Longer and healthier lives for all? Successes and failures of a universal consumer-driven healthcare system, Switzerland, 1990-2014

Trends over the past 15 years in long-term care in Switzerland: a comparison with Germany, Italy, Norway, and the United Kingdom

BACKGROUND

The demographic changes affecting Switzerland and other European countries, including population ageing, will continue to challenge policymakers in building accessible, affordable, comprehensive and high-quality long-term care (LTC) systems. The purpose of this paper is to investigate how Switzerland's LTC system compares to other European countries, in order to inform how to respond to the increasing need for LTC. We carried out a descriptive study using secondary data from key national and international organizations.

METHODS

By comparing the financing, workforce, service delivery and need for LTC in Switzerland, Germany, Italy, Norway and the United Kingdom, we described similarities and differences in these five European countries between 2005-2019. Thirty-three indicators within five domains were analysed: (1) Population statistics and health expenditure, (2) Need for LTC, (3) LTC financing, (4) LTC service delivery, and (5) LTC workforce.

RESULTS

Switzerland has the highest life expectancy in comparison to the other four high-income countries. However, similarly to other countries, the years lived with disability are increasing in Switzerland. Switzerland's public expenditure on LTC as a share of GDP is lower than that of Norway and Germany, yet out-of-pocket expenditure on LTC is highest in Switzerland. Switzerland has the highest proportion of persons receiving formal LTC both in institutions and at home. Switzerland has had the most pronounced increase in the proportion of over 65-year-olds receiving LTC at home. Even though more than fourfold more persons receive care at home, Switzerland still has more workforce in LTC institutions than in home-care. In comparison to Germany and the UK, Switzerland has a lower number of informal carers as a proportion of 50-year-olds and over, as well as fewer nationally available services for informal carers compared to Germany, Italy, Norway and the UK.

CONCLUSIONS

Our comparative study corroborates the importance of improving the affordability of LTC, continuing to support the movement towards home care services, improving the support given to both the professional workforce and informal carers, and improving the amount and quality of LTC data. It also provides a valuable contrast to other European countries to support evidence-informed policymaking.

eHealth interventions for psychiatry in Switzerland and Russia: a comparative study

Introduction

During the past decade, the use of digital technology to promote mental health has increased dramatically. Additionally, the consequences of the COVID-19 pandemic, such as travel restrictions and the disruption of face-to-face interactions, have led to an increase in the use of digital technologies. A wide variety of technologies have been developed, including messaging chatbots, virtual reality technologies, direct-to-consumer apps, and even technologies that are fully integrated into clinical care tools.

Methods

The following qualitative study is based on the opinions of mental health specialists in both countries regarding the use of digital health technologies in psychiatry in Switzerland and Russia in 2019-2020. We investigate the state of adoption of digital technologies in the field of mental health, the meaning of such technologies, and the crucial factors in the use of such technologies in psychiatry.

Results

Health care professionals in both Russia and Switzerland are well aware of these technologies. However, the use of digital technology to promote mental health has taken different paths in these two health care settings.

Between data providers and concerned citizens: Exploring participation in precision public health in Switzerland

This empirical article explores the dynamics of exchange and reciprocity between cohorters, that is, study organizers, and cohortees, that is, study participants. Drawing on literature on bioeconomy and valuation, we analyze cohortees' expectations in return for the "clinical labor" they perform in the pilot phase of a Swiss precision public health study. Based on an ethnography of this cohort and data from seven focus groups with cohortees (n = 37), we identified four positions: (1) the good citizen participant, (2) the critical participant, (3) the concerned participant, and (4) the self-oriented participant. These reveal that cohortees' participation, still framed in altruistic terms, nevertheless engages expectations about reciprocal obligations of the state and science in terms of public health, confirming the deep entanglement of gift-based, financial, and moral economies of participation. The different values emerging from these expectations-robust scientific evidence about environmental exposure and a socially oriented public health-provide rich indications about stake making which might matter for the future of precision public health.

Translational longevity medicine: a Swiss perspective in an ageing country

Breakthroughs in medical research in the last century have led to a significant extension of the human lifespan, resulting in a shift towards an elderly population worldwide. Due to the ongoing progress of global development towards elevated standards of living, this study specifically examines Switzerland as a representative nation to explore the socioeconomic and healthcare ramifications associated with an ageing population, thereby highlighting the tangible impact experienced in this context. Beyond the exhaustion of pension funds and medical budgets, by reviewing the literature and analysing publicly available data, we observe a "Swiss Japanification". Old age is associated with late-life comorbidities and an increasing proportion of time spent in poor health. To address these problems, a paradigm shift in medical practice is needed to improve health rather than respond to existing diseases. Basic ageing research is gaining momentum to be translated into therapeutic interventions and provides machine learning tools driving longevity medicine. We propose that research focus on closing the translational gap between the molecular mechanisms of ageing and a more prevention-based medicine, which would help people age better and prevent late-life chronic diseases.

Preferences of older adults for healthcare models designed to improve care coordination: evidence from Western Switzerland

Implementing innovations in care delivery in Switzerland is challenging due to the fragmented nature of the system and the specificities of the political process (i.e., direct democracy, decentralized decision-making). In this context, it is particularly important to account for population preferences when designing policies. We designed a discrete choice experiment to study population preferences for coordination-improving care models. Specifically, we assessed the relative importance of model characteristics (i.e., insurance premium, presence of care coordinator, access to specialists, use of EMR, cost-sharing for chronic patients, incentives for informal care), and predicted uptake under different policy scenarios. We accounted for heterogeneity in preferences for the status quo option using an error component logit model. Respondents attached the highest importance to the price attribute (i.e. insurance premium) (0.31, CI: 0.27- 0.36) and to the presence of a care coordinator (0.27, CI: 0.23 - 0.31). Policy scenarios showed for instance that gatekeeping would be preferred to free access to specialists if the model includes a GP or an interprofessional team as a care coordinator. Although attachment to the status quo is high in the studied population, there are potential ways to improve acceptance of alternative care models by implementation of positively valued innovations.

Trends in the disability-free life expectancy in Switzerland over a 10-year period: an analysis of survey-based data

INTRODUCTION

Increasing life expectancy raises concerns whether the years gained will be spent free of disability. Lately, trends across countries have been heterogeneous. This work examined recent trends in disability-free life expectancy and life expectancy with mild  or severe disability in Switzerland.

METHODS

Life expectancy was estimated using national life tables, by sex and 5-year age groups. Based on Sullivan's method, disability-free life expectancy and life expectancy with disability were computed using information from the Swiss Health Survey on age- and sex-specific prevalence of mild and severe disability. Life expectancy, disability-free life expectancy and life expectancy with disability were estimated in 2007, 2012, and 2017, at 65 and 80 years of age, for both sexes.

RESULTS

Between 2007 and 2017, disability-free life expectancy at 65 and 80 years of age increased by 2.1 and 1.4 years, respectively, in men and by 1.5 and 1.1 years, respectively, in women. Meanwhile, life expectancy with mild disability decreased by 6 months in both sexes at age 65 and in men at age 80, but only 1 month in women at age 80. Life expectancy with severe disability also decreased at both ages, by approximately 6 months in women but only 2 to 3 months in men. The proportion of disability-free life expectancy increased significantly in both sexes and ages. For example, disability-free life expectancy / life expectancy at age 65 increased from 67% (95% confidence interval [CI] 66‒69) to 73% (95% CI 71‒74) in women and from 77% (95% CI 75‒79) to 82% (95% CI 81‒84) in men.

CONCLUSION

From 2007 to 2017, disability-free life expectancy at age 65 and 80 increased in Swiss women and men. These gains outweighed those in life expectancy, reflecting some compression of morbidity.

Women carry the weight of deprivation on physical inactivity: Moderated mediation analyses in a European sample of adults over 50 Years of age

Deprived people are less physically active than privileged individuals. However, pathways underlying the association between deprivation and physical activity remain overlooked. We examined whether the association between deprivation and physical activity was mediated by body mass index (BMI). Consistent with an intersectional perspective (how the combination of belongingness to vulnerable social categories widens inequalities), we tested whether gender moderated this mediating pathway and hypothesized that the mediating effect of BMI would be stronger among women (vs men). Large-scale longitudinal data from 20,961 adults 50 years of age or older (57% women) from the Survey of Health, Ageing and Retirement in Europe were used. Social and material deprivation were measured by questionnaire, BMI and physical activity were reported from two to six years later. Simple mediation models showed that BMI partly mediated the association of material (total effect c = -0.14, proportion of mediated effect = 8%) and of social deprivation (c = -0.24, proportion of mediated effect = 4%) with physical activity. Moderated mediation models revealed that this mediating pathway was moderated by gender. The effect of deprivation on BMI was stronger among women (vs men), with BMI mediating 18% and 7% of the association of material and social deprivation with physical activity among women (vs 4% and 2% among men). Lower levels of physical activity observed among deprived older adults could be partly attributed to a higher BMI. Critically, this mechanism was exacerbated among women, reinforcing the need to understand how deprivation and gender interact to predict health behaviors.

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Body mass index mediates the association of material and social deprivation with physical activity.

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This mediating pattern is more pronounced among women, relative to men.

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The association between deprivation and a higher body mass index is exacerbated among women, compared to men.

Health and labor force participation among older workers in Switzerland: a growth curve analysis

This study investigated how individual trajectories of self-rated health (SRH) and working hours among older workers in Switzerland are interrelated and how this relationship varies based on occupation. We used data from the Swiss Household Panel to analyze the long-term trajectories of older workers measured in terms of working hours and SRH. The sample included more than 4000 workers aged 50 to 65(men)/64(women). We ran a bivariate response multilevel model for growth that allowed the examination of between- and within-individual changes over time. On a between-individual level, we found that the upper non-manual workers were the most heterogeneous occupational group in terms of working hours and the lower non-manual workers were the most heterogeneous occupational group in terms of health. Within all occupational groups, we found a significant relationship between the level of working hours and level of SRH. The individual-level statistics showed consistently strongest effects for manual workers. This result confirms our hypothesis that labor force participation in individuals of the manual occupational group is more sensitive to their health status. Our findings contribute to the debate regarding the importance of older workers' health in the context of the extension of working life.

Friendship in Later Life: Thirty Years of Progress and Inequalities

Studies examining the impact of social change on individual development and aging postulate the growing importance of flexible relationships, such as friendship. Although friendship is well known as a factor of well-being in later life, the prevalence of friendship in older adult networks and its unequal distribution has been examined only in few studies. Through secondary data analysis of two cross-sectional surveys carried out in Switzerland in 1979 and 2011, respectively, the increasing presence of close friends was confirmed. Our results show that this trend was part of a broader lifestyle change after retirement, with increasing social engagements. However, this trend does not include a general decrease in social inequalities in friendship opportunities. Overall, friendship increase among older adults has contributed to a polarization of living conditions, with a majority of active, healthy persons contrasting with a minority of individuals who accumulate penalties.

General and Vulnerable Population’s Satisfaction With the Healthcare System in Urban and Rural Areas: Findings From the European Social Survey

Introduction: Access to the healthcare system when patients are vulnerable and living outside metropolitan areas can be challenging. Our objective was to explore healthcare system satisfaction of urban and rural inhabitants depending on financial and health vulnerabilities.

Methods: Repeated cross-sectional data from 353,523 European citizens (2002–2016). Multivariable associations between rural areas, vulnerability factors and satisfaction with the healthcare system were assessed with linear mixed regressions and adjusted with sociodemographic and control factors.

Results: In unadjusted analysis, the people who lived in houses in the countryside and those who lived in the suburbs were the most satisfied with the healthcare system. In the adjusted model, residents living in big cities had the highest satisfaction. Financial and health vulnerabilities were associated with less satisfaction with the healthcare system, with a different effect according to the area of residence: the presence of health vulnerability was more negatively correlated with the healthcare system satisfaction of big city inhabitants, whereas financial vulnerability was more negatively correlated with the satisfaction of those living in countryside homes.

Conclusion: Vulnerable residents, depending on their area of residence, may require special attention to increase their satisfaction with the healthcare system.

Social participation and life satisfaction among older adults: diversity of practices and social inequality in Switzerland

This paper examines the associations between social participation and individual life satisfaction among older adults. It specifically considers the diversity of the practices and social inequalities among this population. For analyses, we used a large survey of individuals of 65 years and older conducted in 2011 in Switzerland (N = 2,727). The first set of linear regression analyses examines Diener's Satisfaction with Life Scale and its association with various indicators of social participation. While the second set of logistic regression addresses the issue of social inequalities by evaluating the impacts of gender, age group, region and education on social participation indicators that are significantly associated with the satisfaction with life score. Our results stressed the importance of combining multiple forms of participation for life satisfaction and shows that some forms are particularly meaningful: in particular, the involvement in associations, visitation of family or visitation of friends/acquaintances and church attendance. When inequalities among older adults are considered, having rich and varied social participation, being involved in associations and maintaining private sociability with non-kin appear more elitist. While institutionalised and/or private sociability types of participation appear particularly significant for older adults’ life satisfaction, the most traditional integration forms – i.e. family and religions – are crucial for the more vulnerable. Implications for active ageing was equally discussed as well.

Healthy ageing for all? Comparisons of socioeconomic inequalities in health expectancies over two decades in the Cognitive Function and Ageing Studies I and II

Background

Despite increasing life expectancy (LE), cross-sectional data show widening inequalities in disability-free LE (DFLE) by socioeconomic status (SES) in many countries. We use longitudinal data to better understand trends in DFLE and years independent (IndLE) by SES, and how underlying transitions contribute.

Methods

The Cognitive Function and Ageing Studies (CFAS I and II) are large population-based studies of those aged ≥65 years in three English centres (Newcastle, Nottingham, Cambridgeshire), with baseline around 1991 (CFAS I, n = 7635) and 2011 (CFAS II, n = 7762) and 2-year follow-up. We defined disability as difficulty in activities of daily living (ADL), dependency by combining ADLs and cognition reflecting care required, and SES by area-level deprivation. Transitions between disability or dependency states and death were estimated from multistate models.

Results

Between 1991 and 2011, gains in DFLE at age 65 were greatest for the most advantaged men and women [men: 4.7 years, 95% confidence interval (95% CI) 3.3–6.2; women: 2.8 years, 95% CI 1.3–4.3]. Gains were due to the most advantaged women having a reduced risk of incident disability [relative risk ratio (RRR):0.7, 95% CI 0.5–0.8], whereas the most advantaged men had a greater likelihood of recovery (RRR: 1.8, 95% CI 1.0–3.2) and reduced disability-free mortality risk (RRR: 0.4, 95% CI 0.3–0.6]. Risk of death from disability decreased for least advantaged men (RRR: 0.7, 95% CI 0.6–0.9); least advantaged women showed little improvement in transitions. IndLE patterns across time were similar.

Conclusions

Prevention should target the most disadvantaged areas, to narrow inequalities, with clear indication from the most advantaged that reduction in poor transitions is achievable.

Trends in health expectancies: a systematic review of international evidence

OBJECTIVES

A clear understanding of whether increases in longevity are spent in good health is necessary to support ageing, health and care-related policy.

DESIGN

We conducted a systematic review to update and summarise evidence on trends in health expectancies, in Organisation for Economic Co-operation and Development (OECD) high-income countries.

DATA SOURCES

Four electronic databases (MEDLINE, 1946-19 September 2019; Embase 1980-2019 week 38; Scopus 1966-22 September 2019, Health Management Information Consortium, 1979-September 2019), and the UK Office for National Statistics website (November 2019).

ELIGIBILITY CRITERIA

English language studies published from 2016 that reported trends in healthy, active and/or disability-free life expectancy in an OECD high-income country.

DATA EXTRACTION AND SYNTHESIS

Records were screened independently by two researchers. Study quality was assessed using published criteria designed to identify sources of bias in studies reporting trends, and evidence summarised by narrative synthesis.

FINDINGS

Twenty-eight publications from 11 countries were included, covering periods from 6 to 40 years, between 1970 and 2017. In most countries, gains in healthy and disability-free life expectancy do not match the growth in total life expectancy. Exceptions were demonstrated for women in Sweden, where there were greater gains in disability-free years than life expectancy. Gains in healthy and disability-free life expectancy were greater for men than women in most countries except the USA (age 85), Japan (birth), Korea (age 65) and Sweden (age 77).

CONCLUSION

An expansion of disability in later life is evident in a number of high-income countries, with implications for the sustainability of health and care systems. The recent COVID-19 pandemic may also impact health expectancies in the longer term.

Etiology-specific variation in survival following non-traumatic spinal cord injury: a causal inference approach using data from a population-based cohort

Study design

Observational, population-based cohort study.

Objectives

To evaluate the origin and contribution to excess of survival differences following non-traumatic spinal cord injury (NTSCI) using etiology as proxy for variation in underlying health condition.

Setting

Specialized rehabilitation centers in Switzerland.

Methods

Medical record data collected by the Swiss Spinal Cord Injury cohort (SwiSCI) study were linked with mortality information from the Swiss National Cohort. Considering contemporary theory and empirical evidence, a directed acyclic graph (DAG) was developed to formally evaluate causal differences among NTSCI etiologies, relative to traumatic SCI (TSCI). Statistical inference was contingent on hazard ratios (HRs) and marginal survival differences, derived using flexible parametric modeling.

Results

3643 individuals (NTSCI = 1357; TSCI = 2286) diagnosed with SCI between 1990 and 2011 were included, contributing a cumulative 41,344 person-years and 1323 deaths. Test statistics confirmed DAG-dataset consistency. As compared to TSCI, mortality was elevated in all NTSCI etiological groups; malignant etiologies had the highest HRs (10; 95% CI, 8.0 to 14) followed by infection (2.6; 1.8 to 3.6) and vascular (2.5; 2.0 to 3.2) etiology groups. At the attained age of 55, the estimated reduction in survival among non-malignant etiologies was 9.4% (5.8 to 13) at 5 years and 17% (11 to 23) at 20 years.

Conclusions

Causal differences in survival among NTSCI etiological groups are likely a result of chronic variation in health conditions. This study supports the development of long-term interdisciplinary management and policy for individuals with NTSCI, specific to etiology.