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Salome Landolt,1 Thomas Rosemann,1 Eva Blozik,1,2 Beat Brüngger,2 Carola A Huber1,2 1Institute of Primary Care, University of Zürich, University Hospital Zürich, Zürich, Switzerland; 2Department of Health Sciences, Helsana Insurance Group, Zürich, SwitzerlandCorrespondence: Carola A HuberHelsana Insurance Group, P.O. 8081, Zürich, SwitzerlandTel + 41 43 340 6341Fax +41 43 340 0434Email carola.huber@helsana.chPurpose: This study aimed to give a nationwide comprehensive picture of the prevalence and prescription patterns of benzodiazepines (BZ) and Z-drugs (ZD) in Switzerland and to analyze the association with adverse health care outcomes.Patients and Methods: A population-based, cross-sectional study was conducted, using a large health insurance database in Switzerland. Records from all adult patients with ≥ 1 prescription for a benzodiazepine and/or a Z-drug in 2018 were included. We calculated the prevalence of BZ and ZD user (extrapolated to the Swiss general population), the number of prescriptions and the type of provider (among each BZ and ZD only user). Multivariate logistic regression models were performed to estimate the association between drug prescription and the risk of hospitalization in different healthcare settings.Results: Of a total of 844ʹ692 patients, 95ʹ179 had ≥ 1 BZ and/or ZD prescription in 2018. The extrapolated one-year prevalence for the general Swiss population was 8.1% for a BZ prescription, 3.5% for a ZD prescription, and 10.5% for a BZ and/or ZD prescription, and continuously increased with age. The majority of the elderly (over 65 years) had ≥ 1 prescription (BZ: 51.9%; ZD: 56.9%; BZ and/or ZD: 53.5). The proportion of patients with ≥ 6 prescriptions per year was 23.1% for BZ only user and 35.2% for ZD only user. Most patients had ≥ 1 prescription from a general practitioner. Regression models showed a higher likelihood to be admitted to acute care, psychiatry, rehabilitation, or nursing home with ≥ 1 prescription for a benzodiazepine and/or a Z-drug.Conclusion: This study is the first to give a nationwide overview of the current use of benzodiazepines and Z-drugs in Switzerland based on health insurance claims data. The results revealed a remarkably high prevalence among the general Swiss population, especially in older generations. The negative consequences of heavy BZ and ZD use are a crucial public health problem, that should be addressed.Keywords: anxiolytics, sedatives, pharmacoepidemiology, health insurance claims data

Carola A Huber,1,2 Michael Nagler,3 Thomas Rosemann,2 Eva Blozik,1,2 Markus Näpflin,1 Stefan Markun2 1Department of Health Sciences, Helsana Insurance Group, Zürich, Switzerland; 2Institute of Primary Care, University of Zürich, University Hospital Zürich, Zürich, Switzerland; 3University Institute of Clinical Chemistry, Inselspital Bern University Hospital, University of Bern, Bern, SwitzerlandCorrespondence: Carola A HuberDepartment of Health Sciences, Helsana Insurance Group, P.O. Box, 8081, Zürich, SwitzerlandTel +41 43 340 6341Fax +41 43 340 0434Email carola.huber@helsana.chBackground: Micronutrient laboratory tests (MLT) are increasing in many healthcare systems. This study assessed time trends of annual MLT incidence in the Swiss population and examined the frequency of specific MLT, defined as the number of yearly tests performed in individual persons.Methods: For annual time trends, we used a longitudinal design with a seven-year observation period (2012– 2018) and for yearly testing frequency we used a cross-sectional design (2018 only). The database consisted of nationwide insurance claims from adult persons.Results: Persons with MLT compared to persons without were older (mean age 57.1 years vs 48.6 years) and to a higher proportion female (65.1% vs 45.5%). Between 2012 and 2018, we included 6.7 million person years and found an increase in the proportion of persons receiving any MLT from 24.5% to 35.0%. Tests with strongest absolute increase during the observation period were vitamin D (from 7.4% of persons to 20.4%), vitamin B12 (from 9.0% to 17.6%) and ferritin (from 17.4% to 26.6%). In 2018, vitamin D and vitamin B12 tests were performed more than once in 4.5% and 3.3% of the population, respectively.Conclusion: We found that the Swiss population undergoes MLT with high and increasing frequency. Testing for vitamin D, vitamin B12 and ferritin is very common and of questionable appropriateness.Keywords: laboratory testing, micronutrient, claims data, trend

Eva Blozik,1,2 Caroline Bähler,1 Markus Näpflin,1 Martin Scherer3 1Department of Health Sciences, Helsana Group, Zürich, Switzerland; 2Institute of Primary Care, University of Zürich, Zürich, Switzerland; 3Department of General Practice, Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, GermanyCorrespondence: Eva BlozikDepartment of Health Sciences, Helsana Group, Post Box 8081, Zürich, SwitzerlandTel +41 58 340 7101Fax +41 58 340 03 06Email eva.blozik@helsana.chBackground: Continuity of care is positively associated with beneficial patient outcomes. Data on the level of continuity of care in the ambulatory setting in Switzerland are lacking.Aim: The aim of this study was to evaluate continuity of care in Swiss cancer patients based on routine data of mandatory health insurance using four established continuity scales.Methods: Retrospective analysis of Swiss claims data (N=23ʹ515 patients with incident use of antineoplastics). The Usual Provider Continuity score, the Modified Modified Continuity Index, the Continuity of Care index, and the Sequential Continuity Index were analyzed based on consultations with general practitioners (GPs), physician specialists and ambulatory hospital wards.Results: Using information of health insurance claims, the number of consultations and the general level of continuity of care in Swiss cancer patients are high. Continuity of care scores were significantly associated with sociodemographic and regional factors. When focusing on consultations with GPs only, all four scores consistently showed high values indicating high levels of continuity. Continuity with general practitioners was associated with lower costs and lower risks for hospitalization and death.Conclusion: This is the first study giving insight into continuity of care in Swiss cancer patients. The present study shows that continuity of care is measurable using health insurance claims data. It indicates that continuity with general practitioners is associated with a beneficial outcome.Keywords: continuity, cancer, health insurance, claims data, care, scale

Carola A Huber,1 Reto Agosti,2 Markus Näpflin,1 Eva Blozik1,31Department of Health Sciences, Helsana Insurance Group, Zürich, Switzerland; 2Headache Center Hirslanden, Hirslanden Hospital Group, Zürich, Switzerland; 3Department of Medicine, University of Medical Centre Freiburg, Freiburg, GermanyPurpose: The newly developed calcitonin gene-related peptide (CGRP) antagonists were recently launched on the US and European market, with Switzerland as the second country worldwide. To enable forthcoming comparisons with established migraine therapy, the aim of this study was to provide a comprehensive picture of migraine (prophylactic) treatment patterns. Recent data in daily clinical practice are lacking.Patients and methods: This population-based cohort study included enrollees from a Swiss Healthcare Insurance Database with at least one triptan prescription in 2015. Treatment patterns were defined by assessing subsequent triptan and prophylactic medication use (after index prescription for triptan) within the following year, divided into four quarters.Results: Triptans were used by 10,090 patients (1.3%) in 2015. Most of them used triptan only (82.6%), 12.9% changed the treatment between triptan and prophylactics, and 4.5% received both in combination within 1year. Among triptan users with ≥1 prophylactic prescription in the first quarter, 48.6% used beta-blockers (BB), 40.7% “other prophylactics than BB (eg, topiramate)”, and 10.7% “a combination of both”. Most patients who received both BB and other prophylactics in the first quarter used this drug combination continuously over all four quarters.Conclusion: This study provides comprehensive data on treatment patterns prior to the introduction of a new drug class in migraine therapy. The majority of triptan users had no prophylactic medication therapy; however, a small, but relevant group used BB and other prophylactics concurrently in all quarters. Findings quantify the population in potential need for optimized migraine therapy, ie, the potential target population of the novel CGRP-targeted drugs.Keywords: innovation, headache, migraine, preventive medication, drugs, real-world data

Caroline Bähler,1 Andri Signorell,1 Eva Blozik,1,2 Oliver Reich1 1Department of Health Sciences, Helsana Insurance Group, Zürich, Switzerland; 2Department of Medicine, University Medical Centre Freiburg, Freiburg im Breisgau, Germany Purpose: Current evidence on the care-delivering process and the intensity of treatment at the end-of-life of cancer patients is limited and remains unclear. Our objective was to examine the care-delivering processes in health care during the last months of life with real-life data of Swiss cancer patients. Patients and methods: The study population consisted of adult decedents in 2014 who were insured at Helsana Group. Data on the final cause of death were provided additionally by the Swiss Federal Statistical Office. Of the 10,275 decedents, 2,710 (26.4%) died of cancer. Intensity of treatment and health care utilization (including transitions) at their end-of-life were examined. Intensity measures included the following: last dose of chemotherapy within 14 days of death, a new chemotherapy regimen starting 14 days in hospital in the last month, death in an acute care hospital, more than one emergency visit and ≥1 intensive care unit admission in the last month of life. Results: In the last 6 months of life, 89.5% of cancer patients had ≥1 transition, with 87.2% being hospitalized. Within 30 days before death, 64.2% of the decedents had ≥1 intensive treatment, whereby 8.9% started a new chemotherapy. In the multinomial logistic regression model, older age, higher density of nursing home beds and home care nurses were associated with a decrease, while living in the Italian- or French-speaking part of Switzerland was associated with an increase in intensive care. Conclusion: Swiss cancer patients insured by Helsana Group experience a considerable number of transitions and intensive treatments at the end-of-life, whereby treatment intensity declines with increasing age. Among others, increased home care nursing might be helpful to reduce unwarranted treatments and transitions, therefore leading to better care at the end-of-life. Keywords: cancer, end-of-life care, health care costs, transitions, intensity of treatment, health insurance, regional variation

Eva Blozik,1–3 Roland Rapold,1 Klaus Eichler,4 Oliver Reich1 1Department of Health Sciences, Helsana Group, Zürich, Switzerland; 2Institute of General Practice, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 3Division of General Practice, University Medical Center Freiburg, Freiburg, Germany; 4Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Winterthur, Switzerland Background: Medical therapy for multiple sclerosis (MS) is expensive. Quantifying the burden of MS is fundamental for health-care planning and the allocation of resources for the management of MS. This study provides current national estimates of prevalence, incidence, mortality, and costs of MS in Switzerland using claims data between 2011 and 2015. Methods: We analyzed health insurance claims of adult persons enrolled with a large health insurance group covering about 13% of the Swiss population between 2011 and 2015. The identification of patients with MS was based on prescription data of MS-specific medication using the Anatomical Therapeutic Chemical Classification system as proxy for clinical diagnosis. We estimated prevalence, mortality, and costs of basic health insurance between 2011 and 2015. Furthermore, incidence of MS was calculated for 2015. All results were weighted with census data to achieve an extrapolation to the Swiss general population level. Cost of illness was estimated as direct medical cost from the perspective of a Swiss health insurance using multivariate linear regression analysis. Results: Of the 943,639 subjects in the year 2015, 1,606 were identified as MS patients resulting in a prevalence of 190 per 100,000 (95% CI: 180-190 per 100,000). Incidence was 16 per 100,000 (95% CI: 13-19 per 100,000). According to regression analysis, the total cost of illness for basic mandatory health insurance was 26,710 Swiss Francs (CHF) (95% CI: 26,100–27,300) per person per year with the cost of medication being almost identical 26,960 CHF (95% CI: 26,170–27,800). Conclusions: MS affects 10,000–15,000 persons in Switzerland, and the prevalence has increased over the last 22 years. These persons have high need and demand for health care. High costs are primarily due to expenses for medication. Given the imbalance of MS medication therapy from the perspective of basic health insurance on the disposable resources, it is crucial to increase transparency related to the volume, type, and allocation of expenses. Keywords: health insurance, Switzerland, medication, prescription, management, resources

Thomas D Szucs,1 Kevin P Szillat,2 Eva Blozik3 1University of Basel, Institute of Pharmaceutical Medicine (ECPM), Basel, Switzerland; 2Department of Biology, Institute of Molecular Health Sciences, ETH Zurich, Zürich, Switzerland; 3Department of Health Sciences, Helsana Group, Zürich, Switzerland Abstract: Single-nucleotide polymorphisms (SNPs) can severely impact individual drug response and health outcomes in cancer patients. Genetic tests to screen for marker SNPs are available to adjust the drug dose of oncologicals to the patient’s needs. However, it is unclear whether the positive effects outbalance the increased costs or even lead to an overall cost reduction. This very pragmatic analysis used three frequently used oncologicals for the treatment of breast cancer to evaluate whether preemptive pharmacogenetic testing may have a cost-reducing impact on health care spending in the Swiss health care system. Our results indicate that oncopharmacogenetics might help to reduce health care costs (ie, by avoiding adverse drug effects) and to increase efficiency of drugs in oncologic patients. Keywords: pharmacogenetics, oncology, budget impact model, Switzerland, health insurance

Eva Blozik,1–3 Andri Signorell,1 Oliver Reich1 1Department of Health Sciences, Helsana Group, Zürich, Switzerland; 2Department of Primary Medical Care, University Medical Centre Hamburg-Eppendorf, Hamburg, 3Department of Medicine, University Medical Centre Freiburg, Freiburg im Breisgau, Germany Introduction: Transitions between different levels of health care, such as hospital admission and discharge, pose a significant threat to the quality and continuity of medication therapy. This study aims to explore the role of hospitalization on medication changes as patients are transferred from and back to ambulatory care.Methods: Secondary analysis of claims data from Swiss residents with basic health insurance at the Helsana Group was performed. We evaluated medication invoices of patients who were hospitalized in a Swiss private hospital group in the year 2013. Medication changes were defined as discontinuation, new prescription, or change in the Anatomical Therapeutic Chemical (ATC) Classification System level 4, which is equivalent to a change in the chemical/therapeutic/pharmacological subgroup. Multiple Poisson regression analysis was applied to evaluate whether medication change was predicted by socioeconomic or clinical patient characteristics or by a system factor (physician dispensing of medication allowed in canton of residence).Results: We investigated a total of 10,123 hospitalized patients, among whom a mean number of 3.85 (median 3.00) changes were identified. Change most frequently affected antihypertensives, analgesics, and antirheumatics. If patients were enrolled in a managed care plan, they were less likely to undergo changes. If a patient resided in a canton, in which physicians were allowed to dispense medication directly, the patient was more likely to experience change.Conclusion: There is considerable change in medication when patients shift between ambulatory and inpatient health care levels. This interruption of medication continuity is in part desirable as it responds to clinical needs. However, we hypothesize that there is also a significant proportion of change due to unwarranted factors such as financial incentives for change of products. Keywords: medication, prescribing, safety, hospital, admission, discharge

Ines Baudendistel,1 Stefan Noest,1 Frank Peters-Klimm,1 Heidrun Herzberg,2 Martin Scherer,3 Eva Blozik,3 Stefanie Joos1,4 1Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany; 2Faculty of Health, Nursing, Administration, University of Applied Sciences Neubrandenburg, Neubrandenburg, Germany; 3Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; 4Institute for General Practice and Interprofessional Care, University Hospital Tuebingen, Tuebingen, Germany Background: The German National Disease Management Guideline (NDMG) on chronic heart failure (CHF) derived nine clinical quality indicators (QIs) to enable assessment of quality of health care in patients with CHF. These QIs epitomize an evidence-based and somatic point of view of guided treatment, but little is known about the experiences and views of patients with their guideline-based treatment across multiple health care sectors. Objective: The purpose of this qualitative study was to explore patient perspectives on guided treatment of CHF across multiple health care sectors. Furthermore, it was investigated to what extent patient perspectives are represented by the QIs of the German NDMG. Methods: Using a qualitative approach, semistructured interviews were carried out with 17 CHF patients. Interviews were audio-recorded and transcribed verbatim. Data were analyzed using qualitative content analysis. Results: Patient-identified needs focused primarily on aspects like the doctor–patient relationship, communication, quality of individual-tailored information, and professional advice. Patients perceived shortcomings in processes of care such as communication and cooperation across health care sectors, especially at the transition between hospital and outpatient care. Discussion: From the patient perspectives, the QIs do represent relevant somatic and clinical aims for quality measurement. However, deficits were identified, especially related to communication and cooperation across health care sectors. Given the fact that the inclusion of patient perspectives in quality improvement processes provides an important contribution to patient-centered health care, possible approaches for QI development such as direct and indirect patient involvement or generic vs disease-specific patient-related QIs should be the subject of future discussions. Keywords: quality indicators, patient involvement, patient perspectives, chronic heart failure, national disease management guideline

Eva Blozik,1,2 Roland Rapold,1 Oliver Reich1 1Department of Health Sciences, Helsana Group, Zürich, Switzerland; 2Department of Medicine, Division of General Practice, University Medical Centre Freiburg, Freiburg, Germany Background: Drugs can be supplied either directly from the prescribing physician (physician dispensing [PD]) or via a pharmacy. It is unclear whether the dispensing channel is associated with quality problems. Potentially inappropriate medication (PIM) is associated with adverse outcomes in older persons and can be considered a marker for quality deficits in prescribing. We investigated whether prevalence of PIM differs across dispensing channels. Patients and methods: We analyzed basic health insurance claims of 50,747 person quarter years with PIM use of residents of the Swiss cantons Aargau and Lucerne of the years 2012 and 2013. PIM was identified using the Beers 2012 criteria and the PRISCUS list. We calculated PIM prevalence stratified by supply channel. Adjusted mixed effects logistic regression analysis was done to estimate the effect of obtaining medications through the dispensing physician as compared to the pharmacy channel on receipt of PIM. The most frequent PIMs were identified. Results: There is a small but detectable difference in total PIM prevalence: 30.7% of the population supplied by a dispensing physician as opposed to 29.3% individuals who received medication in a pharmacy. According to adjusted logistic regression individuals who obtained the majority of their medications from their prescribing physician had a 15% higher chance to receive a PIM (odds ratio 1.15, 95% confidence interval 1.08–1.22; P

Nadine Janis Pohontsch,1 Heidrun Herzberg,2 Stefanie Joos,3 Felix Welti,4 Martin Scherer,1 Eva Blozik1 1Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamberg, Germany; 2Faculty of Health, Nursing, Management, Neubrandenburg University of Applied Sciences, Neubrandenburg, Germany; 3Department of General Practice and Health Services Research, Heidelberg University Hospital, Heidelberg, Germany; 4Faculty of Human Sciences, University of Kassel, Kassel, Germany Purpose: There is an international consensus that quality indicators (QIs) of health care ought to represent patient-relevant aspects. Therefore, patient involvement in the development process is essential. However, there is no methodological gold standard for involving patients in QI development. The aim of this study is to explore experts’ views on the representation of patient-relevant aspects in the QI development process using the QIs developed in the context of the German National Disease Management Guideline for Heart Failure as an example. Methods: Semi-structured, open telephone interviews were conducted with 15 German experts (patient representatives, physicians, researchers, and methodologists involved in guideline development or quality assessment). Interview themes were the relevance of the exemplary set of QIs for patients, as well as the legitimacy of, competence of, and collaboration with the patient representative who participated in the development process. Interviews were fully transcribed and content analyzed. Deductive categories derived from the research questions were supplemented by inductively formed categories during the review of the interview material.Results: The qualitative analysis suggests a discrepancy between the guidelines’ QIs and those relevant to patients from an expert’s point of view, such as physician-patient communication and quality of counseling. Experts reported only minor communication and cooperation problems while working together in the guideline/QI development team. Concerns existed, for example, regarding the recruitment of patient representatives for diseases without self-help organizations, the financing of patient representation, and the training of patient representatives. Only few potential strategies for improving the process of patient involvement were mentioned.Conclusion: Integrating the patients’ perspectives through the recruitment of a patient representative to participate in the development team was well established and broadly accepted. However, experts stated that the finally selected QIs represent only a small part of the patient-relevant aspects of medical care. According to the experts’ perceptions, the current processes provide a very limited scope for integrating the patients’ perspectives in a more extensive way. Supplementing the set of “conventional” QIs with additional, separately developed, “patient-side” QIs might help to include patient priorities in quality measurement. Keywords: quality indicators, patient involvement, national disease management guideline, qualitative expert interviews, chronic heart failure

Martina Allemann Iseli,1 Regina Kunz,2 Eva Blozik1,31Swiss Center for Telemedicine Medgate, Basel, Switzerland; 2Academy of Swiss Insurance Medicine, University of Basel, Basel, Switzerland; 3Department of Primary Medical Care, University Medical Center Hamburg–Eppendorf, Martinistrasse, Hamburg, GermanyBackground: Patient satisfaction is crucial for the acceptance, use, and adherence to recommendations from teleconsultations regarding health care requests and triage services.Objectives: Our objectives are to systematically review the literature for multidimensional instruments that measure patient satisfaction after teleconsultation and triage and to compare these for content, reliability, validity, and factor analysis.Methods: We searched Medline, the Cumulative Index to Nursing and Allied Health Literature, and PsycINFO for literature on these instruments. Two reviewers independently screened all obtained references for eligibility and extracted data from the eligible articles. The results were presented using summary tables.Results: We included 31 publications, describing 16 instruments in our review. The reporting on test development and psychometric characteristics was incomplete. The development process, described by ten of 16 instruments, included a review of the literature (n=7), patient or stakeholder interviews (n=5), and expert consultations (n=3). Four instruments evaluated factor structure, reliability, and validity; two of those four demonstrated low levels of reliability for some of their subscales.Conclusion: A majority of instruments on patient satisfaction after teleconsultation showed methodological limitations and lack rigorous evaluation. Users should carefully reflect on the content of the questionnaires and their relevance to the application. Future research should apply more rigorously established scientific standards for instrument development and psychometric evaluation.Keywords: teleconsultation, teletriage, triage, consultation, general practitioner, patient satisfaction, psychometric, evaluation, out-of-hours

Thomas Kötter,1,2 Friederike Anna Schaefer,2 Martin Scherer,2 Eva Blozik1,2 1Institute for Social Medicine and Epidemiology, University of Lübeck, Lübeck, Germany; 2Department of Primary Medical Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany Background: Quality indicators (QI) are used in many health care areas to measure, compare, and improve the quality of care. Ideas of quality differ between health care providers and patients, yet patients are not regularly involved in QI development nor does a methodological standard for patient involvement in QI development exist. In this study we systematically reviewed the medical journal articles and gray literature for published approaches for involving patients in QI development. Methods: We searched medical literature databases (Medline, Excerpta Medica database, and Cumulative Index to Nursing and Allied Health Literature), screened websites, and contacted experts in the field of QI development for publications on approaches to patient involvement in QI development. Results: Eleven relevant journal articles and four web-published documents were included. Four major approaches to patient involvement were extracted from the literature: (1) focus group interviews, (2) self-administered questionnaires, (3) individual interviews, and (4) participation in panels during systematic consensus processes. Patients' views were collected by involving patients, patient representatives, or family members. Conclusion: Although there is a large body of literature on QI, publications that describe approaches to patient involvement in QI development are scarce. In principle, indirect and direct methods of patient involvement can be distinguished, and it seems most promising to combine different approaches. However, the limited number of publications identified clearly shows that further research in this field is overdue and that the quality of reporting found in studies within this field needs to be improved. Keywords: quality indicator, quality in health care, quality measurement, patient involvement, systematic review