLUSIONS: Practice variation research on surgery in patients with degenerative disc disease showed important limitations to identify unwarranted variation and to achieve quality improvement by public reporting. Despite the availability of new evidence, we could not observe a significant decrease in variation over time.

[Reduction in the number of paediatric tonsillectomies and adenoidectomies in the Netherlands between 2005 and 2018]. / Minder vaak neus- en keelamandelen verwijderd bij kinderen.

Tonsillectomy with or without adenoidectomy (ATE) and adenoidectomy have been among the most frequently performed procedures in children for approximately 100 years. Randomized controlled trials were performed in the Netherlands to study the effectiveness of ATEs and adenoidectomies in children with upper respiratory tract infections. Subsequently, evidence-based guidelines were developed and implemented. We described changes in utilization of paediatric ATEs and adenoidectomies in the Netherlands between 2005 and 2018 using administrative databases. A significant decrease in the annual number of ATEs (-39%) and adenoidectomies (-49%) was observed in children between 0 and 15 years of age. The most pivotal change was observed between 2011 and 2012. The decrease in number of procedures led to estimated annual savings of €5.3 million on the healthcare budget and €10.4 million on societal costs. Furthermore, we observed small changes in patients' age, socioeconomic status, and registered diagnosis of surgically treated patients in the period 2012-2018 compared to 2010-2011.

Regional and hospital variation in commonly performed paediatric otolaryngology procedures in the Netherlands: a population-based study of healthcare utilisation between 2016 and 2019.

OBJECTIVE: In the past few decades, there has been an increase in high-quality studies providing evidence on the effectiveness of commonly performed procedures in paediatric otolaryngology. We believe that now is the time to re-evaluate the care process. We aimed to analyse (1) the regional variation in incidence and referrals of adenoidectomies, tonsillectomies and ventilation tube insertions in children in the Netherlands between 2016 and 2019, (2) whether regional surgical rates, referral rates and in-hospital surgical rates were associated with one another, and (3) the hospital variation in healthcare costs, which indicates the utilisation of resources. DESIGN: Repeated cross-sectional analysis. SETTING: Four neighbouring Dutch provinces comprising 2.8 million inhabitants and 14 hospitals. PARTICIPANTS: Children aged 0-15 years. OUTCOME MEASURES: We analysed variation in regional surgical rates and referral rates per 1000 inhabitants and in-hospital surgical rates per 1000 clinic visitors, adjusted for age and socioeconomic status. Furthermore, the relationships between referral rates, regional surgical rates and in-hospital surgical rates were estimated. Lastly, variation in resource utilisation between hospitals was estimated. RESULTS: Adenoidectomy rates differed sixfold between regions. Twofold differences were observed for adenotonsillectomy rates, ventilation tube insertion rates and referral rates. Referral rates were negatively associated with in-hospital surgical rates for adenotonsillectomies, but not for adenoidectomies and ventilation tube insertions. In-hospital surgical rates were positively associated with regional rates for adenoidectomies and adenotonsillectomies. Significant variation between hospitals was observed in costs for all resources. CONCLUSIONS: We observed low variation in tonsillectomies and ventilation tube insertion and high variation in adenoidectomies. Indications for a tonsillectomy and ventilation tube insertion are well defined in Dutch guidelines, whereas this is not the case for an adenoidectomy. Lack of agreement on indications can be expected and high-quality effectiveness research is required to improve evidence-based guidelines on this topic.

Changes in healthcare utilisation for paediatric tonsillectomy and adenoidectomy in the Netherlands: a population-based study.

OBJECTIVES: Tonsillectomy and adenoidectomy in children are controversial subjects with large regional variation in surgical rates, partly explained by cultural differences and lack of high-quality evidence on indications for surgery. A quality of care cycle was executed on this topic in the Netherlands. The objective of this study was to estimate changes in healthcare utilisation for paediatric tonsil surgery in the Netherlands. METHODS: Population-based data on tonsillectomies and adenoidectomies in children up to age 10 were retrieved retrospectively from Dutch administrative databases between 2005 and 2018. A change point analysis was performed to detect the most pivotal change point in surgical rates. We performed univariate analyses to compare surgical patients' characteristics before and after the pivotalpoint . Impact on healthcare budget and societal costs were estimated using current prices and data from cost-effectiveness analyses. RESULTS: The annual number of adenotonsillectomies reduced by 10 952 procedures (-39%; from 129 per 10 000 children to 87 per 10 000 children) between 2005 and 2018, and the number of adenoidectomies by 14 757 procedures (-49%; from 138 per 10 000 children to 78 per 10 000 children). The most pivotal change point was observed around 2012, accompanied by small changes in patient selection for surgery before and after 2012. An estimated €5.3 million per year was saved on the healthcare budget and €10.4 million per year on societal costs. CONCLUSION: The quality of care cycle resulted in fewer operations, with a concomitant reduction of costs. We suggest that part of these savings be invested in new research to maintain the quality of care cycle.

The Relationship of Tinnitus Distress With Personality Traits: A Systematic Review.

Objectives: An association between tinnitus distress with anxiety and depression is described in literature. A similar relationship might exist between tinnitus distress and personality traits, especially since associations between personality traits and other chronic diseases are already revealed. In this systematic review, we aim to investigate whether personality is a risk factor for tinnitus distress. Design: We searched PubMed and EMBASE databases from inception up to December 31, 2018 for articles on the association between tinnitus distress and personality. Two researchers screened titles, abstracts, and full texts for eligibility. Directness of evidence and risk of bias were assessed. From the included studies, study characteristics and outcome data of tinnitus distress and personality traits were extracted. Results: A total of 323 unique articles were screened of which 11 cross-sectional studies were eligible for critical appraisal and were used for data extraction. Including study populations were heterogenous, and studies scored high to moderate risk of bias. Nine out of 11 articles showed an association between tinnitus distress and the personality of neuroticism. Conclusions: By limitations in the methodology of included studies, the evidence on specific personality traits as a risk factor for tinnitus distress is inconclusive. Some evidence on a positive association with neuroticism is identified. To draw conclusions about causal relations, these further studies should be of longitudinal design in a cohort setting. These studies should assess tinnitus distress using validated questionnaires with multiple personality dimensions and validated questionnaires to assess personality traits.

Impact of surgical intervention trials on healthcare: A systematic review of assessment methods, healthcare outcomes, and determinants.

BACKGROUND: Frameworks used in research impact evaluation studies vary widely and it remains unclear which methods are most appropriate for evaluating research impact in the field of surgical research. Therefore, we aimed to identify and review the methods used to assess the impact of surgical intervention trials on healthcare and to identify determinants for surgical impact. METHODS: We searched journal databases up to March 10, 2020 for papers assessing the impact of surgical effectiveness trials on healthcare. Two researchers independently screened the papers for eligibility and performed a Risk of Bias assessment. Characteristics of both impact papers and trial papers were summarized. Univariate analyses were performed to identify determinants for finding research impact, which was defined as a change in healthcare practice. RESULTS: Sixty-one impact assessments were performed in 37 included impact papers. Some surgical trial papers were evaluated in more than one impact paper, which provides a total of 38 evaluated trial papers. Most impact papers were published after 2010 (n = 29). Medical records (n = 10), administrative databases (n = 22), and physician's opinion through surveys (n = 5) were used for data collection. Those data were analyzed purely descriptively (n = 3), comparing data before and after publication (n = 29), or through time series analyses (n = 5). Significant healthcare impact was observed 49 times and more often in more recent publications. Having impact was positively associated with using medical records or administrative databases (ref.: surveys), a longer timeframe for impact evaluation and more months between the publication of the trial paper and the impact paper, data collection in North America (ref.: Europe), no economic evaluation of the intervention, finding no significant difference in surgical outcomes, and suggesting de-implementation in the original trial paper. CONCLUSIONS AND IMPLICATIONS: Research impact evaluation receives growing interest, but still a small number of impact papers per year was identified. The analysis showed that characteristics of both surgical trial papers and impact papers were associated with finding research impact. We advise to collect data from either medical records or administrative databases, with an evaluation time frame of at least 4 years since trial publication.