Determinants of drug expenditure in the Swiss healthcare market in 2006.

BACKGROUND: Several measures are in force in Switzerland to control the cost of drugs, but are not effective enough. There are many determinants influencing these expenditures, related to treatments, markets, physicians, patients and regions, but their impact on costs is not clear. METHODS: We applied a Bayesian multilevel model with five levels to adjust for patients, drugs' market, and physicians 'characteristics, treatment type, and district (i.e. Swiss canton). We used data of the Swiss drugs' market in 2006, offering real choices for doctors and patients (multiple products for similar active substances), with a neutral position of pharmacists (no financial incentives). RESULTS: Variance partitioning of yearly drugs' cost per insured showed that market level (delivered substance) contributed to 76% of the variance, treatment level (delivered product) to 20%, whereas patients' and physicians' levels accounted for only 2% each, without significant differences between Swiss cantons. After adjusting for covariables at each level, the model explained about 51% of the variation at the market and 20% at the treatment levels. We found that older but substitutable drugs, generics, larger size of the market and physician's specialty were associated with lower expenditure, whereas drugs requiring a physician's prescription, the number of prescribers per patient, patient' age, male gender, and comorbidities increased expenditure. Our results show that for a specific medication the yearly cost of recently released drugs was 36 CHF higher than for similar and substitutable drugs introduced 15 years earlier, corresponding to one third of the average annual treatment cost observed in our dataset. Competition did not seem to be effective to reduce expenditure on the drug market. CONCLUSION: The main finding of this study is that recentness of drugs was associated with an increase in drug expenditure in 2006, even after adjustment for all non-controllable determinants. Further research is recommended to confirm those results with updated data.

Measuring medically unjustified hospitalizations in Switzerland.

BACKGROUND: Inappropriate use of acute hospital beds is a major topic in health politics. We present here a new approach to measure unnecessary hospitalizations in Medicine and Pediatrics. METHODS: The necessity of a hospital admission was determined using explicit criteria related to the recorded diagnoses. Two indicators (i.e. "unjustified" and "sometimes justified" stays) were applied to more than 800,000 hospital stays and a random sample of 200 of them was analyzed by two clinicians, using routine data available in medical statistics. The validation of the indicators focused on their precision, validity and adjustment, as well as their usefulness (i.e. interest and risk of abuse). RESULTS: Rates, adjusted for case mix (i.e. age of patient, admission planned or not), showed statistically significant differences among hospitals. Only 6.5% of false positives were observed for "unjustified stays" and 17% for "sometimes justified stays". Respectively 7 and 12% of stays had an unknown status, due to a lack of sufficiently precise data. Considering true positives only, almost one third of medical and pediatric stays were classified as not strictly justified from a medical point of view in Switzerland. Among these stays, about one fifth could have probably been avoided without risk. To enable a larger ambulatory shift, recommendations were made to strengthen the ambulatory care, notably regarding post-emergency follow-up, cardiac and pulmonary functions' monitoring, pain management, falls prevention, and specialized at-home services that should be offered. CONCLUSION: We recommend using "unjustified stays" and "sometimes justified stays" indicators to monitor inappropriate hospitalizations. The latter could help the planning of reinforced ambulatory care measures to pursue the ambulatory shift. Nonetheless, we clearly advise against the use of these two indicators for hospitals financing purposes.

Width of margins in phyllodes tumors of the breast: the controversy drags on?-a systematic review and meta-analysis.

PURPOSE: Phyllodes tumors (PT) of the breast are rare fibroepithelial neoplasms. Information is controversial in the literature regarding to the optimal surgical management. Most studies suggested margins of at least 10 mm while some recent studies suggested narrower margins without an increased risk of local recurrences (LR) and distant metastases (DM). The objective of this systematic review was to identify and compare studies that assessed these different practices. METHODS: A systematic review was performed through five databases up to April 2019. Studies exploring the association between the width of margins, subtypes of PT, and the LR and DM rates were considered for inclusion. A statistical model for analyzing sparse data and rare events was used. RESULTS: Thirteen studies met eligibility criteria and were selected. Considering a threshold of 10 mm (margins < 10 vs margins ≥ 10 mm), the 5-year incidence rate of LR was estimated to be 5.22 vs. 3.63 (diff. -1.59) per 100 person-years for benign PT, 9.60 vs. 7.33 (diff. -2.27) for borderline PT, and 28.58 vs. 21.84 (diff. -6.74) for malignant PT. For DM, it was estimated to be 0.88 vs. 0.86 (diff. -0.02) for benign PT, 1.61 vs. 1.74 (diff. 0.13) for borderline PT, and 4.80 vs 5.18 (diff. 0.38) for malignant PT. The data for a threshold of 1 mm were not sufficient to draw any conclusions. CONCLUSION: Irrespective of tumor grade, we found that DM was a rarer event than LR. Malignant PT had the highest incidence rate of LR and DM. This meta-analysis found a clear association between width of margins and LR rates. Whatever the tumor grade, surgical margins ≥ 10 mm guaranteed a lower risk of LR than margins < 10 mm. On the other hand, the width of margin did not influence the apparition of DM.

Prehospital use of pelvic circumferential compression devices in a physician-based emergency medical service: A 6-year retrospective cohort study.

Fractures of the pelvic ring are a potential source of significant bleeding. Pelvic circumferential compression devices (PCCDs) can reduce and immobilize unstable fractures, but their hemostatic effect is unproven. Our aim was to assess the current practice of prehospital PCCD application and to identify factors available in the field predictive of significant pelvic ring injuries. All interventions (n = 13,435) in the Lausanne University Hospital Emergency Medical Service (EMS) were screened for PCCD placements from January 2008 to November 2014. Significant pelvic ring injuries (Tile types B or C) were considered as potentially benefitting from a PCCD. Data were extracted from the local prehospital registry. During the study period, 2366 trauma missions were performed. A PCCD was applied to 552/2366 (23%) patients. Significant pelvic ring injuries were present in 105/2366 (4.4%). Factors associated with the presence of significant pelvic ring injury were increased respiratory rate (OR 1.04), prolonged capillary refill time (OR 2.11), increased shock index (OR 3.91), pedestrians hit by a vehicle (OR 2.19), and presenting with falls from more than 2 m (OR 1.91). Among patients with a significant pelvic ring injury, a PCCD was placed in 79 (75%) and omitted in 26 (25%). One sixth of patients with a PCCD had a final diagnosis of significant pelvic ring injury. Further studies are needed to better understand which patient-, or accident-related factors are associated with prehospital PCCD omission among patients with significant pelvic ring injury.

Heterogeneity in The drivers of health expenditures financed by health insurance in a fragmented health system: The case of Switzerland.

Switzerland is the world's second largest spender on health care, both per capita and as a share of the Gross Domestic Product (GDP). The Swiss health care system is a federation of 26 cantonal systems with highly fragmented provision and financing of care, leading to important geographical disparities in expenditures. We propose a simple conceptual framework to guide the decomposition of health care expenditures into five core components (i.e. demography, propensity to use health services, substitution between domains of care, quantity of services delivered, and unit price of these services), with the objective of better understanding the drivers of geographic variation. We illustrate this framework using aggregated insurance data from 85 % of the 2006 insured population and measure cross-cantonal variation disaggregated into these five components. Results obtained indicated a West-East gradient of controllable costs after adjusting for demography and propensity to use health services. Moreover, we found specific explanations for cost overruns: visits to physicians in private practice in some cantons, and, e.g., outpatient hospital care or variations in drug related expenses in others. This shows that the simple proposed approach provides interesting insights into the drivers of cost differences between regions, specifically in terms of substitution among health services, quantity of delivered services, and their prices.

Meta-analysis of rare events under the assumption of a homogeneous treatment effect.

We studied the performance of several meta-analysis methods in rare event settings, when the treatment effect is assumed to be homogeneous and baseline prevalences are either homogeneous or heterogeneous. We conducted extensive simulations that included the three most common effect sizes with count data: the odds ratio, the relative risk, and the risk difference. We investigated several important scenarios by varying the level of rareness, the value of the trials' arms unbalance, and the size of the treatment effect. We found that the Mantel-Haenszel method and the Binomial regression model provided the best results across all the scenarios investigated. The Peto method performed satisfactorily only when the true effect size was not too large and the degree of unbalance moderate. Inverse variance was the least reliable method. The use of a continuity correction factor slightly improved the performance of the inverse variance method but deteriorated that of the Peto and Mantel-Haenszel methods. A method based on median unbiased estimators of the probabilities provided similar results to those obtained when using the inverse variance method with a continuity correction. Therefore, when the treatment effect can be assumed to be homogeneous and for either homogeneous or heterogeneous baseline prevalences, we highly recommend using the Mantel-Haenszel method without continuity correction (for all the effect sizes) or the Binomial regression model (for the odds ratio only) to meta-analyze the data.

Real-world evidence was feasible for estimating effectiveness of chemotherapy in breast cancer: a cohort study.

OBJECTIVE: Evidence-based guidelines recommend adjuvant chemotherapy in early stage breast cancer whenever treatment benefit is considered sufficient to outweigh the associated risks. However, many groups of patients were either excluded from or underrepresented in the clinical trials that form the evidence base for this recommendation. This study aims to determine whether using administrative health care data-real world data-and econometric methods for causal analysis to provide "real world evidence" (RWE) are feasible methods for addressing this gap. METHODS: Cases of primary breast cancer in women from 2001 to 2015 were extracted from the Scottish cancer registry (SMR06) and linked to other routine health records (inpatient and outpatient visits). Four methods were used to estimate the effect of adjuvant chemotherapy on disease-specific and overall mortality: (1) regression with adjustment for covariates, (2) propensity score matching, (3) instrumental variables analysis, and (4) regression discontinuity design. Hazard ratios for breast cancer mortality and all-cause mortality were compared to those from a meta-analysis of randomized trials. RESULTS: A total of 39,805 cases were included in the analyses. Regression adjustment, propensity score matching, and instrumental variables were feasible, whereas regression discontinuity was not. Effectiveness estimates were similar between RWE and randomized trials for breast cancer mortality but not for all-cause mortality. CONCLUSIONS: RWE methods are a feasible means to generate estimates of effectiveness of adjuvant chemotherapy in early stage breast cancer. However, such estimates must be interpreted in the context of the available randomized evidence and the potential biases of the observational methods.

Fetal Anthropometric Features: A Postmortem Study of Fetuses After the Termination of Pregnancy for Psychosocial Reasons Between 12 and 20 Gestational Weeks.

INTRODUCTION: Reference ranges in fetal postmortem anthropometric data derive from heterogeneous studies and rely on data obtained after intrauterine fetal death and abortion, which may introduce bias in the reported fetal growth parameters. We report anthropometric findings in fetuses with the least variation due to cause of death or developmental anomalies. METHODS: We analyzed fetuses after the termination of pregnancy for psychosocial reasons. The external measurements, X-ray dimensions, and body and organ weights were recorded as well as the placenta weight. A thorough and standardized postmortem analysis allowed the design of 2 different groups. Group 1 was composed of fetuses (1) born to mothers with no relevant obstetrical history, (2) no X-ray anomaly, (3) no abnormal autopsy findings, and (4) unremarkable placenta histology. An anomaly in any of these 4 entities moved the fetuses to Group 2. For reference ranges and graph construction, a well-designed statistical methodology was applied. RESULTS: A total of 335 fetuses were analyzed during an 11-year period. Group 1 comprised 232 fetuses aged 12 to 20 gestational weeks, whereas 103 fetuses were considered in Group 2. Comparison between the 2 groups showed almost no differences. Only the Group 1 results were submitted to statistical analysis, and reference ranges and graphs were constructed. CONCLUSIONS: To the best of our knowledge, we provide in this study the first anthropometric references established from almost normal fetuses, albeit for a limited fetal timeframe.

Determinants of new drugs prescription in the Swiss healthcare market.

BACKGROUND: Drug markets are very complex and, while many new drugs are registered each year, little is known about what drives the prescription of these new drugs. This study attempts to lift the veil from this important subject by analyzing simultaneously the impact of several variables on the prescription of novelty. METHODS: Data provided by four Swiss sickness funds were analyzed. These data included information about more than 470,000 insured, notably their drug intake. Outcome variable that captured novelty was the age of the drug prescribed. The overall variance in novelty was partitioned across five levels (substitutable drug market, patient, physician, region, and prescription) and the influence of several variables measured at each of these levels was assessed using a non-hierarchical multilevel model estimated by Bayesian Markov Chain Monte Carlo methods. RESULTS: More than 92% of the variation in novelty was explained at the substitutable drug market-level and at the prescription-level. Newer drugs were prescribed in markets that were costlier, less concentrated, included more insured, provided more drugs and included more active substances. Over-the-counter drugs were on average 12.5 years older while generic drugs were more than 15 years older than non-generics. Regional disparities in terms of age of prescribed drugs could reach 2.8 years. CONCLUSIONS: Regulation of the demand has low impact, with little variation explained at the patient-level and physician-level. In contrary, the market structure (e.g. end of patent with generic apparition, concurrence among producers) had a strong contribution to the variation of drugs ages.