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Published on: February 8, 2022
Large regional variation in cardiac closure procedures to prevent ischemic stroke in Switzerland a population-based
Nina Stoller1,2, Maria M Wertli1,3, Alan G Haynes4
1Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
Insights
Regional variations in percutaneous patent foramen ovale (PFO) and left atrial appendage (LAA) closure procedures are high in Switzerland. Factors like sex, language, and insurance influence rates, with significant unexplained variation suggesting differing physician practices.
Area of Science:
- Cardiovascular Interventions
- Health Services Research
- Medical Device Technology
Background:
- Percutaneous closure of patent foramen ovale (PFO) and left atrial appendage (LAA) are controversial stroke prevention methods frequently used in practice.
- Understanding regional variations in these procedures is crucial for optimizing healthcare delivery and patient outcomes.
Purpose of the Study:
- To assess the regional variation in PFO and LAA closure rates across Switzerland.
- To explore potential determinants influencing these procedural variations.
Main Methods:
- A population-based analysis of Swiss hospital discharge data from 2013-2018.
- Hospital service areas (HSAs) were derived, and age-standardized procedure rates and variation indices (EQ, SCV) were calculated.
- Multilevel regression models were used to assess determinants, including demographics, socioeconomic factors, and healthcare supply.
Main Results:
- High to very high regional variation was observed for both PFO (SCV 8.3-12.3) and LAA closures (SCV 32.1).
- Women showed significantly lower rates for both procedures compared to men.
- Language area and private insurance status were associated with LAA closure rates, with 30-45% of variation remaining unexplained.
Conclusions:
- Significant regional disparities exist in PFO and LAA closure rates within Switzerland.
- Procedure rates are influenced by patient sex, language region, and insurance status.
- A substantial portion of the variation is unexplained, likely reflecting differences in physician practices.
Background:
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.
Methods:
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.
Results:
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.
Conclusions:
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.
