Variation in regional implantation patterns of cardiac implantable electronic device in Switzerland

Abstract

Introduction There is a substantial geographical variation in the rates of pacemaker (PM), implantable cardioverter defibrillator (ICD), and cardiac resynchronization therapy (CRT) device implantation across European countries. We assessed the extent of regional variation and potential determinants of such variation. Methods We conducted a population-based analysis using discharge data for PM/ICD/CRT implantations from all Swiss acute care hospitals during 2013–2016. We derived hospital service areas (HSA) by analyzing patient flows. We calculated age- and sex-standardized rates and quantified variation using the extremal quotient (EQ) and the systemic component of variation (SCV). We estimated the reduction in variance of crude implantation rates across HSAs using multilevel regression models, with incremental adjustment for age and sex, language, socioeconomic factors, population health, diabetes mellitus, and the density of cardiologists on the HSA level. Results We analyzed implantations of 8129 PM, 1461 ICD, and 1411 CRT from 25 Swiss HSAs. The mean age- and sex-standardized implantation rate was 29 (range 8–57) per 100,000 persons for PM, 5 (1–9) for ICD, and 5 (2–8) for CRT. There was a very high variation in PM (EQ 7.0; SCV 12.6) and ICD (EQ 7.2; SCV 11.3) and a high variation in CRT implantation rates (EQ 3.9; SCV 7.1) across HSAs. Adjustments for age and sex, language, socioeconomic factors, population health, diabetes mellitus, and density of cardiologists explained 94% of the variance in ICD and 87.5% of the variance in CRT implantation rates, but only 36.3% of the variance in PM implantation rates. Women had substantially lower PM/ICD/CRT implantation rates than men. Conclusion Switzerland has a very high regional variation in PM/ICD implantation and a high variation in CRT implantation rates. Women had substantially lower implantation rates than men. A large share of the variation in PM procedure rates remained unexplained which might reflect variations in physicians’ preferences and practices.

Large regional variation in cardiac closure procedures to prevent ischemic stroke in Switzerland a population-based small area analysis

“…Although women have a lower age-adjusted incidence of atrial fibrillation than men [ 68 ], women with atrial fibrillation have a 31% higher stroke risk and a higher mortality than men [ 71 , 72 ]. It is established that women are less likely to undergo electrical cardioversion and catheter ablation of atrial fibrillation than men [ 73 , 74 ] and had a substantially lower implantation rate in cardiac implantable electronic devices [ 75 ], raising the possibility of referral bias against these interventions in women [ 76 ]. Thus, our finding of substantially lower LAA closure rates in women warrants further studies to elucidate the underlying reasons for this disparity.…”

“…French/Italian speaking areas had a 63% lower LAA closure rate than Swiss German regions, possibly due to more conservative physician practice styles in these areas. We previously found lower rates of other preference-sensitive interventions in the French/Italian speaking regions of Switzerland, including cardiac implantable electronic devices, vertebroplasty, hysterectomy, and joint arthroplasty [ 34 , 36 , 54 , 75 ]. We also found an 86% higher LAA rate in regions with a higher prevalence of (semi)private insurance, raising the question whether additional insurance (which results in higher physician fees) may induce overtreatment.…”

Heart Failure and Cardiac Device Therapy: A Review of Current National Institute of Health and Care Excellence and European Society of Cardiology Guidelines

“…38 The variations in CIED implantation rates across Europe have been reviewed previously, and socioeconomic factors are often touted as the main contributors to these disparities. [46][47][48] For example, the UK and Germany have a similar GDP per capita (US$47,508 versus US$51,238, respectively), but the UK's health spending was 39% less per head than in Germany between 2010 and 2019. 49,50 Adoption of guidelines is the second leading factor, where cultural, economic and epidemiological obstacles impact implementation.…”