1
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Huber F, Mariacher S, Chmiel C. [Gout and CPPD (Chondrocalcinosis)]. Praxis (Bern 1994) 2023; 112:120-125. [PMID: 36722103 DOI: 10.1024/1661-8157/a003957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
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2
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Chmiel C, Valentin S, Beise U, Huber F. [Osteoporosis]. Praxis (Bern 1994) 2023; 112:250-259. [PMID: 36919314 DOI: 10.1024/1661-8157/a003958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Affiliation(s)
| | | | - Uwe Beise
- Verein mediX schweiz, Zürich, Schweiz
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3
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Meier R, Chmiel C, Valeri F, Muheim L, Senn O, Rosemann T. The Effect of Financial Incentives on Quality Measures in the Treatment of Diabetes Mellitus: a Randomized Controlled Trial. J Gen Intern Med 2022; 37:556-564. [PMID: 33904045 PMCID: PMC8858366 DOI: 10.1007/s11606-021-06714-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Financial incentives are often used to improve quality of care in chronic care patients. However, the evidence concerning the effect of financial incentives is still inconclusive. OBJECTIVE To test the effect of financial incentives on quality measures (QMs) in the treatment of patients with diabetes mellitus in primary care. We incentivized a clinical QM and a process QM to test the effect of financial incentives on different types of QMs and to investigate the spill-over effect on non-incentivized QMs. DESIGN/PARTICIPANTS Parallel cluster randomized controlled trial based on electronic medical records database involving Swiss general practitioners (GPs). Practices were randomly allocated. INTERVENTION All participants received a bimonthly feedback report. The intervention group additionally received potential financial incentives on GP level depending on their performance. MAIN MEASURES Between-group differences in proportions of patients fulfilling incentivized QM (process QM of annual HbA1c measurement and clinical QM of blood pressure level below 140/95 mmHg) after 12 months. KEY RESULTS Seventy-one GPs (median age 52 years, 72% male) from 43 different practices and subsequently 3838 patients with diabetes mellitus (median age 70 years, 57% male) were included. Proportions of patients with annual HbA1c measurements remained unchanged (intervention group decreased from 79.0 to 78.3%, control group from 81.5 to 81.0%, OR 1.09, 95% CI 0.90-1.32, p = 0.39). Proportions of patients with blood pressure below 140/95 improved from 49.9 to 52.5% in the intervention group and decreased from 51.2 to 49.0% in the control group (OR 1.16, 95% CI 0.99-1.36, p = 0.06). Proportions of non-incentivized process QMs increased significantly in the intervention group. CONCLUSION GP level financial incentives did not result in more frequent HbA1c measurements or in improved blood pressure control. Interestingly, we could confirm a spill-over effect on non-incentivized process QMs. Yet, the mechanism of spill-over effects of financial incentives is largely unclear. TRIAL REGISTRATION ISRCTN13305645.
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Affiliation(s)
- Rahel Meier
- Institute of Primary Care, University of Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland. .,University Hospital Zurich, Zürich, Switzerland.
| | - Corinne Chmiel
- Institute of Primary Care, University of Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland.,University Hospital Zurich, Zürich, Switzerland
| | - Fabio Valeri
- Institute of Primary Care, University of Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland.,University Hospital Zurich, Zürich, Switzerland
| | - Leander Muheim
- Institute of Primary Care, University of Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland.,University Hospital Zurich, Zürich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland.,University Hospital Zurich, Zürich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, Pestalozzistrasse 24, 8091, Zurich, Switzerland.,University Hospital Zurich, Zürich, Switzerland
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4
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Binz K, Huber F, Chmiel C, Beise U. [Not Available]. Praxis (Bern 1994) 2022; 110:102-108. [PMID: 35105213 DOI: 10.1024/1661-8157/a003805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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5
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Meier R, Chmiel C, Valeri F, Muheim L, Senn O, Rosemann T. Long-Term Effects of Financial Incentives for General Practitioners on Quality Indicators in the Treatment of Patients With Diabetes Mellitus in Primary Care-A Follow-Up Analysis of a Cluster Randomized Parallel Controlled Trial. Front Med (Lausanne) 2021; 8:664510. [PMID: 34765612 PMCID: PMC8576070 DOI: 10.3389/fmed.2021.664510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 09/16/2021] [Indexed: 11/19/2022] Open
Abstract
Background: The effect of financial incentives on the quality of primary care is of high interest, and so is its sustainability after financial incentives are withdrawn. Objective: To assess both long-term effects and sustainability of financial incentives for general practitioners (GPs) in the treatment of patients with diabetes mellitus based on quality indicators (QIs) calculated from routine data from electronic medical records. Design/Participants: Randomized controlled trial using routine data from electronic medical records of patients with diabetes mellitus of Swiss GPs. Intervention: During the study period of 24 months, all GPs received bimonthly feedback reports with information on their actual treatment as reflected in QIs. In the intervention group, the reports were combined with financial incentives for quality improvement. The incentive was stopped after 12 months. Measurements: Proportion of patients meeting the process QI of annual HbA1c measurements and the clinical QI of blood pressure levels below 140/85 mmHg. Results: A total of 71 GPs from 43 different practices were included along with 3,854 of their patients with diabetes mellitus. Throughout the study, the proportion of patients with annual HbA1c measurements was stable in the intervention group (78.8–78.9%) and decreased slightly in the control group (81.5–80.2%) [odds ratio (OR): 1.21; 95% CI: 1.04–1.42, p < 0.05]. The proportion of patients achieving blood pressure levels below 140/85 mmHg decreased in the control group (51.2–47.2%) and increased in the intervention group (49.7–51.9%) (OR: 1.18; 95% CI: 1.04–1.35, p < 0.05) where it peaked at 54.9% after 18 months and decreased steadily over the last 6 months. Conclusion: After the withdrawal of financial incentives for the GPs after 12 months, some QIs still improved, indicating that 1 year might be too short to observe the full effect of such interventions. The decrease in QI achievement rates after 18 months suggests that the positive effects of time-limited financial incentives eventually wane.
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Affiliation(s)
- Rahel Meier
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Corinne Chmiel
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Fabio Valeri
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Leander Muheim
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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6
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Kumati A, Fischer H, Chmiel C. [Skin Lesions with a Lethal Course]. Praxis (Bern 1994) 2021; 110:591-593. [PMID: 34344193 DOI: 10.1024/1661-8157/a003690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Skin Lesions with a Lethal Course Abstract. Dermatological problems are a frequent reason for consultation in the general practitioner's office. Especially in elderly persons, certain efflorescences must be considered as underlying neoplasia. This case report of erythema gyratum repens as the initial manifestation of an otherwise asymptomatic metastatic tubal carcinoma was lethal three months after diagnosis.
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Muheim L, Signorell A, Markun S, Chmiel C, Neuner-Jehle S, Blozik E, Ursprung P, Rosemann T, Senn O. Potentially inappropriate proton-pump inhibitor prescription in the general population: a claims-based retrospective time trend analysis. Therap Adv Gastroenterol 2021; 14:1756284821998928. [PMID: 33948109 PMCID: PMC8053831 DOI: 10.1177/1756284821998928] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 02/09/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Proton-pump inhibitors (PPI) are among the most prescribed drugs worldwide, and a large body of evidence raises concerns about their inappropriate use. Previous estimates of inappropriate use varied due to different definitions and study populations. AIMS We aimed to measure the population-based incidence and time trends of PPI and potentially inappropriate PPI prescriptions (PIPPI) with a novel method, continuously assessing excessive cumulative doses based on clinical practice guidelines. We also assessed association of patient characteristics with PPI prescriptions and PIPPI. METHODS This was an observational study based on a large insurance claims database of persons aged >18 years with continuous claims records of ⩾12 months. The observation period was January 2012 to December 2017. We assessed the incidence and time trends of PPI prescriptions and PIPPI based on doses prescribed, defining ⩾11.5 g of pantoprazole dose equivalents during any consecutive 365 days (average daily dose >31 mg) as inappropriate. RESULTS Among 1,726,491 eligible persons, the annual incidence of PPI prescriptions increased from 19.7% (2012) to 23.0% (2017), (p = <0.001), and the incidence of PIPPI increased from 4.8% (2013) to 6.4% (2017), (p = <0.001). Age, male gender, drugs with bleeding risk and multimorbidity were independent determinants of PIPPI (p = <0.001 for all). CONCLUSIONS This study provides evidence that one of the most prescribed drug groups is commonly prescribed inappropriately in the general population and that this trend is increasing. Multimorbidity and drugs with bleeding risks were strong determinants of PIPPI. Addressing PPI prescriptions exceeding guideline recommendations could reduce polypharmacy and improve patient safety.
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Affiliation(s)
| | | | - Stefan Markun
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Corinne Chmiel
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Stefan Neuner-Jehle
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Eva Blozik
- Department of Health Sciences, Helsana Group, Switzerland
| | - Pascale Ursprung
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zurich, Switzerland
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8
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Chmiel C. [Not Available]. Praxis (Bern 1994) 2021; 110:403-404. [PMID: 33834881 DOI: 10.1024/1661-8157/a003679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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9
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Abstract
Sensible Check-up examinations in general practice - General aspects with a focus on cardiovascular risk Abstract. Patient's desire for check-up examinations is common in primary care. Systematic (yearly) Check-ups for asymptomatic persons outside of the regular care by the own family doctor cannot be recommended based on the current scientific evidence. Check-ups offered in designated specialized centers show no benefit concerning morbidity and mortality and the risk of false positive results is substantial. On the contrary, there is scientific evidence that a Check-up at the own family doctor shows health benefits, since it is able to significantly improve cardiovascular risk factors. It also offers an opportunity for individualized, evidence-based prevention and counseling, for which there is no time during regular consultations concerning acute health problems. Recognizing the motives for the check-up (hidden agenda) and an individualized risk assessment, as well as advice on a healthy lifestyle, are central elements of a check-up at the family doctor. The check-up also offers an opportunity to strengthen the doctor-patient relationship, which is known to be associated with improved health. This article discusses the different components of a check-up consultation and introduces some useful tools, with a focus on cardiovascular screening.
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Affiliation(s)
- Corinne Chmiel
- MediX Praxis Friesenberg, Zürich.,Institut für Hausarztmedizin, Universität und Universitätsspital Zürich
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10
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Chmiel C. Outpatient Care of COVID-19 Patients. Praxis (Bern 1994) 2021; 110:113. [PMID: 33496633 DOI: 10.1024/1661-8157/a003644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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11
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Chmiel C. [Outpatient Care of COVID-19 Patients - V.4.0/12.01.2021; provided by mediX]. Praxis (Bern 1994) 2021; 110:112. [PMID: 33496634 DOI: 10.1024/1661-8157/a003645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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12
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Chmiel C. [Outpatient Care of COVID-19 Patients - V.4.0/12.01.2021; provided by mediX]. Praxis (Bern 1994) 2021; 110:111. [PMID: 33496635 DOI: 10.1024/1661-8157/a003643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
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13
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Chmiel C, Giambarba C, Trachsler J. Sudden Paralysis in an American Football Player! Monster Football? Praxis (Bern 1994) 2021; 110:160-163. [PMID: 33653101 DOI: 10.1024/1661-8157/a003621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
This case of ascending paralysis, following an episode of diarrhea, was initially misinterpreted as Guillain-Barré syndrome. The prominent hypokalemia led to the search for other differential diagnoses, initially interpreted as a rare case of periodic hypokalemic paralysis, which usually occurs in Asians after intake of large amounts of starch foods, such as Spaghetti, or rest after heavy exercise. In this case, the reason for the hypokalemia with associated paralysis was caused by a hyperhyreosis factitia through denied intake of T3.
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Affiliation(s)
- Corinne Chmiel
- University Hospital of Zurich, Institute of Primary Care, Switzerland
- mediX praxis friesenberg, Zurich, Switzerland
- Private Practice Zurich, Switzerland
- City Hospital Waid, Zurich, Switzerland
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Rachamin Y, Meier R, Rosemann T, Flammer AJ, Chmiel C. Heart failure epidemiology and treatment in primary care: a retrospective cross-sectional study. ESC Heart Fail 2020; 8:489-497. [PMID: 33159393 PMCID: PMC7835584 DOI: 10.1002/ehf2.13105] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/25/2020] [Accepted: 10/22/2020] [Indexed: 12/22/2022] Open
Abstract
Aims Heart failure is one of the leading causes of morbidity and mortality worldwide, but little is known on heart failure epidemiology and treatment in primary care. This study described patients with heart failure treated by general practitioners, with focus on drug prescriptions and especially on the only specific treatment for heart failure with reduced ejection fraction, namely sacubitril/valsartan. Methods and results This was a retrospective cross‐sectional study using data from an electronic medical record database of Swiss general practitioners from 2016 to 2019. Multilevel logistic regression was used to find determinants of sacubitril/valsartan prescription; odds ratios (ORs) and 95% confidence intervals (CIs) were reported. We identified 1288 heart failure patients (48.5% women; age: median 85 years, interquartile range 77–90 years) by means of diagnosis code, representing 0.5% of patients consulting a general practitioner during the observation period. About 73.6% received a renin–angiotensin–aldosterone system inhibitor, 67.8% a beta‐blocker, 34.6% a calcium channel blocker, 86.1% a diuretic, and 40.1% another cardiac drug. Sacubitril/valsartan was prescribed in 6% predominantly male patients (OR 2.10, CI 1.25–3.84), of younger age (OR 0.59 per increase in 10 years, CI 0.49–0.71), with diabetes mellitus (OR 1.76, CI 1.07–2.90). The recommended starting dose for sacubitril/valsartan was achieved in 67.1% and the target dose in 28.6% of patients. Conclusions Prevalence of heart failure among patients treated by general practitioners was low. Considering the disease burden and association with multimorbidity, awareness of heart failure in primary care should be increased, with the aim to optimize heart failure therapy.
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Affiliation(s)
- Yael Rachamin
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Pestalozzistrasse 24, Zürich, 8091, Switzerland
| | - Rahel Meier
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Pestalozzistrasse 24, Zürich, 8091, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Pestalozzistrasse 24, Zürich, 8091, Switzerland
| | - Andreas J Flammer
- Department of Cardiology, University Hospital Zurich, Zürich, Switzerland
| | - Corinne Chmiel
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Pestalozzistrasse 24, Zürich, 8091, Switzerland
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Meier R, Valeri F, Senn O, Rosemann T, Chmiel C. Quality performance and associated factors in Swiss diabetes care - A cross-sectional study. PLoS One 2020; 15:e0232686. [PMID: 32369830 PMCID: PMC7200167 DOI: 10.1371/journal.pone.0232686] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 04/17/2020] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Quality indicators and pay-for-performance schemes aim to improve processes and outcomes in clinical practice. However, general practitioner and patient characteristics influence quality indicator performance. In Switzerland, no data on the pay-for-performance approach exists and the use of quality indicators has been marginal. The aim of this study was to describe quality indicator performance in diabetes care in Swiss primary care and to analyze associations of practice, general practitioner and patient covariates with quality indicator performance. METHODS For this cross-sectional study, we used medical routine data from an electronic medical record database. Data from 71 general practitioners and all their patients with diabetes were included. Starting in July 2018, we retrieved 12-month retrospective data about practice, general practitioner and patient characteristics, laboratory values, comorbidities and co-medication. Based on this data, we assessed quality indicator performance of process and intermediate outcomes for glycated hemoglobin, blood pressure, cholesterol and associations of practice, general practitioner and patient characteristics with individual and cumulative quality indicator performance. We calculated odds ratios (OR) and 95% confidence intervals (CI) using regression methods. RESULTS We assessed 3,383 patients with diabetes (57% male, mean age 68.3 years). On average, patients fulfilled 3.56 (standard deviation: 1.89) quality indicators, whereas 17.2% of the patients fulfilled all six quality indicators. On practice and general practitioner level, we found no associations with cumulative quality indicator performance. On patient level, gender (ref = male) (OR: 0.83, CI: 0.78-0.88), number of treating general practitioners (OR: 0.94, CI: 0.91-0.97), number of comorbidities (OR: 1.43, CI: 1.38-1.47) and number of consultations (OR: 1.02, CI: 1.02-1.02) were associated with cumulative quality indicator performance. CONCLUSION The influence of practice, general practitioner and patient characteristics on quality indicator performance was surprisingly small and room for improvement in quality indicator performance of Swiss general practitioners seems to exist in diabetes care.
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Affiliation(s)
- Rahel Meier
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zürich, Switzerland
- * E-mail:
| | - Fabio Valeri
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zürich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zürich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zürich, Switzerland
| | - Corinne Chmiel
- Institute of Primary Care, University of Zurich and University Hospital Zurich, Zürich, Switzerland
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Falck L, Zoller M, Rosemann T, Martínez-González NA, Chmiel C. Toward Standardized Monitoring of Patients With Chronic Diseases in Primary Care Using Electronic Medical Records: Development of a Tool by Adapted Delphi Procedure. JMIR Med Inform 2020; 8:e14483. [PMID: 32209535 PMCID: PMC7142740 DOI: 10.2196/14483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 09/18/2019] [Accepted: 01/21/2020] [Indexed: 12/02/2022] Open
Abstract
Background Long-term care for patients with chronic diseases poses a huge challenge in primary care. There are deficits in care, especially regarding monitoring and creating structured follow-ups. Appropriate electronic medical records (EMR) could support this, but so far, no generic evidence-based template exists. Objective The aim of this study is to develop an evidence-based standardized, generic template that improves the monitoring of patients with chronic conditions in primary care by means of an EMR. Methods We used an adapted Delphi procedure to evaluate a structured set of evidence-based monitoring indicators for 5 highly prevalent chronic diseases (ie, diabetes mellitus type 2, asthma, arterial hypertension, chronic heart failure, and osteoarthritis). We assessed the indicators’ utility in practice and summarized them into a user-friendly layout. Results This multistep procedure resulted in a monitoring tool consisting of condensed sets of indicators, which were divided into sublayers to maximize ergonomics. A cockpit serves as an overview of fixed goals and a set of procedures to facilitate disease management. An additional tab contains information on nondisease-specific indicators such as allergies and vital signs. Conclusions Our generic template systematically integrates the existing scientific evidence for the standardized long-term monitoring of chronic conditions. It contains a user-friendly and clinically sensible layout. This template can improve the care for patients with chronic diseases when using EMRs in primary care.
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Affiliation(s)
- Leandra Falck
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - Marco Zoller
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | | | - Corinne Chmiel
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
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Falck L, Zoller M, Rosemann T, Martínez-González NA, Chmiel C. Toward Standardized Monitoring of Patients With Chronic Diseases in Primary Care Using Electronic Medical Records: Systematic Review. JMIR Med Inform 2019; 7:e10879. [PMID: 31127717 PMCID: PMC6555125 DOI: 10.2196/10879] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 03/20/2019] [Accepted: 04/07/2019] [Indexed: 12/21/2022] Open
Abstract
Background Long-term care for patients with chronic diseases poses a huge challenge in primary care. In particular, there is a deficit regarding monitoring and structured follow-up. Appropriate electronic medical records (EMRs) could help improving this but, so far, there are no evidence-based specifications concerning the indicators that should be monitored at regular intervals. Objective The aim was to identify and collect a set of evidence-based indicators that could be used for monitoring chronic conditions at regular intervals in primary care using EMRs. Methods We searched MEDLINE (Ovid), Embase (Elsevier), the Cochrane Library (Wiley), the reference lists of included studies and relevant reviews, and the content of clinical guidelines. We included primary studies and guidelines reporting about indicators that allow for the assessment of care and help monitor the status and process of disease for five chronic conditions, including type 2 diabetes mellitus, asthma, arterial hypertension, chronic heart failure, and osteoarthritis. Results The use of the term “monitoring” in terms of disease management and long-term care for patients with chronic diseases is not widely used in the literature. Nevertheless, we identified a substantial number of disease-specific indicators that can be used for routine monitoring of chronic diseases in primary care by means of EMRs. Conclusions To our knowledge, this is the first systematic review summarizing the existing scientific evidence on the standardized long-term monitoring of chronic diseases using EMRs. In a second step, our extensive set of indicators will serve as a generic template for evaluating their usability by means of an adapted Delphi procedure. In a third step, the indicators will be summarized into a user-friendly EMR layout.
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Affiliation(s)
- Leandra Falck
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - Marco Zoller
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | | | - Corinne Chmiel
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
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Chmiel C, Giewer I, Frei A, Rosemann T. Reply to Roswitha Koch et al. Swiss Med Wkly 2019; 149:w20009. [DOI: 10.4414/smw.2019.20009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Corinne Chmiel
- University Hospital Zurich, Institute of Primary Care, Zurich, Switzerland
| | - Irina Giewer
- University Hospital Zurich, Institute of Primary Care, Zurich, Switzerland
| | - Anja Frei
- University Hospital Zurich, Institute of Primary Care, Zurich, Switzerland
| | - Thomas Rosemann
- University Hospital Zurich, Institute of Primary Care, Zurich, Switzerland
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Chmiel C, Vavricka SR, Hasler S, Rogler G, Zahnd N, Schiesser S, Tandjung R, Scherz N, Rosemann T, Senn O. Feasibility of an 8-item questionnaire for early diagnosis of inflammatory bowel disease in primary care. J Eval Clin Pract 2019; 25:155-162. [PMID: 30324695 DOI: 10.1111/jep.13046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 08/31/2018] [Indexed: 12/12/2022]
Abstract
AIMS Diagnosis of inflammatory bowel disease (IBD) is often associated with a diagnostic delay. Although faecal calprotectin is a helpful screening tool, the widespread use in primary care (PC) may not be appropriate due to the low prevalence of IBD in this setting. To increase pretest probability for a positive calprotectin test, an 8-item questionnaire (CalproQuest) was tested for its feasibility and acceptability in PC. METHODS Population: PC patients with unspecific gastrointestinal complaints for at least 2 weeks. The CalproQuest consists of four major and four minor questions specific for IBD. It is considered positive if greater than or equal to two major or one major and two minor criteria are positive. PRIMARY OUTCOME feasibility of CalproQuest, secondary outcome: patient's acceptance of stool sampling. RESULTS Of 95 patients with a complete CalproQuest 52 (54.7%) were positive, 39 (41.1%) fulfilled two major and 13 (13.7%) one major and greater than or equal to two minor criteria. Twenty-seven general practitioners completed 83 (87.4%) questionnaires on feasibility which was assessed positive. Eighty-two patients (86.3%) completed questionnaires on acceptance which was high. CONCLUSION The CalproQuest is a feasible instrument for assessing IBD in PC. Further prospective studies concerning validity and cost effectiveness of a combined use with the calprotectin test in this setting are necessary.
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Affiliation(s)
- Corinne Chmiel
- Institute of Primary Care, University and University Hospital of Zurich, Switzerland
| | - Stephan R Vavricka
- Department of Gastroenterology and Hepatology, University Hospital Zürich, 8091, Zürich, Switzerland
| | - Susann Hasler
- Institute of Primary Care, University and University Hospital of Zurich, Switzerland
| | - Gerhard Rogler
- Department of Gastroenterology and Hepatology, University Hospital Zürich, 8091, Zürich, Switzerland
| | - Nadine Zahnd
- Department of Gastroenterology and Hepatology, University Hospital Zürich, 8091, Zürich, Switzerland
| | - Salomé Schiesser
- Institute of Primary Care, University and University Hospital of Zurich, Switzerland
| | - Ryan Tandjung
- Institute of Primary Care, University and University Hospital of Zurich, Switzerland
| | - Nathalie Scherz
- Institute of Primary Care, University and University Hospital of Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University and University Hospital of Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University and University Hospital of Zurich, Switzerland
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Grischott T, Zechmann S, Rachamin Y, Markun S, Chmiel C, Senn O, Rosemann T, Rodondi N, Neuner-Jehle S. Improving inappropriate medication and information transfer at hospital discharge: study protocol for a cluster RCT. Implement Sci 2018; 13:155. [PMID: 30591069 PMCID: PMC6309068 DOI: 10.1186/s13012-018-0839-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 11/15/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Inappropriate medication and polypharmacy increase morbidity, hospitalisation rate, costs and mortality in multimorbid patients. At hospital discharge of elderly patients, polypharmacy is often even more pronounced than at admission. However, the optimal discharge strategy in view of sustained medication appropriateness remains unclear. In particular, unreflectingly switching back to the pre-hospitalisation medication must be avoided. Therefore, both the patients and the follow-up physicians should be involved in the discharge process. In this study, we aim to test whether a brief medication review which takes the patients' priorities into account, combined with a standardised communication strategy at hospital discharge, leads to sustained medication appropriateness and extends readmission times among elderly multimorbid patients. METHODS The study is designed as a two-armed, double-blinded, cluster-randomised trial, involving 42 senior hospital physicians (HPs) with their junior HPs and 2100 multimorbid patients aged 60 years or older. Using a randomised minimisation strategy, senior HPs will be assigned to either intervention or control group. Following instructions of the study team, the senior HPs in the intervention group will teach their junior HPs how to integrate a simple medication review tool combined with a defined communication strategy into their ward's discharge procedure. The untrained HPs in the control group will provide data on usual care, and their patients will be discharged following usual local routines. Primary outcome is the time until readmission within 6 months after discharge, and secondary outcomes cover readmission rates, number of emergency and GP visits, classes and numbers of drugs prescribed, proportions of potentially inappropriate medications, and the patients' quality of life after discharge. Additionally, the characteristics of both the HPs as well as the patients will be collected before the intervention. Process evaluation outcomes will be assessed parallel to the ongoing core study using qualitative research methods. DISCUSSION So far, interventions to reduce polypharmacy are still scarce at the crucial interface between HPs and GPs. To our knowledge, this trial is the first to analyse the combination of a brief deprescribing intervention with a standardised communication strategy at hospital discharge and in the early post-discharge period. TRIAL REGISTRATION ISRCTN, ISRCTN18427377 . Registered 11 January 2018.
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Affiliation(s)
- Thomas Grischott
- Institute of Primary Care (IHAMZ), University and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland
| | - Stefan Zechmann
- Institute of Primary Care (IHAMZ), University and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland
| | - Yael Rachamin
- Institute of Primary Care (IHAMZ), University and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland
| | - Stefan Markun
- Institute of Primary Care (IHAMZ), University and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland
| | - Corinne Chmiel
- Institute of Primary Care (IHAMZ), University and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care (IHAMZ), University and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care (IHAMZ), University and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland
| | - Nicolas Rodondi
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of General Internal Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Stefan Neuner-Jehle
- Institute of Primary Care (IHAMZ), University and University Hospital of Zurich, Pestalozzistrasse 24, CH-8091 Zurich, Switzerland
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Chmiel C, Reich O, Signorell A, Neuner-Jehle S, Rosemann T, Senn O. Effects of managed care on the proportion of inappropriate elective diagnostic coronary angiographies in non-emergency patients in Switzerland: a retrospective cross-sectional analysis. BMJ Open 2018; 8:e020388. [PMID: 30478102 PMCID: PMC6254409 DOI: 10.1136/bmjopen-2017-020388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Guidelines recommend non-invasive ischaemia testing (NIIT) for the majority of patients with suspected ischaemic heart disease in a non-emergency setting. A substantial number of these patients undergo diagnostic coronary angiography (CA) without therapeutic intervention inappropriately due to lacking preceding NIIT. The aim of this study was to evaluate the effect of voluntary healthcare models with limited access on the proportion of patients without NIIT prior to elective purely diagnostic CA. DESIGN Retrospective cross-sectional analysis of insurance claims data from 2012 to 2015. Data included claims of basic and voluntary healthcare models from approximately 1.2 million patients enrolled with the Helsana Insurance Group. Voluntary healthcare models with limited health access are divided into gate keeping (GK) and managed care (MC) capitation models. INCLUSION CRITERIA patients undergoing CA. EXCLUSION CRITERIA Patients<18 years, incomplete health insurance data coverage, acute cardiac ischaemia and emergency procedures, therapeutic CA (coronary angioplasty/stenting or coronary artery bypass grafting). The effect of voluntary healthcare models on the proportion of NIIT undertaken within 2 months before diagnostic CA was assessed by means of multiple logistic regression analysis, controlled for influencing factors. RESULTS 9173 patients matched inclusion criteria. 33.2% (3044) did not receive NIIT before CA. Compared with basic healthcare models, MC was independently associated with a higher proportion of NIIT (p<0.001, OR 1.17, CI 1.045 to 1.312), when additionally controlled for demographics, insurance coverage, inpatient treatment, cardiovascular medication, chronic comorbidities, high-risk status (patients with therapeutic cardiac intervention 1 month after or 18 months prior to diagnostic CA). GK models showed no significant association with the rate of NIIT (p=0.07, OR 1.11, CI 0.991 to 1.253). CONCLUSIONS In a non-GK healthcare system, voluntary MC healthcare models with capitation were associated with a reduced inappropriate use of diagnostic CA compared with GK or basic models.
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Affiliation(s)
- Corinne Chmiel
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Oliver Reich
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Andri Signorell
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | | | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
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Meier R, Muheim L, Senn O, Rosemann T, Chmiel C. The impact of financial incentives to improve quality indicators in patients with diabetes in Swiss primary care: a protocol for a cluster randomised controlled trial. BMJ Open 2018; 8:e023788. [PMID: 29961043 PMCID: PMC6042619 DOI: 10.1136/bmjopen-2018-023788] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION There is only limited and conflicting evidence on the effectiveness of Pay-for-Performance (P4P) programmes, although they might have the potential to improve guideline adherence and quality of care. We therefore aim to test a P4P intervention in Swiss primary care practices focusing on quality indicators (QI) achievement in the treatment of patients with diabetes. METHODS AND ANALYSIS This is a cluster-randomised, two-armed intervention study with the primary care practice as unit of randomisation. The control group will receive bimonthly feedback reports containing last data of blood pressure and glycated haemoglobin (HbA1c) measurements. The intervention group will additionally be informed about a financial incentive for each percentage point improved in QI achievement. Primary outcomes are differences in process (measurement of HbA1c) and clinical QI (blood pressure control) between the two groups. Furthermore, we investigate the effect on non-incentivised QIs and on sustainability of the financial incentives. Swiss primary care practices participating in the FIRE (Family Medicine ICPC Research using Electronic Medical Record) research network are eligible for participation. The FIRE database consists of anonymised structured medical routine data from Swiss primary care practices. According to power calculations, 70 of the general practitioners contributing to the database will be randomised in either of the groups. ETHICS AND DISSEMINATION According to the Local Ethics Committee of the Canton of Zurich, the project does not fall under the scope of the law on human research and therefore no ethical consent is necessary. Results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ISRCTN13305645; Pre-results.
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Affiliation(s)
- Rahel Meier
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Leander Muheim
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Corinne Chmiel
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
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Abstract
A 78-year-old female patient presented to our emergency department with a 5-day history of throat pain, hoarseness and a progressive and dolorous submandibular swelling. Due to non-conclusive clinical examination and the stable but visibly affected patient, we performed a neck CT scan with intravenous contrast, which showed the thumbprint sign typical for acute epiglottitis. Within minutes, the patient’s condition deteriorated and the patient was close to respiratory exhaustion. As intubation was severely complicated by massive swelling of the supraglottic soft tissue, the patient went into hypoxaemia and eventually cardiac arrest. After initiating reanimation protocol, eventually the airway was secured and Return of spontaneous circulation (ROSC) achieved after around 5 min. The initially sampled blood cultures revealed Neisseria meningitidis bactera emia and the patient was successfully treated accordingly. In patients with swelling of the upper airway, rapid clinical deterioration is possible. Diagnostics should not delay therapy, including administration of empiric antibiotics, steroids and intubation.
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Affiliation(s)
| | - Corinne Chmiel
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
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von Babo M, Chmiel C, Müggler SA, Rakusa J, Schuppli C, Meier P, Fischler M, Urner M. Transfusion practice in anemic, non-bleeding patients: Cross-sectional survey of physicians working in general internal medicine teaching hospitals in Switzerland. PLoS One 2018; 13:e0191752. [PMID: 29381721 PMCID: PMC5790246 DOI: 10.1371/journal.pone.0191752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 01/10/2018] [Indexed: 01/02/2023] Open
Abstract
Background Transfusion practice might significantly influence patient morbidity and mortality. Between European countries, transfusion practice of red blood cells (RBC) greatly differs. Only sparse data are available on transfusion practice of general internal medicine physicians in Switzerland. Methods In this cross-sectional survey, physicians working in general medicine teaching hospitals in Switzerland were investigated regarding their self-reported transfusion practice in anemic patients without acute bleeding. The definition of anemia, transfusion triggers, knowledge on RBC transfusion, and implementation of guidelines were assessed. Results 560 physicians of 71 hospitals (64%) responded to the survey. Anemia was defined at very diverging hemoglobin values (by 38% at a hemoglobin <130 g/L for men and by 57% at <120 g/L in non-pregnant women). 62% and 43% respectively, did not define anemia in men and in women according to the World Health Organization. Fifty percent reported not to transfuse RBC according to international guidelines. Following factors were indicated to influence the decision to transfuse: educational background of the physicians, geographical region of employment, severity of anemia, and presence of known coronary artery disease. 60% indicated that their knowledge on Transfusion-related Acute Lung Injury (TRALI) did not influence transfusion practice. 50% of physicians stated that no local transfusion guidelines exist and 84% supported the development of national recommendations on transfusion in non-acutely bleeding, anemic patients. Conclusion This study highlights the lack of adherence to current transfusion guidelines in Switzerland. Identifying and subsequently correcting this deficit in knowledge translation may have a significant impact on patient care.
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Affiliation(s)
- Michelle von Babo
- Department of Internal Medicine, Waid City Hospital, Zurich, Switzerland
| | - Corinne Chmiel
- Department of Internal Medicine, Waid City Hospital, Zurich, Switzerland
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | | | - Julia Rakusa
- Department of Internal Medicine, Waid City Hospital, Zurich, Switzerland
| | - Caroline Schuppli
- Anthropological Institute and Museum, University of Zurich, Zurich, Switzerland
| | - Philipp Meier
- Applied Aquatic Ecology, Swiss Federal Institute of Environmental Science and Technology (EAWAG), Dübendorf, Switzerland
| | - Manuel Fischler
- Department of Internal Medicine, Waid City Hospital, Zurich, Switzerland
| | - Martin Urner
- Department of Internal Medicine, Waid City Hospital, Zurich, Switzerland
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- * E-mail:
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Chmiel C, Giewer I, Frei A, Rosemann T. Four-year long-term follow-up of diabetes patients after implementation of the Chronic Care Model in primary care: a cross-sectional study. Swiss Med Wkly 2017; 147:w14522. [PMID: 29120011 DOI: 10.4414/smw.2017.14522] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
AIMS Implementing the Chronic Care Model (CCM) via involvement of specially trained practice nurses improves cardiovascular risk profiles and perception of care among type 2 diabetes patients in small primary care practices (PCPs) in the short term. Little is known about the long-term effects of this intervention. METHODS Cross-sectional survey among the participants of the cluster randomised controlled CARAT trial (30 PCPs, 303 diabetes patients), 3 years after its completion. OUTCOMES Proportion of patients still treated according to the CCM, possible reasons for discontinuation, glycosylated haemoglobin (HbA1c), blood pressure, low density lipoprotein cholesterol, and accordance with CCM (assessed by means of PACIC [Patient Assessment of Chronic Illness Care]). RESULTS Overall, 40.9% of practices (40.7% of patients) continued using the CCM. PCPs originally randomised to the intervention group were significantly more likely to be still using the CCM (11 PCPs / 88 patients vs 11 PCPs / 94 patients, p <0.001). Main reasons for discontinuation were organisational (40.9%) and financial aspects (18.1%), and the general practitioner refusing to transfer treatment responsibility (18.1%). HbA1c and PACIC development over the long term showed significant positive effects in favour of PCPs originally randomised to the intervention group and practices continuing to treat patients according to the CCM. CONCLUSIONS Diabetes care according to the CCM, including the involvement of trained practice nurses, is a reasonable tool to improve care in the long-term. CCM training of the whole team is essential to overcome organisational challenges. Continuous team education, technical decision support, and recognition of the importance of these new structures in healthcare policy might improve the long-term clinical effect of the team approach.
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Affiliation(s)
- Corinne Chmiel
- Institute of Primary Care, University of Zurich, Switzerland
| | - Irina Giewer
- Institute of Primary Care, University of Zurich, Switzerland
| | - Anja Frei
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, Switzerland
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Scherz N, Bachmann-Mettler I, Chmiel C, Senn O, Boss N, Bardheci K, Rosemann T. Case management to increase quality of life after cancer treatment: a randomized controlled trial. BMC Cancer 2017; 17:223. [PMID: 28351354 PMCID: PMC5368904 DOI: 10.1186/s12885-017-3213-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 03/22/2017] [Indexed: 01/22/2023] Open
Abstract
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.
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Affiliation(s)
- Nathalie Scherz
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Zurich, Switzerland. .,Arud, Centres for Addiction Medicine, Zurich, Switzerland.
| | - Irène Bachmann-Mettler
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Corinne Chmiel
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Nathalie Boss
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Katarina Bardheci
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Zurich, Switzerland
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Webster LM, Fetherston J, Chmiel C, Nelson- Piercy C, Khalil A, Myers J, Chappell LC. H5. Second trimester vascular function parameters in women with chronic hypertension and their association with adverse maternal and perinatal outcomes. J Matern Fetal Neonatal Med 2016. [DOI: 10.1080/14767058.2016.1234800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Cerny T, Rosemann T, Tandjung R, Chmiel C. [Reasons for General Practitioner Shortage – a Comparison Between France and Switzerland]. Praxis (Bern 1994) 2016; 105:619-636. [PMID: 27223415 DOI: 10.1024/1661-8157/a002362] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
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.
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Affiliation(s)
- Thomas Cerny
- 1 Institut für Hausarztmedizin, Universitätsspital Zürich
| | | | - Ryan Tandjung
- 1 Institut für Hausarztmedizin, Universitätsspital Zürich
| | - Corinne Chmiel
- 1 Institut für Hausarztmedizin, Universitätsspital Zürich
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Chmiel C, Wang M, Sidler P, Eichler K, Rosemann T, Senn O. Implementation of a hospital-integrated general practice--a successful way to reduce the burden of inappropriate emergency-department use. Swiss Med Wkly 2016; 146:w14284. [PMID: 26963904 DOI: 10.4414/smw.2016.14284] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Corinne Chmiel
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Switzerland
| | - Mathyas Wang
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Switzerland
| | - Patrick Sidler
- Emergency Department, Waid City Hospital, Zurich, Switzerland
| | - Klaus Eichler
- Emergency Department, Waid City Hospital, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich, University Hospital Zurich, Switzerland
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Baumgartner VA, Eich G, Christen S, Chmiel C. Legionella native valve endocarditis case report and review of literature. Int Arch Med 2016. [DOI: 10.3823/1885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Grueninger P, Nikolic N, Schneider J, Lattmann T, Platz A, Chmiel C, Meier C. 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. Arthroscopy 2015; 31:2173-82. [PMID: 26188785 DOI: 10.1016/j.arthro.2015.05.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 05/17/2015] [Accepted: 05/18/2015] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
| | - Nikola Nikolic
- Institute for Clinical Radiology, Waid Hospital Zurich, Zurich, Switzerland
| | - Joerg Schneider
- Department of Surgery, Waid Hospital Zurich, Zurich, Switzerland; Institute for Clinical Radiology, Waid Hospital Zurich, Zurich, Switzerland
| | - Thomas Lattmann
- Department of Surgery, Triemli Hospital Zurich, Zurich, Switzerland
| | - Andreas Platz
- Department of Surgery, Triemli Hospital Zurich, Zurich, Switzerland
| | - Corinne Chmiel
- Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland
| | - Christoph Meier
- Department of Surgery, Waid Hospital Zurich, Zurich, Switzerland.
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Hess S, Sidler P, Chmiel C, Bögli K, Senn O, Eichler K. Satisfaction of health professionals after implementation of a primary care hospital emergency centre in Switzerland: A prospective before–after study. Int Emerg Nurs 2015; 23:286-93. [DOI: 10.1016/j.ienj.2015.04.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 04/09/2015] [Accepted: 04/09/2015] [Indexed: 10/23/2022]
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Chmiel C, Reich O, Signorell A, Tandjung R, Rosemann T, Senn O. Appropriateness of diagnostic coronary angiography as a measure of cardiac ischemia testing in non-emergency patients - a retrospective cross-sectional analysis. PLoS One 2015; 10:e0117172. [PMID: 25719869 PMCID: PMC4342214 DOI: 10.1371/journal.pone.0117172] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 12/19/2014] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Corinne Chmiel
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
- * E-mail:
| | - Oliver Reich
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Andri Signorell
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Ryan Tandjung
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
| | - Oliver Senn
- Institute of Primary Care, University of Zurich, Zurich, Switzerland
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Rakusa J, Lautenschlager S, Chmiel C. Allopurinol induced DRESS syndrome without eosinophilia and pronounced mucosal involvement. J Eur Acad Dermatol Venereol 2015; 30:865-7. [DOI: 10.1111/jdv.13033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- J. Rakusa
- Internal Medicine; City Hospital Waid; Zürich Switzerland
| | - S. Lautenschlager
- Outpatient Clinic of Dermatology and Venereology; City Hospital Triemli; Zürich Switzerland
| | - C. Chmiel
- Internal Medicine; City Hospital Waid; Zürich Switzerland
- Institute of General Practice and Health Service Research; UniversitäsSpital Zürich; Zürich Switzerland
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Urner M, Schlicker A, Z'graggen BR, Stepuk A, Booy C, Buehler KP, Limbach L, Chmiel C, Stark WJ, Beck-Schimmer B. Inflammatory response of lung macrophages and epithelial cells after exposure to redox active nanoparticles: effect of solubility and antioxidant treatment. Environ Sci Technol 2014; 48:13960-13968. [PMID: 25343230 DOI: 10.1021/es504011m] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
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.
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Affiliation(s)
- Martin Urner
- Institute of Anesthesiology, University Hospital Zurich , CH-8091 Zurich, Switzerland
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Wesbonk J, Chmiel C, Rosemann T, Seidenberg A, Senn O. Prevalence and determinants of sexually transmitted infections in women at risk undergoing abortion in a Swiss primary care setting. Praxis (Bern 1994) 2014; 103:875-882. [PMID: 25051930 DOI: 10.1024/1661-8157/a001724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
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.
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Affiliation(s)
- Jana Wesbonk
- Institute of General Practice, University of Zurich
| | - Corinne Chmiel
- Institute of General Practice, University of Zurich and City Hospital Waid, Zurich
| | | | - André Seidenberg
- Institute of General Practice, University of Zurich and General Private Practice, Zurich
| | - Oliver Senn
- Institute of General Practice, University of Zurich
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Grueninger P, Nikolic N, Schneider J, Lattmann T, Platz A, Chmiel C, Meier C. 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. Arthroscopy 2014; 30:665-72. [PMID: 24704070 DOI: 10.1016/j.arthro.2014.02.030] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 01/16/2014] [Accepted: 02/20/2014] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
| | - Nikola Nikolic
- Institute for Clinical Radiology, Waid Hospital Zurich, Zurich, Switzerland
| | - Joerg Schneider
- Department of Surgery, Waid Hospital Zurich, Zurich, Switzerland
| | - Thomas Lattmann
- Department of Surgery, Triemli Hospital Zurich, Zurich, Switzerland
| | - Andreas Platz
- Department of Surgery, Triemli Hospital Zurich, Zurich, Switzerland
| | - Corinne Chmiel
- Department of Internal Medicine, Waid Hospital Zurich, Zurich, Switzerland; Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland
| | - Christoph Meier
- Department of Surgery, Waid Hospital Zurich, Zurich, Switzerland.
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Frei A, Senn O, Chmiel C, Reissner J, Held U, Rosemann T. Implementation of the chronic care model in small medical practices improves cardiovascular risk but not glycemic control. Diabetes Care 2014; 37:1039-47. [PMID: 24513589 DOI: 10.2337/dc13-1429] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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.
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Wang M, Wild S, Hilfiker G, Chmiel C, Sidler P, Eichler K, Rosemann T, Senn O. Hospital-integrated general practice: a promising way to manage walk-in patients in emergency departments. J Eval Clin Pract 2014; 20:20-6. [PMID: 24033413 DOI: 10.1111/jep.12074] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2013] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Mathyas Wang
- Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland
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Chmiel C, Rosemann T, Senn O. Demand and characteristics of a psychiatric 24-hour emergency service performed by mandatory rotation of licensed psychiatrists in Swiss primary care. Patient Prefer Adherence 2014; 8:383-90. [PMID: 24707172 PMCID: PMC3972023 DOI: 10.2147/ppa.s53950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Corinne Chmiel
- Institute of General Practice and Health Services Research, University of Zurich, Raemistrasse, Zurich, Switzerland
- Correspondence: Corinne Chmiel, University of Zurich, Institute of General Practice and Health Services Research, Raemistrasse 100, 8091 Zurich, Switzerland, Tel +41 44 255 8509, Fax +41 44 255 9097, Email
| | - Thomas Rosemann
- Institute of General Practice and Health Services Research, University of Zurich, Raemistrasse, Zurich, Switzerland
| | - Oliver Senn
- Institute of General Practice and Health Services Research, University of Zurich, Raemistrasse, Zurich, Switzerland
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Philips H, Huibers L, Holm Hansen E, Bondo Christensen M, Leutgeb R, Klemenc-Ketis Z, Chmiel C, Muñoz MA, Kosiek K, Remmen R. Guidelines adherence to lower urinary tract infection treatment in out-of-hours primary care in European countries. Qual Prim Care 2014; 22:221-231. [PMID: 25695532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
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.
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Affiliation(s)
- Hilde Philips
- Department of Primary and Multidisciplinary Care, General Practice, University of Antwerp, Universiteitsplein 1, gebouw R, 3de Verd., B-2610 Wilrijk, Belgium.
| | - Linda Huibers
- Radboud University Medical Centre, Nijmegen, Scientific Institute for Quality of Healthcare, Netherlands
| | - Elisabeth Holm Hansen
- National Centre for Emergency Primary Health Care, Uni Research, Uni Health, Norway; Haraldsplass Deaconess University College, Norway
| | | | - Rüdiger Leutgeb
- Department of General Practice and Health Services Research, University of Heidelberg, Germany
| | - Zalika Klemenc-Ketis
- Department of Family Medicine, Medical School, University of Maribor, and Department of Family Medicine, Medical School, University of Ljubljana, Slovenia
| | - Corinne Chmiel
- Institute of General Practice and Health Services Research University of Zurich, Switzerland
| | - Miguel-Angel Muñoz
- Primary Healthcare University Research Institute IDIAP-Jordi Gol and Catalan Institute of Health, Barcelona, Spain
| | - Katarzyna Kosiek
- Department of Family and Community Medicine, Medical University of Lodz, Poland
| | - Roy Remmen
- Department of Primary and Multidisciplinary Care, General Practice, University of Antwerp, Belgium
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Abstract
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.
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Affiliation(s)
- Corinne Chmiel
- Institute of General Practice and Health Services Research, University of Zurich, Zürich, Switzerland
- Correspondence: Corinne Chmiel, Institute of General Practice and Health Services Research, University of Zurich, Pestalozzistrasse 24, 8091 Zürich, Switzerland, Tel +41 04 4255 9855, Fax +41 04 4255 90 97, Email
| | - Oliver Senn
- Institute of General Practice and Health Services Research, University of Zurich, Zürich, Switzerland
| | - Thomas Rosemann
- Institute of General Practice and Health Services Research, University of Zurich, Zürich, Switzerland
| | - Valerio Del Prete
- Institute of General Practice and Health Services Research, University of Zurich, Zürich, Switzerland
| | - Claudia Steurer-Stey
- Institute of General Practice and Health Services Research, University of Zurich, Zürich, Switzerland
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Raschka C, Chmiel C, Preiss R, Boos C. [Recreational athletes and doping--a survey in 11 gyms in the area of Frankfurt/Main]. MMW Fortschr Med 2013; 155 Suppl 2:41-43. [PMID: 24930320 DOI: 10.1007/s15006-013-1052-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
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.
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Eichler K, Hess S, Chmiel C, Bögli K, Sidler P, Senn O, Rosemann T, Brügger U. Sustained health-economic effects after reorganisation of a Swiss hospital emergency centre: a cost comparison study. Emerg Med J 2013; 31:818-23. [PMID: 23850883 PMCID: PMC4174047 DOI: 10.1136/emermed-2013-202760] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Klaus Eichler
- Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Sascha Hess
- Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Corinne Chmiel
- City Hospital Waid, Zurich, Switzerland Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland
| | | | | | - Oliver Senn
- Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland
| | - Thomas Rosemann
- Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland
| | - Urs Brügger
- Winterthur Institute of Health Economics, Zurich University of Applied Sciences, Winterthur, Switzerland
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Chmiel C, Senn O, Rosemann T, Steurer-Stey C. Reply to Letter to the Editor: The proper blood pressure may impaire cardiovascular risk factors. Swiss Med Wkly 2013; 143:w13787. [DOI: 10.4414/smw.2013.13787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Chmiel C, Wang M, Senn O, Del Prete V, Zoller M, Rosemann T, Steurer-Stey C. Uncontrolled arterial hypertension in primary care--patient characteristics and associated factors. Swiss Med Wkly 2012; 142:w13693. [PMID: 23136051 DOI: 10.4414/smw.2012.13693] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Corinne Chmiel
- Division of Internal Medicine, University Hospital of Zurich and Institute of General Practice, University of Zurich, Switzerland.
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Busato A, Bhend H, Chmiel C, Tandjung R, Senn O, Zoller M, Rosemann T. Improving the quality of morbidity indicators in electronic health records in Swiss primary care. Swiss Med Wkly 2012; 142:w13611. [PMID: 22736075 DOI: 10.4414/smw.2012.13611] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
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.
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Frei A, Herzog S, Woitzek K, Held U, Senn O, Rosemann T, Chmiel C. Characteristics of poorly controlled Type 2 diabetes patients in Swiss primary care. Cardiovasc Diabetol 2012; 11:70. [PMID: 22704274 PMCID: PMC3403845 DOI: 10.1186/1475-2840-11-70] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 06/15/2012] [Indexed: 12/05/2022] Open
Abstract
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.
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Affiliation(s)
- Anja Frei
- Institute of General Practice and Health Services Research, University Hospital of Zurich, Zurich, Switzerland.
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Chmiel C, Birnbaum B, Gensichen J, Rosemann T, Frei A. [The diabetes traffic light scheme - development of an instrument for the case management in patients with diabetes mellitus in primary care]. Praxis (Bern 1994) 2011; 100:1457-1473. [PMID: 22124957 DOI: 10.1024/1661-8157/a000751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
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.
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Affiliation(s)
- C Chmiel
- Institut für Hausarztmedizin der Universität Zürich.
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Chmiel C, Huber CA, Rosemann T, Zoller M, Eichler K, Sidler P, Senn O. Walk-ins seeking treatment at an emergency department or general practitioner out-of-hours service: a cross-sectional comparison. BMC Health Serv Res 2011; 11:94. [PMID: 21554685 PMCID: PMC3123178 DOI: 10.1186/1472-6963-11-94] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Accepted: 05/09/2011] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Corinne Chmiel
- Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland.
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