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Observational Study
. 2021 May 10;11(5):e044090.
doi: 10.1136/bmjopen-2020-044090.

Are weak or negative clinical recommendations associated with higher geographical variation in utilisation than strong or positive recommendations? Cross-sectional study of 24 healthcare services

Agne Ulyte  1 , Wenjia Wei  2 , Oliver Gruebner  2   3 , Caroline Bähler  2   4 , Beat Brüngger  2   4 , Eva Blozik  4   5 , Viktor von Wyl  2 , M Schwenkglenks  2 , Holger Dressel  6
Affiliations
Observational Study

Are weak or negative clinical recommendations associated with higher geographical variation in utilisation than strong or positive recommendations? Cross-sectional study of 24 healthcare services

Agne Ulyte et al. BMJ Open. .

Abstract

Objectives: When research evidence is lacking, patient and provider preferences, expected to vary geographically, might have a stronger role in clinical decisions. We investigated whether the strength or the direction of recommendation is associated with the degree of geographic variation in utilisation.

Design: In this cross-sectional study, we selected 24 services following a comprehensive approach. The strength and direction of recommendations were assessed in duplicate. Multilevel models were used to adjust for demographic and clinical characteristics and estimate unwarranted variation.

Setting: Observational study of claims to mandatory health insurance in Switzerland in 2014.

Participants: Enrolees eligible for the 24 healthcare services.

Primary outcome measures: The variances of regional random effects, also expressed as median odds ratios (MOR). Services grouped by strength and direction of recommendations were compared with Welch's t-test.

Results: The sizes of the eligible populations ranged from 1992 to 409 960 patients. MOR ranged between 1.13 for aspirin in secondary prevention of myocardial infarction to 1.68 for minor surgical procedures performed in inpatient instead of outpatient settings. Services with weak recommendations had a negligibly higher variance and MOR (difference in means (95% CI) 0.03 (-0.06 to 0.11) and 0.05 (-0.11 to 0.21), respectively) compared with strong recommendations. Services with negative recommendations had a slightly higher variance and MOR (difference in means (95% CI) 0.07 (-0.03 to 0.18) and 0.14 (-0.06 to 0.34), respectively) compared with positive recommendations.

Conclusions: In this exploratory study, the geographical variation in the utilisation of services associated with strong vs weak and negative vs positive recommendations was not substantially different, although the difference was somewhat larger for negative vs positive recommendations. The relationships between the strength or direction of recommendations and the variation may be indirect or modified by other characteristics of services. As initiatives discouraging low-value care are gaining attention worldwide, these findings may inform future research in this area.

Keywords: epidemiology; health services administration & management; organisation of health services; protocols & guidelines.

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Conflict of interest statement

Competing interests: MS declares a grant from Helsana Insurance Group, outside the submitted work. Helsana Group provided support in the form of salaries for authors BB, EB and CB, but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The other authors declare no competing interests.

Figures

Figure 1
Figure 1
Geographical variation of the healthcare services grouped by strength (A) and direction (B) of recommendations. (A) weak and strong recommendations; (B) positive and negative recommendations. Boxplots depict the interquartile range values (upper and lower hinges) and the median value. MOR, median OR.
See this image and copyright information in PMC

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