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Regional and temporal variation in end of life care in Switzerland

English title Regional and temporal variation in end of life care in Switzerland
Applicant Clough-Gorr Kerri
Number 139333
Funding scheme NRP 67 End of Life
Research institution University of Bern Institute of Social and Preventive Medicine (ISPM)
Institution of higher education University of Berne - BE
Main discipline Public Health and Health Services
Start/End 01.09.2012 - 31.08.2016
Approved amount 541'935.00
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Keywords (3)

Health Services Reserach; End of life care; Small area analysis

Lay Summary (German)

Lead
Die Studie untersucht die regionale Verteilung der Inanspruchnahme medizinischer Leistungen in den letzten zwölf Lebensmonaten einer sterbenden Person. Regionale Unterschiede können auf medizinische Unter- bzw. Überversorgung hindeuten.
Lay summary

Hintergrund
Untersuchungen aus mehreren Ländern zeigen, dass der Umfang medizinischer Behandlungen in der letzten Lebensphase regional erheblich variieren kann. Die unterschiedlichen Behandlungsmuster widerspiegeln nicht nur die effektiven Bedürfnisse der Patienten und deren Angehörigen, sondern sind vor allem auf eine unterschiedliche Angebotsstruktur, das heisst die unterschiedliche regionale Verfügbarkeit von Spitälern, Ärzten und Ärztinnen und Pflegeheimen zurückzuführen. Dies lässt vermuten, dass eine medizinische Fehlversorgung von Patienten besteht, die sich in einer besonders empfindlichen Lebensphase befinden.

Ziel
Im Rahmen der Studie sollen die regionale Verteilung von Behandlungen am Lebensende in der Schweiz dokumentiert und mögliche Ursachen unterschiedlicher Behandlungsmuster identifiziert werden. Für die Studie werden Einzugsgebiete von Spitälern als geographische Einheiten verwendet. Dieses Vorgehen ermöglicht eine bevölkerungsbezogene Dokumentation der regional vorhandenen Ressourcen (Anzahl Spitäler, Ärzteschaft, Geräte usw. pro 1000 Einwohner) und deren Nutzung, unabhängig von vorgegebenen administrativen oder anderen Grenzen. Mit Hilfe von Daten der Krankenversicherungen werden die Behandlungspfade im ambulanten Bereich, in Spitälern und in Alters- und Pflegeheimen während der letzten zwölf Lebensmonate von Betroffenen abgebildet. Damit können regionale Unterschiede in der Behandlungsintensität und der damit verbundenen Kosten einzelner Patienten bestimmt und im Zusammenhang mit dem regional verfügbaren Angebot von Leistungen untersucht werden.

Bedeutung
Die Resultate sollen dazu beitragen, dass die Bevölkerung auch in der letzten Lebensphase effizient und gleichberechtigt mit der bestmöglichen medizinischen Behandlung versorgt werden kann.

Direct link to Lay Summary Last update: 19.01.2017

Lay Summary (French)

Lead
Cette étude examine la répartition régionale du recours aux prestations médicales au cours des douze derniers mois de la vie de personnes décédées. Les différences régionales pourraient indiquer une prise en charge médicale excessive ou insuffisante à cette phase de la vie.
Lay summary

Contexte
Des enquêtes réalisées dans plusieurs pays montrent que l’ampleur des traitements médicaux dans la dernière phase de la vie peut varier fortement d’une région à l’autre. Les différents modèles de traitement ne reflètent pas seulement les besoins réels des patients et de leurs proches, mais surtout des différences structurelles de l’offre, c’est-à-dire des différences régionales de disponibilité des hôpitaux, médecins et établissements médico-sociaux. Cela permet de supposer que le traitement de patients se trouvant dans une phase de leur vie particulièrement sensible n’est pas toujours adéquat.

But
Il s’agit, dans le cadre de cette étude, de documenter la répartition régionale en Suisse des traitements en fin de vie et d’identifier les causes éventuelles de différences entre les modèles de traitement. L’unité géographique retenue pour cette étude est le périmètre de compétences des hôpitaux. Ce procédé permet d’opérer une documentation des ressources régionales et de leur utilisation en fonction de la population (nombre d’hôpitaux, de médecins, d’appareils, etc. pour 1 000 habitants), indépendamment des frontières administratives ou autres. Les données des assurances-maladie permettent de retracer les chemins cliniques suivis par les personnes au cours des douze derniers mois de leur vie, que ce soit dans le secteur ambulatoire, les hôpitaux, les foyers pour personnes âgées ou les EMS. Cela permettra de déterminer individuellement les différences régionales d’intensité de traitement et les coûts qui y sont liés et de les mettre en rapport avec l’offre de prestations disponible dans les régions.

Portée
Les résultats devraient contribuer à offrir aux personnes en fin de vie le meilleur traitement médical possible, tout en assurant une prise en charge efficace et en veillant à l’égalité des droits.

Direct link to Lay Summary Last update: 19.01.2017

Lay Summary (English)

Lead
This study examines regional patterns of utilising medical services by persons (now deceased) in the last 12 months of their lives. Regional differences indicate possible under- or oversupply of medical services in this phase of life.
Lay summary

In our multilevel analysis, we found substantial variation across HSAs with regard to dying in hospitals versus nursing homes among people 66 years and older in Switzerland. The results show that dying in institutions in Switzerland is not only a function of individual factors. Patients living in French-speaking part were more likely to die in hospital. Living in peri-urban areas was associated with higher probability of dying in hospital compared to urban and rural settings. There was also an association between institutional death and several healthcare supply measures. Our findings indicate that multiple factors at both the micro- and meso-levels influence dying in institutions in Switzerland. Studying geographical variation in cost of care in the last 12 months of life and assessing associations of costs with individual, regional and healthcare supply factors, we found cause of death and age of the decedent to be the most important determinants at the individual level. We found that costs varied substantially between regions and these differences were only partly explained by confounders. Measures of care supply showed no associations with costs. When we included language region, the spatial variation was reduced substantially, especially for elderly women, relevant differences between small regions remained. Results align with previous findings and point to the importance of assessing utilization and spending patterns at the local level. Analyses of the IIEC measures showed that during their last six-months of life patients who died in a hospital spent on average almost a month in the hospital. Moreover, they spent more than half of their last month of life in a hospital. Over one in four had an ICU admission in the last six months of life. IIEC measures were mainly influenced by individual-level and regional characteristics. Older age showed more regional variation of hospital LOS.

Direct link to Lay Summary Last update: 19.01.2017

Responsible applicant and co-applicants

Employees

Publications

Publication
Measuring intensity of end of life care: a systematic review.
Luta Xhyljeta, Maessen Maud, Egger Matthias, Stuck Andreas E, Goodman David, Clough-Gorr Kerri M (2015), Measuring intensity of end of life care: a systematic review., in PloS one, 10(4), 0123764-0123764.
Place of death and health care utilization for people in the last 6 months of life in Switzerland: a retrospective analysis using administrative data
Reich O Signorell A Busato A. (2013), Place of death and health care utilization for people in the last 6 months of life in Switzerland: a retrospective analysis using administrative data, in BMC Health Serv Res, 2013 Mar (13:116), 1-10.
Dying among older adults in Switzerland: who dies in hospital, who dies in a nursing home?
Luta Xhyljeta, Dying among older adults in Switzerland: who dies in hospital, who dies in a nursing home?, in BMC Palliative Care, 15(1), 83.
Regional Variation of Cost of Care in the Last 12 Months of Life in Switzerland: Small-Area Analysis Using Insurance Claims Data
Panczak Radek, Regional Variation of Cost of Care in the Last 12 Months of Life in Switzerland: Small-Area Analysis Using Insurance Claims Data, in Medical Care.

Collaboration

Group / person Country
Types of collaboration
Prof. D.C. Goodman, The Dartmouth Institute for Health Policy and Clinical Practice, NH USA United States of America (North America)
- in-depth/constructive exchanges on approaches, methods or results
- Publication
Dr. Klazien Matter-Wapstra, SAKK, Bern Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
- Publication
Dr. Oliver Reich, Department of Health Sciences, Helsana Insurance Group Zurich, Switzerland Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
- Publication
Dr. Andreas Schoenenberger, Geriatrics, Inspital hospital, Bern Switzerland (Europe)
- in-depth/constructive exchanges on approaches, methods or results
- Publication

Scientific events

Active participation

Title Type of contribution Title of article or contribution Date Place Persons involved
Wennberg International Collaborative 2016 Talk given at a conference What do we know about regional variation in end of life care in Switzerland? 12.06.2016 Oxford, Great Britain and Northern Ireland Luta Xhyljeta;
Assemblée de la Société Suisse de Médecine Interne Générale (SSMIG) Talk given at a conference Are Percutaneous Vertebroplasty and Kyphoplasty overused in Switzerland? Analysis of Regional Utilization Patterns. 25.05.2016 Basel, Switzerland Panczak Radoslaw;
2016 Annual SGIM Meeting Poster Regional Utilization Patterns of Percutaneous Vertebroplasty and Kyphoplasty. 14.05.2016 Florida, United States of America Panczak Radoslaw;
National Palliative Care Day 2015 Talk given at a conference The intensity of end of life care in Switzerland 02.12.2015 Bern, CH, Switzerland Maessen Maud;
GEOMED 2015 Conference Poster The geography of cost of end of life care in Switzerland 01.12.2015 Florence, Italy, Italy Panczak Radoslaw;
Swiss Public Health Conference 2015 Talk given at a conference Variation in institutional deaths in Switzerland: Dying in hospital or nursing homes? 18.10.2015 Geneva, CH, Switzerland Luta Xhyljeta;
Swiss Public Health conference 2015 Talk given at a conference The geography of cost of end of life care in Switzerland 18.10.2015 Geneva, CH, Switzerland Panczak Radoslaw;
Swiss Public Health Conference 2015 Talk given at a conference The intensity of end of life care in Switzerland 18.10.2015 Geneva, CH, Switzerland Maessen Maud;
European Public Health Conference 2015 Poster Variation in institutional deaths in Switzerland: Dying in hospital or nursing homes? 01.10.2015 Milan, Italy, Italy Luta Xhyljeta;
Wennberg International Collaborative 2015 Poster Variation in institutional deaths in Switzerland: Dying in hospital or nursing homes? 01.09.2015 London, UK, Great Britain and Northern Ireland Luta Xhyljeta;
7th European Public Health Conference 2014 Poster Variation in mental health care use at the end of life 19.11.2014 Glasgow, Scotland , Great Britain and Northern Ireland Luta Xhyljeta;
Wennberg International Collaborative 2014 Talk given at a conference Variation in mental health care use at the end of life 19.09.2014 London, UK, Great Britain and Northern Ireland Luta Xhyljeta;
Wennberg International Collaborative 2014 Talk given at a conference Regional variation in end of life care costs in Switzerland 19.09.2014 London, UK, Great Britain and Northern Ireland Panczak Radoslaw;
Swiss Public Health Conference 2014 Talk given at a conference Variation in mental health care use at the end of life 21.08.2014 Geneva, CH, Switzerland Luta Xhyljeta;
World Research congress of the European association for palliative care 2014 Talk given at a conference Measuring treatment intensity at the end of life: A systematic review 05.06.2014 Lleida, Spain, Spain Maessen Maud;


Awards

Title Year
Best Presentation National Palliative Care Day 2015 2015

Abstract

BackgroundPrevious research has documented consistent and wide variation in frequency of use of hospitals, intensive care units, hospices and physicians visits for seriously ill and dying patients. Such variations are of concern as high rates may represent excessive levels of unnecessary care and low rates underutilization of necessary care. Own preliminary analyses of hospital discharges indicate striking regional disparities in the intensity of care for terminally ill patients who died in Swiss acute care hospitals during 2003-2007. The goal of this project is to identify sources of undesired variation in end of life care amenable to societal interventions. The following hypotheses are formulated:1. There is variation of in-hospital mortality and the associated costs across regions and across different settings of end of life care delivery in Switzerland.2. There is variation across regions and across different settings of care in referring patients before death from ambulatory care to hospitals and from hospitals to non-acute inpatient care institutions.3. There is variation across regions and across different settings of care in overall end of life treatment intensity. 4. There is variation across regions and across different settings of care in overall costs and structure of costs associated with end of life care.MethodsThe basic design of the study is a retrospective cohort of decedents who died between 2008-2011 and the analysis of factors that influence volume and costs of care during the last 12 months of life of this cohort. We will use two main approaches to test our hypotheses. The first approach adopts a health systems perspective and is based on Hospital Service Areas of Swiss acute care hospitals. These areas will be used to quantify regional disparities and temporal variation of end of life care in hospitals and other care providers. The second approach adopts the perspective of individual patients and aims to discriminate between supply factors and patient level determinants of care intensity for terminally ill patients. Patterns and volume of referring patients between ambulatory care, hospitals and non-acute inpatient care institutions will be used to develop and validate indicators of treatment intensity. The project is based on large administrative datasets obtained from federal institutions and Swiss health insurers. The statistical analysis of spatial variation across different settings of care will be performed by using multilevel models. Linking data of various settings of care i.e. ambulatory care, acute and non-acute inpatient care and community based services will provide a large data base allowing a comprehensive description of care for persons in the last months of life in Switzerland. The expected results will support an evidence-based approach to end of life care in the seting of the Swiss health system. Such information is essential to inform policies aiming to increase the efficiency our health system while maintaining its high quality.
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