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.

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.

Diagnostic accuracy of dynamic contrast-enhanced perfusion MRI in stratifying gliomas: A systematic review and meta-analysis.

BACKGROUND: T1-weighted dynamic contrast-enhanced (DCE) perfusion magnetic resonance imaging (MRI) has been broadly utilized in the evaluation of brain tumors. We aimed at assessing the diagnostic accuracy of DCE-MRI in discriminating between low-grade gliomas (LGGs) and high-grade gliomas (HGGs), between tumor recurrence and treatment-related changes, and between primary central nervous system lymphomas (PCNSLs) and HGGs. METHODS: We performed this study based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis of Diagnostic Test Accuracy Studies criteria. We systematically surveyed studies evaluating the diagnostic accuracy of DCE-MRI for the aforementioned entities. Meta-analysis was conducted with the use of a random effects model. RESULTS: Twenty-seven studies were included after screening of 2945 possible entries. We categorized the eligible studies into three groups: those utilizing DCE-MRI to differentiate between HGGs and LGGs (14 studies, 546 patients), between recurrence and treatment-related changes (9 studies, 298 patients) and between PCNSLs and HGGs (5 studies, 224 patients). The pooled sensitivity, specificity, and area under the curve for differentiating HGGs from LGGs were 0.93, 0.90, and 0.96, for differentiating tumor relapse from treatment-related changes were 0.88, 0.86, and 0.89, and for differentiating PCNSLs from HGGs were 0.78, 0.81, and 0.86, respectively. CONCLUSIONS: Dynamic contrast-enhanced-Magnetic resonance imaging is a promising noninvasive imaging method that has moderate or high accuracy in stratifying gliomas. DCE-MRI shows high diagnostic accuracy in discriminating between HGGs and their low-grade counterparts, and moderate diagnostic accuracy in discriminating recurrent lesions and treatment-related changes as well as PCNSLs and HGGs.

Diagnosis and treatment choices of suspected benign paroxysmal positional vertigo: current approach of general practitioners, neurologists, and ENT physicians.

PURPOSE: Benign paroxysmal positional vertigo (BPPV) is a frequently underdiagnosed cause of vertigo, potentially due to the underuse of diagnostic and therapeutic canalith repositioning procedures (CRPs). We aimed to investigate self-reported use of the diagnostic and therapeutic approach to BPPV patients by Lithuanian neurologists, ear, nose, and throat (ENT) physicians, and general practitioners (GPs), and to explore potential reasons for the underuse of the maneuvers. METHODS: Neurologists, ENT physicians, and GPs were invited to complete a written questionnaire focused on diagnostic and therapeutic practices related to BPPV. Between-group differences and associations between responses were analyzed statistically. RESULTS: In total, 97 neurologists, 85 ENT physicians and 142 GPs (21.1%, 26.8%, and 5.7%, respectively, of all corresponding licensed Lithuanian physicians) completed the questionnaire. 24% of neurologists, 33% ENT physicians and 50% GPs do not perform diagnostic maneuvers for patients with suspected BPPV, and 28%, 61%, and 84%, respectively, do not perform CRPs. Years of clinical experience was a negative predictor of CRP performance [OR 0.97 (95% CI 0.95-0.99), p = 0.001]. Frequent reasons for not performing CRPs were time taken for the procedure, fear of provoking symptoms, and lack of knowledge. All physicians frequently ordered additional imaging or consultations for suspected BPPV and reported prescribing a range of medications. CONCLUSIONS: A significant proportion of Lithuanian neurologists, ENT physicians, and GPs do not employ diagnostic maneuvers and CRPs for BPPV patients, contrary to established guidelines. Lack of expertise and time available is a common culprit that leads to unnecessary drug prescribing and investigation.

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.

Trends in the incidence and mortality of kidney cancer in Lithuania from 1993 to 2012.

BACKGROUND: The aim of this paper is to analyse trends of kidney cancer incidence and mortality in Lithuania during the period of 1993 to 2012 using joinpoint regression models with special attention to changes in the distribution of stages. MATERIALS AND METHODS: The study was based on all cases of kidney cancer reported to the Lithuanian Cancer Registry between 1993 and 2012. Age group-specific rates and standardized rates were calculated for each sex, using the direct method (world standard population). The joinpoint regression model was used to provide the estimated annual percentage change and to detect points in time where significant changes in the trends occur. RESULTS: During the study period the age-standardized incidence rates increased from 16.89/100,000 in 1993 to 27.77/100,000 in 2012 in males, and from 7.95/100,000 to 13.44/100,000 in females. During this period, annual percentage changes in the age-standardized rates were 2.33% and 1.81% for males and females, respectively. The joinpoint analysis by stage of disease showed the highest increase in stage I kidney cancer, with statistically significant trend change in 2002 for males and in 2001 for females. During the study period, age-standardized mortality rates decreased from 10.42/100,000 in 1993 to 8.96/100,000 in 2012 in males, and from 4.54/100,000 to 3.9/100,000 in females. CONCLUSIONS: The kidney cancer incidence rate in Lithuania rose during the period of 1993 to 2012. The detailed analysis by stage showed the most significant increase in organ-confined incidence of kidney cancer. A stable mortality trend for males and a decreasing mortality trend for females along with increased incidence of early stage kidney cancer indicate that both earlier detection and modern treatment modalities may contribute to the reduction of mortality.

Testicular cancer in two brothers of a quadruplet: a case report and a review of literature.

Introduction. Testicular cancer and a multiple birth are both rare events, and the risk of testicular cancer is increased in twins. In Lithuania, only five quadruplets have been recorded since the middle of the 20th century. In this report, we present two rare events in one family: testicular cancer in two brothers of a quadruplet (three brothers and a sister). Case description. Both patients were diagnosed at 21 years of age and died within two years from the diagnosis despite treatment. The third symptomless brother did not have testicular pathology. We also review the risk factors associated with testicular cancer, and the proposed hypotheses how a multiple birth results in an increased risk. The most consistent risk factors for testicular cancer are cryptorchidism, prior history of testicular cancer, and a positive familial history. According to different studies, the risk of testicular cancer in twins is higher from 22% to 30%, compared to the general population. Conclusions. To our knowledge, we have presented the first case of testicular teratoblastoma in brothers of a quadruplet.

Prognostic value of preoperative dynamic contrast-enhanced MRI perfusion parameters for high-grade glioma patients.

INTRODUCTION: The prognostic value of the dynamic contrast-enhanced (DCE) MRI perfusion and its histogram analysis-derived metrics is not well established for high-grade glioma (HGG) patients. The aim of this prospective study was to investigate DCE perfusion transfer coefficient (Ktrans), vascular plasma volume fraction (vp), extracellular volume fraction (ve), reverse transfer constant (kep), and initial area under gadolinium concentration time curve (IAUGC) as predictors of progression-free (PFS) and overall survival (OS) in HGG patients. METHODS: Sixty-nine patients with suspected anaplastic astrocytoma or glioblastoma underwent preoperative DCE-MRI scans. DCE perfusion whole tumor region histogram parameters, clinical details, and PFS and OS data were obtained. Univariate, multivariate, and Kaplan-Meier survival analyses were conducted. Receiver operating characteristic (ROC) curve analysis was employed to identify perfusion parameters with the best differentiation performance. RESULTS: On univariate analysis, ve and skewness of vp had significant negative impacts, while kep had significant positive impact on OS (P < 0.05). ve was also a negative predictor of PFS (P < 0.05). Patients with lower ve and IAUGC had longer median PFS and OS on Kaplan-Meier analysis (P < 0.05). Ktrans and ve could also differentiate grade III from IV gliomas (area under the curve 0.819 and 0.791, respectively). CONCLUSIONS: High ve is a consistent predictor of worse PFS and OS in HGG glioma patients. vp skewness and kep are also predictive for OS. Ktrans and ve demonstrated the best diagnostic performance for differentiating grade III from IV gliomas.

Prevalence and clinical significance of extracardiac findings in cardiovascular magnetic resonance.

OBJECTIVE: In cardiac magnetic resonance imaging (CMR), incidental pathological findings are frequently found outside the investigated cardiovascular system. Some of these findings might have clinical implications. The aim of this study was to determine the prevalence of incidental extracardiac findings (ECF) in CMR and their clinical significance. METHODS: A total of 4165 CMR reports from 2009-2012 were retrospectively reviewed for ECF. Two hundred-twenty reports with ECF were found. For each case, we obtained information on sex, age of the patient, reported ECF and radiologist recommendation. Follow-up data were analyzed by reviewing available electronic medical records. ECF was considered clinically significant if there was an associated diagnosis, additional treatment or further investigations in the clinical follow-up data. RESULTS: In total, 356 ECF were recorded in 220 (5.3%) CMR reports. Sixty (23.7%) of the 253 ECF with follow-up data available were clinically significant. The most prevalent ECF were pleural effusions (n=54), kidney cysts (n=54), diffuse lung parenchyma changes (n=33) and liver cysts (n=29). Adrenal pathology (n=3, 100% significant), renal masses (n=3, 100%) and pulmonary masses (n=5, 62.5%) were the most clinically significant ECF. Although prevalence of these ECF was low, they were significant particularly frequently. When radiologist recommendations for further investigation were present in the report, the frequency of clinically significant ECF was higher compared to reports with no further investigation recommended (p<0.001). CONCLUSION: In this study, ECF in CMR were reported not very commonly (5.3%). A substantial part of ECF was clinically significant, changing patient diagnosis or management, with an overall prevalence of 1.3%.

Optimal differentiation of high- and low-grade glioma and metastasis: a meta-analysis of perfusion, diffusion, and spectroscopy metrics.

INTRODUCTION: To perform a meta-analysis of advanced magnetic resonance imaging (MRI) metrics, including relative cerebral blood volume (rCBV), normalized apparent diffusion coefficient (nADC), and spectroscopy ratios choline/creatine (Cho/Cr) and choline/N-acetyl aspartate (Cho/NAA), for the differentiation of high- and low-grade gliomas (HGG, LGG) and metastases (MTS). METHODS: For systematic review, 83 articles (dated 2000-2013) were selected from the NCBI database. Twenty-four, twenty-two, and eight articles were included respectively for spectroscopy, rCBV, and nADC meta-analysis. In the meta-analysis, we calculated overall means for rCBV, nADC, Cho/Cr (short TE-from 20 to 35 ms, medium-from 135 to 144 ms), and Cho/NAA for the HGG, LGG, and MTS groups. We used random effects model to obtain weighted averages and select thresholds. RESULTS: Overall means (with 95% CI) for rCBV, nADC, Cho/Cr (short and medium echo time, TE), and Cho/NAA were: for HGG 5.47 (4.78-6.15), 1.38 (1.16-1.60), 2.40 (1.67-3.13), 3.27 (2.78-3.77), and 4.71 (3.24-6.19); for LGG 2.00 (1.71-2.28), 1.61 (1.36-1.87), 1.46 (1.20-1.72), 1.71 (1.49-1.93), and 2.36 (1.50-3.23); for MTS 5.06 (3.85-6.27), 1.35 (1.06-1.64), 1.89 (1.72-2.06), 3.14 (1.57-4.72), (Cho/NAA was not available). LGG had significantly lower rCBV, Cho/Cr, and Cho/NAA values than HGG or MTS. No significant differences were found for nADC. CONCLUSIONS: Best differentiation between HGG and LGG is obtained from rCBV, Cho/Cr, and Cho/NAA metrics. MTS could not be reliably distinguished from HGG by the methods investigated.