1. Espace de l‘Europe 10 CH-2010 Neuchâtel obsan@bfs.admin.ch www.obsan.ch Medical practice variations in Switzerland Dimitri Kohler, Swiss Health Observatory (SHO) Stefan Otto, Federal Office of Public Health (FOPH) Paris, April 26 th 2013 Second expert group meeting on medical practice variations Draft – subject to revisions

2. Dimitri Kohler, Stefan Otto, Medical practice variations in Switzerland, Paris, April 26 th 2013Page 2  Objectives  Identify intercantonal variations of hospital procedures in Switzerland  Highlight the evolution of hospital procedures over time  Scope  Focus on the interventions from the first priority list (including optional procedures) Objectives and scope

3. Dimitri Kohler, Stefan Otto, Medical practice variations in Switzerland, Paris, April 26 th 2013Page 3  Data  Swiss statistics of hospital discharges  Swiss statistics of hospitals  Time period  2005-2011  Regional units  25 cantons (AI and AR are pooled together and analyzed as a single canton [AP])  Population ranging from 1,4mio (ZH) to 35’400 (UR), mean=306’000, median=223’000 Data and method

4. Dimitri Kohler, Stefan Otto, Medical practice variations in Switzerland, Paris, April 26 th 2013Page 4 Data and method  Inclusion/exclusion criteria  Stationary care  Discharge during the year of analysis  Patients with unknown place of life or living abroad are excluded  Procedures identification Based on ICD-9-CM (OECD guidelines) CHOP codes (Swiss codes)  Direct standardization of the rates  Based on age and sex  According to the yearly structure of the Swiss population

5. Dimitri Kohler, Stefan Otto, Medical practice variations in Switzerland, Paris, April 26 th 2013Page 5 Results The rates of all procedures increased over the period 2005-2011.  Four main profiles (preliminary results)  Low increase Coronary bypass, CABG + 0,2% Hospital medical admissions +7,4%  Moderate increase Knee arthroscopy+13,6% Caesarean sections +14,1%  High increase Coronary Catheterisation+20,9% Coronary angioplasty, PTCA+22,3% Admission after hip fracture +28,8%  Very high increase Knee replacement+41,7%

6. Dimitri Kohler, Stefan Otto, Medical practice variations in Switzerland, Paris, April 26 th 2013Page 6 Results Trends in medical practice variations

7. Dimitri Kohler, Stefan Otto, Medical practice variations in Switzerland, Paris, April 26 th 2013Page 7  Coefficients of variation in 2011  Three main groups identified (preliminary results) GroupsProceduresCV Low variations Hospital medical admissions, PTCA, knee replacement, caesarean section [13,5 ; 16,9] Moderate variationsCABG, catheterisation[26,0 ; 26,9] High variationsKnee arthroscopy49,4 Calibration procedureAdmissions after hip fracture20,4 Results

8. Dimitri Kohler, Stefan Otto, Medical practice variations in Switzerland, Paris, April 26 th 2013Page 8 Results  The calibration procedure (Admission after hip fracture)  Gap between 90 e and 10 e percentile is relatively small and stable until 2009  Unexplained increase of the 90 th percentile between 2009 and 2010  8 cantons over 30% increase  CV important increase :

9. Dimitri Kohler, Stefan Otto, Medical practice variations in Switzerland, Paris, April 26 th 2013Page 9  Limitations  Variable proportion of ambulatory interventions for Knee arthroscopy (31%) Catheterisation (22%) PTCA (13%)  Data coverage of ambulatory interventions (Tarifpool, SASIS SA) between 50% and 80%  Ranking of cantons is pretty unstable  Discussion  Evidence of substitution patterns (CABG)  General convergence of the different practices Limitations and discussion

10. Dimitri Kohler, Stefan Otto, Medical practice variations in Switzerland, Paris, April 26 th 2013Page 10  The cantons are responsible for policy / planning but causes of praxis variations seems not to be related to these factor today  The variations within cantons are bigger than between cantons  A study (2012) concerning the cesarean section showed a complex cause and effect relationship; the appraisal of policy options was very difficult  For the detection of causes, smaller areas (urban, rural, hospital catchment areas, …) and procedure specific factors has to be analyzed  The country-differences of the health care systems (and the data- differences) affords country-specific analyzes Conclusions (1)

11. Dimitri Kohler, Stefan Otto, Medical practice variations in Switzerland, Paris, April 26 th 2013Page 11 Thank you for your attention! Contact details dimitri.kohler@bfs.admin.ch sonia.pellegrini@bfs.admin.ch stefan.otto@bag.admin.ch