Transferring Outcomes Data for National Decision Making: The Illusion of Simplicity
17 Oct 2019

Variation in outcomes and health care delivery

Breast Cancer – Part 2

In this blog-post series we are analysing different aspects about transferability of outcomes, either from RCT to Real-World setting or between different settings/countries. In case you missed the introductory blogpost that outlines the scope of this blog series, you can find it here.  

In this blog post we are looking at aspects related to Breast Cancer.


Variation in outcomes and health care delivery based on a case-mix adjusted large cohort (SVEUS)

In the first example, we extracted data from a previous project about value-based health care in Sweden. The data is rather unique in the sense that it includes such a large cohort and that a methodology was applied to adjust the outcomes, based on the case-mix. In the examples below you can see how both the outcomes and some key-variables related to the health care delivery process vary quite significantly. The Swedish health care delivery would in general, be considered as well standardized with similar practice across the country, however there is still some variation.

Differences in outcomes:

The graphs below were created based on an extraction from the graphs in the Sveus report (1). The first graph represents the odds ratio of other regions than the region of interest and each dot represents the results from all the regions included in the analysis. If it is a continuous variable (variables in the second graph), the report (1) represents the averages in other regions than the region of interest and the dot represents the results from each region. The shaded dots refer to the results that are statistically significant.

As can be observed below, there is a broad spread of outcomes. How would this compare if we compared across different countries?



The data is based on a manual extraction of graphs taken from the original report (1). The graphs are conceptual illustrations; however they are well aligned with the real results. See the references for the original data (link).

Differences in healthcare delivery

From the same analysis as the outcomes, by using the Swedish quality register of breast cancer2 2018 (except endocrine therapy which is 2017), several key-variables related to the healthcare delivery are included. We have summarized a few of them to illustrate the magnitude of the difference. This certainly has an impact on the outcomes.


Concluding remarks:

If such a difference can be found in the outcomes and health care delivery of only one country, how much more of a difference could there be when we compare between countries?

To improve the relevance of our decision making in healthcare, we believe it is crucial to gain a better understanding of the issues related to transferability. When this is done, we can also improve the cross-country utilization of Real-World evidence by understanding which results are transferable and how to control the variances in health care delivery.



  1. Sveus report (Page 79-93)
  2. Swedish quality register for breast cancer