Willemijn J. Maas

Background: The relationship among food insecurity, financial strain, and depression and anxiety is complex and likely bidirectional, yet most studies have examined this relationship unidirectionally and cross-sectionally. Our study investigates the longitudinal bidirectional relationship among depression and/or anxiety and food insecurity and financial strain. Methods: Food insecurity and financial strain were measured at four waves across 13 years in the NESDA cohort. Clinical diagnoses of depression and anxiety were determined using the CIDI. Symptom severity was assessed using the IDS-SR and BAI. Lagged multilevel models examined whether food insecurity and financial strain predicted changes in depression and/or anxiety and vice versa. All models adjusted for age, sex, education, household income contributors, and prior outcome levels. Results: Among 2,567 individuals (mean age 42.4 years (SD 13.2), 34.6% women), higher food insecurity and financial strain significantly predicted increased odds of onset of depressive disorders (OR = 2.12, 95% CI: 1.43–3.15 and OR = 1.92, 95% CI: 1.51–2.45, respectively), and greater depressive symptom severity at the next wave (p’s for trend < .001 and p = .001, respectively). Associations with anxiety disorders and symptom severity were weaker. Conversely, depressive disorders and symptoms predicted higher subsequent food insecurity and financial strain, whereas anxiety symptoms did not. Conclusions: Our findings support a bidirectional temporal association among food insecurity, financial strain and depression, with weaker evidence for anxiety. Approaches that address financial hardship and mental health may be beneficial. Further long-term studies in diverse populations are needed to clarify mechanisms linking financial insecurity with mental health and to guide effective intervention development.

Objectives: This study assessed whether a previously developed Monte Carlo simulation model can be reused for evaluating various strategies to minimise time-to-treatment in southwest Netherlands for endovascular thrombectomy (EVT) in patients who had an ischaemic stroke. Design: Reuse of a previously developed simulation model to simulate various strategies in another region, using prospectively collected data from stroke centres and retrospective data from emergency medical services. Participants: Data from 509 patients who had an ischaemic stroke (≥18 years) treated with EVT (2014–2018) were used. Interventions: Input for the simulation model reuse included distributions of observed time delays along the acute stroke pathway. Validation of the baseline models was based on face validity and statistical measures (patient data vs model output) using the Assessment of the Validation Status of Health Economic decision models tool. We simulated strategies for a subregion: interhospital patient transfer by helicopter, transport of the neurointerventionalist to the primary stroke centre (‘drive-the-doctor’), interhospital patient transfer to a thrombectomy-capable stroke centre (TSC) outside the region and prehospital triage using the Rapid Arterial Occlusion Evaluation (RACE) scale. Primary outcome: Onset-to-groin time was the outcome. Results: Reuse of the original simulation model was obtained by minimal effort, implying limited adaptation. Compared with the baseline model, interhospital patient transfer by helicopter or to a TSC outside the region and prehospital routing using the RACE scale reduced mean onset-to-groin time by 16, 13 and 39 min, respectively (95% CrI for all: equal to the point estimate). ‘Drive the doctor’ reduced mean onset-to-groin time by 27 (car), 49 (ambulance) or 58 min (helicopter), each with a 95% CrI equal to the point estimate. Conclusions: The original simulation model can be applied to different regions in the Netherlands. Strategies tested within the subregion resulted in promising results of ‘drive the doctor’ and prehospital patient routing using the RACE scale.

Background and objective In a drive-the-doctor (DD) paradigm, an interventionalist travels from a comprehensive stroke centre (CSC) to primary stroke centres (PSCs) to perform endovascular thrombectomy (EVT) for acute ischaemic stroke due to large vessel occlusion (LVO). The DD paradigm may reduce time delays from onset to recanalisation. This study aimed to analyse the cost-effectiveness of the DD paradigm versus a drip-and-ship (DS) paradigm, where LVO patients are transferred from PSCs to a CSC for EVT in the northern Netherlands. Design Economic evaluation was performed using a simulation model combined with a decision tree and a Markov model. Setting Stroke centres in the northern Netherlands. Participants A hypothetical cohort of 100 000 LVO patients with an average age of 70 years. Interventions Two strategies were tested, including the DD paradigm with one upgraded PSC and the DD paradigm with two upgraded PSCs. Main outcome measures Total costs and quality-adjusted life years (QALYs) were measured over a 15-year time horizon from a Dutch healthcare provider perspective. An incremental cost-effectiveness ratio (ICER) of €50 000 was used as a willingness-to-pay threshold. One-way sensitivity, probabilistic sensitivity and scenario analyses (interventionalist transportation by car, ambulance and helicopter) were conducted to examine parameter uncertainty. Results The DD paradigm using car as a transport modality and two PSCs was the optimal strategy, resulting in the lowest ICER. This strategy provided an additional 0.13 QALYs at incremental costs of €2367, yielding an ICER of €18 306 compared with current practice. The DD paradigm with two PSCs reduced ICERs compared with the scenario with one PSC when varying transportation modalities (car, ambulance and helicopter). Probabilistic sensitivity analyses showed that the DD paradigm with two PSCs using car was preferred in 72% of 10 000 Monte Carlo simulations. Conclusions The DD paradigm appeared cost-effective for LVO patients and may be considered a promising evolution for a regional stroke network.

Background The introduction of immune checkpoint inhibitors (ICIs) has modified treatment modalities for patients with lung cancer, offering new alternatives for treatment. Despite improved survival benefits, ICIs may cause side effects impacting patients’ quality of life (QoL). We aim to study the changes in global QoL (gQoL) of patients with advanced-stage lung cancer up to 18 months after treatment with ICIs between 2015 and 2021. Methods and analysis A longitudinal cohort study was conducted using the Oncological Life Study: Living well as a cancer survivor data-biobank from the University Medical Center Groningen. Participants completed the European Organisation for Research and Treatment of Cancer QoL 30-item questionnaire, at the beginning of their ICI treatment (baseline) and then at 6, 12 and 18 months. Using joint modelling, changes in predicted mean gQoL were studied by treatment regimens from baseline to 18 months, while accounting for the competing risk of death and adjusting for prespecified covariates. Results Of the 418 participants with median age of 66 years, 39% were women. Patients receiving first-line immuno-monotherapy with palliative intent had a small improvement in their gQoL within 6 months and no clinically significant change thereafter. Patients receiving first-line immune-chemotherapy with palliative intent had a small improvement in their gQoL within 12 months and no clinically significant change thereafter. Patients with second/further line immunotherapy with palliative intent or first-line chemoradiotherapy followed by durvalumab with curative intent had no clinically significant change in their gQoL over 18 months. Conclusion The changes in gQoL over time among patients with advanced-stage lung cancer may vary by treatment regimens based on drug intensity, line and intent of treatment, which will help clinicians and patients understand the potential dynamic of treatments on QoL. It may further influence treatment decisions and patient management strategies, reflecting the practical implications of different treatment regimens.

In this paper, we introduce and experimentally assess an innovative big data analytics technique for mining and analyzing Quality-of-Life Indicators (QoL) over time among patients with lung cancer and treated with immunotherapy. In more details, given datasets of QoL indicators collected over time, at regular intervals, the F-TBDA technique (Frequency-based Temporal Big Data Analytics) computes temporal relative frequency tables over fixed-time intervals where data of subsequent observations (i.e., intermediate therapy) are compared with the baseline observation (i.e., starting therapy). Then, on the basis of these relative frequency tables, both simple and complex frequency-based big data analytics tools are developed, in order to unveil hidden patterns over cancer patient therapies. Experimental results on top of a real-life dataset nicely complete the theoretical contributions we provide in our research.

Objectives Regional accessibility and distribution of endovascular thrombectomy (EVT) capable facilities, that is, comprehensive stroke centres (CSCs), may significantly influence time to treatment. We analysed the impact of adding CSCs in the north of the Netherlands, a region with roughly 1.7 million inhabitants currently served by one CSC and eight primary stroke centres (PSCs). Design Monte Carlo simulation modelling was used to establish new CSCs in our region by hypothetically upgrading existing PSCs to CSCs and ensuing adjustments in health services set-up. Setting One CSC and eight PSCs in the north of the Netherlands. Participants 165 patients with acute stroke treated with EVT and underwent interhospital transfer between PSC and CSC (drip and ship patients). Primary and secondary outcomes Time from onset to groin (OTG) puncture and predicted probability of favourable outcome (modified Rankin Scale 0–2) after 90 days. Sensitivity analyses were performed to assess uncertainty in workflow efficiency of CSCs. Results Adding one or two CSCs would reduce the OTG time up to approximately 17 min and increases the predicted probability of favourable outcome by approximately 2%. Sensitivity analyses revealed that ‘slow-acting’ CSCs may reduce OTG by 3–5 min compared with 24–32 min for ‘fast-acting’ CSCs. Conclusions This study suggests that adding one or two CSCs in the north of the Netherlands would have modest impact. Improving workflow efficiencies seems to be more potent when aiming to improve existing acute stroke care systems.

Objective The objective of this study is to identify barriers for the timely delivery of endovascular thrombectomy (EVT) and to investigate the effects of potential workflow improvements in the acute stroke pathway. Design Hospital data prospectively collected in the MR CLEAN Registry were linked to emergency medical services data for each EVT patient and used to build two Monte Carlo simulation models. The ‘mothership (MS) model’, reflecting patients who arrived directly at the comprehensive stroke centre (CSC); and the ‘drip and ship’ (DS) model, reflecting patients who were transferred to the CSC from primary stroke centres (PSCs). Setting Northern region of the Netherlands. One CSC provides EVT, and its catchment area includes eight PSCs. Participants 248 patients who were treated with EVT between July 2014 and November 2017. Outcome measures The main outcome measures were total delay from stroke onset until groin puncture, functional independence at 90 days (modified Rankin Scale 0–2) and mortality. Results Barriers identified included fast-track emergency department routing, prealert for transfer to the CSC, reduced handover time between PSC and ambulance, direct transfer from CSC arrival to angiography suite entry, and reducing time to groin puncture. Taken together, all workflow improvements could potentially reduce the time from onset to groin puncture by 59 min for the MS model and 61 min for the DS model. These improvements could thus result in more patients—3.7% MS and 7.4% DS—regaining functional independence after 90 days, in addition to decreasing mortality by 3.0% and 5.0%, respectively. Conclusions In our region, the proposed workflow improvements might reduce time to treatment by about 1 hour and increase the number of patients regaining functional independence by 6%. Simulation modelling is useful for assessing the potential effects of interventions aimed at reducing time from onset to EVT.

To the Editor: Grotta et al. (Sept. 9 issue)¹ report that the deployment of mobile stroke units (MSUs) in urban regions resulted in better outcomes than standard emergency medical services (EMS) transport for patients with acute ischemic stroke who were eligible for tissue plasminogen activator (t-PA). We are uncertain whether these results can be generalized to other (e.g., rural) regions, as discussed in the accompanying editorial.² Travel times for the MSU to reach a patient with a suspected stroke should be taken into account, so we wonder what would be the appropriate catchment area for a MSU to be cost-effective? . . .