Differences by union status in health and mortality at older ages: Results for 16 European countries

Do Patients Live Longer After THA and Is the Relative Survival Diagnosis-specific?

BACKGROUND

Hip replacements are successful in restoring mobility, reducing pain, and improving quality of life. However, the association between THA and the potential for increased life expectancy (as expressed by mortality rate) is less clear, and any such association could well be influenced by diagnosis and patient-related, socioeconomic, and surgical factors, which have not been well studied.

QUESTIONS/PURPOSES

(1) After controlling for birth year and sex, are Swedish patients who underwent THA likely to survive longer than individuals in the general population? (2) After controlling for relevant patient-related, socioeconomic/demographic factors and surgical factors, does relative survival differ across the various diagnoses for which THAs were performed in Sweden?

METHODS

Data from the Swedish Hip Arthroplasty Register, linked to administrative health databases, were used for this study. We identified 131,808 patients who underwent THA between January 1, 1999, and December 31, 2012. Of these, 21,755 had died by the end of followup. Patient- and surgery-specific data in combination with socioeconomic data were available for analysis. We compared patient survival (relative survival) with age- and sex-matched survival data in the entire Swedish population according to Statistics Sweden. We used multivariable modeling proceeded with a Cox proportional hazards model in transformed time.

RESULTS

Patients undergoing elective THA had a slightly improved survival rate compared with the general population for approximately 10 years after surgery. At 1 year after surgery, the survival in patients undergoing THA was 1% better than the expected survival (r = 1.01; 95% confidence interval [CI], 1.01-1.02; p < 0.001); at 5 years, this increased to 3% (r = 1.03; 95% CI, 1.03-1.03; p < 0.001); at 10 years, the difference was 2% (r = 1.02; 95% CI, 1.02-1.03; p < 0.001); and by 12 years, there was no difference between patients undergoing THA and the general population (r = 1.01; 95% CI, 0.99-1.02; p = 0.13). Using the diagnosis of primary osteoarthritis as a reference, hip arthroplasties performed for sequelae of childhood hip diseases had a similar survival rate (hazard ratio [HR], 1.02; 95% CI, 0.88-1.18; p = 0.77). Patients undergoing surgery for osteonecrosis of the femoral head (HR, 1.69; 95% CI, 1.60-1.79; p < 0.001), inflammatory arthritis (HR, 1.49; 95% CI, 1.38-1.61; p < 0.001), and secondary osteoarthritis (HR, 2.46; 95% CI, 2.03-2.99; p < 0.001) all had poorer relative survival. Comorbidities and the Elixhauser comorbidity index had a negative association with relative survival. Level of achieved education (middle level of education: HR, 0.90, 95% CI, 0.87-0.93, p < 0.001; high level: 0.76, 95% CI, 0.73-0.80, p < 0.001) and marital status (single status: HR, 1.33; 95% CI, 1.28-1.38; p < 0.001) were also negatively associated with survival.

CONCLUSIONS

Whereas it has been known that in most patients, THA improves quality of life, this study demonstrates that it also is associated with a slightly increased life expectancy that lasts for approximately 10 years after surgery, especially among patients whose diagnosis was primary osteoarthritis. This adds further proof of a health-economic value for this surgical intervention. The reasons for the increase in relative survival are unknown but are probably multifactorial.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Risk of Major Depressive Episodes After Separation: The Gender-Specific Contribution of the Income and Support Lost Through Union Dissolution

Marital status and union dissolution are strongly associated with health. Separated men and women have a mental health disadvantage compared to partnered individuals. The lower financial and social resources of separated individuals partly explained their poorer health. However, it is unclear whether this association is due to the loss in income and support precisely experienced through the separation. Due to the frequent asymmetry in partners' individual resources within couples, these losses are gender-specific, giving rise to a debate currently in France. As part of this debate, we explored to what extent gender-specific losses contribute to the separation/mental health association. We used the two-wave survey "Health and Occupational Trajectories," looking at 7321 individuals aged 25-74 in couple in 2006. We analyzed their depressive symptoms self-reported at second wave (2010) and their association with separation between the two waves; we took into account the concomitant social and income changes, as well as the socioeconomic and health situation in 2006. Separation between 2006 and 2010 is significantly associated with depressive symptoms in 2010, independently of the situation in 2006; it is associated with a loss of income, mainly in women, and a loss of support, slightly more pronounced in men. Nested logistic models indicate that the loss of support explained 5.5% of the separation/mental health association in men; the loss of income explained 19.2% of it in women. In France, an economic penalty of separation still primarily affects women and substantially contributes to the mental health vulnerability of newly separated women.