Regional variation in hip and knee arthroplasty rates in Switzerland: A population-based small area analysis

BACKGROUND: Compared to other OECD countries, Switzerland has the highest rates of hip (HA) and knee arthroplasty (KA). OBJECTIVE: We assessed the regional variation in HA/KA rates and potential determinants of variation in Switzerland. METHODS: We conducted a population-based analysis using discharge data from all Swiss hospitals during 2013–2016. We derived hospital service areas (HSAs) by analyzing patient flows. We calculated age-/sex-standardized procedure rates and measures of variation (the extremal quotient [EQ, highest divided by lowest rate] and the systemic component of variation [SCV]). We estimated the reduction in variance of HA/KA rates across HSAs in multilevel regression models, with incremental adjustment for procedure year, age, sex, language, urbanization, socioeconomic factors, burden of disease, and the number of orthopedic surgeons. RESULTS: Overall, 69,578 HA and 69,899 KA from 55 HSAs were analyzed. The mean age-/sex-standardized HA rate was 265 (range 179–342) and KA rate was 256 (range 186–378) per 100,000 persons and increased over time. The EQ was 1.9 for HA and 2.5 for KA. The SCV was 2.0 for HA and 2.2 for KA, indicating a low variation across HSAs. When adjusted for procedure year and demographic, cultural, and sociodemographic factors, the models explained 75% of the variance in HA and 63% in KA across Swiss HSAs. CONCLUSION: Switzerland has high HA/KA rates with a modest regional variation, suggesting that the threshold to perform HA/KA may be uniformly low across regions. One third of the variation remained unexplained and may, at least in part, represent differing physician beliefs and attitudes towards joint arthroplasty.