High Level of Unwarranted Clinical Variation in the Use of Lower Extremity Revascularisation Procedures in Hungary (2013-2017).

OBJECTIVE: Assessment of variations in the use of lower extremity open vascular surgical procedures (LEOPEN) and lower extremity endovascular procedures (LEENDO) across small geographic areas in Hungary from 2013 to 2017. Introduction of a new metric giving a rough estimate of unwarranted clinical variation in revascularisation practice. METHODS: Spatial variation (at local administrative unit level) of referral for LEOPEN and LEENDO was evaluated through a retrospective analysis using healthcare administrative data of all beneficiaries in Hungary. The same assessment was performed for percutaneous coronary intervention in acute myocardial infarction (PCIAMI). The latter was considered a reasonable comparator (similar at risk population, well organised, guideline driven patient pathways, small room for referral discretion). Consequently, the ratio of spatial variations of LEOPEN and LEENDO to PCIAMI (as a reference) are thought to reflect unwarranted clinical variation. RESULTS: A total of 109 882 procedures were identified in the database (LEOPEN, LEENDO, PCIAMI) affecting 85 083 patients. While estimates of spatial variations for LEOPEN and LEENDO turned out to be high (systematic component of variation [SCV] 0.09 and 0.21, respectively), PCIAMI showed a low SCV value of 0.02. Consequently, the ratios of SCVs were SCV/SCVref = 4.67 (LEOPEN) and SCV/SCVref = 10.3 (LEENDO), indicating high levels of unwarranted clinical variation. CONCLUSION: The analysis showed that patients living in different locations of Hungary face very different odds of having lower extremity revascularisation procedures (open or endovascular). This spatial variation is thought to be related mainly to the failure in vascular service organisation. The newly introduced numerical estimate of unwarranted clinical variation may support within, and also between, system comparisons.

Spatial analysis of factors impacting lower limb major amputation rates in Hungary: Is geography partially destiny?

Background: Lower limb major amputations represent a substantial public health burden in Hungary, where previous research revealed markedly high rates with significant spatial variations. Therefore, we aimed to assess to what extent healthcare and socio-economic factors in the local environment explain the regional disparity. Patients and methods: In a retrospective cohort analysis, based on the healthcare administrative data of the Hungarian population, lower limb major amputations were identified from 1st of January 2017 to 31st of December 2019. The permanent residence of the amputees on the local administrative level (197 geographic units) was used to identify potential healthcare (outpatient care, revascularisation activity) and socio-economic (educational attainment, local infrastructure and services, income and employment) determinants of amputations. Spatial effects were modelled using the spatial Durbin error regression model. Results: 10,209 patients underwent 11,649 lower limb major amputations in the observational period. In our spatial analysis, outpatient care was not associated with local amputation rates. However, revascularisation activity in a geographic unit entailed an increased rate of amputations, while revascularisations in the neighbouring areas were associated with a lower rate of amputations, resulting in an overall neutral effect (ß=-0.002, 95% CI: -0.05 - 0.04, p=0.96). The local socio-economic environment had a significant direct inverse association with amputations (ß=-7.45, 95% CI: -10.50 - -4.42, p<0.0001) . Our spatial model showed better performance than the traditional statistical modelling (ordinary least squares regression), explaining 37% of the variation in amputations rates. Conclusions: Regional environmental factors explain a substantial portion of spatial disparities in amputation practice. While the socio-economic environment shows a significant inverse relationship with the regional amputation rates, the impact of the local healthcare-related factors (outpatient care, revascularisation activity) is not straightforward. Unravelling the impact of the location on amputation practice requires complex spatial modelling, which may guide efficient healthcare policy decisions.

Analysis of data from the National Vascular Registry on infrarenal aortic aneurysms (2010­2019) / Infrarenalis aortaaneurysma-mutétek országos eredményeinek elemzése a Nemzeti Érsebészeti Regiszter alapján (2010­2019).

Összefoglaló. Bevezetés: Az elmúlt évtizedekben számos országban jelentos mértékben változott a hasi aortaaneurysmák sebészi kezelése az eredményesebb ellátás céljából: endovascularis beavatkozások terjedése, nagy betegforgalmú aortacentrumok kialakítása. Célkituzés: A Magyarországon, infrarenalis aortaaneurysmák miatt végzett beavatkozások rövid távú eredményeinek elemzése elsosorban mutéti technika (endovascularis vs. nyitott aortareconstructio), intézeti betegforgalom (kis vs. nagy betegforgalmú intézet) és idoszak (2010-2014 vs. 2015-2019) alapján. Módszer: A Nemzeti Érsebészeti Regiszterben 2010. 01. 01. és 2019. 12. 31. között prospektíven rögzített multicentrikus adatok retrospektív feldolgozása. Eredmények: A regiszterben 3206 infrarenalis aortaaneurysma-mutétet rögzítettek. A második öt évben jelentosen nott az endovascularis aortareconstructio aránya a nyitotthoz képest (p<0,0001), illetve a nagy betegforgalmú intézetek szignifikánsan több rupturált aortaaneurysmát láttak el, mint a kis betegforgalmú intézetek (p<0,0001) az elso öt évhez viszonyítva. A perioperatív mortalitás rupturált aortaaneurysma miatt a nagy betegforgalmú intézetekben végzett nyitott aortareconstructio esetén szignifikánsan alacsonyabb volt a kis betegforgalmú intézetekkel szemben az elso öt évben (p = 0,0011), illetve a nagy betegforgalmú intézetekben végzett endovascularis aortareconstructio esetén szignifikánsan alacsonyabb volt a nyitottal szemben a második öt évben (p = 0,029). A nem rupturált aortaaneurysma-mutétek perioperatív mortalitása a nagy betegforgalmú intézetekben végzett nyitott aortareconstructio esetén szignifikánsan alacsonyabb volt a kis betegforgalmú intézetekhez képest az elso és a második öt évben is (p = 0,0007; p = 0,004). Mind a nagy, mind a kis betegforgalmú intézetekben végzett endovascularis aortareconstructio esetén szignifikánsan alacsonyabb volt a perioperatív mortalitás a második öt évben (p<0,0001; p<0,0001). A rupturált és a nem rupturált aortaaneurysmák perioperatív mortalitásának független rizikófaktora az intézetek betegforgalma (p = 0,006; p = 0,004), a betegek életkora (p<0,0001; p = 0,001), a preoperatív renalis megbetegedés (p = 0,007; p = 0,007), a transzfúzióigény (p<0,0001; p<0,0001), illetve nem rupturált aortaaneurysmák esetében a mutéti technika (p<0,0001) is. Következtetés: Endovascularis aortareconstructio és nagy betegforgalmú intézetek esetében szignifikánsan alacsonyabb perioperatív mortalitás érheto el. Orv Hetil. 2021; 162(31): 1233-1243. INTRODUCTION: The organisation of aortic disease care has changed significantly in many countries over the last decade: centralized, high-volume centers were established. OBJECTIVE: To analyse the perioperative mortality and the number of the infrarenal aortic aneurysm repairs according to the type of procedure (endovascular vs. open), patient volume (low vs. high) and time period (2010-2014 vs. 2015-2019). METHODS: The multicentric data registered prospectively in the Hungarian National Vascular Registry between 01. 01. 2010 and 31. 12. 2019 were analysed retrospectively. RESULTS: 3206 infrarenal aortic aneurysms were recorded. The endovascular-open repair rate was significantly higher (p<0.0001) and the high-volume institutes managed significantly more ruptured aneurysms (p<0.0001) in the second period. The perioperative mortality of the open repair of ruptured aneurysms was significantly lower in the high-volume institutes than in the low-volume ones in the first period (p = 0.0011), and the mortality of endovascular repair was significantly lower compared with open repair in the high-volume institutes in the second period (p = 0.029). The perioperative mortality of the open repair of non-ruptured aneurysm was significantly lower in the high-volume institutes in both periods (p = 0.0007; p = 0.004). Furthermore, the mortality of endovascular repair was significantly lower compared with open repair both in the high- and the low-volume institutes in the second period (p<0.0001; p<0.0001). Patient volume (p = 0.006; p = 0.004), age (p<0.0001; p = 0.001), preoperative renal insufficiency (p = 0.007; p = 0.007) and the need of blood transfusion (p<0.0001; p<0.0001) were independent risk factors of the perioperative mortality of ruptured and non-ruptured aneurysms. Type of the procedure was also an independent risk factor in the case of non-ruptured aneurysms (p<0.0001). CONCLUSION: Endovascular repair and aortic surgery in the high-volume institutes result in significantly lower perioperative mortality. Orv Hetil. 2021; 162(31): 1233-1243.

Regional variation of lower limb major amputations on different geographic scales - a Hungarian nationwide study over 13 years.

Background: The incidence of lower limb major amputations is an important healthcare quality indicator, as it reflects all efforts aimed to prevent limb loss. Analysis of within-country regional variations in incidence may reveal the sources of disparities in care. Materials and methods: Based on the data of the Hungarian healthcare beneficiary population from 2004 to 2016, the incidence of lower limb major amputations and its spatial variations was determined regionally on four levels of geographic resolution. Variability and autocorrelation were quantified on different resolutions. Results: A total of 56,468 lower limb major amputation procedures were identified in 49,528 patients over the observation period. Marked regional variations were detected at all geographic scale levels. In the case of county-level and local administrative level, the systematic component of variation was 0.03 and 0.09, respectively. Only half of the variation at local administrative level was explained by county. Conclusions: Lower limb major amputations show marked regional variations on the different geographic levels of resolution. The more granular the assessment, the higher the regional variation was. Assumingly, this observation is partially a mathematical necessity but may also be related to the different characteristics of care at a given level of spatial aggregation. The decomposition of the variance of amputation rates indicates that the potential explanatory factors contributing to spatial variability are multiple and may be interpreted on different levels of geographic resolution. Addressing the unwarranted variations and resolving the issues that contribute to high lower limb major amputation rates needs further explorative analysis.

Analysing the risk factors of doxorubicin-associated heart failure by a retrospective study of integrated, nation-wide databases / A doxorubicinkezeléshez kapcsolódó szívelégtelenség kialakulásának rizikótényezoi a hazai országos adatbázisok integrált, retrospektív elemzése alapján

INTRODUCTION: The incidence of dilated cardiomyopathy after anthracycline chemotherapy is mainly influenced by anthracycline cumulative dose. Previous researches showed doxorubicin treatment under cumulative dose of 450 mg/m2 associated with a low incidence of heart failure. Nowadays, doxorubicin is administered with a lower dose, the development of heart failure is largely determined by other factors. AIM: Our purpose was to identify the risk factors for heart failure due to doxorubicin therapy. METHOD: With the use of the Hungarian financial healthcare databases merged with the National Cancer Registry, we performed a retrospective study. All the patients having confirmation for breast carcinoma between 2004 and 2015 were enrolled. The subjects with a preceding period characterized by any chemotherapy or diagnoses suggesting heart failure were excluded. Heart failure outcome event was defined by the assignment of I50 diagnosis code at hospital discharge or in autopsy reports. STATISTICAL ANALYSIS: We used multivariate binary logistic regression to calculate odds ratios for heart failure. Besides the baseline characteristics, oncological state and cumulative doses of the chemotherapies were also taken into account. RESULTS: Among the analysed 3288, doxorubicin-treated patients, heart failure cumulative incidence was 6.2%. Doxorubicin cumulative dose over 400 mg/m2 increased the risk. The heart failure incidence was essentially influenced by age, even over 50 years the risk rose. Diabetes mellitus and the treatments with pyrimidine-analogues, carboplatin or bevacizumab were also associated with higher risk. CONCLUSION: By the integration of national financial and clinical databases, we could identify the risk factors for doxorubicin-associated heart failure. Orv Hetil. 2020; 161(26): 1094-1102.

Lower Limb Amputations and Revascularisation Procedures in the Hungarian Population: A 14 Year Retrospective Cohort Study.

OBJECTIVE: The aim of this study was to assess the long term trends of lower limb amputation and revascularisation in Hungary over 14 years. METHODS: This was a retrospective cohort study that included all patients who underwent lower limb amputation or revascularisation over a 14 year period (2004-2017) in Hungary. Inpatient administrative data claims covering the entire beneficiary population were incorporated. Lower limb amputations (both minor and major) and revascularisation procedures (both open and endovascular) were identified in the claims files. Incidence rates were calculated and time trends were assessed via a generalised additive model. RESULTS: From 2004 to 2017, a total of 121 351 lower limb amputations (61 154 minor; 60 197 major) and 149 355 revascularisation procedures (89 243 open; 60 112 endovascular) were detected in 140 581 patients. The number of minor amputations decreased moderately in the last few years of the study period, while major amputations showed a slight decline (15%) beginning after 2013, which was more marked (22%) following adjustment for age. While the crude incidence of open vascular surgery procedures decreased by 31% (from 74.5/105 to 51.4/105), endovascular procedures showed growth by 79% (from 33.7/105 to 60.4/105) over the whole observation period. CONCLUSION: Observed amputation and revascularisation trends in Hungary are similar to the international experience. The major difference is a more than one decade lag in the starting point of the decline of amputations and in the move towards endovascular procedures. The number of amputations is more than twofold higher and the number of revascularisations is close to half that reported internationally. This comprehensive report of two vascular care performance indicators reveals an east/west vascular health divide in Europe and indicates the need to improve amputation prevention.

Potentials, challenges, and limitations of the analysis of administrative data on vascular limb amputations in health care.

Although more and more data on lower limb amputations are becoming available by leveraging the widening access to health care administrative databases, the applicability of these data for public health decisions is still limited. Problems can be traced back to methodological issues, how data are generated and to conceptual issues, namely, how data are interpreted in a multidimensional environment. The present review summarised all of the steps from converting the claims data of administrative databases into the analytical data and reviewed the wide array of sources of potential biases in the analysis of such data. The origins of uncertainty of administrative data analysis include uncontrolled confounding due to a lack of clinical data, the left- and right-censored nature of data collection, the non-standardized diagnosis/procedure-based data extraction methods (i.e., numerator/denominator problems) and additional methodological problems associated with temporal and spatial analyses. The existence of these methodological challenges in the administrative data-based analysis should not deter the analysts from using these data as a powerful tool in the armamentarium of clinical research. However, it must be done with caution and a thorough understanding and respect of the methodological limitations. In addition to this requirement, there is a profound need for pursuing further research on methodology and widening the search for other indicators (structural, process or outcome) that allow a deeper insight how the quality of vascular care may be assessed. Effective research using administrative data is based on strong collaboration in three domains, namely expertise in claims data handling and processing, the clinical field, and statistical analysis. The final interpretations of results and the countermeasures on the level of vascular care ought to be grounded on the integrity of research, open discussions and institutionalized mechanisms of science arbitration and honest brokering.

[Analysis of antipsychotic prescription data and attendance of patients with schizophrenia in the Hungarian health system]. / Antipszichotikum gyógyszerkiváltási adatok és szkizofrén betegek pszichiátria ellátórendszerben való megjelenésének elemzése.

Regular care and sustained pharmacotherapy are inevitable for people who suffer from schizophrenia in order to attain an acceptable level of quality of life. The National Health Care Service Center (Állami Egészségügyi Ellátó Központ) has a health care utilization database in which individuals can be identified with a specific number, but anonymously (pseudo-TAJ), and their patient pathways can be retraced. We analyzed the health service utilization of patients with schizophrenia in the inpatient and outpatient care and the patterns of prescription and drug dispensing. The results show that in a given year, 30-35% of patients with schizophrenia do not reach the provision system and do not get adequate ("lege artis") therapy. Data concerning the prescription of antipsychotics show that psychiatrists working in Hungary prefer modern medicinal therapies in accordance with the domestic and international pharmacotherapeutic guidelines. These findings suggest that proper clinical care is provided to those patients with schizophrenia and with psychosis in general, who remain in the care system.

A nationwide study of the epidemiology of relapsing polychondritis.

OBJECTIVE: Relapsing polychondritis (RP) is a rare autoimmune inflammatory disease that attacks mainly cartilaginous structures or causes serious damage in proteoglycan-rich structures (the eyes, heart, blood vessels, inner ear). This study shows results regarding the epidemiology, progression, and associations of this highly variable disease by collecting all cases from a 124-million-person-year Central European nationwide cohort. METHODS: We used the Hungarian Health Care Database to identify all persons with possible RP infection. We followed patients who had International Classification of Diseases 10th edition code M94.1 at least once in their inpatient or outpatient records between January 1, 2002 and December 31, 2013 in Hungary. We classified these patients into disease severity groups by their drug consumption patterns between January 1, 2010 and December 31, 2013. We analyzed the regional distribution of RP incidences as well. Overall maps of comorbidity are presented with network layouts. RESULTS: We identified 256 patients with RP among cumulatively 11.5 million registered inhabitants. We classified these patients into four severity classes as "extremely mild" (n=144), "mild" (n=22), "moderate" (n=41), and "severe" (n=4). Two additional groups were defined for patients without available drug data as "suspected only" (n=23) and "confirmed but unknown treatment" (n=22). The age and sex distributions of patients were similar to worldwide statistics. Indeed, the overall survival was good (95% confidence interval for 5 years was 83.6%-92.9% and for 10 years was 75.0%-88.3% which corresponds to the overall survival of the general population in Hungary), and the associations with other autoimmune disorders were high (56%) in Hungary. Almost any disease can occur with RP; however, the symptoms of chromosomal abnormalities are only incidental. Spondylosis can be a sign of the activation of RP, while Sjögren syndrome is the most frequent autoimmune association. Regional distribution of incidences suggests arsenic drinking water and sunlight exposure as possible triggering factors. CONCLUSION: The good survival rate of RP in Hungary is probably associated with the early diagnosis of the disease.

[Report of the Hungarian Vascular Registry's data of infrarenal aortic aneurysms (2010-2014)]. / Magyarországon végzett infrarenalis aortaaneurysma-mutétek eredményei az Érsebészeti Regiszter adatai alapján (2010-2014).

INTRODUCTION: The Hungarian Society for Vascular Surgery decided to analyse and publish regularly the data of the Hungarian Vascular Registry. AIM: The aim of the authors was to present the outcome of infrarenal aortic aneurysm surgeries performed during the past five years. METHOD: Prospectively collected multicentric data obtained from the Hungarian Vascular Registry between January 1, 2010 and December 31, 2014 were analysed retrospectively. Statistical analysis was performed using Fisher's exact test and odds ratio calculation. RESULTS: It was found that 16.72% of the 1435 operations were performed for ruptured aneurysms. Five institutes having the highest capacity performed 78.4% of the operations. In the ruptured aortic aneurysm group the age of patients was 71.77±9.82 years (mean±SD), and perioperative mortality was 33.75%. In the intact aortic aneurysm group the age of patients was 69.50±8.46 years and the perioperative mortality was 3.51%. In both groups perioperative mortality (ruptured: p<0,05, OR = 0.11; intact: p<0.05, OR = 0.26) and the length of hospital stay (ruptured: p<0.05, OR = 4.55; intact: p<0.001, OR = 4.27) were significantly lower in patients who had endovascular repair compared to those with open repair. In both groups perioperative mortality (ruptured: p<0.0001, OR = 0.32; intact: p<0.0001, OR = 0.23) and length of hospital stay (ruptured: p<0.05, OR = 3.16; intact: p<0.001, OR = 3.84) were significantly lower in the five institutes having the highest capacity than in the remaining institutes. CONCLUSIONS: In patients having endovascular repair and in institutes with high capacity the perioperative mortality and length of hospital stay were significantly lower.

[Report of the 2013 data of the Hungarian Vascular Registry]. / Az Érsebészeti Regiszter 2013-as adatainak elemzése.

INTRODUCTION: Nationwide medical databases started to record observations in the 90s. A Hungarian vascular registry was set up in 2002, which processes data of carotid, aneurysm and lower extremity arterial operations. The Hungarian Society for Angiology and Vascular Surgery decided to analyse the data each year. In this article we show the results of the registered carotid, aneurysmal and lower limb operations which were carried out in 2013. RESULTS: Altogether 3916 vascular surgical cases have been registered: 25.36% of cases were related to carotid arteries, 10.11% to aneurysms and 64.53% to lower limb operations. The surgical procedures were acute in 23.9% and they were performed electively in 76.10%. Stent graft implantation was performed in 31.47% of the abdominal aortic aneurysm cases and 68.53% was operated by open surgery. The average maximum diameter of aneurysms was 62.45 ± 12.05 mm. The mortality in aortic aneurysm surgery was 7.57% and 2.06% related to lower extremity surgeries. Carotid surgery has a combined mortality and stroke rate of 2.62%. CONCLUSIONS: Registers have been proved to be useful in countries where they are used regularly for decision making. Our best common interest is to maintain a well-established national database.

[Establishment and functioning of the Vascular Registry in Hungary]. / Az Érsebészeti Regiszter muködtetése során szerzett tapasztalatok.

Randomized controlled trials provide the best evidence in clinical trials; however, they do have limitations. In order to evaluate the effectiveness of treatments, population based registries may also yield useful information about the actual practice and they may enable users to carry out a dynamic follow-up. To evaluate the outcome of vascular procedures, the Vascular Registry in Hungary has been established in 2002. This article presents the establishment and functioning of the Vascular Registry and provides information about scientific results obtained during the past years. The Vascular Registry is an internet based database with on-line input. The backup server is provided by the National Institute for Quality and Organizational Development in Healthcare and Medicines. The database collects data in three different fields: interventions for carotid artery, aneurysm (any type) and lower extremity vascular diseases. Twenty five vascular surgical units record interventions in the registry, which corresponds to two thirds of the whole activity. Since joining the Vascunet Group of the European Society for Vascular Surgery, the registry has contributed to several publications based on evaluation of a large common dataset in different fields of vascular surgery. A validation process has been recently performed which confirmed the internal and external validity of the database. The authors conclude that despite unsolved problems related to financing issues, the Vascular Registry has proved to be a useful tool during the past years. In order to take advantage of the registry to its fullest, measures should be taken to achieve a more complete data recording, increase publication activity on the national dataset, improve the flow of information during operation and develop a system of regular feedback.

A pilot ontological model of public health indicators.

UNLABELLED: There are various public health databases in the world aiming to provide data to compare health conditions in different countries. Their data sets are more or less overlapping but data from different databases and different countries are hard to compare due to different definitions and interpretations. Our aim was to create a core ontological model that is able to represent public health indicators. We assumed, that by such representation comparability and quality of data could be improved. METHOD: Three sets of indicators were taken, and a core ontology was built from information objects describing their top level entities. The Protégé ontology editor with RDF backend was used for building the ontology. The used indicator sets were the indicators of the Health for All Database of the World Health Organisation (HFA), the OECD Health Data, and the set of indicators proposed by the European Community Health Indicators (ECHI) European project. Then 19 indicators selected from HFA was represented using the core ontology. Strength and weaknesses of the descriptive capability of the model was studied. RESULT: The drafted core model seems to be useful in representing many of the public health indicators. In some cases it really helps improve comparability. However, some of the semantic details cannot be sufficiently expressed by the used ontology representation language. There is a need of merging other domain ontologies to represent indicators related to other domains, such as economy, social and environmental sciences.