International variations in rates of selected surgical procedures across OECD countries. Klim McPherson and Giorgia Gon

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1 rates of selected surgical procedures across OECD Klim McPherson and Giorgia Gon

2 A follow up from 28 rates of a range of medical and surgical procedures Data period 24 Report for the Foundation of Informed Medical Decision Making Maggie Scott, Klim McPherson, Ian McKenzie, Jonathan Meakins and Jeremy Fairbank Page 3

3 Reasons for National health systems face an increasing pressure to prove their efficiency and cost-effectiveness Similarly to intra-national variations, international variations for several discretionary surgical procedures seem to be driven by factors other than population structure or clinical need Recognised the importance of detecting such variation to inform health policy Page 3

4 Methods Procedures of interest: caesarean sections, hysterectomy, prostatectomy, hip replacement, and appendectomy Analysis For all OECD for which data were available Crude rates between 199 and 21 Source: the OECD Health Dataset For Australia, England, Northern Ireland, Scotland, Wales, Germany, Italy, New Zealand, Portugal, Spain, Ireland, Norway, Sweden, Denmark, Iceland and Finland. The number of considered is going to increase: Slovenia, Switzerland, (France, Canada, US?) Age and sex specific rates for 28 Source: individual databases Age standardised rates for 28 Source: individual databases Page 4

5 Explaining variations Patterns of Illness Health System Structure (Stochastic effect) Demand and Individual preferences Rate Incentive System Supply Culture Page 5

6 Crude rates per 1 population Australia Belgium Chile Denmark Finland Germany Hungary Ireland Italy Korea Mexico New Zealand Poland Slovak Republic Spain Switzerland United Kingdom Austria Canada Czech Republic Estonia France Greece Iceland Israel Japan Lux Netherlands Norway Portugal Slovenia Sweden Turkey United States Page 6

7 Caesarean per 1 live births China, 46.2% Hysterectomy (vagina only) Hip Replacement Appendectomy Page 7

8 Transurethral Prostatectomy Open (non-transurethral) Prostatectomy (All) Prostatectomy 1 times 3 times 1 times 3 times 1: Log ratio of Transurethral to Open 3 times -.5 Page 8

9 Age-specific rates per 1 population Data period around 28 Page 9

10 Age-specific rates of Caesarean Section per 1 live births below and above 4-44 (US) (US) Age-specific rates of Hysterectomy per 1 female population Italy Germany New Zealand Wales Scotland Norther Ireland England Spain Australia United States NHDS 24 Canada 24 Ireland Portugal Norway Sweden Iceland Finland Denmark Switzerland France < Page 1

11 < Transurethral Prostatectomy 2 Non Transurethral Prostatectomy Page 11

12 < Hip Replacement (female population) Hip Replacement (male population) Appendectomy (female population) Appendectomy (male population) Page 12

13 Age standardised rates per 1 population Data period around 28 Page 13

14 Australia Canada (exc Quebec) 24/5 Denmark England Finland France Germany Iceland Ireland Italy New Zealand Norther Ireland Norway Portugal Scotland Spain Sweden Switzerland United States 24 Wales Australia Canada (exc Quebec) 24/5 Denmark England Finland France Germany Iceland Ireland Italy New Zealand Norther Ireland Norway Portugal Scotland Spain Sweden Switzerland United States 24 Wales Standardised rates of Caesarean Standardised rates of Hysterectomy Approx: Approx: Page 14

15 Standardised rates of Transurethral and Open Prostatectomy 16 Approx: Transurethral 1 8 Approx: 12,7 Open Page 15

16 1 times 1 Log ratio of Transurethral to Open Prostatectomy arithmetically labelled 3 times.8 1: times.2 1 times 3 times -.2 Page 16

17 Australia Canada (exc Quebec) 24/5 Denmark England Finland France Germany Iceland Ireland Italy New Zealand Norther Ireland Norway Portugal Scotland Spain Sweden Switzerland United States 24 Wales Australia Canada (exc Quebec) 24/5 Denmark England Finland France Germany Iceland Ireland Italy New Zealand Norther Ireland Norway Portugal Scotland Spain Sweden Switzerland United States 24 Wales Females Males 18 Standardised rates of Hip replacement Approx: Standardised rates of Appendectomy Approx: Approx: 2.8 Approx: Page 17

18 Hysterectomy Page 18

19 Standardised rates of Hysterectomy: comparison with previous research (rates for 1989 are not standardised) New Zealand Scotland England 3 Australia United States Canada Denmark 2 Norway Ireland Page 19

20 Cumulative risk of Hysterectomy Italy New Zealand Wales Scotland Norther Ireland England Spain Australia % United States NHDS 24 Canada 24 Ireland Portugal Norway Sweden Iceland Finland Denmark Switzerland France Page 2

21 Extent of the variations between procedures Page 21

22 Variation between Log (standardised rates per 1, men) Males Australia Canada (exc Quebec) 24/5 Denmark 3. Greatest standard deviation Least standard deviation England Finland 2.5 Germany Iceland Ireland 2. Italy New Zealand 1.5 Norther Ireland Norway 1. Portugal Scotland Spain.5 Sweden Switzerland. Non-transurethral (open) prostatectomy Transurethral prostatectomy Prostatectomy (All) Hip replacement Appendicectomy United States 24 Wales Page 22

23 3. Greatest standard deviation Variation between Log (standardised rates per 1, women) Females Least standard deviation Australia Canada (exc Quebec) 24/5 Denmark England 2.5 Finland Germany Iceland 2. Ireland Italy New Zealand 1.5 Norther Ireland Norway Portugal 1. Scotland Spain.5 Sweden Switzerland United States 24. Hysterectomy Hip replacement Caesarean Section Appendicectomy Wales Page 23

24 Limitations Differences between health systems affect The extent to which data can be gathered Quality and comparability of the data A full understanding of the reasons for, and consequences of different utilisation rates demands a detailed understanding of the following factors that affect comparability: clinical reasons, stochastic effect, artefacts, culture (preferences), supply, health system structure, payment structure Page 24

25 Conclusions The preliminary findings support evidence from previous work on the topic There are substantial international variations in these rates but there are also striking similarities between Using these data alone, there is no way of knowing which rate is the right one, nor understand its causes Data accuracy remains a possible limitation Variations across and time are loud. It seems that elective procedures are most affected by the incentive system, individual preference as well as the health system structure; whilst, those less elective: by culture and supply These findings aim to encourage further enquiry and understanding Hypothesis should be investigated with e.g. multilevel modelling Page 25

26 Thank you Page 26

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