Presentazione di Gianfranco Domenighetti

1. ARE THERE EVIDENCES OF
MEDICAL MISUSE
( OVERUSE / UNDERUSE )
IN SWITZERLAND ?
G.DOMENIGHETTI
Platin Symposium SSMI 2013

2. • Research specifically addressing the question
of medical practices misuse (over and
underuse) in Switzerland
• Research on health care variations addressing,
indirectly and at the macro level, medical
practices misuse in Switzerland .
• Conclusions

3. IN PUBLISHED PAPERS AND MEDLINE INDEXES,
«EVIDENCE» OF MEDICAL MISUSE (OVERUSE OR
UNDERUSE) IN SWITZERLAND IS VERY LIMITED
( ALMOST LACKING )
• Published papers and Medline indexes that are coming
from a swiss medical author or institution, relating to
medical practices carried out in Switzerand in the past
10 years : N= 77478
• MESH terms ( Health Service Misuse OR Overuse OR
Underuse OR Overprescription)
N= 11 4 ( 0.005 % )
• MESH terms ( Appropriateness OR Adequacy )
N= 51 10 ( 0.013 % )

4. These studies concern:
• For Misuse/Overuse/Underuse: N=4
Upper gastrointestinal endoscopy/ Diabetes
Care/ COPD management/ Mammography.
• For Appropriateness/Adequacy: N=10
Laminectomy/ Head CT scan/ Rabjes prophylaxis/
ICD therapy (2)/ Infliximab for Crohn`s disease/
Therapy for fistulizing Crohn’s disease/
Hysterectomy/ Venous thromboembolism
prophylaxis/ Antibiotic treatment among drug
users.

5. Hence, according to the scientific literature
published in the past 10 years, the Swiss
health care system does not seem to identify
major problems regarding «misuse» and
«appropriateness» of medical prescriptions.

6. • Consequently I could end my presentation
here and invite you to take an extra morning
coffee, even if everyone in this room knows
that the conclusions drawn from this first look
at published literature do not match the
reality of everyday medical practices.
• Just an example: screening for prostate
cancer with serum prostate specific antigen
marker (PSA).

7. ABLIN J. RICHARD
He discovered PSA in 1970
«I never dreamed that my discovery four decades ago
would lead to such a profit-driven public health
disaster. The medical community must confront reality
and stop the inappropriate use of P.S.A. screening.
Doing so would save billions of dollars and rescue
millions of men from unnecessary, debilitating
treatments. » (NYT, 9 March 2010)
OTIS BRAWLEY
Chief medical officer American Cancer Society
«With PSA screening you have 50 times more
probability to ruin your life than to save it. »
(NYT, 23 March 2009)
The Great Prostate Mistake

8. Importance of PSA test in the early detection of
prostate cancer (
Decision of 31 October 2011)
According to available data, the use of PSA as early
detection marker for prostate cancer in asymptomatic men
with no risk factors (hereditary family history) is not justified.
If PSA determination is requested by a patient with no risk
factors, the physician should give detailed information of
advantages, disadvantages and possible consequences of
testing. In this case, the costs associated to the test should
be supported by the patient and should not be regulated by
the Federal Health Care Insurance Law.

9. Prevalence of Swiss citizens who claim having had a PSA test
(by age group in 2007)
0
5
10
15
20
25
30
35
40
45
50
SOURCE: Swiss Health Survey 2007 (OFS)
%
40-49 50-59 60-69 70-79 80+
Which appropriateness? How many resources were wasted?

10. Source: Leitzmann et al. JAMA 2004
RR= 0.67 ( CI 0.51-0.89 )
- 33 %
Ejaculation: the best behavior for prostate cancer
primary prevention ?

11. RESEARCH ON VARIATIONS IN HEALTH
CARE UTILIZATION
• Analysis of variations in health care (among regions and
socio-economical groups) probably represents the best
way to address the question of misuse and over- and
underuse in the utilization and prescription of medical
services at the macro level.
• Also, variations in health care utilization raise
fundamental questions about effectiveness, efficiency,
equity and appropriateness of professional decision-
making.
• We and others have previously worked on this subject.
Unfortunately new and recent data analysis are almost
lacking.

12. Variation of knee replacement surgery in Europe
(standardized rates 2010 X 100000 inhabitants)
D rate 213
CH rate 212
Source: OCDE Health Data 2012/Eurostat Statistics Database

13. Variation of knee replacement surgery according to the
canton of residence (standardized rates 2003-2005 X 100000
inhabitants)
SOURCE: Cerboni, Domenighetti (Obsan 2010)
OVERUSE ?
UNDERUSE ?
X 2.33

14. Variation of hip replacement surgery according to the canton
of residence (standardized rates 2003-2005 X 100000
inhabitants)
OVERUSE ?
UNDERUSE ?
X 2.17
SOURCE: Cerboni, Domenighetti (Obsan 2010)

15. Variation in surgical treatment of lumbar disk disorders according
to the canton of residence (standardized rates 2003-2005 X 100000
inhabitants)
UNDERUSE ?
SOURCE: Cerboni, Domenighetti (Obsan 2010)
X 2.31
OVERUSE ?

16. Variation of coronary artery bypass graft (CABG) surgery in Switzerland
according to canton of residence. (standardized rates 2010-2011 X
1000000 inhabitants)
OVERUSE ?
UNDERUSE ?
X 3.3
Source: data provided by OBSAN (2013)

17. Variation of caesarean sections rates x 100 live births
among some countries ( 2009)
CH 32.4
NL, Fin, IS, N, S
from 14.3 to 17.1
Among Swiss Cantons
(mean 2008-2010)
ZUG JURA
Highest Lowest
OVERUSE ? UNDERUSE ?
X 2.15
Source: OFS (2012)

18. Variation of median number of hysterectomies performed in
one year according to sex of the gynecologists ( CH 1984 ).
0
10
20
30
40
MALE FEMALE
34
18
N
Source: Domenighetti, Luraschi, Marazzi. NEJM (1985)
MALE GYN. (N= 15) FEMALE GYN. (N=11)
34
18
OVERUSE ?
UNDERUSE ?
X 1.9

19. Variation of lifetime prevalence ( in % ) of some surgical procedure
according to health insurance status (Switzerland 1992-93/ Gen.pop
15-74)
0
10
20
30
40
50
60
70
80
90
100
TONSILLECTOMY APPENDECTOMY HYSTERECTOMY
Source: Bisig, Gutzwiller, Domenighetti. Swiss Surgery 1998
TONSILLECTOMY APPENDECTOMY HYSTERECTOMY
INSURANCE
BASIC
PRIVATE
SEMI-
PRIVATE
29
39
19
27
12
18
P<0.001 P<0.001 P<0.001
OVERUSE ?
UNDERUSE ?X 1.34
X 1.42
X 1.5

20. The most informed consumer of
medical services: the physician.

21. Prevalence of some elective surgical procedures in
physicians, lawyers and in gen. pop.
Tonsillectomy
( children )
P < 0.001 P< 0.01 P< 0.02
Physicians
+ wifes and
children
( N = 1522 )
General
population
( N = 2960 )
Domenighetti et al.Int J Tech Ass Health Care (1993) / Lancet (1995) for tonsillectomy.
Lawyers
+ wifes and
children
( N = 826 )
Hysterectomy Cholecyste-
ctomy
Most informed consumer-patient.
1
ODDS RATIOS
1 1
1.12
NS
0.85
NS
1.03
NS
1.46 1.58 1.84
Herniorraphy
1
1.13
NS
1.83
P< 0.05

22. Variation of outpatient antibiotic prescription in
European countries ( DDD X 1000 inhabitants per day
/ year 2002 )
22
Source: Filippini et al. Health Policy 2006
OVERUSE ?
UNDERUSE ?
X 3.55

23. Variation of outpatient antibiotic prescription in
Switzerland (DDD X 1000 inhabitants per day and canton of
residence /years 2002-4)
Source: Filippini et al. Health Policy 2006
X 2.9

24. Variation of outpatient prescription of platelet
aggregation inhibitors ( DDD X 1000 inhabitants per
day/ year 2006 )
CH TICINO
PLAVIX
ASPIRINE
OVERUSE ?
Source: Caronzolo D. (Tesi USI 2008 )
UNDERUSE ?
X 1.43

25. Variation of outpatient prescription of statins ( DDD X
1000 inhabitants per day/ year 2006 )
CH TICINO
SORTIS
OTHER STATINS
OVERUSE ?
Source: Caronzolo D. (Tesi USI 2008 )
UNDERUSE ?
X 1.5

26. Geographic variation in breast cancer care in
Switzerland
S. Essa, A. Savidana, H. Frick, Ch. Ragethc, G. Vlastosd, U. Lütolfe,
B. Thürlimannf
Considerable disparities in early detection and management of early breast
cancer were found across regions. In particular, the proportion of early
detected cancer varied from 43% in Valais to 27% in St. Gallen-Appenzell.
Mastectomy rates varied from 24% in Geneva to 38% in St. Gallen-
Appenzell and Grisons-Glarus… The use of sentinel node procedure in
patients with nodal negative disease was high in Geneva and low in
Eastern Switzerland. Differences in compliance with recommendations on
the use of endocrine therapy and chemotherapy were less pronounced but
statistically significant.
Cancer Epidemiology 2010

27. What can we learn for Switzerland from the analysis
of variations in health care utilization?
The findings presented here suggest that:
• medical overuse and underuse are well
implemented in the Swiss health care system
(given the gaps between overuse and underuse
from a factor of 1.3 to 3.3), even if it is not
possible to quantify them with certainty.
• medical practices are often based on “personal
guidelines” rather than "evidence“.
• other factors (economic incentives, conflicts of
interest, availability of technology, medical and
hospital supply density) seem to influence the
appropriateness of medical practice.

28. CONCLUSIONS
• Taking into account the scarsity of published scientific
literature from Swiss medical authors or institutions on
medical misuse (overuse and underuse), appropriateness,
adequacy and variation in health care utilization, one must
conclude that these issues are not of great interest to the
medical community in Switzerland.
• Medical profession is uncritical to practice variations.
Nevertheless it had to take responsibility for the question:
“ Which rate is right ?” Otherwise, in the current cost-
containment context, the theory of “The lowest is always
the best” will dominate by default (J.Wennberg) .

29. • Routinely collected data is of insufficient detail and
quality to allow for researching and estimating
misuse, appropriateness and variation in Switzerland
(H.Bucher) .
• Far too little resources are provided for research in
health care services in Switzerland.
• SNSF and health insurers should be embedded into a
national health services research program and
should provide substantial resources.

31. Berne, 4 Décembre 2012