Estimating the cost impact of atrial fibrillation using a prospective cohort study and population-based controls.

AIMS: Atrial fibrillation (AF) costs are expected to be substantial, but cost comparisons with the general population are scarce. Using data from the prospective Swiss-AF cohort study and population-based controls, we estimated the impact of AF on direct healthcare costs from the Swiss statutory health insurance perspective. METHODS: Swiss-AF patients, enrolled from 2014 to 2017, had documented, prevalent AF. We analysed 5 years of follow-up, where clinical data, and health insurance claims in 42% of the patients were collected on a yearly basis. Controls from a health insurance claims database were matched for demographics and region. The cost impact of AF was estimated using five different methods: (1) ordinary least square regression (OLS), (2) OLS-based two-part modelling, (3) generalised linear model-based two-part modelling, (4) 1:1 nearest neighbour propensity score matching and (5) a cost adjudication algorithm using Swiss-AF data non-comparatively and considering clinical data. Cost of illness at the Swiss national level was modelled using obtained cost estimates, prevalence from the Global Burden of Disease Project, and Swiss population data. RESULTS: The 1024 Swiss-AF patients with available claims data were compared with 16 556 controls without known AF. AF patients accrued CHF5600 (EUR5091) of AF-related direct healthcare costs per year, in addition to non-AF-related healthcare costs of CHF11100 (EUR10 091) per year accrued by AF patients and controls. All five methods yielded comparable results. AF-related costs at the national level were estimated to amount to 1% of Swiss healthcare expenditure. CONCLUSIONS: We robustly found direct medical costs of AF patients were 50% higher than those of population-based controls. Such information on the incremental cost burden of AF may support healthcare capacity planning.

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.

Small Area Variation of Adherence to Clinical Recommendations: An Example from Switzerland.

Background: Unwarranted variation in healthcare utilization can only partly be explained by variation in the health care needs of the population, yet it is frequently found globally. This is the first cross-sectional study that systematically assessed geographic variation in the adherence to clinical recommendations in Switzerland. Specifically, we explored 1) the geographic variation of adherence to clinical recommendations across 24 health services at the sub-cantonal level, 2) assessed and mapped statistically significant spatial clusters, and 3) explored possible influencing factors for the observed geographic variation. Methods: Exploratory spatial analysis using the Moran's I statistic on multivariable multilevel model residuals to systematically identify small area variation of adherence to clinical recommendations across 24 health services. Results: Although there was no overall spatial pattern in adherence to clinical recommendations across all health care services, we identified health services that exhibited statistically significant spatial dependence in adherence. For these, we provided evidence about the locations of local clusters. Interpretation: We identified regions in Switzerland in which specific recommended or discouraged health care services are utilized less or more than elsewhere. Future studies are needed to investigate the place-based social determinants of health responsible for the sub-cantonal variation in adherence to clinical recommendations in Switzerland and elsewhere over time.

[Frequency of Prescription of Non-steroidal Anti-inflammatory Drugs: Analysis of Compulsory Health Insurance Billing Data]. / Verschreibung von nicht-steroidalen Antirheumatika: Analyse von Abrechnungsdaten der OKP.

Frequency of Prescription of Non-steroidal Anti-inflammatory Drugs: Analysis of Compulsory Health Insurance Billing Data Abstract. According to the nephrology recommendation in the Choosing Wisely campaign, non-steroidal anti-inflammatory drugs should be avoided in people with cardiac and renal diseases. This study provides quantitative data on the use of NSAIDs in Switzerland as well as indications of how the billing frequency of NSAIDs in high-risk individuals has changed since the introduction of the recommendation. METHOD: Secondary analysis of billing data from compulsory health insurance. The frequency of NSAID use was stratified by sociodemographics and the comorbidities "cardiology" and "renal insufficiency". RESULTS: It was shown for the first time that 33.6% of the total study population, 42.1% of the cardiac risk population and 18% of the renal risk population used NSAIDs. There was a slight tendency for the billing frequency to decrease after the introduction of the recommendation. DISCUSSION: Further studies are needed as a matter of priority to quantify the use of potentially harmful NSAIDs in other risk groups and, on the basis of the ensuing study results, a wider use of the Choosing Wisely recommendations must be considered, especially in the general population.

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.

Are weak or negative clinical recommendations associated with higher geographical variation in utilisation than strong or positive recommendations? Cross-sectional study of 24 healthcare services.

OBJECTIVES: When research evidence is lacking, patient and provider preferences, expected to vary geographically, might have a stronger role in clinical decisions. We investigated whether the strength or the direction of recommendation is associated with the degree of geographic variation in utilisation. DESIGN: In this cross-sectional study, we selected 24 services following a comprehensive approach. The strength and direction of recommendations were assessed in duplicate. Multilevel models were used to adjust for demographic and clinical characteristics and estimate unwarranted variation. SETTING: Observational study of claims to mandatory health insurance in Switzerland in 2014. PARTICIPANTS: Enrolees eligible for the 24 healthcare services. PRIMARY OUTCOME MEASURES: The variances of regional random effects, also expressed as median odds ratios (MOR). Services grouped by strength and direction of recommendations were compared with Welch's t-test. RESULTS: The sizes of the eligible populations ranged from 1992 to 409 960 patients. MOR ranged between 1.13 for aspirin in secondary prevention of myocardial infarction to 1.68 for minor surgical procedures performed in inpatient instead of outpatient settings. Services with weak recommendations had a negligibly higher variance and MOR (difference in means (95% CI) 0.03 (-0.06 to 0.11) and 0.05 (-0.11 to 0.21), respectively) compared with strong recommendations. Services with negative recommendations had a slightly higher variance and MOR (difference in means (95% CI) 0.07 (-0.03 to 0.18) and 0.14 (-0.06 to 0.34), respectively) compared with positive recommendations. CONCLUSIONS: In this exploratory study, the geographical variation in the utilisation of services associated with strong vs weak and negative vs positive recommendations was not substantially different, although the difference was somewhat larger for negative vs positive recommendations. The relationships between the strength or direction of recommendations and the variation may be indirect or modified by other characteristics of services. As initiatives discouraging low-value care are gaining attention worldwide, these findings may inform future research in this area.

Benzodiazepine and Z-Drug Use in Switzerland: Prevalence, Prescription Patterns and Association with Adverse Healthcare Outcomes.

PURPOSE: This study aimed to give a nationwide comprehensive picture of the prevalence and prescription patterns of benzodiazepines (BZ) and Z-drugs (ZD) in Switzerland and to analyze the association with adverse health care outcomes. PATIENTS AND METHODS: A population-based, cross-sectional study was conducted, using a large health insurance database in Switzerland. Records from all adult patients with ≥1 prescription for a benzodiazepine and/or a Z-drug in 2018 were included. We calculated the prevalence of BZ and ZD user (extrapolated to the Swiss general population), the number of prescriptions and the type of provider (among each BZ and ZD only user). Multivariate logistic regression models were performed to estimate the association between drug prescription and the risk of hospitalization in different healthcare settings. RESULTS: Of a total of 844'692 patients, 95'179 had ≥1 BZ and/or ZD prescription in 2018. The extrapolated one-year prevalence for the general Swiss population was 8.1% for a BZ prescription, 3.5% for a ZD prescription, and 10.5% for a BZ and/or ZD prescription, and continuously increased with age. The majority of the elderly (over 65 years) had ≥1 prescription (BZ: 51.9%; ZD: 56.9%; BZ and/or ZD: 53.5). The proportion of patients with ≥6 prescriptions per year was 23.1% for BZ only user and 35.2% for ZD only user. Most patients had ≥1 prescription from a general practitioner. Regression models showed a higher likelihood to be admitted to acute care, psychiatry, rehabilitation, or nursing home with ≥1 prescription for a benzodiazepine and/or a Z-drug. CONCLUSION: This study is the first to give a nationwide overview of the current use of benzodiazepines and Z-drugs in Switzerland based on health insurance claims data. The results revealed a remarkably high prevalence among the general Swiss population, especially in older generations. The negative consequences of heavy BZ and ZD use are a crucial public health problem, that should be addressed.

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.

Going beyond the mean: economic benefits of myocardial infarction secondary prevention.

BACKGROUND: Using the example of secondary prophylaxis of myocardial infarction (MI), our aim was to establish a framework for assessing cost consequences of compliance with clinical guidelines; thereby taking cost trajectories and cost distributions into account. METHODS: Swiss mandatory health insurance claims from 1840 persons with hospitalization for MI in 2014 were analysed. Included persons were predominantly male (74%), had a median age of 73 years, and 71% were pre-exposed to drugs for secondary prophylaxis, prior to index hospitalization. Guideline compliance was defined as being prescribed recommended 4-class drug prophylaxis including drugs from the following four classes: beta-blockers, statins, aspirin or P2Y12 inhibitors, and angiotension-converting enzyme inhibitors or angiotensin receptor blockers. Health care expenditures (HCE) accrued over 1 year after index hospitalization were compared by compliance status using two-part regression, trajectory analysis, and counterfactual decomposition analysis. RESULTS: Only 32% of persons received recommended 4-class prophylaxis. Compliant persons had lower HCE (- 4865 Swiss Francs [95% confidence interval - 8027; - 1703]) and were more likely to belong to the most favorable HCE trajectory (with 6245 Swiss Francs average annual HCE and comprising 78% of all studied persons). Distributional analyses showed that compliance-associated HCE reductions were more pronounced among persons with HCE above the median. CONCLUSIONS: Compliance with recommended prophylaxis was robustly associated with lower HCE and more favorable cost trajectories, but mainly among persons with high health care expenditures. The analysis framework is easily transferrable to other diseases and provides more comprehensive information on HCE consequences of non-compliance than mean-based regressions alone.

Degree of regional variation and effects of health insurance-related factors on the utilization of 24 diverse healthcare services - a cross-sectional study.

BACKGROUND: Regional variation in healthcare utilization could reflect unequal access to care, which may lead to detrimental consequences to quality of care and costs. The aims of this study were to a) describe the degree of regional variation in utilization of 24 diverse healthcare services in eligible populations in Switzerland, and b) identify potential drivers, especially health insurance-related factors, and explore the consistency of their effects across the services. METHODS: We conducted a cross-sectional study using health insurance claims data for the year of 2014. The studied 24 healthcare services were predominantly outpatient services, ranging from screening to secondary prevention. For each service, a target population was identified based on applicable clinical recommendations, and outcome variable was the use of the service. Possible influencing factors included patients' socio-demographics, health insurance-related and clinical characteristics. For each service, we performed a comprehensive methodological approach including small area variation analysis, spatial autocorrelation analysis, and multilevel multivariable modelling using 106 mobilité spaciale regions as the higher level. We further calculated the median odds ratio in model residuals to assess the unexplained regional variation. RESULTS: Unadjusted utilization rates varied considerably across the 24 healthcare services, ranging from 3.5% (osteoporosis screening) to 76.1% (recommended thyroid disease screening sequence). The effects of health insurance-related characteristics were mostly consistent. A higher annual deductible level was mostly associated with lower utilization. Supplementary insurance, supplementary hospital insurance and having chosen a managed care model were associated with higher utilization of most services. Managed care models showed a tendency towards more recommended care. After adjusting for multiple influencing factors, the unexplained regional variation was generally small across the 24 services, with all MORs below 1.5. CONCLUSIONS: The observed utilization rates seemed suboptimal for many of the selected services. For all of them, the unexplained regional variation was relatively small. Our findings confirmed the importance and consistency of effects of health insurance-related factors, indicating that healthcare utilization might be further optimized through adjustment of insurance scheme designs. Our comprehensive approach aids in the identification of regional variation and influencing factors of healthcare services use in Switzerland as well as comparable settings worldwide.

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.

Insights into the protective effects of influenza vaccination: More hospitalizations but lower follow-up mortality during the 2014/15 influenza season in a Swiss cohort.

BACKGROUND: Observational studies of influenza vaccination are criticized as flawed due to unmeasured confounding. The goal of this cohort study was to explore the value and role of secondary claims data to inform the effectiveness of influenza vaccination, while systematically trying to reduce potential bias. METHODS: We iteratively reviewed the components of the PICO approach to refine study design. We analyzed Swiss mandatory health insurance claims of adult patients with chronic diseases, for whom influenza vaccination was recommended in 2014. Analyzed outcomes were all-cause mortality, hospitalization with a respiratory infection or its potential complication, and all-cause mortality after such hospitalization, adjusting for clinical and health care use variables. Cox and multi-state models were applied for time-to-event analysis. RESULTS: Of 343,505 included persons, 22.4% were vaccinated. Vaccinated patients were on average older, had more morbidities, higher health care expenditures, and had been more frequently hospitalized. In non-adjusted models, vaccination was associated with increased risk of events. Adding covariates decreased the hazard ratio (HR) both for mortality and hospitalizations. In the full model, the HR [95% confidence interval] for mortality during season was 0.82 [0.77-0.88], and closer to null effect after season. In contrast, HR for hospitalizations was increased during season to 1.28 [1.15-1.42], with estimates closer to null effect after season. HR in multi-state models were similar to those in the single-outcome models, with HR of mortality after hospitalization negative both during and after season. CONCLUSION: In patients with chronic diseases, influenza vaccination was associated with more frequent specific hospitalizations, but decreased risk of mortality overall and after such hospitalization. Our approach of iteratively considering PICO elements helped to consider various sources of bias in the study sequentially. The selection of appropriate, specific outcomes makes the link between intervention and outcome more plausible and can reduce the impact of confounding.

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.

Exploring geographic variation of and influencing factors for utilization of four diabetes management measures in Swiss population using claims data.

INTRODUCTION: Four strongly recommended diabetes management measures are biannual glycated hemoglobin (HbA1c) testing, annual eye examination, kidney function examination, and low-density lipoprotein (LDL) testing in patients below 75 years. We aimed to describe regional variation in the utilization of the four measures across small regions in Switzerland and to explore potential influencing factors. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional study of adult patients with drug-treated diabetes in 2014 using claims data. Four binary outcomes represented adherence to the recommendations. Possible influencing factors included sociodemographics, health insurance preferences, and clinical characteristics. We performed multilevel modeling with Medstat regions as the higher level. We calculated the median odds ratio (MOR) and checked spatial autocorrelation in region level residuals using Moran's I statistic. When significant, we further conducted spatial multilevel modeling. RESULTS: Of 49 198 patients with diabetes (33 957 below 75 years), 69.6% had biannual HbA1c testing, 44.3% each had annual eye examination and kidney function examination, and 55.5% of the patients below 75 years had annual LDL testing. The effects of health insurance preferences were substantial and consistent. Having any supplementary insurance (ORs across measures were between 1.08 and 1.28), having supplementary hospital care insurance (1.08-1.30), having chosen a lower deductible level (eg, SFr2500 compared with SFr300: 0.57-0.69), and having chosen a managed care model (1.04-1.17) were positively associated with recommendations adherence. The MORs (1.27-1.33) showed only moderate unexplained variation, and we observed inconsistent spatial patterns of unexplained variation across the four measures. CONCLUSION: Our findings indicate that the uptake of strongly recommended measures in diabetes management could possibly be optimized by providing further incentives to patients and care providers through insurance scheme design. The absence of marked regional variation implies limited potential for improvement by targeted regional intervention, while provider-specific promotion may be more impactful.

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.

Real-World Data on Topical Therapies and Annual Health Resource Utilization in Hospitalized Swiss Patients with Ulcerative Colitis.

OBJECTIVES: Topical treatment with aminosalicylates and/or budesonide was shown to be highly effective in patients with ulcerative colitis (UC), while reducing the likelihood of systemic adverse effects. However, previous research has shown that topical treatment is clearly underused. We aimed to evaluate the use of topical therapy in the real-world setting. METHODS: This is an observational study based on claims data of 201 Swiss adult patients who were hospitalized for UC between 2012 and 2014 and who were then followed for 1 year. A variety of factors presumably associated with topical treatment were examined. Annual health care utilization (UC-related medications, diagnostic procedures, consultations, and rehospitalizations) of patients with versus without topical therapy was compared. RESULTS: Of the 201 hospitalized UC patients, 82 (40.8%) were treated with topical 5-acetylsalicylic acid (ASA) and/or topical rectal steroids. The main factors significantly and positively associated with receiving topical treatment were the use of topical treatment in the year prior to the hospitalization, receiving oral 5-ASA, and living in an urban area. The mode of administration was further related to the language area. Patients with topical therapy significantly more often received other UC-related medications, such as combinations with systemic steroids. They significantly more often underwent colonoscopies and calprotectin measurements, and more often consulted a gastroenterologist in the follow-up, while there was no significant difference regarding rehospitalizations. CONCLUSIONS: Topical treatment is underused in patients with UC, which stands in contrast to the current European Crohn's and Colitis Organization guidelines. Patients' preferences and considerations need to be taken into account when prescribing medical therapy.

Hospital readmission risk prediction based on claims data available at admission: a pilot study in Switzerland.

OBJECTIVES: Evaluating whether future studies to develop prediction models for early readmissions based on health insurance claims data available at the time of a hospitalisation are worthwhile. DESIGN: Retrospective cohort study of hospital admissions with discharge dates between 1 January 2014 and 31 December 2016. SETTING: All-cause acute care hospital admissions in the general population of Switzerland, enrolled in the Helsana Group, a large provider of Swiss mandatory health insurance. PARTICIPANTS: The mean age of 138 222 hospitalised adults included in the study was 60.5 years. Patients were included only with their first index hospitalisation. Patients who deceased during the follow-up period were excluded, as well as patients admitted from and/or discharged to nursing homes or rehabilitation clinics. MEASURES: The primary outcome was 30-day readmission rate. Area under the receiver operating characteristic curve (AUC) was used to measure the discrimination of the developed logistic regression prediction model. Candidate variables were theory based and derived from a systematic literature search. RESULTS: We observed a 30-day readmission rate of 7.5%. Fifty-five candidate variables were identified. The final model included pharmacy-based cost group (PCG) cancer, PCG cardiac disease, PCG pain, emergency index admission, number of emergency visits, costs specialists, costs hospital outpatient, costs laboratory, costs therapeutic devices, costs physiotherapy, number of outpatient visits, sex, age group and geographical region as predictors. The prediction model achieved an AUC of 0.60 (95% CI 0.60 to 0.61). CONCLUSIONS: Based on the results of our study, it is not promising to invest resources in large-scale studies for the development of prediction tools for hospital readmissions based on health insurance claims data available at admission. The data proved appropriate to investigate the occurrence of hospitalisations and subsequent readmissions, but we did not find evidence for the potential of a clinically helpful prediction tool based on patient-sided variables alone.

Measuring diabetes guideline adherence with claims data: systematic construction of indicators and related challenges.

OBJECTIVES: Indicators of guideline adherence are frequently used to examine the appropriateness of healthcare services. Only some potential indicators are actually usable for research with routine administrative claims data, potentially leading to a biased selection of research questions. This study aimed at developing a systematic approach to extract potential indicators from clinical practice guidelines (CPG), evaluate their feasibility for research with claims data and assess how the extracted set reflected different types of healthcare services. Diabetes mellitus (DM), Swiss national guidelines and health insurance claims data were analysed as a model case. METHODS: CPG for diabetes patients were retrieved from the Swiss Endocrinology and Diabetes Society website. Recommendation statements involving a specific healthcare intervention for a defined patient population were translated into indicators of guideline adherence. Indicators were classified according to disease stage and healthcare service type. We assessed for all indicators whether they could be analysed with Swiss mandatory health insurance administrative claims data. RESULTS: A total of 93 indicators were derived from 15 CPG, representing all sectors of diabetes care. For 63 indicators, the target population could not be identified using claims data only. For 67 indicators, the intervention could not be identified. Nine (10%) of all indicators were feasible for research with claims data (three addressed gestational diabetes and screening, five screening for complications and one glucose measurement). Some types of healthcare services, eg, management of risk factors, treatment of the disease and secondary prevention, lacked corresponding indicators feasible for research. CONCLUSIONS: Our systematic approach could identify a number of indicators of healthcare service utilisation, feasible for DM research with Swiss claims data. Some areas of healthcare were covered less well. The approach could be applied to other diseases and countries, helping to identify the potential bias in the selection of indicators and optimise research.

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.