Swiss Medical Board Research Articles

Cost-effectiveness analysis of statins in primary care: results from the Arteris cohort study

The Swiss Federal Office of Public Health performed a health technology assessment regarding statins in primary care. The chosen models may lead to a situation where a clinically indicated statin therapy is estimated not to be cost effective. We performed a cohort study regarding cardiovascular events, comparing SCORE and AGLA risk categories with tertiles of carotid plaque burden and used two models for cost-effectiveness analysis of high-potency statins. Subjects (n = 2842) were followed up for 5.9 ± 2.9 years with the occurrence of 154 cardiovascular events (extrapolated 10-year risk was 9.2%). Carotid plaque imaging (total plaque area, TPA) significantly improved cardiovascular risk prediction compared with AGLA and SCORE for event-free survival prediction, test accuracy (discrimination) and calibration. Discrimination was significantly improved by about 4% with the inclusion of TPA. Cost-effectiveness analysis using quality-adjusted life years (QALYs) and sensitivity analyses (based on 16 models) ranged between CHF 144,496 and −128,328 per QALY. Cost-effectiveness analysis using direct and indirect costs showed that a treat-them-all strategy in the Swiss population would be cost effective with a return-on-investment per patient in 10 years of between CHF 4442 and 19,059, and the use of carotid imaging was also cost effective (incremental cost-efficiency ratio −2.97 to −7.86). Carotid ultrasound significantly improved cardiovascular risk stratification and is cost effective. The Swiss Medical Board QALY model presents several drawbacks, which are shown in our sensitivity analysis, where results vary considerably and are not useful for clinical decision making. A “treat them all” strategy with statins in the Swiss population aged 30–65 years may be cost effective, when indirect costs of avoidable cardiovascular events are included, even at an unacceptably low value of a statistical life year.

From facts to arguments: A study of the 2014 Swiss controversy over systematic mammography screening

ObjectiveThe Swiss Medical Board (SMB) has recently revived the controversy over mammography screening by recommending to stop the introduction of new systematic mammography screening programs. This study aimed to examine the Swiss media coverage of the release of the SMB report. MethodsThe dataset consisted of 25 newspaper and “medical magazine” articles, and TV/radio interviews. The analytic approach was based on argumentation theory. ResultsAuthority and community arguments were the most frequent types of arguments. With respect to authority arguments, stakeholders for instance challenged or supported the expertise of the SMB by referring to the competence of external figures of authority. Community arguments were based on common values such as life (saved thanks to systematic mammography screening) and money (costs associated with unnecessary care induced by systematic mammography screening). ConclusionThe efficiency of mammography screening which was the key issue of the debate appeared to be largely eluded, and the question of what women should do endures. Practice implicationsWhile interpersonal and interprofessional communication has become a major topic of interest in the medical community, it appears that media communication on mammography screening is still rather ineffective. We call in particular for a more fact-based discussion.

Medical costs per QALY of statins based on Swiss Medical Board assumptions

Aims: The Swiss Medical Board (SMB) recommends statins in primary care, if risk for coronary death or noncoronary vascular death (SCORE) is above 7.5% in 10 years, because cost per quality-adjusted life years (cost/QALY) is CHF 210 279 over 5 years. Rationale and effect require further examination.

Short Report: Health Technology Assessment (HTA) in Switzerland. The history and work of the Swiss Medical Board (SMB)

Short Report: Health Technology Assessment (HTA) in Switzerland. The history and work of the Swiss Medical Board (SMB)

Recommendations for management of dyslipidemia in 2016 in Switzerland

Discordance between American guidelines and the "Swiss medical Board" position regarding treatment of dyslipidemia raised many questions. While benefits of statins are clear in secondary prevention, care should be individualised according to PROCAM cardiovascular risk score adapted to Switzerland in primary prevention. Lifestyle modification should be the first line therapy and a drug therapy is an option in high or intermediate risk, but not anymore in low cardiovascular risk. Familial dyslipidemia, often identified only after first cardiovascular event, should not be missed, as particular care is needed and riskscores cannot be used in this situation. Statins adverse effects remain a challenge in daily clinical practice.

Impact evaluation of Swiss Medical Board reports on routine care in Switzerland: a case study of PSA screening and treatment for rupture of anterior cruciate ligament.

Evidence-based recommendations play an important role in medical decision-making, but barriers to adherence are common. In Switzerland, the Swiss Medical Board (SMB) publishes evidence reports that conclude with recommendations. We assessed the impact of two SMB reports on service provision (2009: Recommendation of conservative treatment as first option for rupture of the anterior cruciate ligament of the knee; 2011: Recommendation against PSA screening for prostate cancer). We performed an observational study and assessed quantitative data over time via interrupted times series analyses. The primary outcome was the quarterly number of performed prostate-specific antigen (PSA) tests and the annual rates of surgical ACL repair in patients with ACL rupture. Data were adjusted for time trends and relevant confounders. We analysed PSA tests in 662,874 outpatients from 2005-2013 and treatment data in 101,737 patients with knee injury from 1990-2011. For the number of PSA tests, the secular trend before the intervention showed a continuous but diminishing increase over time. A statistically significant reduction in tests was estimated immediately after the intervention, but a later return to the trend before the intervention cannot be ruled out. The rate of surgical ACL repair had already declined after the late 1990s to about 55% in 2009. No relevant additional change emerged in this secular trend after the intervention. Despite some evidence of a possible change, we did not find a sustained and significant impact of SMB recommendations in our case study. Further monitoring is needed to confirm or refute these findings.

Swiss Medical Board Mammography screening predictions for Switzerland: importance of time-periods.

In 2013, the Swiss Medical Board (SMB) concluded that for three breast cancer screens over 13 years in Switzerland, cost-effectiveness was negative, with no additional benefits in quality-adjusted life-years gained. We compared these suggested predicted effects with other estimates. We used an extensively validated model on the natural history of breast cancer in Switzerland, comparing a 13-year time frame, a life-time perspective, and a continuous screening programme, per 10,000 Swiss women. Both approaches used the Swedish randomized controlled trials for the theoretical effect. Over 13 years, both approaches yield comparable life-years gained (56 versus 67), but in expectation in 10,000 women's lifetimes 444 life-years are gained, and in a continuous screening programme (instead of three screens) 839 years. The SMB estimate of 56 life-years gained is counterweighted by 57 negative quality of life adjusted years, primarily resulting from a 5% annual loss for 10% of women, being false-positive results. International literature is consistent with more than four times lower losses on false-positives. The estimate of overdiagnosed cases in the 13-year time frame was four times higher than in the long-term perspective. By restricting life-years gained to a 13-year time frame the SMB prediction on benefits of mammography screening is unrealistically low. Predicting long-term harms and benefits, specifically tailored to observations, regarding the clinical situation before screening commences, and possible data during a screening programme, are crucial for women, professionals, and policymakers.

Check-up examination: recommendations in adults.

Check-up examinations, or periodic health examinations (PHEs), have gained in importance during the last decades and are nowadays among the most common reasons for consultations in primary care settings. The aim of PHEs is to identify risk factors and early signs of disease, but also to prevent future illness by early intervention. Therefore, each PHE should include counselling, immunisation and physical examination according to the patient's age and gender. However, deciding whether to screen a patient and choosing the most appropriate screening method can be challenging for general practitioners. The U.S. Preventive Service Task Force (USPSTF) provides updated recommendations on different existing preventive care measures based on relevant literature review. The aim of this review is to provide an updated statement of recommendations regarding preventive care measures based mostly on the guidelines derived from the USPSTF and the Swiss Medical Board. Among the major updates, there is no recommendation anymore to routinely screen for breast cancer and prostate cancer in asymptomatic adults. Since 2013, however, the USPSTF recommends annual screening for lung cancer with low-dose CT in patients aged 55 to 80 years with a smoking history of ≥30 pack years. During PHEs, the physician should be alert to the patients' hidden agendas, which are the reason for one third of all consultations in primary care.

Comment on: ‘Screening’ for Breast Cancer: Misguided Research Misinforming Public Policies, by O. S. Miettinen

AbstractOur commentary of the article “‘Screening’ for Breast Cancer: Misguided Research Misinforming Public Policies” has two main parts. First we address some of the methodological points raised by Professor Miettinen. Then we review more specific aspects of the Swiss Medical Board statement on mammography screening for early detection of breast cancer.

Swiss Medical Board

Swiss Medical Board

Swiss Medical Board

Swiss Medical Board

Lessons from the Swiss Medical Board recommendation against mammography screening programs.

Lessons from the Swiss Medical Board recommendation against mammography screening programs.

Abolishing Mammography Screening Programs? A View From the Swiss Medical Board

This article discusses the results and implications of the recently published findings of the Swiss Medical Board Panel on the benefits and harms of mammography screening programs. The Board was established by regional ministers of public health. Two of its members, a medical ethicist and a clinical epidemiologist, prepared this report. Other members were a clinical pharmacologist, an oncologic surgeon, a nurse scientist, a lawyer, and a health economist. The Board’s members were unbiased in that they were not part of consensus-building efforts by proponents of breast cancer screening. When they undertook this task, the panel was well aware of the controversy in the last 10 to 15 years on this issue. As they examined the available evidence on the overall benefits of screening, both data supporting the value of screening mammography and data that did not, the panel had a number of concerns. Their first concern was whether the modest benefits of screening found in several trials published between 1963 and 1991 would be found in a trial conducted today. And if there are benefits, do the harms of screening outweigh any benefit? The authors discussed the findings of the Canadian National Breast Cancer Screening Study, which earlier this year published its 25-year follow-up study of patients who had regular screening mammography. The data showed that repeat mammography with subsequent biopsies led to overdiagnosis of breast cancers that would never have become clinically apparent. Cancers were detected in 484 of the 44,925 healthy women who were regularly screened. Twenty-two percent of screen-detected cancers were overdiagnosed and received needless surgery, radiation, chemotherapy, and various combinations of these interventions. Another study, a Cochrane review of 10 trials involving more than 600,000 women, found no evidence for a beneficial effect of mammography screening on overall breast cancer mortality. The Board also noted a marked discrepancy between the perceptions of 50-year-old women in the United States on the benefits of screening and the most likely expected benefits. More than 70% of women in a large sample believed that mammography every 2 years starting at age 50 years reduced the risk of breast cancer deaths by at least half over a 10-year period and that at least 80 deaths would be prevented per 1000 women. However, compared with women who do not undergo screening, the most likely scenario among 50-year-old women in the United States using a relative risk reduction of 20% (accepted by most cancer experts as the expected benefit of regular screening) would be prevention of only 1 breast cancer death per 1000 patients. The Board wondered how women who overestimate the benefits of mammography can make an informed decision. In summary, the Board concluded that mammography screening does not reduce the overall death rate from the disease. The modest reduction in the mortality rate from breast cancer is offset by its harms. Overdiagnosis leads to needless biopsies and harmful treatment of women without life-threatening breast cancers. Therefore, the Board recommended that (1) Switzerland should stop introducing new mammography screening programs and phase out existing ones, and (2) all systematic screening programs should be replaced with screening information and that women make individual choices. Most Swiss and American cancer experts strongly criticized the Swiss Board’s findings and recommendations. However, the authors note that it is difficult to justify from an ethical perspective any public health program that produces more harms than benefits.