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Abstract
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.
- epidemiology
- organisation of health services
- protocols & guidelines
- health services administration & management
Data availability statement
Data may be obtained from a third party and are not publicly available. The data underlying this study cannot be shared publicly because they are the property of Helsana (https://www.helsana.ch/en/helsana-group), and have restricted public access on grounds of patient privacy. The data are managed by Helsana and subsets of the database are available for researchers after request and under specific conditions. Data are available from Helsana (gesundheitskompetenz@helsana.ch) for researchers who meet the criteria for access to confidential data. Helsana will consider the possibilities of the research proposal and decide to grant access if the research questions can be answered with use of the Helsana data. When requests are granted, data are accessible only in a secure environment.
This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
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- epidemiology
- organisation of health services
- protocols & guidelines
- health services administration & management
Data availability statement
Data may be obtained from a third party and are not publicly available. The data underlying this study cannot be shared publicly because they are the property of Helsana (https://www.helsana.ch/en/helsana-group), and have restricted public access on grounds of patient privacy. The data are managed by Helsana and subsets of the database are available for researchers after request and under specific conditions. Data are available from Helsana (gesundheitskompetenz@helsana.ch) for researchers who meet the criteria for access to confidential data. Helsana will consider the possibilities of the research proposal and decide to grant access if the research questions can be answered with use of the Helsana data. When requests are granted, data are accessible only in a secure environment.
Supplementary materials
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Footnotes
Contributors MS, VvW and HD developed the underlying study program. AU and HD developed study design, with support from all authors. AU, WW, CB, EB, BB did data extraction, preparation and management. WW, MS and OG developed multilevel models applied in this study. AU and WW analysed the data. AU drafted the manuscript, with major inputs from HD and MS, and contributions from all authors. All authors read and approved the final manuscript.
Funding This work was supported by the Swiss National Science Foundation (SNSF) National Research Program ‘Smarter Health Care’ (NRP 74), as part of project number 26, grant number 407440_167349.
Competing interests MS declares a grant from Helsana Insurance Group, outside the submitted work. Helsana Group provided support in the form of salaries for authors BB, EB and CB, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The other authors declare no competing interests.
Provenance and peer review Not commissioned; externally peer reviewed.
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