Are Tumor Marker Tests Applied Appropriately in Clinical Practice? A Healthcare Claims Data Analysis.

Tumor markers (TM) are crucial in the monitoring of cancer treatment. However, inappropriate requests for screening reasons have a high risk of false positive and negative findings, which can lead to patient anxiety and unnecessary follow-up examinations. We aimed to assess the appropriateness of TM testing in outpatient practice in Switzerland. We conducted a retrospective cohort study based on healthcare claims data. Patients who had received at least one out of seven TM tests (CEA, CA19-9, CA125, CA15-3, CA72-4, Calcitonin, or NSE) between 2018 and 2021 were analyzed. Appropriate determinations were defined as a request with a corresponding cancer-related diagnosis or intervention. Appropriateness of TM determination by patient characteristics and prescriber specialty was estimated by using multivariate analyses. A total of 51,395 TM determinations in 36,537 patients were included. An amount of 41.6% of all TM were determined appropriately. General practitioners most often determined TM (44.3%) and had the lowest number of appropriate requests (27.8%). A strong predictor for appropriate determinations were requests by medical oncologists. A remarkable proportion of TM testing was performed inappropriately, particularly in the primary care setting. Our results suggest that a considerable proportion of the population is at risk for various harms associated with misinterpretations of TM test results

Current Knowledge on Factor V Leiden Mutation as a Risk Factor for Recurrent Venous Thromboembolism: A Systematic Review and Meta-Analysis.

Background Thrombophilia screening is widely done in clinical practice, and it is claimed that the extent of venous thromboembolism (VTE) recurrence risk in patients with common defects is still not fully understood. Aim We aimed to summarize data of all observational studies prospectively assessing the association of heterozygous factor V Leiden (FVL) mutation and recurrent VTE in patients with VTE, and to calculate pooled relative risks (RR), overall and in various subgroups. Methods We searched MEDLINE and EMBASE databases for cohort studies prospectively assessing VTE recurrence in patients with and without FVL mutation (PROSPERO: CRD42021182800). Data were extracted on cohort and study-level. The methodological quality was assessed using the Newcastle-Ottawa Scale (NOS). RR were calculated overall and in subgroups using a random-effects model. Results From 31 cohorts, 24 studies were finally included summarizing 13,571 patients. Heterozygous FVL mutation was identified in 2,840 individuals (21%). The methodological quality was estimated to be high in 20 studies (83%). The overall RR was 1.46 (95% CI: 1.31, 1.64), consistent across subgroups. Conclusions Pooling all high-quality epidemiological data, the risk of recurrent VTE was increased by 46% in patients with heterozygous FVL mutation. Against the background of established risk factors, the FVL mutation plays only a marginal role in the risk assessment for recurrent VTE

Screening and prevention in Swiss primary care: a systematic review

BACKGROUND AND OBJECTIVES: Prevention is a challenging area of primary care. In Switzerland, little is known about attitudes to and performance of screening and prevention services in general practice. To implement prevention services in primary care it is important to know about not only potential facilitators but also barriers. Primary care encompasses the activities of general practitioners, including those with particular interest and/or specializations (eg, pediatrics, gynecology). The aim of this study was to review all studies with a focus on prevention services which have been conducted in Switzerland and to reveal barriers and facilitators for physicians to participate in any preventive measures. METHODS: The Cochrane Library, PubMed, EMBASE and BIOSIS were searched from January 1990 through December 2010. Studies focussing on preventive activities in primary care settings were selected and reviewed. The methodological quality of the identified studies was classified according to the guidelines in the Consolidated Standards of Reporting Trials (CONSORT) statement. RESULTS: We identified 49 studies including 45 descriptive studies and four randomised controlled trials (RCTs). Twelve studies addressed the prevention of epidemics, eleven out of them vaccinations. Further studies focused on lifestyle changes, physical activity counselling, smoking cessation, cardiovascular prevention and cancer screening. Perceived lack of knowledge/training and lack of time were the most commonly stated barriers. Motivation, feasibility and efficiency were the most frequently reported supporting factors for preventive activities. The methodological quality was weak, only one out of four RCTs met the applied quality criteria. CONCLUSION: Most studies focussing on screening and prevention activities in primary care addressed vaccination, lifestyle modification or cardiovascular disease prevention. Identified barriers and facilitators indicate a need for primary-care-adapted education and training which are easy to handle, time-saving and reflect the specific needs of general practitioners. If new prevention programs are to be implemented in general practices, RCTs of high methodological quality are needed to assess their impact

The provision of out-of-hours care and associated costs in an urban area of Switzerland: a cost description study

BACKGROUND: In Switzerland, General Practitioners (GPs) play an important role for out-of-hours emergency care as one service option beside freely accessible and costly emergency departments of hospitals. The aim of this study was to evaluate the services provided and the economic consequences of a Swiss GP out-of-hours service. METHODS: GPs participating in the out-of-hours service in the city of Zurich collected data on medical problems (ICPC coding), mode of contact, mode of resource use and services provided (time units; diagnostics; treatments). From a health care insurance perspective, we assessed the association between total costs and its two components (basic costs: charges for time units and emergency surcharge; individual costs: charges for clinical examination, diagnostics and treatment in the discretion of the GP). RESULTS: 125 GPs collected data on 685 patient contacts. The most prevalent health problems were of respiratory (24%), musculoskeletal (13%) and digestive origin (12%). Home visits (61%) were the most common contact mode, followed by practice (25%) and telephone contacts (14%). 82% of patients could be treated by ambulatory care. In 20% of patients additional technical diagnostics, most often laboratory tests, were used. The mean total costs for one emergency patient contact were €144 (95%-CI: 137-151). The mode of contact was an important determinant of total costs (mean total costs for home visits: €176 [95%-CI: 168-184]; practice contact: €90 [95%-CI: 84-98]; telephone contact: €48 [95%-CI: 40-55]). Basic costs contributed 83% of total costs for home visits and 70% of total costs for practice contacts. Individual mean costs were similarly low for home visits (€30) and practice contacts (€27). Medical problems had no relevant influence on this cost pattern. CONCLUSIONS: GPs managed most emergency demand in their out-of-hours service by ambulatory care. They applied little diagnostic testing and basic care. Our findings are of relevance for policy makers even from other countries with different pricing policies. Policy makers should be interested in a reimbursement system promoting out-of-hours care run by GPs as one valuable service option

A set of four simple performance measures reflecting adherence to guidelines predicts hospitalization: a claims-based cohort study of patients with diabetes

BACKGROUND: The link between guideline adherence and outcomes is a highly demanded issue in diabetes care. We aimed to assess the adherence to guidelines and its impact on hospitalization using a simple set of performance measures among patients with diabetes. METHODS: We performed a retrospective cohort study, using health care claims data for adult patients with treated diabetes (2011-2013). Patients were categorized into three drug treatment groups (with oral antidiabetic agents [OAs] only, in combination with insulin, and insulin only). Performance measures were based on international established guidelines for diabetes care. Multivariate logistic regression models predicted the probability of hospitalization (2013) by adherence level (2011) among all treatment groups. RESULTS: A total of 40,285 patients with diabetes were enrolled in 2011. Guideline adherence was quite low: about 70% of all patients received a biannual hemoglobin A1c measurement and 19.8% had undergone an annual low-density lipoprotein cholesterol test. Only 4.8% were exposed to full adherence including all performance measures (OAs: 3.7%; insulin: 7.7%; and in combination: 7.2%). Increased guideline adherence was associated with decreased probability of hospitalization. This effect was strongest in patients using OAs and insulin in combination. CONCLUSION: Our study showed that measures to reflect physicians' guideline adherence in diabetes care can easily be calculated based on already available datasets. Furthermore, these measures are clearly linked with the probability of hospitalization suggesting that a better guideline adherence by physicians could help to prevent a large number of hospitalizations

A set of four simple performance measures reflecting adherence to guidelines predicts hospitalization: a claims-based cohort study of patients with diabetes

BACKGROUND: The link between guideline adherence and outcomes is a highly demanded issue in diabetes care. We aimed to assess the adherence to guidelines and its impact on hospitalization using a simple set of performance measures among patients with diabetes. METHODS: We performed a retrospective cohort study, using health care claims data for adult patients with treated diabetes (2011-2013). Patients were categorized into three drug treatment groups (with oral antidiabetic agents [OAs] only, in combination with insulin, and insulin only). Performance measures were based on international established guidelines for diabetes care. Multivariate logistic regression models predicted the probability of hospitalization (2013) by adherence level (2011) among all treatment groups. RESULTS: A total of 40,285 patients with diabetes were enrolled in 2011. Guideline adherence was quite low: about 70% of all patients received a biannual hemoglobin A1c measurement and 19.8% had undergone an annual low-density lipoprotein cholesterol test. Only 4.8% were exposed to full adherence including all performance measures (OAs: 3.7%; insulin: 7.7%; and in combination: 7.2%). Increased guideline adherence was associated with decreased probability of hospitalization. This effect was strongest in patients using OAs and insulin in combination. CONCLUSION: Our study showed that measures to reflect physicians' guideline adherence in diabetes care can easily be calculated based on already available datasets. Furthermore, these measures are clearly linked with the probability of hospitalization suggesting that a better guideline adherence by physicians could help to prevent a large number of hospitalizations

Prevalence, trends, and individual patterns of long-term antidepressant medication use in the adult Swiss general population

Erworben im Rahmen der Schweizer Nationallizenzen (http://www.nationallizenzen.ch)Purpose: Antidepressant use has increased in many European countries, mostly driven by longer treatment duration. The aim of this study was to provide prevalence rates of long-term users of antidepressants for the Swiss population over the last decade and to investigate associated factors for longer use. Methods: We examined the prevalence rates of individuals with at least one prescription for antidepressants using longitudinal health claims data for 2013 to 2021. We defined short- ( two years) for 2015 to 2019. We applied a binary logistic regression model to investigate the effects of population (gender, age, area of living, language, health insurance plan, and nursing home) and treatment characteristics (psychiatric or psychotherapeutic care) on long-term compared to short- and medium-term users in 2019. Results: In 2021, 9% of the Swiss population (n = 770,698) received at least one antidepressant prescription, which remained stable since 2013. In 2019, the proportion of long-term users was 57.4%, with steady increase since 2015. The proportion of medium- and short-term users has decreased. Older age, being a woman, living in an urban area, living in a nursing home, being enrolled in a standard care plan, and receiving psychiatric or psychotherapeutic care were factors positively associated with being a long-term user. Conclusion: The proportion of long-term users in Switzerland is high and steadily increasing. Given the ongoing debate about the confounding effects of relapse and withdrawal, more research is needed to investigate longer use of antidepressants that could indicate overprescribing

The Impact of COVID-19 on Mental Healthcare Utilization in Switzerland Was Strongest Among Young Females—Retrospective Study in 2018–2020

Objectives: To provide a thorough assessment of the impact of the COVID-19 pandemic on the utilization of inpatient and outpatient mental healthcare in Switzerland. Methods: Retrospective cohort study using nationwide hospital data (n > 8 million) and claims data from a large Swiss health insurer (n > 1 million) in 2018–2020. Incidence proportions of different types of psychiatric inpatient admissions, psychiatric consultations, and psychotropic medication claims were analyzed using interrupted time series models for the general population and for the vulnerable subgroup of young people. Results: Inpatient psychiatric admissions in the general population decreased by 16.2% (95% confidence interval: −19.2% to −13.2%) during the first and by 3.9% (−6.7% to −0.2%) during the second pandemic shutdown, whereas outpatient mental healthcare utilization was not substantially affected. We observed distinct patterns for young people, most strikingly, an increase in mental healthcare utilization among females aged <20 years. Conclusion: Mental healthcare provision for the majority of the population was largely maintained, but special attention should be paid to young people. Our findings highlight the importance of monitoring mental healthcare utilization among different populations

Secondary prevention of venous thromboembolism: Predictors and outcomes of guideline adherence in a long-term prospective cohort study.

Background Prevention of recurrent venous thromboembolism (VTE) is considered a main goal of VTE management. However, the extent to which physicians adhere to the recommendations from evidence-based guidelines is unknown. Aim From a large, prospective clinical cohort, we aimed to (1) quantify the adherence of treatment recommendations to evidence-based guidelines and establish its predictors, and (2) estimate its impact on clinical outcomes and costs in patients with VTE. Methods We included 6'243 consecutive patients with VTE treated at the university outpatient unit. Detailed clinical characteristics and treatment recommendations were recorded. Adherence of treatment recommendations to evidence-based guidelines at risk assessment was assessed in terms of duration of anticoagulant treatment. Data on death were obtained from the Swiss Central Compensation Office. Health care claims data recorded between 2014 and 2019 were retrieved from Helsana, one of the largest Swiss health insurance companies. Results The adherence to evidence-based guidelines was 36.1%. Among patients with non-adherence, overtreatment was present in 70.1%. Significant patient-related predictors of guideline adherence were (a) age above 50 years, (b) male sex, (c) pulmonary embolism, (d) unprovoked VTE, (e) multiple VTE, (f) laboratory tests not ordered, and (g) various cardiovascular comorbidities. Non-adherence was not significantly associated with mortality, hospitalization, admission to nursing home, and costs. Conclusions The adherence to evidence-based guidelines was low, and several unrelated predictors appeared. Although these results need to be confirmed in other settings, they highlight the need for implementation of evidence-based guidelines in clinical practice