Regional variation in orthopedic surgery in Switzerland

Practice Variation Research in Degenerative Lumbar Disc Surgery: A Literature Review on Design Characteristics and Outcomes

STUDY DESIGN

Literature review.

OBJECTIVE

To describe whether practice variation studies on surgery in patients with lumbar degenerative disc disease used adequate study methodology to identify unwarranted variation, and to inform quality improvement in clinical practice. Secondary aim was to describe whether variation changed over time.

METHODS

Literature databases were searched up to May 4^th, 2021. To define whether study design was appropriate to identify unwarranted variation, we extracted data on level of aggregation, study population, and case-mix correction. To define whether studies were appropriate to achieve quality improvement, data were extracted on outcomes, explanatory variables, description of scientific basis, and given recommendations. Spearman's rho was used to determine the association between the Extreme Quotient (EQ) and year of publication.

RESULTS

We identified 34 articles published between 1990 and 2020. Twenty-six articles (76%) defined the diagnosis. Prior surgery cases were excluded or adjusted for in 5 articles (15%). Twenty-three articles (68%) adjusted for case-mix. Variation in outcomes was analyzed in 7 articles (21%). Fourteen articles (41%) identified explanatory variables. Twenty-six articles (76%) described the evidence on effectiveness. Recommendations for clinical practice were given in 9 articles (26%). Extreme Quotients ranged between 1-fold and 15-fold variation and did not show a significant change over time (rho= -.33, P= .09).

CONCLUSIONS

Practice variation research on surgery in patients with degenerative disc disease showed important limitations to identify unwarranted variation and to achieve quality improvement by public reporting. Despite the availability of new evidence, we could not observe a significant decrease in variation over time.

Geographical variation in orthopedic procedures in Norway: Cross-sectional population-based study

Background:

Standardized surgery rates for common orthopedic procedures vary across geographical areas in Norway. We explored whether area-level factors related to demand and supply in publicly funded healthcare are associated with geographical variation in surgery rates for six common orthopedic procedures.

Methods:

The present study is a cross-sectional population-based study of hospital referral areas in Norway. We included adult admissions for arthroscopy for degenerative knee disease, arthroplasty for osteoarthritis of the knee and hip, surgical treatment for hip fracture, and decompression with/without fusion for lumbar disk herniation and lumbar spinal stenosis in 2012–2016. Variation in age and sex standardized rates was estimated using extremal quotients, coefficients of variation, and systematic components of variation (SCV). Associations between surgery rates and the socioeconomic factors urbanity, unemployment, low-income, high level of education, mortality, and number of surgeons and hospitals were explored with linear regression analyses.

Results:

Knee arthroscopy showed highest level of variation (SCV 10.3) and decreased in numbers. Variation was considerable for spine surgery (SCV 3.8–4.9), moderate to low for arthroplasty procedures (SCV 0.8–2.6), and small for hip fracture surgery (SCV 0.2). Higher rates of knee arthroscopy were associated with more orthopedic surgeons (adjusted coefficient 24.8, 95% confidence interval (CI): 2.7–47.0), and less urban population (adjusted coefficient −13.3, 95% CI: −25.4 to −1.2). Higher spine surgery rates were associated with more hospitals (adjusted coefficient 22.4, 95% CI: 4.6–40.2), more urban population (adjusted coefficient 2.1, 95% CI: 0.4–3.8), and lower mortality (adjusted coefficient −192.6, 95% CI: −384.2 to −1.1). Rates for arthroplasty and hip fracture surgery were not associated with supply/demand factors included.

Conclusions:

Arthroscopy for degenerative knee disease decreased in line with guidelines, but showed high variation of surgery rates. Socioeconomic factors included in this study did not explain geographical variation in orthopedic surgery.

Delineating natural catchment health districts with routinely collected health data from women's travel to give birth in Ghana

Background

Health service areas are essential for planning, policy and managing public health interventions. In this study, we delineate health service areas from routinely collected health data as a robust geographic basis for presenting access to maternal care indicators.

Methods

A zone design algorithm was adapted to delineate health service areas through a cross-sectional, ecological study design. Health sub-districts were merged into health service areas such that patient flows across boundaries were minimised. Delineated zones and existing administrative boundaries were used to provide estimates of access to maternal health services. We analysed secondary data comprising routinely collected health records from 32,921 women attending 27 hospitals to give birth, spatial demographic data, a service provision assessment on the quality of maternal healthcare and health sub-district boundaries from Eastern Region, Ghana.

Results

Clear patterns of cross border movement to give birth emerged from the analysis, but more women originated closer to the hospitals. After merging the 250 sub-districts in 33 districts, 11 health service areas were created. The minimum percent of internal flows of women giving birth within any health service area was 97.4%. Because the newly delineated boundaries are more “natural” and sensitive to observed flow patterns, when we calculated areal indicator estimates, they showed a marked improvement over the existing administrative boundaries, with the inclusion of a hospital in every health service area.

Conclusion

Health planning can be improved by using routine health data to delineate natural catchment health districts. In addition, data-driven geographic boundaries derived from public health events will improve areal health indicator estimates, planning and interventions.

Association between the appropriateness of surgery, according to appropriate use criteria, and patient-rated outcomes after surgery for lumbar degenerative spondylolisthesis

INTRODUCTION

Treatment failures in spine surgery are often attributable to poor patient selection and the application of inappropriate treatment. We used published appropriate use criteria (AUC) to evaluate the appropriateness of surgery in a large group of patients operated for lumbar degenerative spondylolisthesis (LDS) and to evaluate its association with outcome.

METHODS

This was a retrospective analysis of prospectively collected outcome data from patients operated in our Spine Centre, 2005-2012. Appropriateness of surgery was judged based on the AUC. Patients had completed the multidimensional Core Outcome Measures Index (COMI) before surgery and at 3 months' and 1, 2 and 5 years' follow-up (FU).

RESULTS

In total, 448 patients (69.8 ± 9.6 years; 323 (72%) women) were eligible for inclusion and the AUC could be applied in 393 (88%) of these. Surgery was considered appropriate (A) in 234 (59%) of the patients, uncertain/equivocal (U) in 90 (23%) and inappropriate (I) in 69 (18%). A/U patients had significantly (p < 0.05) greater improvements in COMI than I patients at each FU time point. The minimal clinically important change (MCIC) score for COMI was reached by 82% A, 76% U and 54% I patients at 1-year FU (p < 0.001, I vs A and U); the odds of achieving MCIC were 3-4 times greater in A/U patients than in I patients.

CONCLUSIONS

The results suggest a relationship between appropriateness of surgery for LDS and the improvements in COMI score after surgery. The findings require confirmation in prospective studies that also include a control group of non-operated patients.

Regional variation in hip and knee arthroplasty rates in Switzerland: A population-based small area analysis

Background

Compared to other OECD countries, Switzerland has the highest rates of hip (HA) and knee arthroplasty (KA).

Objective

We assessed the regional variation in HA/KA rates and potential determinants of variation in Switzerland.

Methods

We conducted a population-based analysis using discharge data from all Swiss hospitals during 2013–2016. We derived hospital service areas (HSAs) by analyzing patient flows. We calculated age-/sex-standardized procedure rates and measures of variation (the extremal quotient [EQ, highest divided by lowest rate] and the systemic component of variation [SCV]). We estimated the reduction in variance of HA/KA rates across HSAs in multilevel regression models, with incremental adjustment for procedure year, age, sex, language, urbanization, socioeconomic factors, burden of disease, and the number of orthopedic surgeons.

Results

Overall, 69,578 HA and 69,899 KA from 55 HSAs were analyzed. The mean age-/sex-standardized HA rate was 265 (range 179–342) and KA rate was 256 (range 186–378) per 100,000 persons and increased over time. The EQ was 1.9 for HA and 2.5 for KA. The SCV was 2.0 for HA and 2.2 for KA, indicating a low variation across HSAs. When adjusted for procedure year and demographic, cultural, and sociodemographic factors, the models explained 75% of the variance in HA and 63% in KA across Swiss HSAs.

Conclusion

Switzerland has high HA/KA rates with a modest regional variation, suggesting that the threshold to perform HA/KA may be uniformly low across regions. One third of the variation remained unexplained and may, at least in part, represent differing physician beliefs and attitudes towards joint arthroplasty.

Results of a patient-oriented second opinion program in Germany shows a high discrepancy between initial therapy recommendation and second opinion

Background

As of 2015, second opinions are legally implemented in Germany. However, empirical results from German second opinion programs are lacking. The aim of this study was to examine several aspects within a population of a German second opinion program.

Methods

Study population consisted of patients who sought a second opinion in the period from August 2011 to December 2016. Multivariate logistic regression and ANOVA were used to examine differences in patient characteristics, differentiated by agreement of initial therapy recommendation and second opinion. Follow-up points for patient satisfaction and HRQoL were defined at 1, 3 and 6 months after obtaining the second opinion.

Results

Total number of patients who sought a second opinion was 1414. Most common indications concerned the knee (37.3%), spine (27.3%), hip (11.5%) and shoulder (10.1%). The independent specialists did not confirm the initial therapy recommendations in two out of three cases. The type of indication influenced the agreement between initial therapy recommendation and the second opinion significantly (p = 0.035). The second opinion and the offered service was highly valued by the patients (89%).

Conclusions

The second opinion offers patients the possibility to confirm a medical indication independently and support patients in their decision making process. Reasons for the large discrepancy between initial therapy recommendation and second opinion should be addressed in future research.

Automated delineation of hospital service areas as a new tool for health care planning

OBJECTIVE

To develop an automated, reproducible method for delineating hospital service areas (HSAs).

DATA SOURCES/SETTING

Discharge data from all Swiss acute care hospitals for the years 2013 to 2016.

STUDY DESIGN

We derived HSAs and hospital referral regions for Switzerland using a newly developed flow-based, automated, objective, and reproducible method using all discharge data. We compared our method to the classical, partially subjective approach used to delineate the Swiss Health Care Atlas by delineating four sets of intervention-specific HSAs.

PRINCIPAL FINDINGS

Based on 4 105 885 discharges, the fully automated method delineated 63 HSAs. Comparison with existing HSAs reveals good overlap and comparable measures of health utilization between the methods and shows that in the Swiss setting, our method outperforms a cluster-based approach to defining HSAs. While the classical method potentially takes an entire day to delineate the regions, our method took approximately 10 minutes.

CONCLUSIONS

Hospital service areas are used to analyze differences in use of health care that may indicate underuse and overuse. Our new, fully automated, objective, and reproducible method provides a useful tool for hospital services researchers that will enable them to delineate and update patient-flow-based HSAs.

Geographical variation in musculoskeletal surgical care in public hospitals in Ireland: a repeated cross-sectional study

OBJECTIVE

To examine the extent of geographical variation across musculoskeletal surgical procedures and associated factors in Ireland.

DESIGN

Repeated cross-sectional study.

SETTING

36 public hospitals in Ireland.

PARTICIPANTS

Adult admissions for hip fracture, hip and knee replacement, knee arthroscopy and lumbar spine interventions over 5 years (2012-2016).

PRIMARY OUTCOME MEASURE

Standardised discharge rate (SDR).

ANALYSIS

Age and sex SDRs were calculated for 21 geographical areas. Extremal quotients, coefficients of variation and systematic components of variance were calculated. Linear regression analyses were conducted exploring the relationship between SDRs and year, unemployment, % urban population, number of referral hospitals, % on waiting lists>6 months and % with private health insurance for each procedure.

RESULTS

Across 36 public hospitals, n=102 756 admissions were included. Hip fracture repair showed very low variation. Elective hip and knee procedures showed high variation in particular years, while variation for lumbar interventions was very high. Knee arthroscopy rates decreased over time. Higher unemployment was associated with knee and hip replacement rates and urban areas had lower hip replacement rates. Spinal procedure rates were associated with a lower number of referral hospitals in a region and spinal injection rates were associated with shorter waiting lists. A higher proportion of patients having private health insurance was associated with higher rates of hip and knee replacement and lumbar spinal procedures.

CONCLUSIONS

Variation and factors associated with SDRs for publicly funded hip and knee procedures are consistent with similar international research in this field. Further research should explore reasons for high rates of spinal injections and the impact of private practice on musculoskeletal procedure variation.

Exploring geographical variation in access to general surgery in Ireland: Evidence from a national study

BACKGROUND

Improving the equity of surgical services is an important objective of all clinical programmes both local and overseas. Variations in access to care threaten to dismantle the structural paradigm of any health service and such information can aid in promoting quality and access to surgical services. The aim of this study was to explore the geographical variation in the utilisation of common general surgical procedures in Ireland as a measure of the population's access to surgical interventions.

METHODS

Age- and gender-standardized rates for 6 common general surgical procedures were calculated for 28 geographic areas (counties) in the Republic of Ireland using data from the national Hospital Inpatient Enquiry System. Standard statistical indicators (systematic component of variation, coefficient of variation and extremal quotient) were used to measure the extent of regional variation.

RESULTS

A total of 998,406 episodes of hospital care were included in the analysis. Large variation in utilisation was present between the studied counties; CV > 0.3 (range 19.4-31.2), SCV > 5 (range 5.2-14.6). Most procedures were utilised at substantially higher rates outside the larger cities (Dublin, Galway, Waterford).

CONCLUSION

Variations stemming from inefficient and unequal access are important components and markers of modern health systems and should be minimal. County of residence appears to have a clear influence on a patients' inaccessibility to certain interventions. Our findings imply a need for improved access at a regional level by facilitating the integration of public policies and promoting services at the appropriate settings.

The clinical and economic consequences of practice style variations in common surgical interventions: A protocol for systematic review

BACKGROUND

Surgical intervention is one of the common therapeutic interventions applied to a vast class of diseases. Unwarranted variation in practice style in different locations is considered as practice style variations (PSVs), which cause undesirable effects on patient health status and economic consequences. The magnitude of the variations in surgical interventions and its effects on clinical outcomes of patients and also utilization of resources have been investigated in recent years. But the findings show considerable heterogeneities in magnitude and consequences. We develop a protocol to systematically review the current literature of PSV to explain the magnitude of PSV and its clinical and economic consequences.

METHOD

This systematic review will include observational and experimental studies to investigate magnitude and consequences of PSV in common surgical interventions, cardiovascular disease, urological, and ophthalmological diseases. Source of information is scientific databases, theses, clinical trials registrations website, and grey literature. A comprehensive electronic search will be conducted through PubMed, Web of Science, EBSCO, EMBASE, and Scopus databases. Studies are assessed systematically by 2 investigators. Methodological quality of the included studies is evaluated by the STROBE and CONSORT checklists. In case of data availability, we will pool findings of included studies by meta-analysis techniques in the CMA software. Subgroup analyses are based on the type of the interventions and selected diseases.

RESULTS

This study has ethical approval from ethical committee of Iran University of Medical Sciences, ethic code: IR.IUMS.REC1395.9221504203. The results will be published in a peer-reviewed journal.

CONCLUSION

A systematic review is considered as an appropriate scientific method for reaching a consensus on magnitude as well as consequences of PSV. Results of this study will help clinical experts to attain more knowledge about PSV and encourage them to use some tools such as clinical guidelines and shared decision making to alleviate its consequences.

[First results of a German second opinion program show high patient satisfaction and large discrepancies between initial therapy recommendations and second opinion]

BACKGROUND AND OBJECTIVES

Although legally anchored, there are no empirical results from German second opinion programs. In this study, various aspects within a population of a second opinion program are examined.

METHODS

In this study patients were analyzed who sought a second opinion in the period from August 2011 to December 2016. Differences in patient characteristics, differentiated by agreement of first and second opinion, were analyzed using multivariate logistic regression. Patients' satisfaction and quality of life were examined one, three and six months after obtaining the second opinion.

RESULTS

In total, 1,414 patients sought a second opinion. Most frequently, second opinions were sought on knee (38.7 %), back (26.8 %), hip (11.7 %), and shoulder (10.2 %) complaints. Except for the indication (p=0.035), no patient characteristic had influence on the conformation of the second opinion. Approximately two out of three initial recommendations were not confirmed by the specialists. 89 % of the patients were satisfied or very satisfied with the second opinion and the service offered.

CONCLUSIONS

The second opinion offers patients the opportunity to seek an additional independent medical opinion and thus provides support for decision making. Further research is needed to examine the reasons for the high discrepancies between the first and second opinions.

Ambulatory Care-Sensitive Condition Hospitalizations Among Medicare Beneficiaries

INTRODUCTION

This study examined the association between the distribution of primary care physicians and Medicare beneficiaries' ambulatory care sensitive condition hospitalizations using both statistical and spatial analyses.

METHODS

Data from the 2014 County Health Rankings, 2013-2014 Area Resource File, and the 2014 Food Environment Atlas Data File were integrated to perform county-level ordinary least squares and geographically weighted regression. Analyses were conducted in late 2015.

RESULTS

Primary care physician density was found to be negatively associated with Medicare beneficiaries' ambulatory care sensitive condition hospitalization rate in both ordinary least squares (β=-5.88, p=0.0037) and geographically weighted regression models (37.08% of all counties), with the latter model finding significant relationships in the South and Northeast.

CONCLUSIONS

Preventable hospitalizations are high in areas of the U.S. that have low primary care physician density and other healthcare resources, large non-white populations, high levels of area deprivation, and rural designations. Using geospatial techniques helped document areas of greatest concern for potential intervention. Future research needs to account for these regional differences and target surveillance accordingly.

The pathway to orthopaedic surgery: a population study of the role of access to primary care and availability of orthopaedic services in Ontario, Canada

OBJECTIVE

To examine the impact of access to primary care physicians (PCPs), geographic availability of orthopaedic surgeons, socioeconomic status (SES), proportion of older population (≥65 years) and proportion of rural population on orthopaedic surgeon office visits and orthopaedic surgery.

DESIGN

Population multilevel study.

SETTING

Ontario, Canada.

PARTICIPANTS

Ontario residents 18 years or older who had visits to orthopaedic surgeons or an orthopaedic surgery for musculoskeletal disorders in 2007/2008.

PRIMARY AND SECONDARY OUTCOMES

Office visits to orthopaedic surgeons and orthopaedic surgery.

RESULTS

Access to PCPs and the index of geographic availability of orthopaedic surgeons, but not SES, were significantly associated with orthopaedic surgeon office visits. There was a significant interaction between access to PCPs and orthopaedic surgeon geographic availability for the rate of office visits, with access to PCPs being more important in areas of low geographic availability of orthopaedic surgeons. After controlling for office visits with orthopaedic surgeons, the index of geographic availability of orthopaedic surgeons was no longer significantly associated with orthopaedic surgery.

CONCLUSIONS

The findings suggest that, particularly, in areas with low access to PCPs or with fewer available orthopaedic surgeons, residents are less likely to have orthopaedic surgeon office visits and in turn are less likely to receive surgery. Efforts to address adequate access to orthopaedic surgery should also include improving and facilitating access to PCPs for referral, particularly in geographic areas with low orthopaedic surgeon availability.

Avoidable hospitalizations in Switzerland: a small area analysis on regional variation, density of physicians, hospital supply and rurality

Background

Avoidable hospitalizations (AH) are hospital admissions for diseases and conditions that could have been prevented by appropriate ambulatory care. We examine regional variation of AH in Switzerland and the factors that determine AH.

Methods

We used hospital service areas, and data from 2008–2010 hospital discharges in Switzerland to examine regional variation in AH. Age and sex standardized AH were the outcome variable, and year of admission, primary care physician density, medical specialist density, rurality, hospital bed density and type of hospital reimbursement system were explanatory variables in our multilevel poisson regression.

Results

Regional differences in AH were as high as 12-fold. Poisson regression showed significant increase of all AH over time. There was a significantly lower rate of all AH in areas with more primary care physicians. Rates increased in areas with more specialists. Rates of all AH also increased where the proportion of residences in rural communities increased. Regional hospital capacity and type of hospital reimbursement did not have significant associations. Inconsistent patterns of significant determinants were found for disease specific analyses.

Conclusion

The identification of regions with high and low AH rates is a starting point for future studies on unwarranted medical procedures, and may help to reduce their incidence. AH have complex multifactorial origins and this study demonstrates that rurality and physician density are relevant determinants. The results are helpful to improve the performance of the outpatient sector with emphasis on local context. Rural and urban differences in health care delivery remain a cause of concern in Switzerland.

[Differences in the use of health care services--is everything unethical?]

BACKGROUND

Regional differences in the use of health services have been known for several decades. This variability is often overall regarded as undesirable in discussions and ethical-moral argumentation takes place. The description and analysis of this variability and the underlying causes are the subject of numerous investigations in various health care systems.

RESEARCH QUESTION

The purpose of this research was to determine which causes can the current health care situation be attributed to and which approaches exist to counteract undesirable variability.

MATERIAL AND METHODS

On the basis of a selective literature search, an overview on the identification of variations in surgical care as well as a presentation of possible causes and solution approaches were created.

RESULTS

Numerous factors influencing the decision-making process regarding surgical interventions could be identified. These can be patient-related, disease-/intervention-related, physician-related, or system-related and are partially linked with each other. The optimal strategies to minimize variability in health care are still unclear. Scientific evidence to assess the benefit and risk of an intervention, physician's attitudes and preferences as well as the involvement of patients in the decision-making process, however, seem to be important starting points.

CONCLUSION

The description of regional differences is an important step toward provision of evidence-based and tailored health care. Differences in health care provision and especially regionally varying high intervention rates are not per se problematic. Whether a patient receives an intervention or not should, however, not depend any more on where he or she lives and which physician is being consulted, but on his or her individual medical condition or preferences. Target group-oriented evidence-based information can help to minimize undesirable variability.

Strategies for reducing regional variation in the use of surgery: a systematic review

OBJECTIVE

To review the literature evaluating the effect of practice guidelines and decision aids on use of surgery and regional variation.

BACKGROUND

The use of surgical procedures varies widely across geographic regions. Although practice guidelines and decision aids have been promoted for reducing variation, their true effectiveness is uncertain.

METHODS

Studies evaluating the influence of clinical practice guidelines or consensus statements, shared decision making and decision aids, or provider feedback of comparative utilization, on rates of surgical procedures were identified through literature searches of Ovid MEDLINE, EMBASE, and Web of Science.

RESULTS

A total of 1946 studies were identified and 27 were included in the final review. Of the 12 studies evaluating implementation of guidelines, 6 reported a significant effect. Those examining overall population-based rates had mixed effects, but all studies evaluating procedure choice described at least a small increase in use of recommended therapy. Three of 5 studies examining the effect of guidelines on regional variation reported a significant reduction after dissemination. Of the 15 studies examining decision aids, 5 revealed significant effects. Many studies of decision aids reported decreases in population-based procedure rates. Nearly all studies evaluating the impact of decision aids on procedure choice reported increases in rates of less invasive procedures. Only one study of decision aids assessed changes in regional variation and found mixed results.

CONCLUSIONS

Both practice guidelines and decision aids have been proven effective in many clinical contexts. Expanding the clinical scope of these tools and eliminating barriers to implementation will be essential to further efforts directed toward reducing regional variation in the use of surgery.

Geographical variation in incidence of knee arthroscopy for patients with osteoarthritis: a population-based analysis of Victorian hospital separations data

BACKGROUND/AIM

To evaluate the frequency and geographical variation in knee arthroscopy for adults (>25 years) with a concomitant diagnosis of osteoarthritis.

METHODS

This was a retrospective cohort study of hospital separations involving an elective knee arthroscopy in public and private hospitals in Victoria, Australia. Participants included patients receiving knee arthroscopies with a diagnosis code indicating osteoarthritis (OA) from 1 July 2008 to 30 June 2009. Records were excluded if the patient was under 25 years or their arthroscopy involved a ligament reconstruction. Crude rates per 100 000 population and negative binomial regression offset by total knee arthroscopy volume were used to analyse differences by region.

RESULTS

There were 9620 arthroscopic procedures meeting the inclusion criteria. There were 5500 (57.2%) admissions where the principal diagnosis was knee OA (gonarthrosis) and 3510 (36.5%) where the principal diagnosis indicated a mechanical derangement and there was a primary or associated diagnosis of OA. When we examined the incidence rate ratios (IRR) by region, after adjustment for relevant factors and accounting for the total knee arthroscopy volume within each region, we identified significant variation in knee arthroscopy rates for patients with OA. The region with the highest adjusted IRR was Barwon South Western (IRR: 1.26, 95% confidence interval (CI): 1.16-1.36) and the region with lowest adjusted incidence rate ratio was the Gippsland region (IRR: 0.89, 95% CI: 0.80-0.98).

CONCLUSIONS

We identified considerable geographical variation in arthroscopies for people with OA across Victoria. Further investigation is needed to understand whether this variation is a reflection of differences in OA prevalence, clinical decision-making or access.

Supply sensitive services in Swiss ambulatory care: an analysis of basic health insurance records for 2003-2007

Background

Swiss ambulatory care is characterized by independent, and primarily practice-based, physicians, receiving fee for service reimbursement. This study analyses supply sensitive services using ambulatory care claims data from mandatory health insurance. A first research question was aimed at the hypothesis that physicians with large patient lists decrease their intensity of services and bill less per patient to health insurance, and vice versa: physicians with smaller patient lists compensate for the lack of patients with additional visits and services. A second research question relates to the fact that several cantons are allowing physicians to directly dispense drugs to patients ('self-dispensation') whereas other cantons restrict such direct sales to emergencies only. This second question was based on the assumption that patterns of rescheduling patients for consultations may differ across channels of dispensing prescription drugs and therefore the hypothesis of different consultation costs in this context was investigated.

Methods

Complete claims data paid for by mandatory health insurance of all Swiss physicians in own practices were analyzed for the years 2003-2007. Medical specialties were pooled into six main provider types in ambulatory care: primary care, pediatrics, gynecology & obstetrics, psychiatrists, invasive and non-invasive specialists. For each provider type, regression models at the physician level were used to analyze the relationship between the number of patients treated and the total sum of treatment cost reimbursed by mandatory health insurance.

Results

The results show non-proportional relationships between patient numbers and total sum of treatment cost for all provider types involved implying that treatment costs per patient increase with higher practice size. The related additional costs to the health system are substantial. Regions with self-dispensation had lowest treatment cost for primary care, gynecology, pediatrics and for psychiatrists whereas "prescription only" areas had lowest cost for specialists with non-invasive and invasive activities.

Conclusions

The results indicate that payment methods for services and for prescription drugs are associated with variations in treatment cost that are unlikely warranted by different medical needs of patients alone. Promoting physician accountability of care by linking reimbursements to quality, not quantity, of services are important policy measures to be considered for health care in Switzerland.

The implementation of DRG-based hospital reimbursement in Switzerland: A population-based perspective

Background

Switzerland introduces a DRG (Diagnosis Related Groups) based system for hospital financing in 2012 in order to increase efficiency and transparency of Swiss health care. DRG-based hospital reimbursement is not simultaneously realized in all Swiss cantons and several cantons already implemented DRG-based financing irrespective of the national agenda, a setting that provides an opportunity to compare the situation in different cantons. Effects of introducing DRGs anticipated for providers and insurers are relatively well known but it remains less clear what effects DRGs will have on served populations. The objective of the study is therefore to analyze differences of volume and major quality indicators of care between areas with or without DRG-based hospital reimbursement from a population based perspective.

Methods

Small area analysis of all hospitalizations in acute care hospitals and of all consultations reimbursed by mandatory basic health insurance for physicians in own practice during 2003-2007.

Results

The results show fewer hospitalizations and a relocation of resources to outpatient care in areas with DRG reimbursement. Overall burden of disease expressed as per capita DRG cost weights was almost identical between the two types of hospital reimbursement and no distinct temporal differences were detected in this respect. But the results show considerably higher 90-day rehospitalization rates in DRG areas.

Conclusion

The study provides evidence of both desired and harmful effects related to the implementation of DRGs. Systematic monitoring of outcomes and quality of care are therefore essential elements to maintain in the Swiss health system after DRG's are implemented on a nationwide basis in 2012.