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Cardiovascular Disease in Switzerland – Health Care, Mortality and Geographical Pattern

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Cardiovascular Disease in Switzerland – Health Care, Mortality and Geographical Pattern Graduate School for Health Sciences University of Bern Cardiovascular disease in Switzerland – health care, mortality and geographical pattern PhD Thesis submitted by Claudia Berlin from Germany for the degree of PhD in Health Sciences (Epidemiology) Thesis advisor Prof. Dr. Marcel Zwahlen Institute of Social and Preventive Medicine Faculty of Medicine of the University of Bern Thesis co-advisor Prof. Dr. Danny Dorling School of Geography and the Environment University of Oxford, UK Accepted by the Faculty of Medicine and the Faculty of Human Sciences of the University of Bern Bern, Dean of the Faculty of Medicine Bern, Dean of the Faculty of Human Sciences TABLE OF CONTENTS ABBREVATIONS…………………………………………………………………………………………………………………………………..7 SUMMARY………………………………………………………………………………………………………………………………………….9 1 Introduction…………………………………………………………………………………………………………………………………..11 1.1 Swiss health care system……………………………………………………………………………………………………………11 1.2 Health services research…………….………………………………………………………………………………………………13 1.3 Regional variation………………………………………………………………………………………………………………………13 1.4 CVD – epidemiology, aetiology and treatment…………………………………………………………………………..14 1.4.1 Aetiology of CVD………………………………………………………………………………………………………………….14 1.4.2 Treatment of CVD………………………………………………………………………………………………………………..15 1.5 Methods and data………………………………………………………………………………………………………………………17 1.5.1 Study designs……………………………………………………………………………………………………………………….17 1.5.2 Data sources………………………………………………………………………………………………………………………..19 1.6 Geographical units and their spatial congruence………………………………………………………………………..22 1.7 Objectives of this thesis……………………………………………………………………………………………………………..25 1.8 References…………………………………………………………………………………………………………………………………26 2 Manuscripts……………………………………………………………………………………………………………………………….33 2.1 Article 1: Avoidable hospitalisations…………………………………………………………………………………………..35 2.2 Article 2: Revascularization treatment of STEMI patients..............................................................57 2.3 Article 3: The geography of end of life care cost…..…….....………………………………………………………….81 2.4 Article 4: AMI and stroke mortality vary by distance to hospital?................................................135 3 Discussion……………………………………………………………………………………………………………………………..…169 3.1 Main findings……………………………………………………………………………………………………………………………169 3.2 Strengths and limitations………………………………………………………………………………………………………….170 3.3 Implications for policy and future research……………………………………………………………..……………….171 3.3.1 Application of treatment guidelines…………………………………………………………………………………..171 3.3.2 Missing factors influencing the costs at the end of life……………………………………………………….172 3.3.3 Distance to hospital matters………………………………………………………………………………………………172 3.3.4 Supporting ambulatory care to reduce potentially avoidable hospitalisations……………………173 3.4 The data issue – opportunities and challenges in the future…………………………………………………….173 3.4.1 New Research Program “Smarter Health Care”………………………………………………………………….173 3.4.2 Available and missing data…………………………………………………………………………………………………174 3.4.3 Implementation of SwissDRG…………………………………………………………………………………………….175 3.4.4 Future research with the available data…………………………………………………………………………….176 3.5 Conclusion……………………………………………………………………………………………………………………………….176 3.6 References……………………………………………………………………………………………………………………………….178 ACKNOWLEDGEMENTS………….……………………………………………………………………………………………………….181 CURRICULUM VITAE……………………………………………………………………………………………………………………….183 LIST OF PUBLICATIONS……………………………………………………………………………………………………………………185 CONFERENCE PRESENTATIONS……………………………………………………………………………………………………….187 DECLARATION OF ORIGINALITY………………………………………………………………………………………………………189 5 6 ABBREVATIONS ACS Acute coronary syndromes AH Avoidable hospitalisations AMI Acute myocardial infarction CABG Coronary artery bypass surgery CHOP Swiss operation procedure code CPR Cardiopulmonary resuscitation CVD Cardiovascular disease DRG Diagnosis Related Groups EMS Emergency medical services EOLC End of life care HSA Hospital service area or health service area HSR Health services research ICD International Classification of Diseases MedStat Geographical region defined for the hospital discharge and hospital statistics NCDs Non-communicable diseases NSTEMI Non-ST-segment elevation myocardial infarction OECD Organisation for Economic Co-operation and Development PCI Percutaneous coronary intervention SEP Swiss neighbourhood socioeconomic position index SFSO Swiss Federal Statistical Office SNC Swiss National Cohort SNSF Swiss National Science Foundation STEMI ST-segment elevation myocardial infarction WHO World Health Organization 7 8 SUMMARY Switzerland is facing an aging population and a growing amount of patients with chronic diseases. It is crucial to display health care processes and pathways, to identify inequalities and obstacles, and to point out possibilities for improvements of the Swiss health care system (e.g. increase efficiency). The introductory part of the thesis presents a brief description of the Swiss health care system, health services research and regional variation as well as an introduction of CVD and its epidemiological key figures, aetiology and treatments. This is followed by the description of the utilized methods and data, and the objectives of this thesis. The subsequent sections present the four articles included in this thesis. The first article focuses on a small area analysis on regional variation of avoidable hospitalisations in Switzerland including density of primary care physicians and specialists, rurality and hospital supply factors as explanatory variables in the analysis. Lower rates of avoidable hospitalisations were found in areas with very high supply of primary care physicians, increased avoidable hospitalisation rates in areas with more specialists and in areas with higher proportion of rural residents. The second article aims to examine whether emergency patients with acute ST-segment elevation myocardial infarction were adequately treated, i.e. according to the treatment guidelines, in Switzerland. Results show that older and female patients were less likely to receive revascularization which suggests that the treatment guidelines may not be uniformly applied in Switzerland. Similar to the first article, also in the third article a small area analysis was performed but this time investigating regional variation in costs at the end of life. Strongest associations of cost was found with cause of death, age and language region of the decedents. The strong spatial variation of costs could only partly be explained by the included covariates. Article four aims to examine the relationship of distance to different hospital types and mortality from AMI or stroke. We found that AMI mortality in the Swiss population 30 and older and stroke mortality in those 65 and above increased with distance to central and university hospitals, while adjusting for sociodemographic and economic characteristics of the population. The presentation of the four articles is followed by a discussion, which summarizes the main findings and the strengths and limitations of the presented articles. The thesis concludes with a discussion about the challenges for policy, practice and future research. 9 10 1 Introduction This thesis is a contribution to the field of cardiovascular disease (CVD) epidemiology and health services research (HSR) in Switzerland. The four articles presented in this thesis address different research questions and utilize a wide variety of methods and data, reflecting the multidisciplinary field of health services research. This thesis first addresses the determinants of regional variations in avoidable hospitalisations in article 1. Avoidable hospitalisations are also called ambulatory-care sensitive conditions, indicating that appropriate ambulatory care can contribute to the prevention of avoidable hospitalisations. The thesis presents a study investigating avoidable hospitalisations including diabetes, hypertension and congestive heart failure. These conditions are risk factors for, or precursors or sequelae of, severe cardiovascular diseases such as acute myocardial infarction or stroke. In article 2, the application of treatment guidelines in emergency patients with acute ST-segment elevation myocardial infarction (STEMI) is examined throughout Switzerland. The analysis included several characteristics of the patients and hospitals as possible factors to induce the treatment of STEMI patients. At the end of life, health care costs often increase sharply. CVD is the number one cause of death in Switzerland and also plays a major role in the generated costs at the end of life. However, it remains unclear why health care costs differ between regions. An investigation of possible reasons for these differences is presented in the third article in this thesis. A major research focus of HSR is access to health care. Time to treatment is an important factor to prevent severe health outcomes of life-threatening diseases such as acute myocardial infarction (AMI) and stroke. The fourth article of this thesis explores geographical access to Swiss hospitals and its influence on mortality due to AMI and stroke. The following sections provide background information about the Swiss health care system, cardiovascular diseases, health services research, regional variations, the study designs and data used, and the objectives of this thesis. 1.1 Swiss health care system The Swiss health care system is considered to be among the best health care systems worldwide,
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