Integrated care organizations in Switzerland

INTRODUCTION: The Swiss health care system is characterized by its decentralized structure and high degree of local autonomy. Ambulatory care is provided by physicians working mainly independently in individual private practices. However, a growing part of primary care is provided by networks of physicians and health maintenance organizations (HMOs) acting on the principles of gatekeeping. TOWARDS INTEGRATED CARE IN SWITZERLAND: The share of insured choosing an alternative (managed care) type of basic health insurance and therefore restrict their choice of doctors in return for lower premiums increased continuously since 1990. To date, an average of one out of eight insured person in Switzerland, and one out of three in the regions in north-eastern Switzerland, opted for the provision of care by general practitioners in one of the 86 physician networks or HMOs. About 50% of all general practitioners and more than 400 other specialists have joined a physician networks. Seventy-three of the 86 networks (84%) have contracts with the healthcare insurance companies in which they agree to assume budgetary co-responsibility, i.e., to adhere to set cost targets for particular groups of patients. Within and outside the physician networks, at regional and/or cantonal levels, several initiatives targeting chronic diseases have been developed, such as clinical pathways for heart failure and breast cancer patients or chronic disease management programs for patients with diabetes. CONCLUSION AND IMPLICATIONS: Swiss physician networks and HMOs were all established solely by initiatives of physicians and health insurance companies on the sole basis of a healthcare legislation (Swiss Health Insurance Law, KVG) which allows for such initiatives and developments. The relevance of these developments towards more integration of healthcare as well as their implications for the future are discussed

Differences of the quality of care experience: the perception of patients with either network or conventional health plans

Background. Various studies have been performed on differences in quality measures between different models of primary care with inconclusive results. In Switzerland, up to a third of the population chooses network health plans including gatekeeping to profit from lower premiums and almost half of GPs work in primary care networks. Objective. To determine differences in the quality of interpersonal care and practice management between patients consulting a physician organized in a GP network or in independent practice. Methods. We analysed data of the European Project on Patient Evaluation of General Practice Care (EUROPEP) questionnaire measuring the quality of the patient-physician interaction and practice management of 473 primary care physicians. From the 25 178 patients who completed the questionnaire, 72.2% (18 174) consulted a physician participating in a network and 27.8% (7004) a physician working in independent practice. Results. The overall answer pattern of EUROPEP questions shows that patients were generally more satisfied with physicians in independent practice. Particularly, questions within the domains ‘relation and communication' and ‘information and support' and to a lesser degree within ‘Medical care' were significantly answered more favourable by patients of independent physicians. Stratification for chronic diseases showed that significant differences favouring independent physicians were less evident in patients with chronic diseases than in the non-chronic group. Conclusions. The results show differences in the quality of interpersonal care and practice management experienced by patients consulting network—or independent physicians. Therefore, we suggest that efforts to reduce health care spending by promoting more integrated care must also focus on monitoring and improving patient perceived qualitie

Integrated care programmes for adults with chronic conditions: a meta-review

Objective To review systematic reviews and meta-analyses of integrated care programmes in chronically ill patients, with a focus on methodological quality, elements of integration assessed and effects reported. Design Meta-review of systematic reviews and meta-analyses identified in Medline (1946-March 2012), Embase (1980-March 2012), CINHAL (1981-March 2012) and the Cochrane Library of Systematic Reviews (issue 1, 2012). Main Outcome Measures Methodological quality assessed by the 11-item Assessment of Multiple Systematic Reviews (AMSTAR) checklist; elements of integration assessed using a published list of 10 key principles of integration; effects on patient-centred outcomes, process quality, use of healthcare and costs. Results Twenty-seven systematic reviews were identified; conditions included chronic heart failure (CHF; 12 reviews), diabetes mellitus (DM; seven reviews), chronic obstructive pulmonary disease (COPD; seven reviews) and asthma (five reviews). The median number of AMSTAR checklist items met was five: few reviewers searched for unpublished literature or described the primary studies and interventions in detail. Most reviews covered comprehensive services across the care continuum or standardization of care through inter-professional teams, but organizational culture, governance structure or financial management were rarely assessed. A majority of reviews found beneficial effects of integration, including reduced hospital admissions and re-admissions (in CHF and DM), improved adherence to treatment guidelines (DM, COPD and asthma) or quality of life (DM). Few reviews showed reductions in costs. Conclusions Systematic reviews of integrated care programmes were of mixed quality, assessed only some components of integration of care, and showed consistent benefits for some outcomes but not other

How well do final year undergraduate medical students master practical clinical skills?

Introduction: The clinical examination and other practical clinical skills are fundamental to guide diagnosis and therapy. The teaching of such practical skills has gained significance through legislative changes and adjustments of the curricula of medical schools in Germany. We sought to find out how well final year undergraduate medical students master practical clinical skills. Methods: We conducted a formative 4-station objective structured clinical examination (OSCE) focused on practical clinical skills during the final year of undergraduate medical education. Participation was voluntary. Besides the examination of heart, lungs, abdomen, vascular system, lymphatic system as well as the neurological, endocrinological or orthopaedic examination we assessed other basic clinical skills (e.g. interpretation of an ECG, reading a chest X-ray). Participants filled-out a questionnaire prior to the exam, inter alia to give an estimate of their performance. Results: 214 final year students participated in our study and achieved a mean score of 72.8% of the total score obtainable. 9.3% of participants (n= 20) scored insufficiently (<60%). We found no influence of sex, prior training in healthcare or place of study on performance. Only one third of the students correctly estimated their performance (35.3%), whereas 30.0% and 18.8% over-estimated their performance by 10% and 20% respectively. Discussion: Final year undergraduate medical students demonstrate considerable deficits performing practical clinical skills in the context of a formative assessment. Half of the students over-estimate their own performance. We recommend an institutionalised and frequent assessment of practical clinical skills during undergraduate medical education, especially in the final year

Team functioning across different tumour types: Insights from a Swiss cancer center using qualitative and quantitative methods.

BACKGROUND: Multidisciplinary care is pivotal in cancer centres and the interaction of all cancer disease specialists in decision making processes is state-of-the-art. AIM: To describe differences of MDTMs by tumour type. METHODS: Twelve multidisciplinary team meetings (MDTMs) with participation of different cancer disease specialists at a tertiary hospital were assessed by an exploratory sequential mixed method approach with interviews, observations and a survey to address the following five topics: organisational structure and supporting technology; leadership; teamwork; decision-making, perceived value and motivation. Thirteen persons with different tumour specialities and levels of seniority were interviewed. The 12 MDTMs were observed twice by uninvolved persons and evaluated by the participating physicians with a survey. RESULTS: There were no systematic differences between MDTMs for different tumour types with the exception of the non-disease specific type MDTM, which was the only one for which the organisational structure was not driven by an electronic tool. However, several factors could be identified that generally influenced the functioning of the MDTMs. In particular, the quality of decision-making was highly dependent on the availability of case-based information and the presence of relevant cancer disease specialists. Leadership and teamwork were rated as important and were comparable across the MDTM. Team participants' motivation and perceived value of MDTMs was high across all meetings. CONCLUSION: MDTM at a single institution did not demonstrate disease specific characteristics. An effective MDTM, irrespective of the tumour type, can be successfully structured by technical means and a chairperson coordinating the interaction of cancer disease specialists to improve the decision-making process

Transcriptional profiling of fibroblasts from patients with mutations in MCT8 and comparative analysis with the human brain transcriptome

Thyroid hormone (TH) is crucial for normal brain development. TH transporters control TH homeostasis in brain as evidenced by the complex endocrine and neurological phenotype of patients with mutations in monocarboxylate transporter 8 (MCT8). We investigated the mechanisms of disease by analyzing gene expression profiles in fibroblasts from patients with MCT8 mutations. Studying MCT8 and its transcriptional context in different comprehensive spatial and temporal human brain transcriptome data sets revealed distinct region-specific MCT8 expression. Furthermore, MCT8 demonstrated a clear age-dependent decrease, suggesting its importance in early brain development. Performing comparative transcriptome analysis, we linked the genes differentially expressed (DE) in patient fibroblasts to the human brain transcriptome. DE genes in patient fibroblasts were strongly over-represented among genes highly correlated with MCT8 expression in brain. Furthermore, using the same approach we identified which genes in the classical TH signaling pathway are affected in patients. Finally, we provide evidence that the TRα2 receptor variant is closely connected to MCT8. The present study provides amolecular basis for understanding which pathways are likely affected in the brains of patients with mutations in MCT8. Our data regarding a functional relationship between MCT8 and TRα2 suggest an unanticipated role for TRα2 in the (patho)physiology of TH signaling in the brain. This study demonstrates how genome-wide expression data from patient-derived non-neuronal tissue related to the human brain transcriptome may be successfully employed to improve our understanding of neurological disease

Eisosome proteins assemble into a membrane scaffold

Membrane organization by eisosomes is mediated by self-assembly of its main components into a membrane-bound protein scaffold with lipid-binding specificity