Medication adherence in patients with diabetes mellitus: does physician drug dispensing enhance quality of care? Evidence from a large health claims database in Switzerland

BACKGROUND

The drug-dispensing channel is a scarcely explored determinant of medication adherence, which is considered as a key indicator for the quality of care among patients with diabetes mellitus. In this study, we investigated the difference in adherence between diabetes patients who obtained their medication directly from a prescribing physician (physician dispensing [PD]) or via a pharmacy.

METHODS

A retrospective cohort study was conducted using a large health care claims database from 2011 to 2014. Patients with diabetes of all ages and receiving at least one oral antidiabetic drug (OAD) prescription were included. We calculated patients' individual adherence to OADs defined as the proportion of days covered (PDC), which was measured over 1 year after patient identification. Good adherence was defined as PDC ≥80%. Multivariate logistic regression analysis was performed to assess the relationship between the PDC and the dispensing channel (PD, pharmacy).

RESULTS

We identified a total of 10,430 patients prescribed drugs by a dispensing physician and 16,292 patients receiving drugs from a pharmacy. Medication adherence was poor in both patient groups: ~40% of the study population attained good adherence to OADs. We found no significant impact of PD on the adherence level in diabetes patients. Covariates associated significantly with good adherence were older age groups, male sex, occurrence of comorbidity and combined diabetes drug therapy.

CONCLUSION

In conclusion, adherence to antihyperglycemic medication is suboptimal among patients with diabetes. The results of this study provide evidence that the dispensing channel does not have an impact on adherence in Switzerland. Certainly, medication adherence needs to be improved in both supply settings. Physicians as well as pharmacists are encouraged to develop and implement useful tools to increase patients' adherence behavior.

A set of four simple performance measures reflecting adherence to guidelines predicts hospitalization: a claims-based cohort study of patients with diabetes

BACKGROUND

The link between guideline adherence and outcomes is a highly demanded issue in diabetes care. We aimed to assess the adherence to guidelines and its impact on hospitalization using a simple set of performance measures among patients with diabetes.

METHODS

We performed a retrospective cohort study, using health care claims data for adult patients with treated diabetes (2011-2013). Patients were categorized into three drug treatment groups (with oral antidiabetic agents [OAs] only, in combination with insulin, and insulin only). Performance measures were based on international established guidelines for diabetes care. Multivariate logistic regression models predicted the probability of hospitalization (2013) by adherence level (2011) among all treatment groups.

RESULTS

A total of 40,285 patients with diabetes were enrolled in 2011. Guideline adherence was quite low: about 70% of all patients received a biannual hemoglobin A1c measurement and 19.8% had undergone an annual low-density lipoprotein cholesterol test. Only 4.8% were exposed to full adherence including all performance measures (OAs: 3.7%; insulin: 7.7%; and in combination: 7.2%). Increased guideline adherence was associated with decreased probability of hospitalization. This effect was strongest in patients using OAs and insulin in combination.

CONCLUSION

Our study showed that measures to reflect physicians' guideline adherence in diabetes care can easily be calculated based on already available datasets. Furthermore, these measures are clearly linked with the probability of hospitalization suggesting that a better guideline adherence by physicians could help to prevent a large number of hospitalizations.

[25-year old patient with angina pectoris during religious fasting]

HISTORY AND PRESENTATION AT ADMISSION: A 25-year-old male patient presented with acute left sided chest pain. The patient reported no physical exercise but daytime fasting (with neither food nor liquid intake) which he had started several days before.

INVESTIGATIONS

ECG, echocardiography and chest X-ray were normal, but blood examination revealed elevated levels for creatine kinase (CK) and lactate dehydrogenase (LDH). Ischemic lactate ammonia test revealed no increase of lactate during exercise. Muscle biopsy confirmed suspected diagnosis of glycogen storage disease type V (McArdle's disease).

TREATMENT AND COURSE

As causal treatments are unavailable for McArdle's disease, careful counselling regarding adequate exercise and regular, carbohydrate rich nutrition are mandatory to ameliorate symptoms.

CONCLUSION

McArdle's disease represents a rare differential diagnosis of cardiac chest pain and somatoform myalgic complaints. When taking the patient's history, questions regarding the "Second wind"-phenomenon are helpful for initiating the adequate investigations early on.

Multimorbidity, health care utilization and costs in an elderly community-dwelling population: a claims data based observational study

Background

Chronic conditions and multimorbidity have become one of the main challenges in health care worldwide. However, data on the burden of multimorbidity are still scarce. The purpose of this study is to examine the association between multimorbidity and the health care utilization and costs in the Swiss community-dwelling population, taking into account several sociodemographic factors.

Methods

The study population consists of 229'493 individuals aged 65 or older who were insured in 2013 by the Helsana Group, the leading health insurer in Switzerland, covering all 26 Swiss cantons. Multimorbidity was defined as the presence of two or more chronic conditions of a list of 22 conditions that were identified using an updated measure of the Pharmacy-based Cost Group model. The number of consultations (total and divided by primary care physicians and specialists), the number of different physicians contacted, the type of physician contact (face-to-face, phone, and home visits), the number of hospitalisations and the length of stay were assessed separately for the multimorbid and non-multimorbid sample. The costs (total and divided by inpatient and outpatient costs) covered by the compulsory health insurance were calculated for both samples. Multiple linear regression modelling was conducted to adjust for influencing factors: age, sex, linguistic region, purchasing power, insurance plan, and nursing dependency.

Results

Prevalence of multimorbidity was 76.6%. The mean number of consultations per year was 15.7 in the multimorbid compared to 4.4 in the non-multimorbid sample. Total costs were 5.5 times higher in multimorbid patients. Each additional chronic condition was associated with an increase of 3.2 consultations and increased costs of 33%. Strong positive associations with utilization and costs were also found for nursing dependency. Multimorbid patients were 5.6 times more likely to be hospitalised. Furthermore, results revealed a significant age-gender interaction and a socioeconomic gradient.

Conclusions

Multimorbidity is associated with substantial higher health care utilization and costs in Switzerland. Quantified data on the current burden of multimorbidity are fundamental for the management of patients in health service delivery systems and for health care policy debates about resource allocation. Strategies for a better coordination of multimorbid patients are urgently needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0698-2) contains supplementary material, which is available to authorized users.

Epidemiology and costs of diabetes mellitus in Switzerland: an analysis of health care claims data, 2006 and 2011

BACKGROUND

Quantifying the burden of diabetes mellitus is fundamental for managing patients in health service delivery systems and improves the understanding of the importance of prevention and early intervention of diabetes. In Switzerland, epidemiological data on diabetes are very scarce. In this study we provide a first national overview of the current situation of diabetes mellitus in Switzerland as well as the development of the prevalence, incidence, mortality and costs between 2006 and 2011.

METHODS

Using health care claims data of a large health insurance group, current epidemiology and costs were determined from a sample of adult enrollees in 2011. The identification of patients with diabetes was based on prescription data of diabetes related drugs using the Anatomical Therapeutic Chemical Classification as proxy for clinical diagnosis. We further evaluated changes in epidemiology and costs between 2006 and 2011. All results were weighted with census data to achieve an extrapolation to the Swiss general population level.

RESULTS

A total of 920'402 patients were enrolled in 2011 and 49'757 (5.4%) were identified as diabetes cases. The extrapolated overall prevalence of diabetes in Switzerland was 4.9% (2006, 3.9%). The incidence was 0.58% in 2011 (2007, 0.63%). The extrapolated mortality rate was 2.6% with no significant change over time. Annual diabetes costs to the mandatory health insurance increased from EUR 5,036 per patient in 2006 to EUR 5'331 per patient in 2011.

CONCLUSIONS

This study shows a high medical and economic burden of diabetes. The prevalence and costs of diabetes in Switzerland increased substantially over time. Findings stress the need for public health strategies to manage patients with chronic conditions and optimize resource allocation in health service delivery systems.

The patient's perspective of placebo use in daily practice: a qualitative study

QUESTIONS UNDER STUDY

The use of placebo outside of randomised controlled trials raises ethical and legal issues. So far, patients' perspectives have been considered only in quantitative studies. These studies did not distinguish between pure placebos (no pharmacological effect) and impure placebos (pharmacological ingredient, but no disease-specific effect). The aim of our study was to explore patients' conceptualisation, experiences and attitudes regarding the use of placebos in daily clinical practice.

METHODS

Qualitative study with a convenience sample of 12 patients and semistructured interviews. The interviews were digitally recorded; full transcripts were obtained. The information was analysed in accordance with the qualitative content analysis method.

RESULTS

The definition of placebo given by the participants mostly matched the common understanding of a pure placebo. Most participants supposed that placebos were mainly effective in diseases in which psychological influences play an important role. Furthermore, most participants believed that placebos themselves mainly worked via psychological effects. The acceptance of a hypothetical earlier use of a placebo depended on the success of the therapy.

CONCLUSION

Patients were not aware of the differences between pure and impure placebos. Even regarding pure placebos, patients were more open than many physicians would expect. Trust between the patient and the general practitioner is an important element of the acceptance of a placebo. Appropriate communication could further increase the acceptance. Further research is needed to adapt the information given to the patient about possible placebo therapy.

Estimating the prevalence of comorbid conditions and their effect on health care costs in patients with diabetes mellitus in Switzerland

BACKGROUND

Estimating the prevalence of comorbidities and their associated costs in patients with diabetes is fundamental to optimizing health care management. This study assesses the prevalence and health care costs of comorbid conditions among patients with diabetes compared with patients without diabetes. Distinguishing potentially diabetes- and nondiabetes-related comorbidities in patients with diabetes, we also determined the most frequent chronic conditions and estimated their effect on costs across different health care settings in Switzerland.

METHODS

Using health care claims data from 2011, we calculated the prevalence and average health care costs of comorbidities among patients with and without diabetes in inpatient and outpatient settings. Patients with diabetes and comorbid conditions were identified using pharmacy-based cost groups. Generalized linear models with negative binomial distribution were used to analyze the effect of comorbidities on health care costs.

RESULTS

A total of 932,612 persons, including 50,751 patients with diabetes, were enrolled. The most frequent potentially diabetes- and nondiabetes-related comorbidities in patients older than 64 years were cardiovascular diseases (91%), rheumatologic conditions (55%), and hyperlipidemia (53%). The mean total health care costs for diabetes patients varied substantially by comorbidity status (US$3,203-$14,223). Patients with diabetes and more than two comorbidities incurred US$10,584 higher total costs than patients without comorbidity. Costs were significantly higher in patients with diabetes and comorbid cardiovascular disease (US$4,788), hyperlipidemia (US$2,163), hyperacidity disorders (US$8,753), and pain (US$8,324) compared with in those without the given disease.

CONCLUSION

Comorbidities in patients with diabetes are highly prevalent and have substantial consequences for medical expenditures. Interestingly, hyperacidity disorders and pain were the most costly conditions. Our findings highlight the importance of developing strategies that meet the needs of patients with diabetes and comorbidities. Integrated diabetes care such as used in the Chronic Care Model may represent a useful strategy.

Identifying patients with chronic conditions using pharmacy data in Switzerland: an updated mapping approach to the classification of medications

Background

Quantifying population health is important for public health policy. Since national disease registers recording clinical diagnoses are often not available, pharmacy data were frequently used to identify chronic conditions (CCs) in populations. However, most approaches mapping prescribed drugs to CCs are outdated and unambiguous. The aim of this study was to provide an improved and updated mapping approach to the classification of medications. Furthermore, we aimed to give an overview of the proportions of patients with CCs in Switzerland using this new mapping approach.

Methods

The database included medical and pharmacy claims data (2011) from patients aged 18 years or older. Based on prescription drug data and using the Anatomical Therapeutic Chemical (ATC) classification system, patients with CCs were identified by a medical expert review. Proportions of patients with CCs were calculated by sex and age groups. We constructed multiple logistic regression models to assess the association between patient characteristics and having a CC, as well as between risk factors (diabetes, hyperlipidemia) for cardiovascular diseases (CVD) and CVD as one of the most prevalent CCs.

Results

A total of 22 CCs were identified. In 2011, 62% of the 932′612 subjects enrolled have been prescribed a drug for the treatment of at least one CC. Rheumatologic conditions, CVD and pain were the most frequent CCs. 29% of the persons had CVD, 10% both CVD and hyperlipidemia, 4% CVD and diabetes, and 2% suffered from all of the three conditions. The regression model showed that diabetes and hyperlipidemia were strongly associated with CVD.

Conclusions

Using pharmacy claims data, we developed an updated and improved approach for a feasible and efficient measure of patients’ chronic disease status. Pharmacy drug data may be a valuable source for measuring population’s burden of disease, when clinical data are missing. This approach may contribute to health policy debates about health services sources and risk adjustment modelling.

Improved prediction of medical expenditures and health care utilization using an updated chronic disease score and claims data

OBJECTIVE

To predict future medical expenditures, health care utilization, and mortality in Switzerland using an updated chronic disease score (CDS), a chronic morbidity measure based on pharmacy data.

STUDY DESIGN AND SETTING

We performed a cohort study using medical claims data from insured persons enrolled in 2009 and 2010. Patient's characteristics, chronic conditions, and health care costs from baseline were used to calculate each patient's disease score. Two-part regression models were fit to predict health care expenditures, utilization, and mortality during the following year using the score's baseline values. We calculated the proportion of explained variation for each regression model to assess their performance.

RESULTS

The CDS model, controlled for sociodemographics and health insurance plan, showed a significant improvement in explained variance of health care costs, outpatient costs, and outpatient visits in 2010. Future outpatient visits were predicted best with an R(2) of 29.2% (age group: 18-65 years) and 22.9% (>65 years), and models predicted future mortality with a c-statistic of 0.8.

CONCLUSION

The CDS showed reasonable predictive validity of future health care utilization and medical expenditure based on pharmacy dispensing data, which may support health care decision makers in the planning delivery systems and resource allocation.

Effects of cost sharing on seeking outpatient care: a propensity-matched study in Germany and Switzerland

BACKGROUND

Several studies have assessed the effect of cost sharing on health service utilization (HSU), mostly in the USA. Results are heterogeneous, showing different effects. Whereas previous studies compared insurants within one health care system but different modes of insurance, we aimed at comparing two different health care systems in Europe: Germany and Switzerland. Furthermore, we assessed the impact of cost sharing depending on socio-demographic factors as well as health status.

METHODS

Two representative samples of 5197 Swiss insurants with and 5197 German insurants without cost sharing were used to assess the independent association between cost sharing and the use of outpatient care. To minimize confounding, we performed cross-sectional analyses between propensity score matched Swiss and German insurants. We investigated subgroups according to health and socio-economic status to assess a potential social gradient in HSU.

RESULTS

We found a significant association between health insurance scheme and the use of outpatient services. German insurants without cost sharing (visit rate: 4.8 per year) consulted a general practitioner or specialist more frequently than Swiss insurants with cost sharing (visit rate: 3.0 per year; P < 0.01). Subgroup analyses showed that vulnerable populations were differently affected by cost sharing. In the group of respondents with poor health and low socio-economic status, the cost-sharing effect was strongest.

CONCLUSION

Cost-sharing models reduce HSU. The challenge is to create cost-sharing models which do not preclude vulnerable populations from seeking essential health care.

Obesity management and continuing medical education in primary care: results of a Swiss survey

Background

The worldwide increase in obesity is becoming a major health concern. General practitioners (GPs) play a central role in managing obesity. We aimed to examine Swiss GPs self-reported practice in diagnosis and treatment of obesity with a special focus on the performance of waist measurement.

Methods

A structured self-reported questionnaire was mailed to 323 GPs recruited from four urban physician networks in Switzerland. Measures included professional experience, type of practice, obesity-related continuing medical education (CME) and practice in dealing with obesity such as waist measurement. We assessed the association between the performance of waist measurement and obesity-related CME by multivariate ordered logistic regression controlling for GP characteristics as potential confounders.

Results

A total of 187 GPs responded to the questionnaire. More than half of the GPs felt confident in managing obesity. The majority of the GPs (73%) spent less than 4 days in the last 5 years on obesity-related CME. More than half of GPs gave advice to reduce energy intakes (64%), intakes of high caloric and alcoholic drinks (56%) and to increase the physical activity (78%). Half of the GPs seldom performed waist measurement and documentation. The frequency of obesity-related CME was independently associated with the performance of waist measurement when controlled for GPs' characteristics by multivariate ordered logistic regression.

Conclusions

The majority of GPs followed guideline recommendations promoting physical activity and dietary counselling. We observed a gap between the increasing evidence for waist circumference assessment as an important measure in obesity management and actual clinical practice. Our data indicated that specific obesity-related CME might help to reduce this gap.

Screening and prevention in Swiss primary care: a systematic review

BACKGROUND AND OBJECTIVES

Prevention is a challenging area of primary care. In Switzerland, little is known about attitudes to and performance of screening and prevention services in general practice. To implement prevention services in primary care it is important to know about not only potential facilitators but also barriers. Primary care encompasses the activities of general practitioners, including those with particular interest and/or specializations (eg, pediatrics, gynecology). The aim of this study was to review all studies with a focus on prevention services which have been conducted in Switzerland and to reveal barriers and facilitators for physicians to participate in any preventive measures.

METHODS

The Cochrane Library, PubMed, EMBASE and BIOSIS were searched from January 1990 through December 2010. Studies focussing on preventive activities in primary care settings were selected and reviewed. The methodological quality of the identified studies was classified according to the guidelines in the Consolidated Standards of Reporting Trials (CONSORT) statement.

RESULTS

We identified 49 studies including 45 descriptive studies and four randomised controlled trials (RCTs). Twelve studies addressed the prevention of epidemics, eleven out of them vaccinations. Further studies focused on lifestyle changes, physical activity counselling, smoking cessation, cardiovascular prevention and cancer screening. Perceived lack of knowledge/training and lack of time were the most commonly stated barriers. Motivation, feasibility and efficiency were the most frequently reported supporting factors for preventive activities. The methodological quality was weak, only one out of four RCTs met the applied quality criteria.

CONCLUSION

Most studies focussing on screening and prevention activities in primary care addressed vaccination, lifestyle modification or cardiovascular disease prevention. Identified barriers and facilitators indicate a need for primary-care-adapted education and training which are easy to handle, time-saving and reflect the specific needs of general practitioners. If new prevention programs are to be implemented in general practices, RCTs of high methodological quality are needed to assess their impact.

Interventions in primary care to improve cardiovascular risk factors and glycated haemoglobin (HbA1c) levels in patients with diabetes: a systematic review

Most patients with diabetes are treated in primary care (PC). We performed a systematic review to assess the effect of single and combined interventions on cardiovascular risk factors (CVRFs) and glycated haemoglobin (HbA1c) levels in patients with diabetes in PC settings. We searched the MEDLINE database from January 1990 to October 2008. According to the Cochrane Effective Practice and Organization of Care Group (EPOC) criteria, (cluster-)randomized control studies and controlled before-and-after studies were selected and reviewed. Identified interventions were classified according to a modified EPOC intervention taxonomy. We included 68 studies. Forty-five studies evaluated the effect of any intervention on HbA1c. Seventeen studies presented a significant improvement in HbA1c. Nine out of 27 studies evaluating CVRFs [cholesterol, blood pressure (BP)] and HbA1c showed a significant improvement in at least two of these factors. Audit and feedback on performance, clinical decision support systems, multi-professional teams and patient education seemed to be successful strategies. The increasing evidence regarding the treatment of persons with chronic illnesses, summarized in the Chronic Care Model (CCM), is not reflected in most recent studies about diabetes treatment in PC. Most interventions still seem only partly adapted to the CCM. The methodological quality of many studies is still poor and often the pivotal outcomes, CVRFs and HbA1c, are not appropriately addressed. As a consequence, the potential of PC in the care of patients with diabetes may still be underestimated.

Diagnostic scope in out-of-hours primary care services in eight European countries: an observational study

Background

In previous years, out- of-hours primary care has been organised in large-scale organisations in many countries. This may have lowered the threshold for many patients to present health problems at nights and during the weekend. Comparisons of out-of-hours care between countries require internationally comparable figures on symptoms and diagnoses, which were not available. This study aimed to describe the symptoms and diagnoses in out-of-hours primary care services in regions in eight European countries.

Methods

We conducted a retrospective observational study based on medical records from out-of-hours primary care services in Belgium, Denmark, Germany, the Netherlands, Norway, Slovenia, Spain, and Switzerland. We aimed to include data on 1000 initial contacts from up to three organisations per country. Excluded were contacts with an administrative reason. The International Classification for Primary Care (ICPC) was used to categorise symptoms and diagnoses. In two countries (Slovenia and Spain) ICD10 codes were translated into ICPC codes.

Results

The age distribution of patients showed a high consistency across countries, while the percentage of males varied from 33.7% to 48.3%. The ICPC categories that were used most frequently concerned: chapter A 'general and unspecified symptoms' (mean 13.2%), chapter R 'respiratory' (mean 20.4%), chapter L 'musculoskeletal' (mean 15.0%), chapter S 'skin' (mean 12.5%), and chapter D 'digestive' (mean 11.6%). So, relatively high numbers of patients presenting with infectious diseases or acute pain related syndromes. This was largely consistent across age groups, but in some age groups chapter H ('ear problems'), chapter L ('musculoskeletal') and chapter K ('cardiovascular') were frequently used. Acute life-threatening problems had a low incidence.

Conclusions

This international study suggested a highly similar diagnostic scope in out-of-hours primary care services. The incidence rates of acute life-threatening health problems were low in all countries.

Walk-ins seeking treatment at an emergency department or general practitioner out-of-hours service: a cross-sectional comparison

Background

Emergency Departments (ED) in Switzerland are faced with increasing numbers of patients seeking non-urgent treatment. The high rate of walks-ins with conditions that may be treated in primary care has led to suggestions that those patients would best cared for in a community setting rather than in a hospital. Efficient reorganisation of emergency care tailored to patients needs requires information on the patient populations using the various emergency services currently available. The aim of this study is to evaluate the differences between the characteristics of walk-in patients seeking treatment at an ED and those of patients who use traditional out-of-hours GP (General Practitioner) services provided by a GP-Cooperative (GP-C).

Methods

In 2007 and 2009 data was collected covering all consecutive patient-doctor encounters at the ED of a hospital and all those occurring as a result of contacting a GP-C over two evaluation periods of one month each. Comparison was made between a GP-C and the ED of the Waid City Hospital in Zurich. Patient characteristics, time and source of referral, diagnostic interventions and mode of discharge were evaluated. Medical problems were classified according to the International Classification of Primary Care (ICPC-2). Patient characteristics were compared using non-parametric tests and multiple logistic regression analysis was applied to investigate independent determinants for contacting a GP-C or an ED.

Results

Overall a total of 2974 patient encounters were recorded. 1901 encounters were walk-ins and underwent further analysis (ED 1133, GP-C 768). Patients consulting the GP-C were significantly older (58.9 vs. 43.8 years), more often female (63.5 vs. 46.9%) and presented with non-injury related medical problems (93 vs. 55.6%) in comparison with patients at the ED. Independent determining factors for ED consultation were injury, male gender and younger age. Walk-in distribution in both settings was equal over a period of 24 hours and most common during daytime hours (65%).

Outpatient care was predominant in both settings but significantly more so at the GP-C (79.9 vs. 85.7%).

Conclusions

We observed substantial differences between the two emergency settings in a non gate-keeping health care system. Knowledge of the distribution of diagnoses, their therapy, of diagnostic measures and of the factors which determine the patients' choice of the ED or the GP-C is essential for the efficient allocation of resources and the reduction of costs.

The use of pure and impure placebo interventions in primary care - a qualitative approach

BACKGROUND

Placebos play an important role in clinical trials and several surveys have shown that they are also common in daily practice. Previous research focused primarily on the frequency of placebo use in outpatient care. Our aim was to explore physicians' views on the use of placebos in daily practice, whereby distinction was made between pure placebos (substances with no pharmacological effect, e.g. sugar pills) and impure placebos (substances with pharmacological effect but not on the condition being treated, e.g. antibiotics in viral infections or vitamins).

METHODS

We performed semi-structured interviews with a sample of twelve primary care physicians (PCPs). The interview addressed individual definitions of a placebo, attitudes towards placebos and the participants' reasons for prescribing them. The interviews were transcribed and analysed using qualitative content analysis.

RESULTS

The definition of a placebo given by the majority of the PCPs in our study was one which actually only describes pure placebos. This definition, combined with the fact that most impure placebos were not regarded as placebos at all, means that most of the participating PCPs were not aware of the extent to which placebos are used in daily practice. The PCPs stated that they use placebos (both pure and impure) mainly in the case of non-severe diseases for which there was often no satisfactory somatic explanation. According to the PCPs, cases like this are often treated by complementary and alternative therapies and these, too, are associated with placebo effects. However, all PCPs felt that the ethical aspects of such treatment were unclear and they were unsure as to how to communicate the use of placebos to their patients. Most of them would appreciate ethical guidelines on how to deal with this issue.

CONCLUSIONS

Many PCPs seem to be unaware that some of the drugs they prescribe are classified as impure placebos. Perceptions of effectiveness and doubts about the legal and ethical aspects of the use of placebos by PCPs may discourage their application. Dissemination of guidelines and consensus papers may be one approach, but it has to be acknowledged that the topic itself is in conflict with the PCPs' perception of themselves as professional and reliable physicians.

Out-of-hours demand in primary care: frequency, mode of contact and reasons for encounter in Switzerland

RATIONALE, AIMS AND OBJECTIVES

To investigate the demand for traditional out-of-hours general practitioner (GP) emergency care in Switzerland including GPs' satisfaction and reasons for encounter (RFE).

METHOD

During a 2-month period (2009), a questionnaire-based, cross-sectional study was performed in GPs participating in the mandatory out-of-hours service in the city of Zurich, Switzerland. The number and mode of patient contacts were assessed to investigate the demand for GP care in traditional out-of-hours services. GPs and patient characteristics, including RFE according to the International Classification of Primary Care, were noted. Descriptive statistics and non-parametric tests were conducted.

RESULTS

Out of the 295 out-of-hours episodes during the study period, 148 (50%) duty periods were documented by a total of 93 GPs (75% men) with a mean (SD) age of 48.0 (6.2) years. The median (interquartile range) number of out-of-hours contacts was 5 (3-8) and the demand for home visits was significantly more common compared with practice and telephone consultations. A total of 112 different RFEs were responsible for the 382 documented patient contacts with fever accounting for the most common complaint (13.9%). Although 80% of GPs agreed to be satisfied overall with their profession as primary care provider, 57.6% among them were dissatisfied with the current out-of-hours service. Inappropriate payment and interference with their daily work in practice were most frequently reported.

CONCLUSIONS

Our findings indicate that there is still strong patient demand for out-of-hours care with special need for home visits, suggesting that new organizational models such as integrating GPs into emergency care may not be an appropriate approach for all patients. Therefore, the ongoing reorganization of the out-of-hours-service in many health care systems has to be evaluated carefully in order not to miss important patient needs.

The provision of out-of-hours care and associated costs in an urban area of Switzerland: a cost description study

BACKGROUND

In Switzerland, General Practitioners (GPs) play an important role for out-of-hours emergency care as one service option beside freely accessible and costly emergency departments of hospitals. The aim of this study was to evaluate the services provided and the economic consequences of a Swiss GP out-of-hours service.

METHODS

GPs participating in the out-of-hours service in the city of Zurich collected data on medical problems (ICPC coding), mode of contact, mode of resource use and services provided (time units; diagnostics; treatments). From a health care insurance perspective, we assessed the association between total costs and its two components (basic costs: charges for time units and emergency surcharge; individual costs: charges for clinical examination, diagnostics and treatment in the discretion of the GP).

RESULTS

125 GPs collected data on 685 patient contacts. The most prevalent health problems were of respiratory (24%), musculoskeletal (13%) and digestive origin (12%). Home visits (61%) were the most common contact mode, followed by practice (25%) and telephone contacts (14%). 82% of patients could be treated by ambulatory care. In 20% of patients additional technical diagnostics, most often laboratory tests, were used. The mean total costs for one emergency patient contact were €144 (95%-CI: 137-151). The mode of contact was an important determinant of total costs (mean total costs for home visits: €176 [95%-CI: 168-184]; practice contact: €90 [95%-CI: 84-98]; telephone contact: €48 [95%-CI: 40-55]). Basic costs contributed 83% of total costs for home visits and 70% of total costs for practice contacts. Individual mean costs were similarly low for home visits (€30) and practice contacts (€27). Medical problems had no relevant influence on this cost pattern.

CONCLUSIONS

GPs managed most emergency demand in their out-of-hours service by ambulatory care. They applied little diagnostic testing and basic care. Our findings are of relevance for policy makers even from other countries with different pricing policies. Policy makers should be interested in a reimbursement system promoting out-of-hours care run by GPs as one valuable service option.

[Osteoarthritis - which approach is evidence based?]

Paracetamol is the first choice mediation for osteoarthritis. The analgetic potential of NSAIDs is slightly higher and they also have some antiphlogistic effect, but their use has to be strictly limited to a short period of time. They should mainly be used in the therapy of the acute and painful phase of osteoarthritis. Among the NSAIDs, Diclofenac is the medication of first choice. In patients with an increased risk of gastrointestinal complications, a protonpumpinhibitor should be added. Patients with cardiovascular risk factors should receive NSAIDs only in case of no appropriate alternative treatments. Opioids have their place in osteoarthritis treatment and should be part of an individualized pain regime, which should also contain a pain diary and proactive monitoring. It is important to emphasize the positive effects of physical activity on the function of the joints as well as the negative effect of overweight and immobility.

[Medical check-ups on the <<Gesundheitsschiff>>. Benefit for population at risk or self-selection of healthy and health-conscious patients?]

The aim of the present study was to assess health related characteristics and reasons for participation on the <<check-up-cruise>>, second, to compare these variables with a representative Swiss Health Survey (SHS). Characteristics of the participants were collected cross-sectionally and afterwards compared with results of the SHS. Response rate was 74.6% (n = 206). Compared to the SHS population smoking rate and alcohol consumption were significantly lower and a doctor's visit within the last 12 months more frequent. Considerable differences in health related characteristics exist between our study and the SHS suggesting a self-selection of healthy people. Thus a potential health gain by this kind of medical prevention program is at least questionable.

Reasons why people in Switzerland seek assisted suicide: the view of patients and physicians

BACKGROUND

Assisted suicide is permitted in Switzerland provided that assistance is not motivated by selfish reasons. Suicides are commonly performed with the assistance of right-to-die organisations and the use of a lethal dose of barbiturates prescribed by a participating physician. We examined the reasons physicians provided for writing the prescription and the reasons patients gave for requesting assistance in dying.

METHODS

We analysed all reported cases of assisted suicide that were facilitated by right-to-die organisations between 2001 and 2004 in the city of Zurich, and for which both the medical report and the optional letter written by the decedent providing information on their reasons for seeking assistance in suicide (N = 165).

RESULTS

The reasons most often reported by physicians (ph), as well as persons who sought help (p), were: pain (ph: 56% of all assisted suicides, p: 58%), need for long-term care (ph: 37%, p: 39%), neurological symptoms (ph: 35%, p: 32%), immobility (ph: 23%, p: 30%) and dyspnoea (ph: 23%, p: 23%). Control of circumstances over death (ph: 12%, p: 39%); loss of dignity (ph: 6%, p: 38%); weakness (ph: 13%, p: 26%); less able to engage in activities that make life enjoyable (ph: 6%, p: 18%); and insomnia and loss of concentration (ph: 4%, p: 13%) were significantly more often mentioned by decedents than by physicians.

CONCLUSIONS

Both prescribing physicians and;patients provided with assistance to die quite often mentioned pain and other concerns, many of which were objectively assessable and related to unbearable suffering or unreasonable disability. Concerns referable to autonomy and individual judgement were more often noted by people seeking help than by the prescribing physicians.

Suicide assisted by two Swiss right-to-die organisations

BACKGROUND

In Switzerland, non-medical right-to-die organisations such as Exit Deutsche Schweiz and Dignitas offer suicide assistance to members suffering from incurable diseases.

OBJECTIVES

First, to determine whether differences exist between the members who received assistance in suicide from Exit Deutsche Schweiz and Dignitas. Second, to investigate whether the practices of Exit Deutsche Schweiz have changed since the 1990s.

METHODS

This study analysed all cases of assisted suicide facilitated by Exit Deutsche Schweiz (E) and Dignitas (D) between 2001 and 2004 and investigated by the University of Zurich's Institute of Legal Medicine (E: n = 147; D: n = 274, total: 421). Furthermore, data from the Exit Deutsche Schweiz study which investigated all cases of assisted suicide during the period 1990-2000 (n = 149) were compared with the data of the present study.

RESULTS

More women than men were assisted in both organisations (D: 64%; E: 65%). Dignitas provided more assistance to non-residents (D: 91%; E: 3%; p = 0.000), younger persons (mean age in years (SD): D: 64.5 (14.1); E: 76.6 (13.3); p = 0.001), and people suffering from fatal diseases such as multiple sclerosis and amyotrophic lateral sclerosis (D: 79%; E: 67%; p = 0.013). Lethal medications were more often taken orally in cases assisted by Dignitas (D: 91%; E: 76%; p = 0.000). The number of women and the proportion of older people suffering from non-fatal diseases among suicides assisted by Exit Deutsche Schweiz has increased since the 1990s (women: 52% to 65%, p = 0.031; mean age in years (SD): 69.3 (17.0) to 76.9 (13.3), p = 0.000), non-fatal diseases: 22% to 34%, p = 0.026).

CONCLUSIONS

Weariness of life rather than a fatal or hopeless medical condition may be a more common reason for older members of Exit Deutsche Schweiz to commit suicide. The strong over-representation of women in both Exit Deutsche Schweiz and Dignitas suicides is an important phenomenon so far largely overlooked and in need of further study.

Einkommensverluste durch den Empfang von Krankengeld - Wann macht Krankheit arm?

PURPOSE

When absent from work due to sickness, most employees in Germany receive continued pay from their employer for six weeks. After this period, sick employees receive sickness benefits from their Statutory Sickness Fund. These sickness benefits are calculated in a rather complicated way as a percentage of gross and net salary. The paper focuses on two questions that have rarely been studied: which income groups show a particularly large difference between net salary and net sickness benefits? Which income groups move below the poverty line after receiving sickness benefits?

METHODS

We calculated how much sickness benefit is actually paid to the insured, for different income and tax groups. The definition for the poverty line is outlined as well. Due to methodological difficulties, the comparison between sickness benefits and poverty must be confined to single-person households.

RESULTS

In the income groups chosen here (gross salary up to 4000 Euro per month), net sickness benefits amount to about 77 % of net salary, for all insured. Financial problems can mainly be expected for the lower and the upper income groups. Expressed in absolute terms, the upper income groups experience a large reduction in net income. The lower income groups come close to the poverty line or fall below it.

CONCLUSIONS

Sickness benefits provide income in case of sickness; this is an important achievement of social policy. However, we should study the financial burden which sickness benefits could have for the insured. More in-depth analyses would require data that are not yet available (e. g. on the number of insured per income group and the income of other household members). The analyses presented here already show that sickness benefits could lead to severe financial problems for at least some insured. They point to the need for more studies in this neglected field.

Nanowire Array Composites

Long, nanometer-size metallic wires can be synthesized by injection of the conducting melt into nanochannel insulating plates. Large-area arrays of parallel wires 200 nanometers in diameter and 50 micrometers long with a packing density of 5 x 10(8) per square centimeter have been fabricated in this way. When charged, the ends of the wires generate strong, short-range electric fields. The nanowire electric fields have been imaged at high spatial resolution with a scanning force microscope.