Regional shortages in a small country: how to provide the right care in the right place?

Background

The Netherlands, though being a relatively small and densely populated country, is faced with a similar challenge as other countries in terms of regional differences in access to care and attractiveness for care workers to build their careers. Both in primary care and hospital care new solutions are being sought which should help resolve these growing difficulties.

Methods

We conducted a literature review, survey and registry analysis, and held interviews with key stakeholders.

Results

Substantial differences exist between regions in the supply of both primary care and hospital care doctors. Particular and less populated regions appear to be hit in multiple ways, both with an extra ageing population requiring more care as well as by limited attractiveness for both primary care and hospital care workers. Solutions being used so far are mostly initiated by individual health care settings, such as strategic personnel management, redistribution of tasks and campaigns to increase the inflow of staff. Increasingly, solutions are also being explored at regional level, including a growing emphasis on regional collaboration, both in providing the right care in the right place as well as in terms of joint recruitment strategies. Still, such approaches only have a limited effect as a result of which new approaches are needed.

Conclusions

Strategies to improve the attractiveness of particular regions are now often fragmented, both between types of professions and sectors and different regions. In addition, innovative and new solutions appear to be hampered by vested interests of stakeholders. If new solutions are to be developed it is key that stakeholders are willing to compromise, be it when it comes to the autonomy of health care professionals and their associations and to the financial commitments required from government and insurer side.

Live birth rate after intrauterine insemination is not different between women with lower quartile versus higher quartile normal range thyroid stimulating hormone levels

STUDY QUESTION

Does lower quartile normal range thyroid stimulating hormone (TSH) compared to higher quartile normal range in women without thyroid hormone substitution affect live birth rate after a complete IUI treatment series?

SUMMARY ANSWER

Lower quartile normal range TSH, in women without thyroid hormone substitution, does not affect live birth rate after a complete intrauterine insemination treatment series compared to higher quartile normal range TSH.

WHAT IS KNOWN ALREADY

TSH is historically seen as the most sensitive test for thyroid function. Its distribution is right-skewed. Whether the preconceptional upper reference TSH values in subfertile women should be 2.5 or 4.5 mIU/L is under debate. Studies have shown that IUI patients treated with levothyroxine for TSH levels above 2.5 mIU/L show higher pregnancy rates. However, no adverse outcome is associated with untreated high normal TSH levels studied in first IUI cycles. Thyroid peroxidase antibodies have also impaired outcomes in some studies whereas others have shown an effect only in combination with high normal TSH levels. As a subgroup, patients with unexplained infertility showed increased levels of TSH. This article adds to the value of TSH evaluation and fertility outcome in four quartiles and in the context of a completed IUI treatment modus of a maximum of six inseminations.

STUDY DESIGN, SIZE, DURATION

This is a retrospective cohort study in 909 women undergoing 3588 IUI cycles starting treatment between the first of January 2008 and the first of March 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women aged 22–45 years with TSH 0.3–4.5 mIU/L without thyroid hormone substitution were included at Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands, an Iodine-sufficient area. The primary endpoint was live birth. Clinical pregnancy, pregnancy loss and ongoing pregnancy were secondary endpoints. Logistic regression was used with the natural logarithm of TSH as a continuous predictor. Chi-square tests and logistic regression were used to compare groups of patients based on TSH values in four quartile TSH groups (0.3–1.21 mIU/L; 1.22–1.75 mIU/L; 1.76–2.34 mIU/L; 2.35–4.5 mIU/L) on basic characteristics and on the endpoints while adjusting for confounders.

MAIN RESULTS AND THE ROLE OF CHANCE

Analysis with the natural logarithm of TSH as a continuous variable showed no association with live birth, pregnancy chance or pregnancy loss. There were no differences in any of the outcomes across the quartile TSH level ranges after regression analysis before and after adjusting for age, BMI, use of alcohol, tobacco, use or gonadotrophins, sperm count, diminished ovarian reserve, unexplained infertility and primary or secondary subfertility.

The distribution of primary and secondary subfertility and smoking characteristics were remarkably different across the four groups, with proportionally the lowest prevalence of primary subfertility and the highest rate of smoking in the lowest TSH group (0.3–1.20 mIU/L).

LIMITATIONS, REASONS FOR CAUTION

Unknown values of free thyroxine and thyroid peroxidase antibodies, as well as the retrospective character of the study, limit the clinical interpretability.

WIDER IMPLICATIONS OF THE FINDINGS

TSH in the highest quartile range (2.35–4.5 mIU/L) in subfertile women preceding IUI is not associated with a lower live birth rate or rate of clinical and ongoing pregnancy, or with loss of pregnancies, compared to subfertile women with TSH in the lower three quartile groups after complete intrauterine insemination treatment.

STUDY FUNDING/COMPETING INTEREST(s)

The department of Obstetrics and Gynaecology, division of Reproductive Medicine, and of Internal Medicine, division of Endocrinology provided support. There are no competing interests.

TRIAL REGISTRATION NUMBER

N/A.