Systematic Component Of Variation Research Articles

Identifying potentially low value surgical care: A national ecological study in England.

High variation in clinical practice may indicate uncertainty and potentially low-value care. Methods to identify low value care are often not well defined or transparent and can be time intensive. In this paper we explore the usefulness of variation analysis of routinely-collected data about surgical procedures in England to identify potentially low-value surgical care. This is a national ecological study using Hospital Episode Statistics linked to mid-year population estimates and indices of multiple deprivation in England, 2014/15-2018/19. We identified the top 5% of surgical procedures in terms of growth in standardised procedure rates for 2014/15 to 2018/19 and variation in procedure rates between clinical commissioning groups as measured by the systematic component of variance (SCV). A targeted literature review was conducted to explore the evidence for each of the identified techniques. Procedures without evidence of cost-effectiveness were viewed as of potentially low value. We identified six surgical procedures that had a high growth rate of 37% or more over 5years, and four with higher geographical variation (SCV >1.6). There was evidence for two of the 10 procedures that surgery was more cost-effective than non-surgical treatment albeit with uncertainty around optimal surgical technique. The evidence base for eight procedures was less clear cut, with uncertainty around clinical- and/or cost-effectiveness. These were: deep brain stimulation; removing the prostate; surgical spine procedures; a procedure to alleviate pain in the spine; surgery for dislocated joints due to trauma and associated surgery for traumatic fractures; hip joint replacement with cemented pelvic component or cemented femoral component; and shoulder joint replacement. This study demonstrates that variation analysis could be regularly used to identify potentially low-value procedures. This can provide important insights into optimising services and the potential de-adoption of costly interventions and treatments that do not benefit patients and the health system more widely. Early identification of potentially low value care can inform prioritisation of clinical trials to generate evidence on effectiveness and cost-effectiveness before treatments become established in clinical practice.

Regional variation and temporal trends in transcatheter and surgical aortic valve replacement in Switzerland: A population-based small area analysis.

Aortic valve stenosis (AS) is the most common valvular heart disease and if severe, is treated with either transcatheter (TAVR) or surgical aortic valve replacement (SAVR). We assessed temporal trends and regional variation of these interventions in Switzerland and examined potential determinants of geographic variation. We conducted a population-based analysis using patient discharge data from all Swiss public and private acute care hospitals from 2013 to 2018. We generated hospital service areas (HSAs) based on patient flows for TAVR. We calculated age-standardized mean procedure rates and variation indices (extremal quotient [EQ] and systematic component of variation [SCV]). Using multilevel regression, we calculated the influence of calendar year and regional demographics, socioeconomic factors (language, insurance status), burden of disease, and number of cardiologists/cardiovascular surgeons on geographic variation. Overall, 8074 TAVR and 11,825 SAVR procedures were performed in 8 HSAs from 2013 to 2018. Whereas the age-/sex-standardized rate of TAVR increased from 12 to 22 procedures/100,000 persons, the SAVR rate decreased from 33 to 24 procedures during this period. After full adjustment, the predicted TAVR and SAVR rates varied from 12 to 22 and 20 to 35 per 100,000 persons across HSAs, respectively. The regional procedure variation was low to moderate over time, with a low overall variation in TAVR (EQ 1.9, SCV 3.9) and SAVR (EQ 1.6, SCV 2.2). In multilevel regression, TAVR rates increased annually by 10% and SAVR rates decreased by 5%. Determinants of higher TAVR rates were older age, male sex, living in a German speaking area, and higher burden of disease. A higher proportion of (semi)private insurance was also associated with higher TAVR and lower SAVR rates. After full adjustment, 10.6% of the variance in TAVR and 18.4% of the variance in SAVR remained unexplained. Most variance in TAVR and SAVR rates was explained by language region and insurance status. The geographic variation in TAVR and SAVR rates was low to moderate across Swiss regions and largely explained by differences in regional demographics and socioeconomic factors. The use of TAVR increased at the expense of SAVR over time.

Large regional variation in cardiac closure procedures to prevent ischemic stroke in Switzerland a population-based small area analysis.

Percutaneous closure of a patent foramen ovale (PFO) or the left atrial appendage (LAA) are controversial procedures to prevent stroke but often used in clinical practice. We assessed the regional variation of these interventions and explored potential determinants of such a variation. We conducted a population-based analysis using patient discharge data from all Swiss hospitals from 2013-2018. We derived hospital service areas (HSAs) using patient flows for PFO and LAA closure. We calculated age-standardized mean procedure rates and variation indices (extremal quotient [EQ] and systematic component of variation [SCV]). SCV values >5.4 indicate a high and >10 a very high variation. Because the evidence on the efficacy of PFO closure may differ in patients aged <60 years and ≥60 years, age-stratified analyses were performed. We assessed the influence of potential determinants of variation using multilevel regression models with incremental adjustment for demographics, cultural/socioeconomic, health, and supply factors. Overall, 2574 PFO and 2081 LAA closures from 10 HSAs were analyzed. The fully adjusted PFO and LAA closure rates varied from 3 to 8 and from 1 to 9 procedures per 100,000 persons per year across HSAs, respectively. The regional variation was high with respect to overall PFO closures (EQ 3.0, SCV 8.3) and very high in patients aged ≥60 years (EQ 4.0, SCV 12.3). The variation in LAA closures was very high (EQ 16.2, SCV 32.1). In multivariate analysis, women had a 28% lower PFO and a 59% lower LAA closure rate than men. French/Italian language areas had a 63% lower LAA closure rate than Swiss German speaking regions and areas with a higher proportion of privately insured patients had a 86% higher LAA closure rate. After full adjustment, 44.2% of the variance in PFO closure and 30.3% in LAA closure remained unexplained. We found a high to very high regional variation in PFO closure and LAA closure rates within Switzerland. Several factors, including sex, language area, and insurance status, were associated with procedure rates. Overall, 30-45% of the regional procedure variation remained unexplained and most probably represents differing physician practices.

Geographic variation in the utilisation of specialist healthcare for patients with severe mental illness in Norway: a population-based registry study

PurposeThe aim of this study is to measure geographic variations in mental healthcare service utilisation among patients with severe mental illness in Norway.MethodWe analysed data from the Norwegian patient registry for 2014–2018 for patients with severe mental illness. The outcomes measured in this study were: outpatient contact, admission, bed days and total contact rates. Total contacts were calculated as the sum of observed outpatient contacts plus four times the hospital bed days for each hospital catchment area based on the Norwegian health director’s report on clinical activity and patient treatment cost. Geographic variations were measured using extreme quotient (EQ), coefficient of variation (CV) and systematic component of variation (SCV). Maps, figures, and tables were used to visualise geographic variation.ResultsThe geographic variations saw a six-fold increase in the outpatient contact rate and a three-fold increase in the admission rate between the areas with lowest rate and areas with the highest rate. However, there was low geographic variation in calculated total contact rates (Eqs. 5 − 95 =1.77). The low-level geographic variation in the total calculated contact rate was also confirmed with an SCV of less than three.ConclusionThe levels of geographic variations in the utilisation of outpatient and inpatient mental healthcare services among patients with severe mental illness are high. However, the geographic variation in total services provided by hospital catchment areas calculating the two service modalities together using their treatment cost ratio, is low. This may reflect the relatively equal performance of hospital catchment areas in terms of resource utilisation regardless which service modality they prioritise. Factors contributing to high geographic variation in individual service modalities need further investigation.

Is there variation between hospitals within each region in postoperative mortality for lung cancer surgery in France? A nationwide study from 2013 to 2020.

The practice of thoracic surgery for lung cancer is subject to authorization in France. We evaluated the performance of hospitals using 30-day post-operative mortality as a quality indicator, estimating its distribution within each region and measuring its variability between regions. All data for patients who underwent pulmonary resection for lung cancer in France (2013-2020) were collected from the national hospital administrative database. Thirty-day mortality was defined as any patient who died in hospital (including transferred patients) within the first 30 days after the operation and those who died later during the initial hospitalization. The Standardized Mortality ratio (SMR) was the smoothed, adjusted, hospital-specific mortality rate divided by the expected mortality. To describe the variation in hospital mortality between hospitals in each region, we used different commonly used indicators of variation such as coefficients of variation (CV), interquartile interval or range (IQR), extreme ratio, and systematic component of variance (SCV). In 2013-2020, 87,232 patients underwent lung resection for cancer in France. The number of deaths was 2,537, a rate of 2.91%. The median SMR of 199 hospitals was 0.99 with an IQR of 0.86 to 1.18 and a CV of 0.25. Among the regions that had the most hospitals performing lung resections for cancer, the extreme ratio was >2, which means that the maximum value is twice as high as the minimum value. The SCV between hospitals was >10 for two of these regions, which is considered indicative of very high variation. For the other regions (with few hospitals performing lung resections for cancer), the variation between hospitals was lower. Globally, the variability between regions concerning the SMR was moderate, 6% of the variance was due to differences across regions. On the contrary, the hospital volume was significantly related to the SMR (p = 0.003) with a negative linear trend, whatever the region. This work shows significant differences in the practices of the various hospitals within regions. However, overall, the variability in the 30-day mortality rate between regions was moderate. Our findings raises questions regarding the regionalization of major surgical procedures in France.

Regional practice variation in pelvic organ prolapse surgery in Tuscany, Italy: a retrospective cohort study on administrative health data

ObjectivesTo explore determinants of practice variation in both access, and quality and efficiency of surgical care for pelvic organ prolapse (POP).Design and settingA retrospective cohort study employing administrative health data...

Variations in the use of cemented implants for hip fracture repair in Nova Scotia, Canada

<h3>Background:</h3> Opinions differ on the use of a cemented versus uncemented implant for repair of femoral neck fractures. The purpose of this study was to compare variation in the use of cemented implants for patients with hip fracture in Nova Scotia, Canada. <h3>Methods:</h3> The study population was all patients who underwent primary emergency hip fracture arthroplasty in Nova Scotia between 2010/11 and 2019/20. We calculated 3 aggregate measures of variation across all hospitals: the extremal quotient (EQ) (ratio of the highest to the lowest rate of variation), the weighted coefficient of variation (WCV) (standard deviation divided by mean) and the systematic component of variation (SCV) (the between-surgeon variation, excluding the random component). Bootstrapped 95% confidence intervals (CIs) were computed. <h3>Results:</h3> Our study population included 3787 patients with hip fracture who underwent arthroplasty at 5 hospitals, of whom 2219 (58.6%, 95% CI 57.1%–60.2%) received cemented implants. The age- and sex-adjusted proportion of cemented cases ranged from 36.6% (95% CI 33.6%–40.0%) to 71.1% (95% CI 68.4%–73.8%). The highest EQ value was 30.3 (95% CI 0.0–80.0). The WCV ranged from 32.6 (95% CI 28.5–36.7) to 77.3 (95% CI 68.3–86.3). The SCV indicated very high between-surgeon variation at all hospitals. The WCV and SCV resulted in the same rankings for all hospitals, indicating consistency between the 2 measures. <h3>Conclusion:</h3> We found considerable variation across surgeons in the use of cemented implants for patients with hip fracture in Nova Scotia. Guidelines could help build consensus on this practice among surgeons.

High Level of Unwarranted Clinical Variation in the Use of Lower Extremity Revascularisation Procedures in Hungary (2013–2017)

Assessment of variations in the use of lower extremity open vascular surgical procedures (LEOPEN) and lower extremity endovascular procedures (LEENDO) across small geographic areas in Hungary from 2013 to 2017. Introduction of a new metric giving a rough estimate of unwarranted clinical variation in revascularisation practice. Spatial variation (at local administrative unit level) of referral for LEOPEN and LEENDO was evaluated through a retrospective analysis using healthcare administrative data of all beneficiaries in Hungary. The same assessment was performed for percutaneous coronary intervention in acute myocardial infarction (PCIAMI). The latter was considered a reasonable comparator (similar at risk population, well organised, guideline driven patient pathways, small room for referral discretion). Consequently, the ratio of spatial variations of LEOPEN and LEENDO to PCIAMI (as a reference) are thought to reflect unwarranted clinical variation. A total of 109 882 procedures were identified in the database (LEOPEN, LEENDO, PCIAMI) affecting 85 083 patients. While estimates of spatial variations for LEOPEN and LEENDO turned out to be high (systematic component of variation [SCV] 0.09 and 0.21, respectively), PCIAMI showed a low SCV value of 0.02. Consequently, the ratios of SCVs were SCV/SCVref = 4.67 (LEOPEN) and SCV/SCVref = 10.3 (LEENDO), indicating high levels of unwarranted clinical variation. The analysis showed that patients living in different locations of Hungary face very different odds of having lower extremity revascularisation procedures (open or endovascular). This spatial variation is thought to be related mainly to the failure in vascular service organisation. The newly introduced numerical estimate of unwarranted clinical variation may support within, and also between, system comparisons.

Regional and gender variations in appendicectomy : Nationwide small-area development of operation rates in the time series

HintergrundFrühere Analysen kleinräumiger Appendektomieraten zeigen erheblich höhere regionale Unterschiede der Operationshäufigkeiten bei Frauen als bei Männern.ZielDie Arbeit identifiziert valide Messgrößen zur Darstellung regionaler Unterschiede und analysiert geschlechtsspezifische Veränderungen der Appendektomieraten auf Landkreisebene in der Zeitreihe.Material und MethodenDatengrundlage sind die der DRG-Statistik entnommenen Appendektomiehäufigkeiten für 2014, 2016 sowie 2018 nach Geschlecht auf Landkreisebene. Die regionalen Unterschiede werden mittels der „systematic component of variation“ (SCV) berechnet und beurteilt. Die SCV ist im Vergleich zu Extrem-Ratio und Variationskoeffizient robuster gegenüber stark schwankender Nennerpopulationen. SCV-Werte über 5 geben einen Hinweis auf hohe Variationen und größer 10 auf sehr hohe Variationen.ErgebnisseBei der männlichen Population lassen sich nur geringe regionale Unterschiede der Operationsraten feststellen, die im Zeitverlauf stabil bleiben (SCV2014 = 2,1, SCV2016 = 1,8 und SCV2018 = 2,0). Bei Frauen hingegen liegt die SCV in den Jahren 2014 sowie 2016 (SCV2014 = 6,1, SCV2016 = 5,3) über 5 und sinkt 2018 auf 4,5 ab. Darstellungen als Funnel-Plot berücksichtigen höhere Streuungen der Operationsraten in Landkreisen mit niedrigen Einwohnerzahlen.DiskussionBei Frauen ist ein rückläufiger Trend in den Appendektomiehäufigkeiten zu erkennen. Unklar ist, ob dieser Trend auf einer Veränderung der Indikationsstellung oder auf einem geänderten allgemeinen Behandlungsmanagement bei einem Appendizitisverdacht beruht. Durch robuste Variationsmaße und der graphischen Aufbereitung als Funnel-Plots ist es möglich, systematisch bedingte regionale Versorgungsunterschiede von Zufallseffekten zu unterscheiden.

High Level of Unwarranted Clinical Variation in the Use of Lower Extremity Revascularisation Procedures in Hungary (2013–2017)

Assessment of variations in the use of lower extremity open vascular surgical procedures (LEOPEN) and lower extremity endovascular procedures (LEENDO) across small geographic areas in Hungary from 2013 to 2017. Introduction of a new metric giving a rough estimate of unwarranted clinical variation in revascularisation practice. Spatial variation (at local administrative unit level) of referral for LEOPEN and LEENDO was evaluated through a retrospective analysis using healthcare administrative data of all beneficiaries in Hungary. The same assessment was performed for percutaneous coronary intervention in acute myocardial infarction (PCIAMI). The latter was considered a reasonable comparator (similar at risk population, well organised, guideline driven patient pathways, small room for referral discretion). Consequently, the ratio of spatial variations of LEOPEN and LEENDO to PCIAMI (as a reference) are thought to reflect unwarranted clinical variation. A total of 109 882 procedures were identified in the database (LEOPEN, LEENDO, PCIAMI) affecting 85 083 patients. While estimates of spatial variations for LEOPEN and LEENDO turned out to be high (systematic component of variation [SCV] 0.09 and 0.21, respectively), PCIAMI showed a low SCV value of 0.02. Consequently, the ratios of SCVs were SCV/SCVref= 4.67 (LEOPEN) and SCV/SCVref= 10.3 (LEENDO), indicating high levels of unwarranted clinical variation. The analysis showed that patients living in different locations of Hungary face very different odds of having lower extremity revascularisation procedures (open or endovascular). This spatial variation is thought to be related mainly to the failure in vascular service organisation. The newly introduced numerical estimate of unwarranted clinical variation may support within, and also between, system comparisons.

Avoidable Hospitalization Trends From Ambulatory Care-Sensitive Conditions in the Public Health System in México.

ObjectivesTo estimate and identify the variations in rates of Avoidable Hospitalization for Ambulatory Care Sensitive Conditions (AH-ACSC) in public institutions of the Mexican health system during the period 2010–2017.MethodsSecondary analysis of the hospital discharge database of the Ministry of Health (MoH) from 2010 to 2017. AH for ACSC was calculated by age group and sex per 100,000. Variations per year between institutions were calculated with the extreme quotient (EQ), coefficient of variation (CV) and systematic component of variance (SCV). Adjusted AH rates were calculated by group of causes (acute, chronic and preventable by vaccination). Adjusted AH trend rates were analyzed by Join Point Regression.ResultsFor the period 2010–2017, the number of AH for ACSC decreased from 676,705 to 612,897, going from almost 13% to 10.7% of hospital discharges. There is consistency in terms of relative variance magnitude. But, with regards to SCV, the change remained constant, and in a second period of 2015–2017, high variation was observed by SCV ≥ 3. All-cause AH is diminishing in all institutions. AH rates for diabetes are the highest, but like other chronic diseases, there was a decline in the period from 2010 to 2017. The relative reduction varied from 15% for heart failure to 38% for complications from diabetes or hypertension, to 75% for angina.ConclusionsAH for ACSC is an indirect indicator of quality and access to first-level care. Variations by institutions are observed. This variation in CV and SCV across subsystems and states may be due to inequities in the provision of services. The factors that contribute to the burden of AH for ACSC in the Mexican Health System require detailed analysis.

High regional variation in prostate surgery for benign prostatic hyperplasia in Switzerland.

BackgroundAmong various treatment options for benign prostatic hyperplasia (BPH), surgical therapy is the most invasive. As Switzerland has the highest transurethral prostatectomy rate among OECD countries, we assessed the regional variation in prostate surgery for BPH and explored potential determinants of variation.MethodsWe conducted a population-based analysis using discharge data for men aged ≥40 years with transurethral or simple prostatectomy from all Swiss hospitals during 2013–2018. After excluding patients with genitourinary/prostate cancer, we derived hospital service areas (HSAs) by analyzing patient flows. We calculated age-standardized mean procedure rates and variation indices (extremal quotient [EQ] and systematic component of variation [SCV]). We estimated the reduction in variance across HSAs of prostatectomy rates in multilevel regression models, with incremental adjustment for age, regional cultural and socioeconomic factors, disease burden, density of urologists, and the time since urologists’ graduation.ResultsOverall, 44,253 prostatectomies (42,710 transurethral and 1543 simple) from 44 HSAs were analyzed. The mean age-standardized prostate surgery rate was 314 (range 166–500) per 100,000 men aged ≥40 years per year. The EQ was 3.01 and the SCV 5.53, indicating a high regional variation. In multivariate models, men aged 75–79 years had an 11.6-fold higher prostatectomy rate than those aged 50–54 years. French/Italian language areas had a 21% lower rate than Swiss German speaking areas. Socioeconomic factors, disease burden, and density of urologist/time since graduation were not associated with prostatectomy rates. After full adjustment, 80% of the variance in prostate surgery across HSAs remained unexplained.ConclusionWe found a remarkably high regional variation in prostate surgery rates for BPH within Switzerland.

Trends and regional variation in vertebroplasty and kyphoplasty in Switzerland: a population-based small area analysis

SummaryRegional variation in procedure use often reflects the uncertainty about the risks and benefit of procedures. In Switzerland, regional variation in vertebroplasty and balloon kyphoplasty rates was high, although the variation declined between 2013 and 2018. Substantial parts of the variation remained unexplained, and likely signal unequal access and differing physician opinion.PurposeTo assess trends and regional variation in percutaneous vertebroplasty (VP) and balloon kyphoplasty (BKP) use across Switzerland.MethodsWe conducted a population-based analysis using patient discharge data from all Swiss acute care hospitals for 2013–2018. We calculated age/sex-standardized mean procedure rates and measures of variation across VP/BKP-specific hospital areas (HSAs). We assessed the influence of potential determinants of variation using multilevel regression models with incremental adjustment for demographics, cultural/socioeconomic, health, and supply factors.ResultsWe analyzed 7855 discharges with VP/BKP from 31 HSAs. The mean age/sex-standardized procedure rate increased from 16 to 20/100,000 persons from 2013 to 2018. While the variation in procedure rates across HSAs declined, the overall variation remained high (systematic component of variation from 56.8 to 6.9 from 2013 to 2018). Determinants explained 52% of the variation.ConclusionsVP/BKP procedure rates increased and regional variation across Switzerland declined but remained at a high level. A substantial part of the regional variation remained unexplained by potential determinants of variation.

PNS63 A Longitudinal Study to Identify Potentially Low-Value Clinical Procedures Using Hospital Episode Statistics Linked to Deprivation and Ethnicity in England, 2014/15-2018/19

It is important that surgery is effective and good value for money. Different methods have been used to identify ‘low value’ surgical procedures for which use should be reduced or stopped; for example, reviewing current evidence/guidelines, or stakeholder consultation. We investigated whether high geographical or temporal variation in surgery rates in England might indicate uncertainty about their effectiveness or cost-effectiveness, potentially identifying them as ‘low value’. Longitudinal observational study of surgical procedures in England using Hospital Episode Statistics, 2014/15-2018/19, adjusted for age, sex, deprivation, and ethnicity using indirect standardisation. Procedures were defined by 3-character OPCS-4 codes. We highlighted surgeries in the top 5% for growth in surgery rates (2014/15-2018/19) and/or systematic component of variation (2018/19) and conducted a literature review of the evidence supporting these procedures. High temporal or geographical variation was associated with uncertainty in the evidence base: In five cases, it was unclear whether surgery was more cost-effective than non-surgical interventions (e.g. radiofrequency denervation of the facet joint); for another five procedures there was evidence that surgery is effective, but the most cost-effective method was unclear (e.g. bariatric surgery for obesity). Deep brain stimulation was recommended by NICE in particular circumstances, and there was little evidence about pressure manometry. Some observed variation was due to coding anomalies, highlighting the limitations of the OPCS system for research. Most procedures had not been previously identified as potentially ‘low value’ by other methods. Exploring temporal and geographical variation is a potential method of identifying clinical uncertainty about surgery. This type of analysis could be carried out on a regular basis to quickly identify increasing use of uncertain procedures. Early recognition could facilitate better regulation (e.g. only in trials) to generate evidence on cost-effectiveness before potentially ‘low value’ procedures become established in clinical practice.

Regional variation of lower limb major amputations on different geographic scales – a Hungarian nationwide study over 13 years

Background: The incidence of lower limb major amputations is an important healthcare quality indicator, as it reflects all efforts aimed to prevent limb loss. Analysis of within-country regional variations in incidence may reveal the sources of disparities in care. Materials and methods: Based on the data of the Hungarian healthcare beneficiary population from 2004 to 2016, the incidence of lower limb major amputations and its spatial variations was determined regionally on four levels of geographic resolution. Variability and autocorrelation were quantified on different resolutions. Results: A total of 56,468 lower limb major amputation procedures were identified in 49,528 patients over the observation period. Marked regional variations were detected at all geographic scale levels. In the case of county-level and local administrative level, the systematic component of variation was 0.03 and 0.09, respectively. Only half of the variation at local administrative level was explained by county. Conclusions: Lower limb major amputations show marked regional variations on the different geographic levels of resolution. The more granular the assessment, the higher the regional variation was. Assumingly, this observation is partially a mathematical necessity but may also be related to the different characteristics of care at a given level of spatial aggregation. The decomposition of the variance of amputation rates indicates that the potential explanatory factors contributing to spatial variability are multiple and may be interpreted on different levels of geographic resolution. Addressing the unwarranted variations and resolving the issues that contribute to high lower limb major amputation rates needs further explorative analysis.

Regional variation of hysterectomy for benign uterine diseases in Switzerland

BackgroundHysterectomy is the last treatment option for benign uterine diseases, and vaginal hysterectomy is preferred over more invasive techniques. We assessed the regional variation in hysterectomy rates for benign uterine diseases across Switzerland and explored potential determinants of variation.MethodsWe conducted a population-based analysis using patient discharge data from all Swiss hospitals between 2013 and 2016. Hospital service areas (HSAs) for hysterectomies were derived by analyzing patient flows. We calculated age-standardized mean procedure rates and measures of regional variation (extremal quotient [EQ], highest divided by lowest rate) and systematic component of variation [SCV]). We estimated the reduction in the variance of crude hysterectomy rates across HSAs in multilevel regression models, with incremental adjustment for procedure year, age, cultural/socioeconomic factors, burden of disease, and density of gynecologists.ResultsOverall, 40,211 hysterectomies from 54 HSAs were analyzed. The mean age-standardized hysterectomy rate was 298/100,000 women (range 186–456). While the variation in overall procedure rate was moderate (EQ 2.5, SCV 3.7), we found a very high procedure-specific variation (EQ vaginal 5.0, laparoscopic 6.3, abdominal 8.0; SCV vaginal 17.5, laparoscopic 11.2, abdominal 16.9). Adjusted for procedure year, demographic, cultural, and sociodemographic factors, a large share (64%) of the variance remained unexplained (vaginal 63%, laparoscopic 85%, abdominal 70%). The main determinants of variation were socioeconomic/cultural factors. Burden of disease and the density of gynecologists was not associated with procedure rates.ConclusionsSwitzerland has a very high regional variation in vaginal, laparoscopic, and abdominal hysterectomy for benign uterine disease. After adjustment for potential determinants of variation including demographic factors, socioeconomic and cultural factors, burden of disease, and the density of gynecologists, two thirds of the variation remain unexplained.

Exploring geographic variation in acute appendectomy in Ireland: results from a national registry study

ObjectiveTo explore geographic variations in Irish laparoscopic and open appendectomy procedures.DesignAnalysis based on 2014–2017 administrative hospital data from public hospitals.SettingCounties of Ireland.ParticipantsIrish residents with hospital admissions for an appendectomy as...

Regional Inequalities in Maternal and Neonatal Health Services in Iraq and Syria From 2000 to 2011

We analyze regional inequalities in access to maternal and neonatal health services in Iraq and Syria during the period 2000-2011, before the rise of the Islamic State in Iraq and Syria, ISIS. Utilizing nationally representative survey data (Iraq 2000, 2006, 2011; Syria 2006, 2009), we examine changes in the rate of babies weighed at birth and women delivering at home. We calculate 4 regional inequality indicators: (1) extremal quotient, (2) interquartile quotient, (3) coefficient of variation, and (4) systematic component of variation. Despite national improvements in both countries over time, indicators show increasing regional inequalities in access to maternal and neonatal health services, particularly in Syria between 2006 and 2009. Spatial regression results indicate that these inequalities associate with inequalities in maternal education, rurality, and wealth. Regions where women experienced deteriorating access over time, reflecting overall inequalities, are those that fell under the control of ISIS. Inequalities in access to basic services (education and health) deserve more attention in understanding social and political change in the Arab region.

Lower Extremity Amputation in Germany: Regional Analysis using Nationwide Hospital Discharge Data 2011-2015

Amputations reduce irreversibly the quality of life. Health care always aims at avoiding amputations, and the quality of such care provided nationwide should be the same. This study aims to display rates of amputations at the county level and to uncover differences in health care. Using German nationwide hospital discharge data, amputations between 2011 and 2015 were identified. Regional variation is displayed using raw and risk-standardized rates per 100,000 persons. Furthermore, the Systematic Component of Variation (SCV) was computed and Funnel Plots display the Standardized Morbidity Ratio (SMR). The median amputation rate during the observation period was 67 cases per 100,000 persons with a 6-fold variation between counties. Variation between counties remained independent of demographic differences. Higher rates got visible especially within counties in the East and Southeast. The highest systematic variation was seen in amputation heights toe/foot ray (SCV 11.8) and foot complete and mid-/forefoot (SCV 11.7). In Germany, there are significant regional variations of amputation rates at the county level. The systematic variation is strongest within peripheral amputation heights. Especially in the East and Southeast of Germany, clusters of high amputation rates give insights in the potential regional need for improvement.

A spatial analysis of geographic variation and factors associated with hospitalization for bacterial pneumonia in Korea

BackgroundThe incidence of pneumonia in Korea started to increase in the 1990’s after a period of decrease and stabilization, and the mortality and hospitalization rates for pneumonia in Korea are alarmingly high. This study was performed to examine geographic variation and factors associated with hospitalization for bacterial pneumonia in Korea.MethodsData were acquired from the inpatient claims of the 2015 period of the National Health Insurance Service. The age- and sex-standardized hospitalization rates for bacterial pneumonia were calculated for three age groups. Geographic variation was measured with the coefficient of variation, the ratio of the 90th to the 10th percentile of the distribution of rates, and the systematic component of variation. Considering the results of Moran’s I statistic which suggested spatial autocorrelation, we estimated spatial regression models using spatial error models.ResultsThe hospitalization rate for bacterial pneumonia was 79.1 per 10,000 population, and the rate was the highest in the age group 0–14 at 325.3, and it was 161.5 among the elderly. The geographic variation statistics showed high variation with the coefficient variation at 0.6. The deprivation score showed positive associations, and the number of primary care physicians had a negative association with the hospitalization rates across all age groups but the age group 0–14. The number of beds in hospitals with less than 300 beds had a positive association with the hospitalization rates for bacterial pneumonia, and the impact was the strongest in the age group 0–14.ConclusionsThe present study shows that pneumonia can be a major public health issue even in a developed country. Socioeconomic conditions can still be a concern for pneumonia in developed countries, and the role of primary care physicians in preventing hospitalization for bacterial pneumonia needs to be recognized. Most of all, the strong impact of hospital beds on the hospitalization rates for pneumonia, especially for the children, should be addressed. High disease burden of pneumonia in Korea can partly be attributable to oversupply of hospital beds. These factors should be taken into consideration in establishing policy measures for the rise in pneumonia.