Despite differences in the structure of health care delivery systems, health care spending continues to outpace gross domestic product (GDP) and average wage globally. This highlights the stark... Show moreDespite differences in the structure of health care delivery systems, health care spending continues to outpace gross domestic product (GDP) and average wage globally. This highlights the stark reality that health systems today are – in many cases – financially unsustainable. Further, most health care services today are paid for via a fee-for-service or payment for each service provided mechanism, which does not ensure a focus on optimal health outcomes for patients; this includes clinical outcomes most important to them, such as function, pain, andquality of life. As such, bold reforms are needed to better align incentives to “bend” the cost curve and to ensure high-quality health care and the best possible patient outcomes. This dissertation includes scientific studies that highlight how the core principles of value-based health care, which focuses on maximizing the outcomes achieved per dollar spent, may be able to begin to address some of the issues plaguing our strained health care delivery systems globally, including within orthopaedic surgery. Show less
Background Socioeconomic status and ethnicity are not explicitly incorporated as risk factors in the four SCORE2 cardiovascular disease (CVD) risk models developed for country-wide implementation... Show moreBackground Socioeconomic status and ethnicity are not explicitly incorporated as risk factors in the four SCORE2 cardiovascular disease (CVD) risk models developed for country-wide implementation across Europe (low, moderate, high and very-high model). The aim of this study was to evaluate the performance of the four SCORE2 CVD risk prediction models in an ethnic and socioeconomic diverse population in the Netherlands.Methods The SCORE2 CVD risk models were externally validated in socioeconomic and ethnic (by country of origin) subgroups, from a population-based cohort in the Netherlands, with GP, hospital and registry data. In total 155,000 individuals, between 40 and 70 years old in the study period from 2007 to 2020 and without previous CVD or diabetes were included. Variables (age, sex, smoking status, blood pressure, cholesterol) and outcome first CVD event (stroke, myocardial infarction, CVD death) were consistent with SCORE2. Findings 6966 CVD events were observed, versus 5495 events predicted by the CVD low-risk model (intended for use in the Netherlands). Relative underprediction was similar in men and women (observed/predicted (OE-ratio), 1.3 and 1.2 in men and women, respectively). Underprediction was larger in low socioeconomic subgroups of the overall study population (OE-ratio 1.5 and 1.6 in men and women, respectively), and comparable in Dutch and the combined "other ethnicities" low socioeconomic subgroups. Underprediction in the Surinamese subgroup was largest (OE-ratio 1.9, in men and women), particularly in the low socioeconomic Surinamese subgroups (OE-ratio 2.5 and 2.1 in men and women). In the subgroups with underprediction in the low-risk model, the intermediate or high-risk SCORE2 models showed improved OE-ratios. Discrimination showed moderate performance in all subgroups and the four SCORE2 models, with C-statistics between 0.65 and 0.72, similar to the SCORE2 model development study.Interpretation The SCORE 2 CVD risk model for low-risk countries (as the Netherlands are) was found to underpredict CVD risk, particularly in low socioeconomic and Surinamese ethnic subgroups. Including socioeconomic status and ethnicity as predictors in CVD risk models and implementing CVD risk adjustment within countries is desirable for adequate CVD risk prediction and counselling. Show less
To improve primary diabetes care in the Netherlands, in 2007 a ‘care group’ system is initiated. We first studied the association between adherence to a structured diabetes protocol and patient... Show moreTo improve primary diabetes care in the Netherlands, in 2007 a ‘care group’ system is initiated. We first studied the association between adherence to a structured diabetes protocol and patient outcomes. We then investigated what practices actually require when seeking to adjust care to patient needs. With that aim in mind, we explored the effect of dispensing with protocol and the key conditions for successful implementation of self-management interventions. Finally, we measured patient outcomes with regard to treatment satisfaction, quality of life and monitoring.A structured care protocol has added value for people with diabetes; the proportion of people having recommended monitoring increases sharply. Practices likely undergo an intensive learning process when they join a care group and appear to reach the same as experienced practice within a year. When comparing the HbA1 levels of people with recommended and incomplete monitoring, we found that the HbA1c levels in people with recommended monitoring are significantly circa 2 mmol/mol lower compared to incomplete monitoring. In other words, recommended monitoring is far more than merely an administrative procedure; it actually reflects better real-world HbA1c levels. Differences in HbA1c level between people with recommended versus incomplete monitoring were greater in vulnerable populations, to the extent of approximately 3 mmol/mol, whereas a circa 1 mmol/mol difference was found in the intermediate category. In other words, within a care group setting people in the deprived category derive the most benefit from recommended monitoring.Protocol-free care provided room for reflection concerning ‘tailored care’; varying self-management interventions were chosen Our study revealed three key conditions for successful implementation of self-management interventions. Considering that patient satisfaction and monitoring decreased, this thesis ends with a roadmap consisting of several recommendations to improve and tailor diabetes care in general practice. Show less
BACKGROUND: The setting of a randomized trial can determine whether its findings are generalizable and can therefore apply to different settings. The contribution of low- and middle-income... Show moreBACKGROUND: The setting of a randomized trial can determine whether its findings are generalizable and can therefore apply to different settings. The contribution of low- and middle-income countries (LMICs) to neurosurgical randomized trials has not been systematically described before.OBJECTIVE: To perform a systematic analysis of design characteristics and methodology, funding source, and interventions studied between trials led by and/or conducted in high-income countries (HICs) vs LMICs.METHODS: From January 2003 to July 2016, English-language trials with >5 patients assessing any one neurosurgical procedure against another procedure, nonsurgical treatment, or no treatment were retrieved from MEDLINE, Scopus, and Cochrane Library. Income classification for each country was assessed using the World Bank Atlas method.RESULTS: A total of 73.3% of the 397 studies that met inclusion criteria were led by HICs, whereas 26.7% were led by LMICs. Of the 106 LMIC-led studies, 71 were led by China. If China is excluded, only 8.8% were led by LMICs. HIC-led trials enrolled a median of 92 patients vs a median of 65 patients in LMIC-led trials. HIC-led trials enrolled from 7.6 sites vs 1.8 sites in LMIC-led studies. Over half of LMIC-led trials were institutionally funded (54.7%). The majority of both HIC- and LMIC-led trials evaluated spinal neurosurgery, 68% and 71.7%, respectively.CONCLUSION: We have established that there is a substantial disparity between HICs and LMICs in the number of published neurosurgical trials. A concerted effort to invest in research capacity building in LMICs is an essential step towards ensuring context- and resource-specific high-quality evidence is generated. Show less
Morgan, R.; Cassidy, M.; DeGeus, S.W.L.; Tseng, J.; McAneny, D.; Sachs, T. 2019
IntroductionGastric cancer is decreasing nationally but remains pervasive globally. We evaluated our experience with gastric cancer at a safety-net hospital with a substantial immigrant population... Show moreIntroductionGastric cancer is decreasing nationally but remains pervasive globally. We evaluated our experience with gastric cancer at a safety-net hospital with a substantial immigrant population.MethodsDemographics, pathology, and treatment were analyzed for gastric adenocarcinoma at our institution (2004–2017). Chi-square analyses were performed for dependence of staging on demographics. Survival was evaluated with Kaplan-Meier and Cox regression analyses.ResultsWe identified 249 patients (median age 65 years). Patients were predominantly born outside the USA or Canada (74.3%), non-white (70.7%), and federally insured (71.4%), and presented with late-stage disease (52.2%). Hispanic ethnicity, Central American birthplace, Medicaid insurance, and zip code poverty > 20% were associated with late-stage presentation (all p < 0.05). Univariate analyses showed decreased survival for patients with late-stage disease, highest zip code poverty, and age ≥ 65 (all p < 0.05). On multivariate analysis, survival was negatively associated with late-stage presentation (HR 4.45, p < 0.001), age ≥ 65 (1.80, p = 0.018), and H. pylori infection (2.02, p = 0.036).ConclusionHispanic ethnicity, Central American birthplace, Medicaid insurance, and increased neighborhood poverty were associated with late-stage presentation of gastric cancer with poor outcomes. Further study of these populations may lead to screening protocols in order to increase earlier detection and improve survival. Show less
In this thesis we aimed to investigate ways to optimize treatment strategies and the choice of treatment for individual patients, to be implemented in a worldwide context. Although major advances... Show moreIn this thesis we aimed to investigate ways to optimize treatment strategies and the choice of treatment for individual patients, to be implemented in a worldwide context. Although major advances have been made in the treatment of RA, it is still uncertain which treatment is the best choice for each individual patient. This can result in both overtreatment and undertreatment, increasing the burden of RA for patients as well as for society. In clinical trials and daily practice there appears to be a development towards earlier treatment, with higher dosages of medication and more stringent treatment targets. In part 1 of this thesis, some of these developments were investigated and challenged. In countries across the world, patients do not benefit similarly from recent advances in the treatment of RA. In part 2 of this thesis, we aimed to identify contributing factors to inequalities in access to treatment and care and clinical outcomes across countries, as a first step towards improvement. Show less
Alden, D.L.; Friend, J.; Schapira, M.; Stiggelbout, A. 2014
