Case management to increase quality of life after cancer treatment: a randomized controlled trial

Background

Case management has been shown to be beneficial in phases of cancer screening and treatment. After treatment is completed, patients experience a loss of support due to reduced contact with medical professionals. Case management has the potential to offer continuity of care and ease re-entry to normal life. We therefore aim to investigate the effect of case management on quality of life in early cancer survivors.

Methods

Between 06/2010 and 07/2012, we randomized 95 patients who had just completed cancer treatment in 11 cancer centres in the canton of Zurich, Switzerland. Patients in the case management group met with a case manager at least three times over 12 months. Patient-reported outcomes were assessed after 3, 6 and 12 months using the Functional Assessment of Cancer Therapy (FACT-G) scale, the Patient Assessment of Chronic Illness Care (PACIC) and the Self-Efficacy scale.

Results

The change in FACT-G over 12 months was significantly greater in the case management group than in the control group (16.2 (SE 2.0) vs. 9.2 (SE 1.5) points, P = 0.006). The PACIC score increased by 0.20 (SE 0.14) in the case management group and decreased by 0.29 (SE 0.12) points in the control group (P = 0.009). Self-Efficacy increased by 3.1 points (SE 0.9) in the case management group and by 0.7 (SE 0.8) points in the control group (P = 0.049).

Conclusions

Case management has the potential to improve quality of life, to ease re-entry to normal life and to address needs for continuity of care in early cancer survivors.

Trial registration

The study has been submitted to the ISRCTN register under the name “Case Management in Oncology Rehabilitation” on the 12th of October 2010 and retrospectively registered under the number ISRCTN41474586 on the 24th of November 2010.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-017-3213-9) contains supplementary material, which is available to authorized users.

[Reasons for General Practitioner Shortage – a Comparison Between France and Switzerland]

BACKGROUND AND OBJECTIVES

Both France and Switzerland face a general practitioner (GP) shortage. What differences or parallels exist between the two countries with regard to the causes for this shortage? What conclusions might be drawn from a systematic comparison?

METHODS

Literature review with qualitative and semi-quantitative content analysis.

RESULTS

Parallels exist in the comparing categories work contents, working structure, income and social status, medical school formation, private life, psychological motives. Differences are found in the categories biography and social selection, medical socialisation, residency. In Switzerland, residency is not uniformly structured, rarely institutionally organised and contains only few elements specific to general medicine. In France, medical socialisation not only exalts the specialists, but also strongly devaluates the GPs.

CONCLUSIONS

By systematic analysis and comparison of both countries' pertinent literature, France and Switzerland can deepen their understanding of GP shortage. This paper identifies possible fields of action from medical school through residency up to workplace conditions that are pivotal in addressing the shortage of GPs.

Implementation of a hospital-integrated general practice--a successful way to reduce the burden of inappropriate emergency-department use

PRINCIPLES

Emergency departments (EDs) are overcrowded by lower acuity patients, which might be more efficiently treated by general practitioners (GPs). This study evaluated the impact of triaging lower acuity patients to a new hospital-integrated general practice (HGP) on ED case-load and the reasons for choosing the ED/HGP.

METHODS AND RESULTS

Patients were consecutively assessed according to the emergency severity index (ESI) to triage lower acuity patients to the HGP. Consultation numbers at the emergency centre (ED and HGP) increased by 43% between 2007 (n = 16 974) and 2011 (n = 24 331) (implementation of HGP in 2009). Although self-referrals increased significantly at the emergency centre from 54% to 63% (p <0.001), the proportion of self-referrals at the ED was significantly reduced to 48% (p = 0.007). The HGP was able to reduce the burden of increasing total consultations by 36%; 4.6% were referred back to the ED after triaging to the HGP. Overall, 95% of HGP patients were self-referred, Swiss nationals (65%) and with a personal GP (82%) they attended regularly (69%). The most common reason for presenting at the emergency centre was not being able to reach the GP (60%). Diagnoses were injury- (29%) and infection- (23%) related problems affecting the musculoskeletal (27%) system and skin (21%).

CONCLUSION

The HGP succeeded in reducing the burden of inappropriate ED use: the majority of low acuity self-referred patients were conclusively treated at the HGP. The HGP does not represent competition to the GP out-of-hours care service, since the main reason for presenting at the hospital was not lacking a relationship but the GPs' inaccessibility.

Arthroscopic Repair of Massive Cuff Tears With Large Subscapularis Tendon Ruptures (Lafosse III/IV): A Prospective Magnetic Resonance Imaging-Controlled Case Series of 26 Cases With a Minimum Follow-up of 1 Year

PURPOSE

To prospectively assess arthroscopic repair of massive cuff tears (MCT) in a highly selective patient group with large subscapularis (SSC) tendon tears by means of clinical results and magnetic resonance imaging (MRI) studies.

METHODS

Between April 2009 and December 2010, 26 patients with MCT were treated with arthroscopic rotator cuff repair. Only lesions involving a large tear of the SSC tendon (Lafosse III or IV) in combination with a complete tear of the supraspinatus (SSP) tendon and a tear of at least the anterior third of the infraspinatus (ISP) tendon were included. Minimum follow-up was 1 year. Pre- and postoperative assessment included a standardized clinical examination, subjective patient outcome, and MRI (structural integrity, fatty muscle infiltration, and muscular mass).

RESULTS

Mean follow-up was 17 months (range, 12 to 34 months). MRI was performed in 25 patients. In 21 (84%) the cuff repair was intact. A partial retear of the SSC was found in 2 patients (8%). In 2 patients (8%) a full-thickness retear of the posterosuperior cuff was observed (1 SSP, 1 SSP/ISP). A significant increase of the muscle mass and decrease of fatty infiltration was observed for the SSC and SSP but not for the ISP. The mean Constant-Murley score improved from 36 to 86 points (P < .001) with all its subscores as well (P < .001). Muscular strength improved for the SSC (4.9 v 3.0, P < .001), SSP (4.6 v 2.9, P < .001), and ISP (4.8 v 3.4, P < .001). Overall patient satisfaction was high (3.6 ± 0.8).

CONCLUSIONS

Arthroscopic repair of MCT involving the ISP, SSP, and large tears of the SSC provides a reliable tendon healing, in particular for the SSC tendon, combined with good functional results.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Appropriateness of diagnostic coronary angiography as a measure of cardiac ischemia testing in non-emergency patients - a retrospective cross-sectional analysis

Background

Adequate application of guidelines concerning non-invasive ischemia testing (NIIT) could avoid inappropriate invasive testing in non-emergency situations. Hardly any data exists regarding frequency and appropriateness of diagnostic coronary angiography (CA). The aim of this study was to evaluate the proportion and predictors of patients without NIIT prior to elective purely diagnostic CA without therapeutic intervention.

Methods

Retrospective cross-sectional analysis of insurance claims data from 2012 and 2013. Patients <18 years, acute cardiac ischemia and emergency procedures and patients insured in a managed care model were excluded from analysis. The proportion of patients with NIIT procedures (stress-ECG, transthoracic echocardiography, stress echocardiography, scintigraphy, computer tomography, heart MRI) undertaken within two months before diagnostic CA was assessed. Multiple logistic regression analysis was applied to investigate independent determinants for receiving NIIT.

Findings

2714 patients were included for analysis. 37.5% (1018) did not receive any NIIT before CA. When high risk patients (patients having received therapeutic cardiac intervention within one month after or 18 months prior to diagnostic CA, n = 766) were excluded 34.3% (669) did not receive NIIT before CA. High risk status as well as >6 chronic comorbidities were independently associated with a lower proportion of NIIT (p<0.0001, OR 0.607 and p = 0.0041, OR 0.648), when additionally controlled for age, sex, language area, insurance coverage, inpatient treatment, cardiovascular medication and lower number of chronic comorbidities. Age (p<0.05, OR 1.009) and intake of oral antiplatelet therapy (p<0.0001, OR 1.914) were independently associated with a higher proportion of NIIT when controlled for the mentioned cofactors.

Conclusions

Our data show that despite the existence of guidelines a substantial overuse of a potentially harmful and inappropriate diagnostic intervention is performed suggesting the need for improvement of diagnostic pathways prior to invasive testing.

Inflammatory response of lung macrophages and epithelial cells after exposure to redox active nanoparticles: effect of solubility and antioxidant treatment

The effects of an exposure to three mass-produced metal oxide nanoparticles-similar in size and specific surface area but different in redox activity and solubility-were studied in rat alveolar macrophages (MAC) and epithelial cells (AEC). We hypothesized that the cell response depends on the particle redox activity and solubility determining the amount of reactive oxygen species formation (ROS) and subsequent inflammatory response. MAC and AEC were exposed to different amounts of Mn3O4 (soluble, redox-active), CeO2 (insoluble, redox-active), and TiO2 (insoluble, redox-inert) up to 24 h. Viability and inflammatory response were monitored with and without coincubation of a free-radical scavenger (trolox). In MAC elevated ROS levels, decreased metabolic activity and attenuated inflammatory mediator secretion were observed in response to Mn3O4. Addition of trolox partially resolved these changes. In AEC, decreased metabolic activity and an attenuated inflammatory mediator secretion were found in response to CeO2 exposure without increased production of ROS, thus not sensitive to trolox administration. Interestingly, highly redox-active soluble particles did not provoke an inflammatory response. The data reveal that target and effector cells of the lung react in different ways to particle exposure making a prediction of the response depending on redox activity and intracellular solubility difficult.

Prevalence and determinants of sexually transmitted infections in women at risk undergoing abortion in a Swiss primary care setting

BACKGROUND

Specific prevalence data are needed to assess the burden of sexually transmitted infections (STIs) in specific settings where data are scant, such as women seeking early termination of pregnancy (TOP). We aimed to investigate the prevalence of STIs and its determinants in women at risk (e. g. pathological cervical swab) undergoing TOP in a primary care setting in Switzerland.

METHODS

Cross-sectional study of 620 women seeking abortion counselling at a general practice in Zurich, Switzerland. Patients' characteristics were assessed and in case of pathological cervical swab a PCR-based screening for Chlamydia trachomatis (CT), Mycoplasma genitalium (MG) and Neisseria gonorrhoeae (NG) was initiated to estimate STI prevalence. Bi-and multivariable analysis were used to investigate STI determinants.

RESULTS

585 out of the 620 women presenting for counselling resulted in TOP. 581 (93,7%) cervical specimens were available with 272 having pathological signs (46,8%), thus were considered at risk for STIs. In 192 screened samples 28 STIs (14,6%) (95% CI: 10,3-20,3%) were detected, predominantly CT (17 cases) followed by MG (9 cases) and NG (2 cases). Compared to non-immigrants, immigrants were more likely to have a STI (adjusted OR 2,63; p=0,037) Non-screened women were significantly more often self-payers (31,3%) compared to screened women (8,3%) (p<0,001).

CONCLUSION

We found a high STI prevalence in women presenting for TOP in a Swiss primary care setting. Women with a migration background seemed to be a vulnerable subgroup. Public health efforts are needed to implement cost-effective screening and case management programmes in this population at risk for STIs.

Arthroscopic repair of traumatic isolated subscapularis tendon lesions (Lafosse Type III or IV): a prospective magnetic resonance imaging-controlled case series with 1 year of follow-up

PURPOSE

The purpose of this study was to prospectively assess the efficacy of arthroscopic repair of isolated high-grade subscapularis (SSC) tendon lesions by means of clinical follow-up combined with magnetic resonance imaging investigations.

METHODS

Between January 2008 and September 2010, 11 patients (9 men and 2 women; mean age, 45 ± 10 years) with Lafosse type III or IV traumatic isolated SSC tendon lesions underwent arthroscopic repair including tenodesis of the long head of the biceps tendon. All patients were preoperatively assessed by clinical examination (Constant-Murley score [CMS]) and contrast-enhanced magnetic resonance arthrography. At 1 year of follow-up, specific clinical SSC tests, the CMS, and the loss of external rotation were evaluated. A native magnetic resonance investigation was performed to assess the structural integrity of the repair. The SSC muscle was compared with its preoperative condition regarding fatty infiltration and size (cross-sectional area). Patient satisfaction was graded from 1 (poor) to 4 (excellent).

RESULTS

The mean time interval from trauma to surgery was 3.7 months. A concomitant lesion of the biceps tendon was observed in 10 patients (91%). The mean CMS improved from 44 to 89 points (P < .001). The functional tests showed a significant increase in strength (P < .05) (belly-press test, 4.8 v 2.9; lift-off test, 4.8 v 2.9). The mean loss of external rotation at 0° of abduction was 10° compared with the contralateral side (P < .05). Patient satisfaction was high. Magnetic resonance imaging evaluation showed complete structural integrity of the tendon repair in all studies. The SSC showed a significant decrease in fatty infiltration and increase in the cross-sectional area.

CONCLUSIONS

Arthroscopic repair of higher-grade isolated SSC lesions provides reliable tendon healing accompanied by excellent functional results 1 year after surgery.

LEVEL OF EVIDENCE

Level IV, prospective therapeutic case series.

Implementation of the chronic care model in small medical practices improves cardiovascular risk but not glycemic control

OBJECTIVE To test whether the implementation of elements of the Chronic Care Model (CCM) via a specially trained practice nurse leads to an improved cardiovascular risk profile among type 2 diabetes patients. RESEARCH DESIGN AND METHODS This cluster randomized controlled trial with primary care physicians as the unit of randomization was conducted in the German part of Switzerland. Three hundred twenty-six type 2 diabetes patients (age >18 years; at least one glycosylated hemoglobin [HbA1c] level of ≥7.0% [53 mmol/mol] in the preceding year) from 30 primary care practices participated. The intervention included implementation of CCM elements and involvement of practice nurses in the care of type 2 diabetes patients. Primary outcome was HbA1c levels. The secondary outcomes were blood pressure (BP), LDL cholesterol, accordance with CCM (assessed by Patient Assessment of Chronic Illness Care [PACIC] questionnaire), and quality of life (assessed by the 36-item short-form health survey [SF-36]). RESULTS After 1 year, HbA1c levels decreased significantly in both groups with no significant difference between groups (-0.05% [-0.60 mmol/mol]; P = 0.708). Among intervention group patients, systolic BP (-3.63; P = 0.050), diastolic BP (-4.01; P < 0.001), LDL cholesterol (-0.21; P = 0.033), and PACIC subscores (P < 0.001 to 0.048) significantly improved compared with control group patients. No differences between groups were shown in the SF-36 subscales. CONCLUSIONS A chronic care approach according to the CCM and involving practice nurses in diabetes care improved the cardiovascular risk profile and is experienced by patients as a better structured care. Our study showed that care according to the CCM can be implemented even in small primary care practices, which still represent the usual structure in most European health care systems.

Hospital-integrated general practice: a promising way to manage walk-in patients in emergency departments

RATIONALE, AIMS AND OBJECTIVES

The inappropriate use and overcrowding of emergency departments (EDs) by walk-in patients are well-known problems in many countries. The current study aimed to determine whether ambulatory walk-in patients could be treated more efficiently in a new hospital-integrated general practice (HGP) for emergency care services compared to a traditional ED.

METHODS

We conducted a pre-post comparison before and after the implementation of a new HGP. Participants were walk-in patients attending the ED of a city hospital in Zurich. Main outcome measures were differences in total process time, time intervals between stages of care and diagnostic resources used.

RESULTS

The median process time from admission to discharge was 120 minutes in the ED [interquartile range (IQR): 80-165] versus 60 minutes in the HGP (IQR: 40-90) (P < 0.001). The adjusted odds ratio of receiving any additional diagnostics was 1.86 (95% confidence interval 1.06-3.27; P = 0.032) for ED doctors versus general practitioners (GPs) when controlling for patients' age, sex and injury-related medical problems.

CONCLUSION

The HGP is an efficient way to manage walk-in patients with regard to process time and utilization of additional diagnostic resources. The involvement of GPs in the HGPs should be considered as a promising model to overcome the inappropriate use of resources in EDs for walk-in patients who can be treated by ambulatory care.

Demand and characteristics of a psychiatric 24-hour emergency service performed by mandatory rotation of licensed psychiatrists in Swiss primary care

BACKGROUND

To investigate characteristics of and satisfaction with psychiatric 24-hour emergency primary care performed by mandatory rotation of licensed psychiatrists as a viable baseline for possible reorganizational measures.

METHODS

This was a questionnaire-based cross-sectional study (November 2010-April 2011). The number of patient-psychiatrist encounters, modes of contact, and patient and psychiatrist characteristics were assessed. Diagnoses were coded with ICD-10 (International Classification of Diseases, version 10).

RESULTS

From 167 duty episodes, 74 (44%) were recorded. Of the psychiatrists (n=44), 52% were female, and mean age (standard deviation) was 49.9 (5.2) years. The median number of encounters per episode was 4 (interquartile range 0-8), mainly in the evenings. Demand for "face-to-face" (direct) patient visits was significantly more common (64.0%) than practice (1.3%) or telephone consultations (34.7%). In 83.8%, psychiatrists judged the encounter as adequate at the patient's location. A total of 43 different diagnoses were recorded: mainly schizophrenic disorders (23.9%), suicidal behavior (15.2%), and acute stress reactions (10.3%). Psychiatrists felt burdened by services (62.5%): in 39.2%, they felt threatened; and in 6.8%, violence occurred. In 32.4%, bills were not paid for. If services were optional, 45.2% would participate.

CONCLUSION

Our findings indicate justified demand for direct mobile patient visits, suggesting that emergency care should be multifaceted, and sole provision of psychiatric care at stationed emergency facilities may not always be appropriate. Reorganization of 24-hour emergency services should carefully evaluate patient and provider's needs before changing established structures.

Guidelines adherence to lower urinary tract infection treatment in out-of-hours primary care in European countries

BACKGROUND

The substantial prevalence of bacterial lower urinary tract infections (LUTIs) in out-of-hours (OOH) primary care is a reason for frequent prescription of antibiotics. Insight in guideline adherence in OOH primary care concerning treatment of LUTIs is lacking.

AIMS

To check feasibility of the use of OOH routine data to assess guideline adherence for the treatment of LUTI in OOH primary care, in different regions of Europe.

METHODS

We compared guidelines for diagnosis and treatment of uncomplicated LUTIs in nine European countries, followed by an observational study on available data of guideline adherence. In each region a convenience sample of registration data of at least 100 contacts per OOH primary care setting was collected. Data on adherence (% of contacts) was identified for type of antibiotic and for full treatment adherence (i.e. recommended type and dose and duration).

RESULTS

Six countries were able to provide data on treatment of LUTIs. Four of them succeeded to collect data on type, dosage and duration of treatment. Mostly, trimethoprim was the treatment of first choice, sometimes combined with sulfamethoxazol or sulfamethizol. Adherence with the type of antibiotics varied from 25% to 100%. Denmark achieved a full treatment adherence of 40.0%, the Netherlands 72.7%, Norway 38.3%, and Slovenia 22.2%.

CONCLUSION

Guidelines content is similar to a large extent in the participating countries. The use of OOH routine data for analysis of guideline adherence in OOH primary care seems feasible, although some challenges remain. Adherence regarding treatment varies and suggests room for improvement in most countries.

CoCo trial: Color-coded blood pressure Control, a randomized controlled study

BACKGROUND

Inadequate blood pressure (BP) control is a frequent challenge in general practice. The objective of this study was to determine whether a color-coded BP booklet using a traffic light scheme (red, >180 mmHg systolic BP and/or >110 mmHg diastolic BP; yellow, >140-180 mmHg systolic BP or >90-110 mmHg diastolic BP; green, ≤140 mmHg systolic BP and ≤90 mmHg diastolic BP) improves BP control and adherence with home BP measurement.

METHODS

In this two-group, randomized controlled trial, general practitioners recruited adult patients with a BP >140 mmHg systolic and/or >90 mmHg diastolic. Patients in the control group received a standard BP booklet and the intervention group used a color-coded booklet for daily home BP measurement. The main outcomes were changes in BP, BP control (treatment goal <140/90 mmHg), and adherence with home BP measurement after 6 months.

RESULTS

One hundred and twenty-one of 137 included patients qualified for analysis. After 6 months, a significant decrease in systolic and diastolic BP was achieved in both groups, with no significant difference between the groups (16.1/7.9 mmHg in the intervention group versus 13.1/8.6 mmHg in the control group, P=0.3/0.7). BP control (treatment target <140/90 mmHg) was achieved significantly more often in the intervention group (43% versus 25%; P=0.037; number needed to treat of 5). Adherence with home BP measurement overall was high, with a trend in favor of the intervention group (98.6% versus 96.2%; P=0.1).

CONCLUSION

Color-coded BP self-monitoring significantly improved BP control (number needed to treat of 5, meaning that every fifth patient utilizing color-coded self-monitoring achieved better BP control after 6 months), but no significant between-group difference was observed in BP change. A markedly higher percentage of patients achieved BP values in the normal range. This simple, inexpensive approach of color-coded BP self-monitoring is user-friendly and applicable in primary care, and should be implemented in the care of patients with arterial hypertension.

[Recreational athletes and doping--a survey in 11 gyms in the area of Frankfurt/Main]

BACKGROUND

Doping no longer concerns exclusively competitive sports, but also recreational sports.

METHOD

Survey of 484 recreational athletes in 11 gyms in the area of Frankfurt/Main.

RESULTS

12.9% of the men and 3.6% of the women reported to take anabolic drugs. Theyconsumed anabolic steroids (100%; 35% p.o., 71% parenterally), stimulants (14%) and growth hormone (5%). Suppliers were friends (39%), sports mates (28%), physicians (28%) and coaches (6%). The acquisition costs amounted to an average intake over 9 weeks to 175 Euro. Information about doping side effects came from literature (67%), physicians (38%), sports mates and the so-called Black Book (14% respectively), coaches, friends and Internet (5% respectively). 2% of the athletes with abuse of doping substances were smokers, 11% had a drink several times a week, 3% also consumed other drugs, 35% had consumed other drugs in the past. Abusers of doping substances primarily intended to increase muscle size (86%) and strength (61%).

CONCLUSION

From a sports medical point of view it is concerning that the proportion of doping drugs prescribed by physicians has doubled in the decade after the publication of the predecessor study in Northern Germany despite optimized sports medical and legal education measures.

Sustained health-economic effects after reorganisation of a Swiss hospital emergency centre: a cost comparison study

Background

Emergency departments (EDs) are increasingly overcrowded by walk-in patients. However, little is known about health-economic consequences resulting from long waiting times and inefficient use of specialised resources. We have evaluated a quality improvement project of a Swiss urban hospital: In 2009, a triage system and a hospital-associated primary care unit with General Practitioners (H-GP-unit) were implemented beside the conventional hospital ED. This resulted in improved medical service provision with reduced process times and more efficient diagnostic testing. We now report on health-economic effects.

Methods

From the hospital perspective, we performed a cost comparison study analysing treatment costs in the old emergency model (ED, only) versus treatment costs in the new emergency model (triage plus ED plus H-GP-unit) from 2007 to 2011. Hospital cost accounting data were applied. All consecutive outpatient emergency contacts were included for 1 month in each follow-up year.

Results

The annual number of outpatient emergency contacts increased from n=10 440 (2007; baseline) to n=16 326 (2011; after intervention), reflecting a general trend. In 2007, mean treatment costs per outpatient were €358 (95% CI 342 to 375). Until 2011, costs increased in the ED (€423 (396 to 454)), but considerably decreased in the H-GP-unit (€235 (221 to 250)). Compared with 2007, the annual local budget spent for treatment of 16 326 patients in 2011 showed cost reductions of €417 600 (27 200 to 493 600) after adjustment for increasing patient numbers.

Conclusions

From the health-economic point of view, our new service model shows ‘dominance’ over the old model: While quality of service provision improved (reduced waiting times; more efficient resource use in the H-GP-unit), treatment costs sustainably decreased against the secular trend of increase.

Uncontrolled arterial hypertension in primary care--patient characteristics and associated factors

PRINCIPLES

Most patients with arterial hypertension are treated in primary care. The objective is to assess characteristics of patients with uncontrolled arterial hypertension and its associated determinants in Swiss primary care.

METHOD

Data on 122 adult patients with uncontrolled hypertension (mm Hg >140 systolic and/or >90 diastolic) was collected from the baseline data of the on-going randomised controlled "CoCo" trial: Colour-coded Blood Pressure Control. Patient and general practitioner characteristics were analysed to investigate the relationship between BP and patient characteristics.

RESULTS

From October 2009 to March 2011 30 general practitioners recruited 122 patients; median age 64 years (IQR 54.8-72), 50% male, median BMI 28.3 kg/m2 (IQR 25.3-31.7), 21.5% smokers. 65.6% performed home blood pressure measurement, 88.5% received pharmacological treatment, 41.8% mono-therapy. Most frequent dual drug combinations: diuretics/angiotensin-receptor-blockers (33.3%), angiotensin-converting-enzyme-inhibitors/beta blockers (both 28.1%). BMI, smoking and age were independent predictors for elevated systolic blood pressure when controlled for gender, home blood pressure measurement, education, pulse rate and number of antihypertensive substances. We found a significant non-linear association between systolic blood pressure and number of antihypertensive substances. Age and any amount of antihypertensive substances were independently and inversely correlated with diastolic blood pressure. The findings did not change when additionally controlled for general practitioner clustering effect.

CONCLUSION

Smoking and high BMI are strong and independent factors associated with higher blood pressure levels in patients with uncontrolled arterial hypertension. A high rate of monotherapy and a decrease in the incremental gain on blood pressure control when more antihypertensive agents are used highlight the importance of adequate pharmacological treatment as well as risk factor control.

Improving the quality of morbidity indicators in electronic health records in Swiss primary care

QUESTIONS UNDER STUDY

The FIRE Project established a standardised data collection to facilitate research and quality improvement projects in Swiss primary care. The project is based on the concept of merging clinical and administrative data. Since chronic conditions and multimorbidity are major challenges in primary care, in this study we investigated the agreement between different approaches to identify patients with chronic and multimorbid conditions in electronic medical records (EMRs).

METHODS

A total of 60 primary care physicians were included and data were collected between October 2008 and June 2011. In total, data from 509594 consultations derived from 98152 patients were analysed. Chronic and multimorbid conditions were identified either by ICPC-2 codes or by the type of prescribed medication. We compared these different approaches regarding the completeness of the data to describe chronic conditions and multimorbidity of patients in primary care practices.

RESULTS

The data showed a high correlation between the two morbidity schemes and both indicators apparently provide reliable measures of morbidity within practices. There was considerable variability of patients with chronic conditions across practices, irrespective of whether ICPC-2-diagnoses or prescribed drugs were used to code clinical encounters. Obvious discrepancies between diagnoses and therapies across major disease categories existed.

CONCLUSIONS

This study describes the current situation of EMRs in terms of the ability to measure the burden of chronic conditions in primary care practices. The results illustrate a need of action for this specific topic and the results of this study will be incorporated into the functional specification of EMRs of a planned eHealth project in Swiss primary care.

Characteristics of poorly controlled Type 2 diabetes patients in Swiss primary care

Background

Although a variety of treatment guidelines for Type 2 diabetes patients are available, a majority of patients does not achieve recommended targets. We aimed to characterise Type 2 diabetes patients from Swiss primary care who miss HbA1c treatment goals and to reveal factors associated with the poorly controlled HbA1c level.

Methods

Cross-sectional study nested within the cluster randomised controlled Chronic Care for Diabetes study. Type 2 diabetes patients with at least one HbA1c measurement ≥7.0 % during the last year were recruited from Swiss primary care. Data assessment included diabetes specific and general clinical measures, treatment factors and patient reported outcomes.

Results

326 Type 2 diabetes patients from 30 primary care practices with a mean age 67.1 ± 10.6 years participated in the study. The patients’ findings for HbA1c were 7.7 ± 1.3 %, for systolic blood pressure 139.1 ± 17.6 mmHg, for diastolic blood pressure 80.9 ± 10.5 mmHg and for low density lipoprotein 2.7 ± 1.1. 93.3 % of the patients suffered from at least one comorbidity and were treated with 4.8 ± 2.1 different drugs. No determining factor was significantly related to HbA1c in the multiple analysis, but a significant clustering effect of GPs on HbA1c could be found.

Conclusions

Within our sample of patients with poorly controlled Type 2 diabetes, no “bullet points” could be pointed out which can be addressed easily by some kind of intervention. Especially within this subgroup of diabetes patients who would benefit the most from appropriate interventions to improve diabetes control, a complex interaction between diabetes control, comorbidities, GPs’ treatment and patients’ health behaviour seems to exist. So far this interaction is only poorly described and understood.

Trial registration

Current Controlled Trials ISRCTN05947538.

[The diabetes traffic light scheme - development of an instrument for the case management in patients with diabetes mellitus in primary care]

In order to sustain the continuity and quality of treatment in diabetic primary care patients, it is necessary to introduce structured and regularly performed monitoring system into the practice team. The monitoring aims at early and valid recognition of potential complications resulting from a chronic disease. Ideally the practice nurse is in charge of the case management. The central element of the case management is a colour coded instrument, the diabetes traffic light scheme, by which means the most important clinical parameters and patient adherence can be screened in regular intervals. Additionally, the instrument regulates in-practice communication by means of stratified action plans and enables ideal treatment continuity also in larger teams. The experiences resulting from the development of this diabetes-specific traffic light scheme can be beneficial for the future development of similar instruments in other chronic diseases.

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.