Continuity of care and treatment intensity at the end of life in Swiss cancer patients.

BACKGROUND: Continuity of care (COC) was shown to be associated with fewer hospitalizations. We aimed to evaluate whether COC was associated with intensive intervention(s) at the end of life (IEOL), a preference-sensitive outcome, in cancer patients. METHODS: The study is based on claims data of patients with incident use of anti-neoplastics in Switzerland. COC Index, Usual Provider Continuity score, Sequential Continuity index and Modified Modified Continuity Index were calculated based on consultations with the usual ambulatory care physician. Treatment intensity was evaluated in the last 6 months of life, and COC was evaluated in months 18-6 before death in those who died between 24 and 54 months after incident cancer. IEOL comprised life-sustaining interventions (cardiac catheterization, cardiac assistance device implantation, pulmonary artery wedge monitoring, cardiopulmonary resuscitation/cardiac conversion, gastrostomy, blood transfusion, dialysis, mechanical ventilator utilization and intravenous antibiotics) and measures specifically used in cancer patients (last dose of chemotherapy ≤14 days of death, a new chemotherapy regimen starting <30 days before death, ≥1 emergency visit in the last month of life, ≥1 hospital admission or spending >14 days in hospital in the last month of life and death in an acute-care hospital). RESULTS: All COC scores were inversely associated with the occurrence of an IEOL, as were older age, homecare nursing utilization and density of ambulatory care physicians. For COC Index, odds ratio was 0.55 (95% confidence interval 0.37-0.83). CONCLUSIONS: COC scores were consistently and inversely related to IEOL. The study supports efforts to improve COC for cancer patients at their end of life.

Opioid prescriptions after knee replacement: a retrospective study of pathways and prognostic factors in the Swiss healthcare setting.

OBJECTIVES: The optimal use of opioids after knee replacement (KR) remains to be determined, given the growing evidence that opioids are no more effective than other analgesics and that their adverse effects can impair quality of life. Therefore, the objective is to examine opioid prescriptions after KR. DESIGN: In this retrospective study, we used descriptive statistics and estimated the association of prognostic factors using generalised negative binomial models. SETTING: The study is based on anonymised claims data of patients with mandatory health insurance at Helsana, a leading Swiss health insurance. PARTICIPANTS: Overall, 9122 patients undergoing KR between 2015 and 2018 were identified. PRIMARY AND SECONDARY OUTCOME MEASURES: Based on reimbursed bills, we calculated the dosage (morphine equivalent dose, MED) and the episode length (acute: <90 days; subacute: ≥90 to <120 days or <10 claims; chronic: ≥90 days and ≥10 claims or ≥120 days). The incidence rate ratios (IRRs) for postoperative opioids were calculated. RESULTS: Of all patients, 3445 (37.8%) received opioids in the postoperative year. A large majority had acute episodes (3067, 89.0%), 2211 (65.0%) had peak MED levels above 100 mg/day and most patients received opioids in the first 10 postoperative weeks (2881, 31.6%). Increasing age (66-75 and >75 vs 18-65) was associated with decreased IRR (0.776 (95% CI 0.7 to 0.859); 0.723 (95% CI 0.649 to 0.805)), whereas preoperative non-opioid analgesics and opioids were associated with higher IRR (1.271 (95% CI 1.155 to 1.399); 3.977 (95% CI 4.409 to 3.591)). CONCLUSION: The high opioid demand is unexpected given that current recommendations advise using opioids only when other pain therapies are ineffective. To ensure medication safety, it is important to consider alternative treatment options and ensure that benefits outweigh potential risks.

Therapy Patterns and Surveillance Measures of Inflammatory Bowel Disease Patients beyond Disease-Related Hospitalization: A Claims-Based Cohort Study.

Introduction: Medical care and surveillance of inflammatory bowel disease (IBD) patients have been shown to be far from satisfactory. Data on therapy patterns and surveillance measures in IBD patients are scarce. We, therefore, aimed to compare the therapy patterns and surveillance management of IBD patients in the year before and after IBD-related hospitalization. Methods: We examined medical therapy, surveillance management (influenza vaccination, dermatologist visits, Pap smear screening, creatinine measurements, iron measurements, and ophthalmologist visits) and healthcare utilization in 214 ulcerative colitis (UC) and 259 Crohn's disease (CD) patients who underwent IBD-related hospitalization from 2012 to 2014. Results: IBD-related drug classes changed in 64.5% of IBD patients following hospitalization. During the 1-year follow-up period, biological treatment increased in UC and CD patients, while steroid use decreased. Following hospitalization, 63.1% of UC and 27.0% of CD patients received 5-ASA. Only 21.6% of all IBD patients had a flu shot, and 19.6% of immunosuppressed IBD patients were seen by a dermatologist in the follow-up; other surveillance measures were more frequent. Surveillance before hospital admission and consultations by gastroenterologists were strongly correlated with surveillance during the postoperative follow-up, while gender and diagnosis (UC vs. CD) were not. During the 1-year follow-up, 20.5% of all IBD patients had no diagnostic or disease-monitoring procedure. Discussion/Conclusion: Surveillance measures for IBD patients are underused in Switzerland. Further research is needed to examine the impact of annual screenings and surveillance on patient outcomes.

Change in Colorectal Cancer Tests Submitted for Reimbursement in Switzerland 2012-2018: Evidence from Claims Data of a Large Insurance.

Objectives: Guidelines recommend colorectal cancer (CRC) screening by fecal occult blood test (FOBT) or colonoscopy. In 2013, Switzerland introduced reimbursement of CRC screening by mandatory health insurance for 50-69-years-olds, after they met their deductible. We hypothesized that the 2013 reimbursement policy increased testing rate. Methods: In claims data from a Swiss insurance, we determined yearly CRC testing rate among 50-75-year-olds (2012-2018) and the association with socio-demographic, insurance-, and health-related covariates with multivariate-adjusted logistic regression models. We tested for interaction of age (50-69/70-75) on testing rate over time. Results: Among insurees (2012:355'683; 2018:348'526), yearly CRC testing rate increased from 2012 to 2018 (overall: 8.1-9.9%; colonoscopy: 5.0-7.6%; FOBT: 3.1-2.3%). Odds ratio (OR) were higher for 70-75-year-olds (2012: 1.16, 95%CI 1.13-1.20; 2018: 1.05, 95%CI 1.02-1.08). Deductible interacted with changes in testing rate over time (p < 0.001). The increase in testing rate was proportionally higher among 50-69-years-olds than 70-75-year-olds over the years. Conclusions: CRC testing rate in Switzerland increased from 2012 to 2018, particularly among 50-69-years-olds, the target population of the 2013 law. Future studies should explore the effect of encouraging FOBT or waiving deductible.

Surgical procedures in inpatient versus outpatient settings and its potential impact on follow-up costs.

OBJECTIVE: We examined real-world effects of cantonal legislations to direct surgery patients from the inpatient to the outpatient setting in Switzerland. METHODS: Analyses were based on claims data of the Helsana Group, a leading Swiss health insurance. The study population consisted of 13'145 (in 2014), 12'455 (in 2016), and 12'875 (in 2018) insured persons aged >18 years who had haemorrhoidectomy, inguinal hernia repair, varicose vein surgery, knee arthroscopy/meniscectomy or surgery of the cervix/uterus. We assessed the proportion of inpatient procedures, index costs, length of hospital stays, outpatient costs and hospitalizations during follow-up, stratified by procedure, in-/outpatient setting, and the presence (enacted/effective in 2018) of a cantonal legislation. We used difference-in-differences methods to study the impact of cantonal legislations. RESULTS: Overall, the proportion of procedures performed in the inpatient setting decreased between 2014 and 2018 (p < 0.001). The decrease between 2016 and 2018 was significantly steeper in cantons with a legislation (p < 0.001; effect size: 0.57; 95% CI: 0.51, 0.64), leading to steeper decreases in healthcare costs of index procedures in cantons with a legislation, with no impact on length of hospital stays. The legislation also had no impact on outpatient costs or hospitalizations during follow-up. CONCLUSIONS: The cantonal legislations achieved the intended effects of inpatient surgery substitution by outpatient surgery, with no evidence suggesting negative effects on costs or hospitalizations during follow-up.

Temporal trends and regional disparities in cancer screening utilization: an observational Swiss claims-based study.

BACKGROUND: We examined colorectal, breast, and prostate cancer screening utilization in eligible populations within three data cross-sections, and identified factors potentially modifying cancer screening utilization in Swiss adults. METHODS: The study is based on health insurance claims data of the Helsana Group. The Helsana Group is one of the largest health insurers in Switzerland, insuring approximately 15% of the entire Swiss population across all regions and age groups. We assessed proportions of the eligible populations receiving colonoscopy/fecal occult blood testing (FOBT), mammography, or prostate-specific antigen (PSA) testing in the years 2014, 2016, and 2018, and calculated average marginal effects of individual, temporal, regional, insurance-, supply-, and system-related variables on testing utilization using logistic regression. RESULTS: Overall, 8.3% of the eligible population received colonoscopy/FOBT in 2014, 8.9% in 2016, and 9.2% in 2018. In these years, 20.9, 21.2, and 20.4% of the eligible female population received mammography, and 30.5, 31.1, and 31.8% of the eligible male population had PSA testing. Adjusted testing utilization varied little between 2014 and 2018; there was an increasing trend of 0.8% (0.6-1.0%) for colonoscopy/FOBT and of 0.5% (0.2-0.8%) for PSA testing, while mammography use decreased by 1.5% (1.2-1.7%). Generally, testing utilization was higher in French-speaking and Italian-speaking compared to German-speaking region for all screening types. Cantonal programs for breast cancer screening were associated with an increase of 7.1% in mammography utilization. In contrast, a high density of relevant specialist physicians showed null or even negative associations with screening utilization. CONCLUSIONS: Variation in cancer screening utilization was modest over time, but considerable between regions. Regional variation was highest for mammography use where recommendations are debated most controversially, and the implementation of programs differed the most.

Continuity of Care in Swiss Cancer Patients Using Claims Data.

BACKGROUND: Continuity of care is positively associated with beneficial patient outcomes. Data on the level of continuity of care in the ambulatory setting in Switzerland are lacking. AIM: The aim of this study was to evaluate continuity of care in Swiss cancer patients based on routine data of mandatory health insurance using four established continuity scales. METHODS: Retrospective analysis of Swiss claims data (N=23'515 patients with incident use of antineoplastics). The Usual Provider Continuity score, the Modified Modified Continuity Index, the Continuity of Care index, and the Sequential Continuity Index were analyzed based on consultations with general practitioners (GPs), physician specialists and ambulatory hospital wards. RESULTS: Using information of health insurance claims, the number of consultations and the general level of continuity of care in Swiss cancer patients are high. Continuity of care scores were significantly associated with sociodemographic and regional factors. When focusing on consultations with GPs only, all four scores consistently showed high values indicating high levels of continuity. Continuity with general practitioners was associated with lower costs and lower risks for hospitalization and death. CONCLUSION: This is the first study giving insight into continuity of care in Swiss cancer patients. The present study shows that continuity of care is measurable using health insurance claims data. It indicates that continuity with general practitioners is associated with a beneficial outcome.

Follow-Up Ileocolonoscopy Is Underused in Crohn's Disease Patients after Ileocecal Resection despite Higher Total and Inpatient Health-Care Costs Compared to Controls.

BACKGROUND: Postoperative recurrence is frequently observed after ileocecal resection in Crohn's disease (CD) patients. Since 2010, endoscopy within 1 year is considered the gold standard for its diagnosis. However, if and how frequent such endoscopies are performed in clinical practice remains unknown. METHODS: We analyzed 1-year follow-up data on CD patients who underwent ileocecal resection between 2012 and 2014 and compared them with hospitalized, non-resected CD controls. Data were extracted from the Helsana database. Helsana is one of the largest Swiss health insurance companies providing coverage for 1.2 million individuals. RESULTS: A total of 645 CD patients were identified with ≥1 hospitalization between 2012 and 2014 and a follow-up of 1 year. Of these, 79 (12.2%) underwent ileocecal resection. Although endoscopy rates increased over time and were higher in patients with resection versus controls (p = 0.029), in only 54.4% a 1-year follow-up ileocolonoscopy was performed. Postoperative prophylaxis with anti-tumor necrosis factor or azathioprine was prescribed in 63.3%. Female sex and age >60 years were independent predictors for not receiving prophylaxis (odds ratio [OR] 0.36, p = 0.048, and OR 0.2, p = 0.022). Patients with resection had significantly lower numbers of rehospitalizations (1.2 vs. 1.8, p = 0.021), with resection being an independent negative predictor for number of rehospitalizations in a Poisson regression model (incident risk ratio 0.64, p = 0.029). However, disease-related surgery was more often the cause for rehospitalization after resection versus controls (47.6 vs. 22.1%, p = 0.015). Total and inpatient health-care costs were higher in these patients. CONCLUSION: Endoscopies are underused after ileocecal resection. This contrasts current guidelines. Physicians should be aware of this underuse and perform follow-up examinations more often.

Regional differences in healthcare costs at the end of life: an observational study using Swiss insurance claims data.

OBJECTIVES: We evaluated healthcare cost differences at the end of life (EOL) between language regions in Switzerland, accounting for a comprehensive set of variables, including treatment intensity. METHODS: We evaluated 9716 elderly who died in 2014 and were insured at Helsana Group, with data on final cause of death provided by the Swiss Federal Statistical Office. EOL healthcare costs and utilization, ≥ 1 ICU admission and 10 life-sustaining interventions (cardiac catheterization, cardiac assistance device implantation, pulmonary artery wedge monitoring, cardiopulmonary resuscitation, gastrostomy, blood transfusion, dialysis, mechanical ventilation, intravenous antibiotics, cancer chemotherapies) reimbursed by compulsory insurance were examined. RESULTS: Taking into consideration numerous variables, relative cost differences decreased from 1.27 (95% CI 1.19-1.34) to 1.06 (CI 1.02-1.11) between the French- and German-speaking regions, and from 1.12 (CI 1.03-1.22) to 1.08 (CI 1.02-1.14) between the Italian- and German-speaking regions, but standardized costs still differed. Contrary to individual factors, density of home-care nurses, treatment intensity, and length of inpatient stay explain a substantial part of these differences. CONCLUSIONS: Both supply factors and health-service provision at the EOL vary between Swiss language regions and explain a substantial proportion of cost differences.

Variation of colorectal, breast and prostate cancer screening activity in Switzerland: Influence of insurance, policy and guidelines.

Variation in utilization of healthcare services is influenced by patient, provider and healthcare system characteristics. It could also be related to the evidence supporting their use, as reflected in the availability and strength of recommendations in clinical guidelines. In this study, we analyzed the geographic variation of colorectal, breast and prostate cancer screening utilization in Switzerland and the influence of available guidelines and different modifiers of access. Colonoscopy, mammography and prostate specific antigen (PSA) testing use in eligible population in 2014 was assessed with administrative claims data. We ran a multilevel multivariable logistic regression model and calculated Moran's I and regional level median odds ratio (MOR) statistics to explore residual geographic variation. In total, an estimated 8.1% of eligible persons received colonoscopy, 22.3% mammography and 31.3% PSA testing. Low deductibles, supplementary health insurance and enrollment in a managed care plan were associated with higher screening utilization. Cantonal breast cancer screening programs were also associated with higher utilization. Spatial clustering was observed in the raw regional utilization of all services, but only for prostate cancer screening in regional residuals of the multilevel model. MOR was highest for prostate cancer screening (1.24) and lowest for colorectal cancer screening (1.16). The reasons for the variation of the prostate cancer screening utilization, not recommended routinely without explicit shared decision-making, could be further investigated by adding provider characteristics and patient preference information. This first cross-comparison of different cancer screening patterns indicates that the strength of recommendations, mediated by specific health policies facilitating screening, may indeed contribute to variation.

Systematic analysis of therapeutic patterns and healthcare use during 12 months before inflammatory bowel disease-related hospitalization in Switzerland.

BACKGROUND AND AIMS: Given the lack of data, we aimed to systematically analyze therapeutic patterns and health resource utilization in the year before inflammatory bowel disease (IBD)-related hospitalization. METHODS: Based on claims data of the Helsana health insurance group, therapy patterns and health resource utilization were assessed, and costs reimbursed by mandatory basic health insurance were calculated during a one-year period before an index hospitalization between 1 January 2013 to 31 December 2015. RESULTS: We analyzed 344 IBD patients (140 ulcerative colitis [40.7%], 204 Crohn's disease [59.3%]). Drug regimens applied in the year before index hospitalization were as follows: no IBD drugs (43.6% ulcerative colitis, 43.1% Crohn's disease); 5-ASA (45.7% ulcerative colitis, 19.1% Crohn's disease); local steroids (17.9% ulcerative colitis, 17.6% Crohn's disease); systemic steroids (38.6% ulcerative colitis, 29.4% Crohn's disease); immunomodulators (10.7% ulcerative colitis, 18.1% Crohn's disease); biologics (10% ulcerative colitis, 24% Crohn's disease); and calcineurin inhibitors (2.1% ulcerative colitis, 1.5% Crohn's disease). Forty-five percent of ulcerative colitis patients and 31.4% of Crohn's disease patients had no diagnostic procedures [computed tomography (CT), MRI, radiograph, sonography, colonoscopy, and calprotectin] in the year before hospitalization. Total annual health care costs before index hospitalization was EUR 4060 (interquartile range (IQR) 2360-7390) for ulcerative colitis and EUR 4900 (IQR 1520-14 880) for Crohn's disease patients, respectively. CONCLUSIONS: Over 40% of ulcerative colitis and Crohn's disease patients did not receive any treatment in the year before index hospitalization. Efforts should be launched to timely diagnose and adequately treat IBD outpatients.

The Evolution of Health Care Utilisation and Costs for Inflammatory Bowel Disease Over Ten Years.

BACKGROUND AND AIMS: Inflammatory bowel disease [IBD] places an economic strain on health systems due to expensive pharmaceutical therapy, risk of hospitalisation and surgery, and long-term monitoring. The evolving treatment guidelines advocate rapid scale-up to biologic agents in order to improve health outcomes and quality of life. This study evaluated changes in health care utilisation and expenditures for IBD in Switzerland over time. METHODS: We extracted clinical, patient, and resource consumption data from the Swiss IBD Cohort Study between 2006 and 2016. Average unit costs for IBD-related events were derived from Swiss claims data and pharmaceutical price lists. We used multivariate regression, controlling for patient-level characteristics, to estimate trends and determinants of direct and indirect costs and resource utilisation. RESULTS: We included 2365 adults diagnosed with Crohn's disease [CD; N = 1353] and ulcerative colitis [UC; N = 1012]. From 2006-16, mean health care expenditures per patient per year were 9504 euros [70% drugs, 23% inpatient, 7% outpatient] for CD and 5704 euros [68% drugs, 22% inpatient, 10% outpatient] for UC. Health care costs increased by 7% [CD] and 10% [UC] per year, largely due to rising pharmaceutical expenditures driven by increased biologic agent use. Inpatient, outpatient, and indirect costs fluctuated and did not offset increased pharmaceutical costs. Disease characteristics were important predictors of costs. CONCLUSIONS: Increased expenditure for IBD was marked by a shift towards greater pharmaceutical management over the past decade. This study highlights the need to identify cost-effective treatment strategies in the face of increased uptake and expenditures associated with innovative treatments.

Variation of preoperative chest radiography utilization in Switzerland and its influencing factors: a multilevel study with claims data.

Clinical recommendations discourage routine use of preoperative chest radiography (POCR). However, there remains much uncertainty about its utilization, especially variation across small areas. We aimed to assess the variation of POCR use across small regions, and to explore its influencing factors. Patients undergoing inpatient surgery during 2013 to 2015 were identified from insurance claims data. Possible influencing factors of POCR included socio-demographics, health insurance choices, and clinical characteristics. We performed multilevel modelling with region and hospital as random effects. We calculated 80% interval odds ratios (IOR-80) to describe the effect of hospital type, and median odds ratios (MOR) to assess the degree of higher level variation. Utilization rates of POCR varied from 2.5% to 44.4% across regions. Higher age, intrathoracic pathology, and multi-morbidity were positively associated with the use of POCR. Female gender, choice of high franchise and supplementary hospital insurance showed a negative association. MOR was 1.25 and 1.69 for region and hospital levels, respectively. IOR-80s for hospital type were wide and covered the value of one. We observed substantial variation of POCR utilization across small regions in Switzerland. Even after controlling for multiple factors, variation across small regions and hospitals remained. Underlying mechanisms need to be studied further.

Systematic analysis of annual health resource utilization and costs in hospitalized patients with inflammatory bowel disease in Switzerland.

BACKGROUND AND AIMS: Real-life data on health resource utilization and costs of hospitalized patients with inflammatory bowel disease are lacking in Switzerland. We aimed to assess health resource utilization and costs during a 1-year follow-up period starting with an index hospitalization. PATIENTS AND METHODS: On the basis of claims data of the Helsana health insurance group, health resource utilization was assessed and costs reimbursed by mandatory basic health insurance [in Swiss Francs (CHF); 1 CHF=0.991 US$] were calculated during a 1-year follow-up period starting with an index hospitalization in the time period between 1 January 2013 and 31 December 2014. RESULTS: Of 202 002 patients with at least one hospitalization in 2013-2014, a total of 270 (0.13%) patients had inflammatory bowel disease as main diagnosis [112 (41.5%) ulcerative colitis (UC), 158 (58.5%) Crohn's disease (CD), 154/270 (57.0%) females]. In comparison with patients with UC, patients with CD were significantly more frequently treated with biologics (45.6 vs. 20.5%, P<0.001) and more frequently underwent surgery during index hospitalization (27.8 vs. 9.8%, P=0.002). Compared with patients with UC, those with CD had significantly more consultations [odds ratio (OR): 1.06, 95% confidence interval (CI): 1.01-1.12, P=0.016], higher median annual total costs (OR: 1.25, 95% CI: 1.05-1.48, P=0.012), and higher outpatient costs (OR: 1.33, 95% CI: 1.07-1.66, P=0.011). In the bivariate model, median total costs for patients with CD and those with UC were 24 270 and 17 270 CHF, respectively (P=0.032). CONCLUSION: When compared with patients with UC, hospitalized patients with CD have during a 1-year follow-up a higher rate of outpatient consultations and generate higher costs.

Intensity of treatment in Swiss cancer patients at the end-of-life.

PURPOSE: Current evidence on the care-delivering process and the intensity of treatment at the end-of-life of cancer patients is limited and remains unclear. Our objective was to examine the care-delivering processes in health care during the last months of life with real-life data of Swiss cancer patients. PATIENTS AND METHODS: The study population consisted of adult decedents in 2014 who were insured at Helsana Group. Data on the final cause of death were provided additionally by the Swiss Federal Statistical Office. Of the 10,275 decedents, 2,710 (26.4%) died of cancer. Intensity of treatment and health care utilization (including transitions) at their end-of-life were examined. Intensity measures included the following: last dose of chemotherapy within 14 days of death, a new chemotherapy regimen starting <30 days before death, more than one hospital admission or spending >14 days in hospital in the last month, death in an acute care hospital, more than one emergency visit and ≥1 intensive care unit admission in the last month of life. RESULTS: In the last 6 months of life, 89.5% of cancer patients had ≥1 transition, with 87.2% being hospitalized. Within 30 days before death, 64.2% of the decedents had ≥1 intensive treatment, whereby 8.9% started a new chemotherapy. In the multinomial logistic regression model, older age, higher density of nursing home beds and home care nurses were associated with a decrease, while living in the Italian- or French-speaking part of Switzerland was associated with an increase in intensive care. CONCLUSION: Swiss cancer patients insured by Helsana Group experience a considerable number of transitions and intensive treatments at the end-of-life, whereby treatment intensity declines with increasing age. Among others, increased home care nursing might be helpful to reduce unwarranted treatments and transitions, therefore leading to better care at the end-of-life.

Chronic comorbidities associated with inflammatory bowel disease: prevalence and impact on healthcare costs in Switzerland.

OBJECTIVE: Inflammatory bowel disease (IBD) was shown to be associated with a variety of chronic comorbidities. We aimed to evaluate the frequency of 21 chronic conditions and compared frequencies in IBD and non-IBD populations. Further, healthcare costs of those (additional) chronic conditions were calculated. PATIENTS AND METHODS: A total of 4791 IBD patients, who were insured at Helsana Insurance Group in 2014, were compared with 1 114 638 individuals without IBD. Entropy balancing was performed to create balanced samples. Chronic conditions were identified by means of the updated Pharmacy-based Cost Group model. Multivariate log-transformed linear regression modeling was performed to estimate the effect of the morbidity status (non-IBD +none, +1, +2, and +3 or more chronic conditions) on the healthcare costs. RESULTS: Overall, 78% of IBD patients had at least one comorbidity, with a median of three comorbidities. Largest differences between individuals with and without IBD were found for rheumatologic conditions, acid-related disorders, pain, bone diseases, migraines, cancer, and iron-deficiency anemia, whereas no significant differences between the two groups were found for diabetes, dementia, hyperlipidemia, glaucoma, gout, HIV, psychoses, and Parkinson's disease after adjustments for a variety of covariates. Each increase in the morbidity status led to increased healthcare costs; rheumatologic conditions, acid-related disorders, and pain as the most frequent comorbidities more than doubled total costs in IBD patients. CONCLUSION: We found a considerably high prevalence of concomitant chronic diseases in IBD patients. This was associated with considerably higher healthcare costs, especially in the outpatient setting.

Increased mortality after a first myocardial infarction in human immunodeficiency virus-infected patients; a nested cohort study.

AIMS: HIV infection may be associated with an increased recurrence rate of myocardial infarction. Our aim was to determine whether HIV infection is a risk factor for worse outcomes in patients with coronaray artery disease. METHODS: We compared data aggregated from two ongoing cohorts: (i) the Acute Myocardial Infarction in Switzerland (AMIS) registry, which includes patients with acute myocardial infarction (AMI), and (ii) the Swiss HIV Cohort Study (SHCS), a prospective registry of HIV-positive (HIV+) patients. We included all patients who survived an incident AMI occurring on or after 1st January 2005. Our primary outcome measure was all-cause mortality at one year; secondary outcomes included AMI recurrence and cardiovascular-related hospitalisations. Comparisons used Cox and logistic regression analyses, respectively. RESULTS: There were 133 HIV+, (SHCS) and 5,328 HIV-negative [HIV-] (AMIS) individuals with incident AMI. In the SHCS and AMIS registries, patients were predominantly male (72% and 85% male, respectively), with a median age of 51 years (interquartile range [IQR] 46-57) and 64 years (IQR 55-74), respectively. Nearly all (90%) of HIV+ individuals were on successful antiretroviral therapy. During the first year of follow-up, 5 (3.6%) HIV+ and 135 (2.5%) HIV- individuals died. At one year, HIV+ status after adjustment for age, sex, calendar year of AMI, smoking status, hypertension and diabetes was associated with a higher risk of death (HR 4.42, 95% CI 1.73-11.27). There were no significant differences in recurrent AMIs (4 [3.0%] HIV+ and 146 [3.0%] HIV- individuals, OR 1.16, 95% CI 0.41-3.27) or in hospitalization rates (OR 0.68 [95% CI 0.42-1.11]). CONCLUSIONS: HIV infection was associated with a significantly increased risk of all-cause mortality one year after incident AMI.

Lower age at first myocardial infarction in female compared to male smokers.

BACKGROUND: Smoking is one of the most important risk factors for myocardial infarction. Smokers usually suffer their first myocardial infarction earlier in life compared to non-smokers. This age difference seems to be greater in women than in men. The aim of this study was to examine the age and sex differences in terms of smoking in patients with first myocardial infarction who were enrolled in the Swiss National Registry of myocardial infarction, AMIS Plus. METHODS: Data of 15,711 patients admitted to an AMIS Plus hospital between 1999 and 2008 with a first myocardial infarction were analysed. Several multivariate regression, interaction and sensitivity analyses were conducted. RESULTS: The mean age at first myocardial infarction was 68.5 ± 12.2 years for non-smokers and 56.6 ± 11.7 years for smokers (P < 0.001). After stratification by sex the difference between non-smokers and smokers was 10.2 years in men and 13.1 years in women. Even after adjustment for risk factors (overweight, hypertension, dyslipidaemia, diabetes), comorbidities (peripheral vascular disease, cerebrovascular disease, chronic lung disease), regular cardiovascular medication intake before admission, Killip classification and ECG on admission, male smokers were 8.7 years younger than male non-smokers at first myocardial infarction. In women, the age difference between smokers and non-smokers was 10.8 years, giving a sex-specific difference of 2.1 years (P < 0.001). CONCLUSIONS: In the AMIS Plus cohort, smoking was associated with younger age at first myocardial infarction and this was much more pronounced in women. Public health campaigns should take into account the impact of smoking on premature first myocardial infarction, especially in women.