To improve the quality of nursing home care, reliable estimates of outcomes are essential. Obtaining such estimates requires optimal use of limited data, especially for small homes. We analyze the ...variation in mortality and hospital admissions across nursing homes in the Netherlands during the years 2010–2013. We use administrative data on all nursing home clients. We apply mixed-effects survival models, empirical Bayes estimation, and machine-learning techniques to optimally use the available longitudinal data. We find large differences in both outcomes across nursing homes, yet the estimates are surrounded by substantial uncertainty. We find no correlation between performance on mortality and avoidable hospital admissions, suggesting that these are related to different aspects of quality. Hence, caution is needed when evaluating the performance of individual nursing homes, especially when the number of outcome indicators is limited.
Abstract
Background
The burden of the COVID-19 pandemic resulted in a reduction of available health care capacity for regular care. To guide prioritisation of semielective surgery in times of ...scarcity, we previously developed a decision model to quantify the expected health loss due to delay of surgery, in an academic hospital setting. The aim of this study is to validate our decision model in a nonacademic setting and include additional elective surgical procedures.
Methods
In this study, we used the previously published three-state cohort state-transition model, to evaluate the health effects of surgery postponement for 28 surgical procedures commonly performed in nonacademic hospitals. Scientific literature and national registries yielded nearly all input parameters, except for the quality of life (QoL) estimates which were obtained from experts using the Delphi method. Two expert panels, one from a single nonacademic hospital and one from different nonacademic hospitals in the Netherlands, were invited to estimate QoL weights. We compared estimated model results (disability adjusted life years (DALY)/month of surgical delay) based on the QoL estimates from the two panels by calculating the mean difference and the correlation between the ranks of the different surgical procedures. The eventual model was based on the combined QoL estimates from both panels.
Results
Pacemaker implantation was associated with the most DALY/month of surgical delay (0.054 DALY/month, 95% CI: 0.025–0.103) and hemithyreoidectomy with the least DALY/month (0.006 DALY/month, 95% CI: 0.002–0.009). The overall mean difference of QoL estimates between the two panels was 0.005 (95% CI -0.014–0.004). The correlation between ranks was 0.983 (
p
< 0.001).
Conclusions
Our study provides an overview of incurred health loss due to surgical delay for surgeries frequently performed in nonacademic hospitals. The quality of life estimates currently used in our model are robust and validate towards a different group of experts. These results enrich our earlier published results on academic surgeries and contribute to prioritising a more complete set of surgeries.
In many developed countries, long-term care expenditures are a major source of concern, which has urged policy makers to reduce costs. However, long-term care financing is highly fragmented in most ...countries and hence reducing total costs might be complicated by spillover effects: spending reductions on one type of care may be offset elsewhere in the system if consumers shop around for substitutes. These spillovers may be substantial, as we show using a reform in the budget for municipalities for the most common type of publicly financed home care in the Netherlands, domestic help. This reform generated an exogenous change in the grant for domestic help that does not depend on changes in its demand. We show that the change in budget affected consumption of this care type, but that this effect was mitigated by offsetting changes in the consumption of three other types of home care that are financed through another public scheme and are organized through regional single payers. We find that a 10 euro increase in the grant for domestic help increased use of domestic help and nursing by 0.13 and 0.03 h per capita (4.4 and 5.2% of use in 2007), whereas it decreases use of individual assistance and personal care by 0.03 and 0.05 h per capita (4.1 and 2.9% of use in 2010 and 2007, respectively). As a result, the total spending effect is closer to zero than the effect on domestic help suggests. This finding means that the fragmentation of long-term care financing limits the ability to control expenditure growth.
The prevalence of multimorbidity among rheumatoid arthritis (RA) patients is increasing and associated with worse outcomes. Therefore, management of multimorbid patients requires a multidisciplinary ...approach. However, healthcare systems consist of mono-disciplinary subsystems, which limits collaboration across subsystems. To study the importance of a multidisciplinary, integrated approach, associations between expenditures and multimorbidity are assessed in real-life data. Retrospective data on RA patients from a Dutch single-hospital are analyzed and compared to the Dutch RA population data. The Elixhauser index is used to measure the multimorbidity prevalence. Regression analyses were conducted to derive the relationship between multimorbidity, healthcare costs and self-reported quality of life (e.g. EQ-5D). When analyzing the impact of multimorbidity within RA patients in context of a single-hospital context, multimorbidity is only partially captured: 13% prevalence versus 24% of the Dutch population. Multimorbidity is associated with higher care expenditures. Depending on the type of multimorbidity, expenditures are €43–€5821 higher in a single-hospital and from €2259–€9648 in population data. Finally, medication use associated with chronic diseases and self-reported aspects of well-being are associated with similar increases in healthcare expenditures as multimorbidity based on hospital care. Within RA, a single-hospital approach underestimates the association between multimorbidity and healthcare expenditures as 43% of healthcare utilization and expenditures are missed. To overcome a single-provider perspective in healthcare and efficiently coordinate multimorbid patients, besides providing holistic care, professionals also need to use data providing comprehensive pictures of patients.
Nursing home residents constituted a vulnerable population during the COVID-19 pandemic, and half of all cause-attributed COVID-19 deaths occurred within nursing homes. Yet, given the low life ...expectancy of nursing home residents, it is unclear to what extent COVID-19 mortality increased overall mortality within this population. Moreover, there might have been differences between nursing homes in their ability to protect residents against excess mortality. This article estimates the number of excess deaths among Dutch nursing home residents during the pandemic, the variation in excess deaths across nursing homes, and its relationship with nursing home characteristics.
Retrospective, use of administrative register data.
All residents (N = 194,432) of Dutch nursing homes (n = 1463) in 2016-2021.
We estimated the difference between actual and predicted mortality, pooled at the nursing home level, which provided an estimate of nursing home–specific excess mortality corrected for resident case-mix differences. We show the variation in excess mortality across nursing homes and relate this to nursing home characteristics.
In 2020 and 2021, the mortality probability among nursing home residents was 4.0 and 1.6 per 100 residents higher than expected. There was considerable variation in excess deaths across nursing homes, even after correcting for differences in resident case mix and regional factors. This variation was substantially larger than prepandemic mortality and was in 2020 related to prepandemic spending on external personnel and satisfaction with the building, and in 2021 to prepandemic staff absenteeism.
The variation in excess mortality across nursing homes was considerable during the COVID-19 pandemic, and larger compared with prepandemic years. The association of excess mortality with the quality of the building and spending on external personnel indicates the importance of considering differences across nursing home providers when designing policies and guidelines related to pandemic preparedness.
Although end-of-life medical spending is often viewed as a major component of aggregate medical expenditure, accurate measures of this type of medical spending are scarce. We used detailed health ...care data for the period 2009-11 from Denmark, England, France, Germany, Japan, the Netherlands, Taiwan, the United States, and the Canadian province of Quebec to measure the composition and magnitude of medical spending in the three years before death. In all nine countries, medical spending at the end of life was high relative to spending at other ages. Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan. This suggests that high aggregate medical spending is due not to last-ditch efforts to save lives but to spending on people with chronic conditions, which are associated with shorter life expectancies.
Informal caregiving is a potentially attractive alternative to formal care but may entail health costs for the caregiver. We examine the mental and physical health impact of providing informal care ...and disentangle the caregiving effect – the effect of caring for someone in need – from the family effect – the effect of caring about someone in need. We account for the main sources of endogeneity in the caregiving decision using Arellano-Bond difference GMM models. We use four waves (2010–2013) of panel data from the Dutch Study on Transitions in Employment, Ability and Motivation (STREAM).
We find that caregiving harms the mental health of caregivers; the effect is more prominent for spousal caregivers. On top of this, a negative health shock of a family member also has a direct negative effect on mental health, providing evidence of a family effect. Our findings thus highlight that the total effect of having a sick relative may be underestimated when the family effect is not adequately accounted for. As the caregiving effect differs substantially between various types of caregivers, policies to cushion these effects should specifically target those subgroups of caregivers that carry the largest burden of informal caregiving.
Background The aim of this study was to analyze the clinical and radiological results of elbow arthroplasty using the instrumented Bone Preserving (iBP) elbow prosthesis, which is the 6th iteration ...of the Kudo prosthesis, in patients with rheumatoid arthritis. Methods From December 1999 to August 2006, 20 total elbow replacements in 19 patients with rheumatoid arthritis were performed by 2 surgeons using the iBP. The humeral component is uncemented and the ulnar component cemented. There were 14 women and 5 men. The period of follow-up was 2-8 years, with a mean of 49 months. The mean age at time of operation was 62 years (range, 32-80). The Larsen grade and The Mayo Elbow Performance Score were used. Possible radiolucent lines or displacement of the components were evaluated yearly. Results The preoperative radiographs showed that all of the involved elbows were in grade 3-5 with an average of 4.1. All patients had a poor elbow before operation. Two elbows were moderately unstable. Three complications occurred: 1 intraoperative fracture of the medial condyl, 1 postoperative dislocation, and 1 persistent sensory ulnar neuropathy. After surgery, at the last follow-up, 3 patients had fair results, 5 good, and 12 excellent. In 6 cases, radiographic loosening of the ulnar component was observed without any clinical symptoms; none around the humeral component. Conclusion The iBP elbow prosthesis in patients with rheumatoid arthritis shows good to excellent clinical results, despite radiolucency around the cemented ulnar component in some cases.
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