Hysterectomy is the last treatment option for benign uterine diseases, and vaginal hysterectomy is preferred over more invasive techniques. We assessed the regional variation in hysterectomy rates ...for benign uterine diseases across Switzerland and explored potential determinants of variation.
We conducted a population-based analysis using patient discharge data from all Swiss hospitals between 2013 and 2016. Hospital service areas (HSAs) for hysterectomies were derived by analyzing patient flows. We calculated age-standardized mean procedure rates and measures of regional variation (extremal quotient EQ, highest divided by lowest rate) and systematic component of variation SCV). We estimated the reduction in the variance of crude hysterectomy rates across HSAs in multilevel regression models, with incremental adjustment for procedure year, age, cultural/socioeconomic factors, burden of disease, and density of gynecologists.
Overall, 40,211 hysterectomies from 54 HSAs were analyzed. The mean age-standardized hysterectomy rate was 298/100,000 women (range 186-456). While the variation in overall procedure rate was moderate (EQ 2.5, SCV 3.7), we found a very high procedure-specific variation (EQ vaginal 5.0, laparoscopic 6.3, abdominal 8.0; SCV vaginal 17.5, laparoscopic 11.2, abdominal 16.9). Adjusted for procedure year, demographic, cultural, and sociodemographic factors, a large share (64%) of the variance remained unexplained (vaginal 63%, laparoscopic 85%, abdominal 70%). The main determinants of variation were socioeconomic/cultural factors. Burden of disease and the density of gynecologists was not associated with procedure rates.
Switzerland has a very high regional variation in vaginal, laparoscopic, and abdominal hysterectomy for benign uterine disease. After adjustment for potential determinants of variation including demographic factors, socioeconomic and cultural factors, burden of disease, and the density of gynecologists, two thirds of the variation remain unexplained.
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.
Phenylketonuria (PKU) is an autosomal recessive metabolic disorder characterized by increased phenylalanine (Phe) concentrations in the blood and brain. Despite wide agreement on treatment during ...childhood, recommendations for adults are still controversial.
To assess the impact of a 4-week increase in Phe intake (simulating normal dietary Phe consumption) on cognition, mood, and depression in early-treated adults with PKU in a double-blind, randomized controlled trial (RCT).
In a single-site crossover trial, 30 adult patients with classical PKU diagnosed at birth were recruited. All patients underwent a 4-week period of oral Phe administration (1500–3000 mg Phe/d) and a 4-week placebo period in a randomly assigned order with age, sex, and place of usual medical care as stratification factors. Analyses were based on the intention-to-treat (ITT) and per protocol (PP) approach to claim noninferiority (noninferiority margin –4%), with working memory accuracy as the primary endpoint and additional cognitive domains, mood, and depression as secondary endpoints.
For the primary endpoint, a 4-week increase of Phe intake was noninferior to placebo with respect to working memory accuracy in both the ITT point estimate 0.49; lower limit 95% confidence interval (CI): −1.99 and the PP analysis (point estimate −1.22; lower limit 95% CI: −2.60). Secondary outcomes (working memory reaction time, manual dexterity, mood, and depression) did not significantly differ between the Phe and placebo period, except for sustained attention (point estimate 31.0; lower limit 95% CI: 9.0). Adverse events were more frequent during the Phe than during the placebo period (95% CI: 1.03, 2.28, P = 0.037).
In early-treated adult patients with PKU, a 4-week high Phe intake was noninferior to continuing Phe restriction regarding working memory accuracy, and secondary outcomes did not differ except for sustained attention. Longer-term RCTs are required to determine whether low Phe levels need to be maintained throughout different periods of adulthood.
This trial was registered at the clinicaltrials.gov as NCT03788343.
There is a substantial geographical variation in the rates of pacemaker (PM), implantable cardioverter defibrillator (ICD), and cardiac resynchronization therapy (CRT) device implantation across ...European countries. We assessed the extent of regional variation and potential determinants of such variation.
We conducted a population-based analysis using discharge data for PM/ICD/CRT implantations from all Swiss acute care hospitals during 2013-2016. We derived hospital service areas (HSA) by analyzing patient flows. We calculated age- and sex-standardized rates and quantified variation using the extremal quotient (EQ) and the systemic component of variation (SCV). We estimated the reduction in variance of crude implantation rates across HSAs using multilevel regression models, with incremental adjustment for age and sex, language, socioeconomic factors, population health, diabetes mellitus, and the density of cardiologists on the HSA level.
We analyzed implantations of 8129 PM, 1461 ICD, and 1411 CRT from 25 Swiss HSAs. The mean age- and sex-standardized implantation rate was 29 (range 8-57) per 100,000 persons for PM, 5 (1-9) for ICD, and 5 (2-8) for CRT. There was a very high variation in PM (EQ 7.0; SCV 12.6) and ICD (EQ 7.2; SCV 11.3) and a high variation in CRT implantation rates (EQ 3.9; SCV 7.1) across HSAs. Adjustments for age and sex, language, socioeconomic factors, population health, diabetes mellitus, and density of cardiologists explained 94% of the variance in ICD and 87.5% of the variance in CRT implantation rates, but only 36.3% of the variance in PM implantation rates. Women had substantially lower PM/ICD/CRT implantation rates than men.
Switzerland has a very high regional variation in PM/ICD implantation and a high variation in CRT implantation rates. Women had substantially lower implantation rates than men. A large share of the variation in PM procedure rates remained unexplained which might reflect variations in physicians' preferences and practices.
Percutaneous closure of a patent foramen ovale (PFO) or the left atrial appendage (LAA) are controversial procedures to prevent stroke but often used in clinical practice. We assessed the regional ...variation of these interventions and explored potential determinants of such a variation.
We conducted a population-based analysis using patient discharge data from all Swiss hospitals from 2013-2018. We derived hospital service areas (HSAs) using patient flows for PFO and LAA closure. We calculated age-standardized mean procedure rates and variation indices (extremal quotient EQ and systematic component of variation SCV). SCV values >5.4 indicate a high and >10 a very high variation. Because the evidence on the efficacy of PFO closure may differ in patients aged <60 years and ≥60 years, age-stratified analyses were performed. We assessed the influence of potential determinants of variation using multilevel regression models with incremental adjustment for demographics, cultural/socioeconomic, health, and supply factors.
Overall, 2574 PFO and 2081 LAA closures from 10 HSAs were analyzed. The fully adjusted PFO and LAA closure rates varied from 3 to 8 and from 1 to 9 procedures per 100,000 persons per year across HSAs, respectively. The regional variation was high with respect to overall PFO closures (EQ 3.0, SCV 8.3) and very high in patients aged ≥60 years (EQ 4.0, SCV 12.3). The variation in LAA closures was very high (EQ 16.2, SCV 32.1). In multivariate analysis, women had a 28% lower PFO and a 59% lower LAA closure rate than men. French/Italian language areas had a 63% lower LAA closure rate than Swiss German speaking regions and areas with a higher proportion of privately insured patients had a 86% higher LAA closure rate. After full adjustment, 44.2% of the variance in PFO closure and 30.3% in LAA closure remained unexplained.
We found a high to very high regional variation in PFO closure and LAA closure rates within Switzerland. Several factors, including sex, language area, and insurance status, were associated with procedure rates. Overall, 30-45% of the regional procedure variation remained unexplained and most probably represents differing physician practices.
Background Among various treatment options for benign prostatic hyperplasia (BPH), surgical therapy is the most invasive. As Switzerland has the highest transurethral prostatectomy rate among OECD ...countries, we assessed the regional variation in prostate surgery for BPH and explored potential determinants of variation. Methods We conducted a population-based analysis using discharge data for men aged greater than or equal to40 years with transurethral or simple prostatectomy from all Swiss hospitals during 2013-2018. After excluding patients with genitourinary/prostate cancer, we derived hospital service areas (HSAs) by analyzing patient flows. We calculated age-standardized mean procedure rates and variation indices (extremal quotient EQ and systematic component of variation SCV). We estimated the reduction in variance across HSAs of prostatectomy rates in multilevel regression models, with incremental adjustment for age, regional cultural and socioeconomic factors, disease burden, density of urologists, and the time since urologists' graduation. Results Overall, 44,253 prostatectomies (42,710 transurethral and 1543 simple) from 44 HSAs were analyzed. The mean age-standardized prostate surgery rate was 314 (range 166-500) per 100,000 men aged greater than or equal to40 years per year. The EQ was 3.01 and the SCV 5.53, indicating a high regional variation. In multivariate models, men aged 75-79 years had an 11.6-fold higher prostatectomy rate than those aged 50-54 years. French/Italian language areas had a 21% lower rate than Swiss German speaking areas. Socioeconomic factors, disease burden, and density of urologist/time since graduation were not associated with prostatectomy rates. After full adjustment, 80% of the variance in prostate surgery across HSAs remained unexplained. Conclusion We found a remarkably high regional variation in prostate surgery rates for BPH within Switzerland.
To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) examining the effectiveness of continuous positive airway pressure (CPAP) in stroke patients with sleep ...disordered breathing (SDB).
In a systematic literature search of electronic databases (MEDLINE, Embase, and the Cochrane Library) from 1980 to November 2016, we identified RCTs that assessed CPAP compared to standard care or sham CPAP in adult patients with stroke or TIA with SDB. Mean CPAP use, odds ratios (ORs), and standardized mean differences (SMDs) were calculated. The prespecified outcomes were adherence to CPAP, neurologic improvement, adverse events, new vascular events, and death.
Ten RCTs (564 participants) with CPAP as intervention were included. Two studies compared CPAP with sham CPAP; 8 compared CPAP with usual care. Mean CPAP use across the trials was 4.53 hours per night (95% confidence interval CI 3.97-5.08). The OR of dropping out with CPAP was 1.83 (95% CI 1.05-3.21,
= 0.033). The combined analysis of the neurofunctional scales (NIH Stroke Scale and Canadian Neurological Scale) showed an overall neurofunctional improvement with CPAP (SMD 0.5406, 95% CI 0.0263-1.0548) but with a considerable heterogeneity (
= 78.9%,
= 0.0394) across the studies. Long-term survival was improved with CPAP in 1 trial.
CPAP use after stroke is acceptable once the treatment is tolerated. The data indicate that CPAP might be beneficial for neurologic recovery, which justifies larger RCTs.
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.
Aortic valve stenosis (AS) is the most common valvular heart disease and if severe, is treated with either transcatheter (TAVR) or surgical aortic valve replacement (SAVR). We assessed temporal ...trends and regional variation of these interventions in Switzerland and examined potential determinants of geographic variation.
We conducted a population-based analysis using patient discharge data from all Swiss public and private acute care hospitals from 2013 to 2018. We generated hospital service areas (HSAs) based on patient flows for TAVR. We calculated age-standardized mean procedure rates and variation indices (extremal quotient EQ and systematic component of variation SCV). Using multilevel regression, we calculated the influence of calendar year and regional demographics, socioeconomic factors (language, insurance status), burden of disease, and number of cardiologists/cardiovascular surgeons on geographic variation.
Overall, 8074 TAVR and 11,825 SAVR procedures were performed in 8 HSAs from 2013 to 2018. Whereas the age-/sex-standardized rate of TAVR increased from 12 to 22 procedures/100,000 persons, the SAVR rate decreased from 33 to 24 procedures during this period. After full adjustment, the predicted TAVR and SAVR rates varied from 12 to 22 and 20 to 35 per 100,000 persons across HSAs, respectively. The regional procedure variation was low to moderate over time, with a low overall variation in TAVR (EQ 1.9, SCV 3.9) and SAVR (EQ 1.6, SCV 2.2). In multilevel regression, TAVR rates increased annually by 10% and SAVR rates decreased by 5%. Determinants of higher TAVR rates were older age, male sex, living in a German speaking area, and higher burden of disease. A higher proportion of (semi)private insurance was also associated with higher TAVR and lower SAVR rates. After full adjustment, 10.6% of the variance in TAVR and 18.4% of the variance in SAVR remained unexplained. Most variance in TAVR and SAVR rates was explained by language region and insurance status.
The geographic variation in TAVR and SAVR rates was low to moderate across Swiss regions and largely explained by differences in regional demographics and socioeconomic factors. The use of TAVR increased at the expense of SAVR over time.
The aim of this study was to examine the frequency, timing, and association of access-site and non–access-site bleeding with mortality in the setting of transcatheter aortic valve replacement (TAVR) ...during long-term follow-up.
Bleeding is frequent and associated with impaired prognosis in patients undergoing TAVR. It is currently unknown whether the site of bleeding differentially influences the outcomes of TAVR patients.
In total, 926 consecutive patients undergoing TAVR from 2007 through 2014 were evaluated. Bleeding was assessed according to the Valve Academic Research Consortium 2 criteria. The primary outcome of interest was all-cause mortality up to 5 years of follow-up.
A total of 285 patients (30.7%) experienced at least 1 (minor, major, or life-threatening) bleeding event up to 5 years. Compared with patients not experiencing bleeding, the adjusted risk for all-cause mortality was significantly increased among patients with access-site (hazard ratio: 1.34; 95% confidence interval: 1.01 to 1.76; p = 0.04) and non–access-site bleeding (hazard ratio: 2.08; 95% confidence interval: 1.60 to 2.71; p < 0.001). However, non–access-site bleeding conferred a significantly higher risk for mortality compared with access-site bleeding (hazard ratio: 1.56; 95% confidence interval: 1.12 to 2.18; p = 0.009). At multivariate analysis, female sex was a significant correlate of access-site bleeding, whereas chronic kidney disease and the Society of Thoracic Surgeons score were significantly associated with non–access-site bleeding.
Among patients with severe aortic stenosis undergoing TAVR, access-site and non–access-site bleeding were independently associated with an increased risk for mortality, with the greatest risk related to non–access-site bleeding during long-term follow-up.
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