Andri Signorell

Place of death and health care utilization for people in the last 6 months of life in Switzerland: a retrospective analysis using administrative data

BackgroundThere is a growing interest in examining the current state of care and identifying opportunities for improving care and reducing costs at the end of life. The aim of this study is to examine patterns of health care use at the end of life and place of death and to describe the basic characteristics of the decedents in the last six months of their life.MethodsThe empirical analysis is based on data from 58,732 Swiss residents who died between 2007 and 2011. All decedents had mandatory health insurance with Helsana Group, the largest health insurer in Switzerland. Descriptive statistical techniques were used to provide a general profile of the study population and determinants of the outcome for place of death were analyzed with an econometric approach.ResultsThere were substantial and significant differences in health care utilization in the last six months of life between places of death. The mean numbers of consultations with a general practitioner or a specialist physician as well as the number of different medications and the number of hospital days was consistently highest for the decedents who died in a hospital. We found death occurred in Switzerland most frequently in hospitals (38.4% of all cases) followed by nursing homes (35.1%) and dying at home (26.6%). The econometric analysis indicated that the place of death is significantly associated with age, sex, region and multiple chronic conditions.ConclusionsThe importance of nursing homes and patients’ own homes as place of death will continue to grow in the future. Knowing the determinants of place of death and patterns of health care utilization of decedents can help decision makers on the allocation of these needed health care services in Switzerland.

Improved prediction of medical expenditures and health care utilization using an updated chronic disease score and claims data.

OBJECTIVE To predict future medical expenditures, health care utilization, and mortality in Switzerland using an updated chronic disease score (CDS), a chronic morbidity measure based on pharmacy data. STUDY DESIGN AND SETTING We performed a cohort study using medical claims data from insured persons enrolled in 2009 and 2010. Patients characteristics, chronic conditions, and health care costs from baseline were used to calculate each patients disease score. Two-part regression models were fit to predict health care expenditures, utilization, and mortality during the following year using the scores baseline values. We calculated the proportion of explained variation for each regression model to assess their performance. RESULTS The CDS model, controlled for sociodemographics and health insurance plan, showed a significant improvement in explained variance of health care costs, outpatient costs, and outpatient visits in 2010. Future outpatient visits were predicted best with an R(2) of 29.2% (age group: 18-65 years) and 22.9% (>65 years), and models predicted future mortality with a c-statistic of 0.8. CONCLUSION The CDS showed reasonable predictive validity of future health care utilization and medical expenditure based on pharmacy dispensing data, which may support health care decision makers in the planning delivery systems and resource allocation.

Changes over time in prescription practices of pain medications in Switzerland between 2006 and 2013: an analysis of insurance claims

BackgroundIn Europe, scant information is available about prescription practices for pain medications. The aim of this research was to assess changes in prescription rates of non-opioid, weak opioid, and strong opioid medications between 2006 and 2013 in the Swiss population.MethodsUsing insurance claims data covering one-sixth of the Swiss population, we analyzed the numbers of reimbursed pain medications, the number of reimbursements per persons, and the cumulative dose in milligrams. For opioids, the morphine equivalent dose and treatment days were calculated. Data were extrapolated to the dose per day per 100’000 population stratified by age, gender, and canton.ResultsIn total, 4’746’942 paracetamol, 2’156’620 NSAIDs or Coxibs, 931’129 metamizole, 1’322’272 weak opioid, and 807’835 strong opioid claims were analyzed. Between 2006 and 2013, the increase in claims per 100’000 persons was 32% for paracetamol, 242% for metamizole, 107% for NSAIDS, 86% for Coxibs, 13% for weak opioids, and 121% for strong opioids. For strong opioids the total MED in mg /100’000 increased by 117%, the treatment days /100’000 by 101%. For strong opioids, fentanyl was most frequently used (increase between 2006 and 2013 by 91% for MED/100’000 persons and 94% treatment days / 100’000) followed by buprenorphine and oxycodone. The highest proportional increase in MED / 100’000 was observed for methadone (+1414%) and oxycodone (+313%). Marked geographical variation was detected in the use of metamizole, paracetamole, and strong opioids in different cantons.ConclusionThe analysis of insurance claims data provides evidence that the prescription rates for pain medications increased in Switzerland within the last ten years, in particular for metamizole and strong opioids. Furthermore, the prescription rates for metamizole, paracetamol, and strong opioids varied substantially between different cantons in Switzerland.

Comparison of Outcomes and Costs of Ranibizumab and Aflibercept Treatment in Real-Life.

Background Treatment efficacy and costs of anti-VEGF drugs have not been studied in clinical routine. Objective To compare treatment costs and clinical outcomes of the medications when adjusting for patients’ characteristics and clinical status. Design Comparative study. Setting The largest public ophthalmologic clinic in Switzerland. Patients Health care claims data of patients with age-related macular degeneration, diabetic macula edema and retinal vein occlusion were matched to clinical and outcome data. Measurements Patients’ underlying condition, gender, age, visual acuity and retinal thickness at baseline and after completing the loading phase, the total number of injections per treatment, the visual outcome and vital status was secured. Results We included 315 patients (19595 claims) with a follow-up time of 1 to 99 months (mean 32.7, SD 25.8) covering the years 2006–2014. Mean age was 78 years (SD 9.3) and 200 (63.5%) were female. At baseline, the mean number of letters was 55.6 (SD 16.3) and the central retinal thickness was 400.1 μm (SD 110.1). Patients received a mean number of 15.1 injections (SD 13.7; range 1 to 85). Compared to AMD, adjusted cost per month were significantly higher (+2174.88 CHF, 95%CI: 1094.50–3255.27; p<0.001) for patients with DME, while cost per month for RVO were slightly but not significantly higher. (+284.71 CHF, 95% CI: -866.73–1436.15; p = 0.627). Conclusions Patients with DME are almost twice as expensive as AMD and RVO patients. Cost excess occurs with non-ophthalmologic interventions. The currently licensed anti-VEGF medications did not differ in costs, injection frequency and clinical outcomes. Linking health care claims to clinical data is a useful tool to examine routine clinical care.

Appropriateness of Diagnostic Coronary Angiography as a Measure of Cardiac Ischemia Testing in Non-Emergency Patients - A Retrospective Cross-Sectional Analysis

Background Adequate application of guidelines concerning non-invasive ischemia testing (NIIT) could avoid inappropriate invasive testing in non-emergency situations. Hardly any data exists regarding frequency and appropriateness of diagnostic coronary angiography (CA). The aim of this study was to evaluate the proportion and predictors of patients without NIIT prior to elective purely diagnostic CA without therapeutic intervention. Methods Retrospective cross-sectional analysis of insurance claims data from 2012 and 2013. Patients <18 years, acute cardiac ischemia and emergency procedures and patients insured in a managed care model were excluded from analysis. The proportion of patients with NIIT procedures (stress-ECG, transthoracic echocardiography, stress echocardiography, scintigraphy, computer tomography, heart MRI) undertaken within two months before diagnostic CA was assessed. Multiple logistic regression analysis was applied to investigate independent determinants for receiving NIIT. Findings 2714 patients were included for analysis. 37.5% (1018) did not receive any NIIT before CA. When high risk patients (patients having received therapeutic cardiac intervention within one month after or 18 months prior to diagnostic CA, n = 766) were excluded 34.3% (669) did not receive NIIT before CA. High risk status as well as >6 chronic comorbidities were independently associated with a lower proportion of NIIT (p<0.0001, OR 0.607 and p = 0.0041, OR 0.648), when additionally controlled for age, sex, language area, insurance coverage, inpatient treatment, cardiovascular medication and lower number of chronic comorbidities. Age (p<0.05, OR 1.009) and intake of oral antiplatelet therapy (p<0.0001, OR 1.914) were independently associated with a higher proportion of NIIT when controlled for the mentioned cofactors. Conclusions Our data show that despite the existence of guidelines a substantial overuse of a potentially harmful and inappropriate diagnostic intervention is performed suggesting the need for improvement of diagnostic pathways prior to invasive testing.

Health Care Utilization and Expenditures in Persons Receiving Social Assistance in 2012 Evidence From Switzerland

Introduction: Lower socioeconomic position and measures of social and material deprivation are associated with morbidity and mortality. These inequalities in health among groups of various statuses remain one of the main challenges for public health. The aim of the study was to investigate differences in health care use and costs between recipients of social assistance and non-recipients aged 65 years and younger within the Swiss healthcare system. Methods: We analyzed claims data of 13 492 individuals living in Bern, Switzerland of which 391 received social assistance. For the year 2012, we compared the number of physician visits, hospitalizations, prescribed drugs, and total health care costs as covered by mandatory health insurance. Linear and logistic adjusted regression analyses were made to estimate the effect of receipt of social assistance on health service use and costs. Results: Multivariate linear regression analysis revealed that health care costs increased on average by 1 666 CHF if individuals received social assistance. Recipients of social assistance had on average 1.2 more ambulatory consultations than non-recipients and got 1.65 more different medications prescribed as compared to non-recipients. The chance for recipients of social assistance to be hospitalized was almost twice that of non-recipients (Odds Ratio 1.96, 95% confidence interval 1.49-2.59). Conclusions: Recipients of social assistance demonstrate an exceedingly high use of health services. The need for interventions to alleviate the identified inequalities in health and health care needs is obvious.

Glucocorticoids and the Risk of Peptic Ulcer Bleeding: Case–Control Analysis Based on Swiss Claims Data

IntroductionControversy exists as to whether glucocorticoids (GC) are ulcerogenic per se and may thus cause peptic ulcer bleeding (PUB) independent of concomitantly prescribed nonsteroidal anti-inflammatory drugs (NSAIDs).ObjectiveTo investigate the association between GC use and PUB with or without co-medication with NSAIDs.MethodsWe conducted a case–control study using administrative claims data from the Swiss health insurance company Helsana. We identified 1191 cases with incident PUB between 2012 and 2016 and matched up to 10 PUB-free controls to each case on age, sex, region and number of years insured with Helsana. We compared prior GC exposure between cases and controls using multivariate conditional logistic regression analyses controlling for several potential confounders. Patients with or without concomitant NSAID exposure were analysed separately.ResultsPatients with prior exposure to both GC and NSAIDs were five times more likely to experience PUB than patients who neither used GC nor NSAIDs (adjusted odds ratio [adj. OR] 4.80, 95% CI 3.55–6.71). Although the risk of PUB among patients who used NSAIDs without GC was increased threefold (adj. OR 3.20, 95% CI 2.59–3.95), we observed only a moderately increased risk among patients who used GC alone without NSAIDs (adj. OR 1.63, 95% CI 1.20–2.42).ConclusionsThe use of NSAIDs with or without GC was associated with a markedly higher risk of PUB compared with GC monotherapy. Use of GC alone was associated with a moderately increased risk of PUB, which might be causal or attributed to confounding by indication.

How does hospitalization affect continuity of drug therapy: an exploratory study

Introduction Transitions between different levels of health care, such as hospital admission and discharge, pose a significant threat to the quality and continuity of medication therapy. This study aims to explore the role of hospitalization on medication changes as patients are transferred from and back to ambulatory care. Methods Secondary analysis of claims data from Swiss residents with basic health insurance at the Helsana Group was performed. We evaluated medication invoices of patients who were hospitalized in a Swiss private hospital group in the year 2013. Medication changes were defined as discontinuation, new prescription, or change in the Anatomical Therapeutic Chemical (ATC) Classification System level 4, which is equivalent to a change in the chemical/therapeutic/pharmacological subgroup. Multiple Poisson regression analysis was applied to evaluate whether medication change was predicted by socioeconomic or clinical patient characteristics or by a system factor (physician dispensing of medication allowed in canton of residence). Results We investigated a total of 10,123 hospitalized patients, among whom a mean number of 3.85 (median 3.00) changes were identified. Change most frequently affected antihypertensives, analgesics, and antirheumatics. If patients were enrolled in a managed care plan, they were less likely to undergo changes. If a patient resided in a canton, in which physicians were allowed to dispense medication directly, the patient was more likely to experience change. Conclusion There is considerable change in medication when patients shift between ambulatory and inpatient health care levels. This interruption of medication continuity is in part desirable as it responds to clinical needs. However, we hypothesize that there is also a significant proportion of change due to unwarranted factors such as financial incentives for change of products.

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

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

Perinatal mental disorders in Switzerland: prevalence estimates and use of mental-health services

BACKGROUND Perinatal mental disorders (PMDs) are the most common complication of pregnancy and the first postpartum year. Since PMD prevalence and use of mental-health services by perinatal women in Switzerland are unknown, we analysed existing health statistics. METHODS We used statistics from a large health insurance company, hospitals and freelance midwives. We assessed the annual rates of mental-healthcare use in perinatal women (n = 13 969). We ascertained the annual rates of PMD treatment in obstetric inpatients (n = 89 699), and annual rates of PMD records by freelance midwives (n = 57 951). In 15 104 women who gave birth in 2012 or 2013, we assessed use of mental healthcare before and during pregnancy, and in the postpartum year. For the same sample, we determined proportions of medication and consultation treatments. We used multiple regression analysis to estimate the influence of PMD on overall healthcare costs of mandatory health insurance. RESULTS The annual rate of mental-healthcare use by perinatal women was 16.7%. The annual rate of PMD treatment in obstetric inpatients was 1.1%. The annual rate of PMD records in the midwifery care setting was 2.9%. Women with PMD use mental health services mainly in non-obstetric outpatient settings. Medication was the most frequent treatment. Primary care providers and mental health specialists contributed almost equally to consultation treatments. PMD during pregnancy raised overall costs of healthcare in the postpartum year by 1214 Swiss francs. CONCLUSIONS Health-system research and perinatal healthcare should take into consideration the high prevalence of PMD. Real PMD prevalence may be even higher than our data suggest and could be assessed with a survey using our model of PMD prevalence.