The use of pediatric health care services in Switzerland : a claims data analysis (preliminary results)

Exposure to unfavorable circumstances in childhood has been shown to have negative implications on physical, cognitive and psychological health in adulthood. Health problems in childhood should, therefore, be detected and treated at an early stage. Adequate pediatric health care, and in particular, preventive pediatric health screenings, play a key role in this context. In Switzerland, children and adolescents from 0-14 years are recommended to go through ten preventive health screenings. These screenings are performed at the parents’ initiative by the pediatrician or family doctor, except for two to three compulsory screenings at around the age of 6, 10 and 14 years, which are typically performed by the school medical services. However, little is known about the extent to which these screenings are performed and about potential barriers limiting the utilization of health care services. The aim of our study is to evaluate children’s access to adequate health care in Switzerland. In particular, we aim to identify potential inequalities in the use of pediatric health care between socioeconomic groups. We employ two strategies: a) Using data from the school medical services in the city of Bern, we assess the extent of foregone pediatric health care in different socioeconomic groups by evaluating the incidence of untreated or inadequately treated health problems. b) Using claims data from a large Swiss health insurer, we assess the health care utilization patterns throughout childhood and the extent to which preventive health screenings are performed. The identification of groups at risk of inadequate health care and a better understanding of the underlying mechanisms can contribute to improving access to preventive health care services and, hence, to reducing health inequalities in childhood

Effects of passive smoking on heart rate variability, heart rate and blood pressure: an observational study

Background Exposure to environmental tobacco smoke (ETS) has been shown to increase the risk for cardiovascular diseases and death, and autonomic dysfunction (specifically, reduced heart rate variability (HRV)) is a predictor of increased cardiac risk. This study tests the hypothesis that ETS exposure reduces HRV in the general population and discusses possible pathways. Methods This cross-sectional study was conducted between 2001 and 2003 and is part of the SAPALDIA (Swiss Cohort Study on Air Pollution and Lung Diseases in Adults) study. The analysis included 1218 randomly selected non-smokers aged 50 and above who participated in 24-h electrocardiogram recordings. Other examinations included an interview, investigating health status (especially respiratory and cardiovascular health and health relevant behaviours and exposure to ETS) and measurements of blood pressure, body height and weight. Results Subjects exposed to ETS at home or at work for more than 2 h/day had a difference of −15% in total power (95%CI: −26 to −3%), low frequency power (−28 to −1%), low/high frequency ratio (−26 to −3%) and −18% (−29 to −4%) in ultralow frequency power of HRV compared with subjects not exposed to ETS at home or work. We also found a 2.7% (−0.01 to 5.34%) higher heart rate during the recording in exposed subjects. Conclusions Exposure to ETS at home and work is associated with lower HRV and with higher heart rate in an ageing population. Our findings suggest that exposure to ETS increases cardiac risk through disturbances in the autonomic nervous syste

Effect of physical activity on heart rate variability in normal weight, overweight and obese subjects: results from the SAPALDIA study

Many studies have demonstrated an association of both a sedentary lifestyle and a high body mass index (BMI) with greater risk for cardiovascular disease. Within the prospective SAPALDIA cohort (Swiss cohort Study on Air Pollution and Lung Diseases in Adults), we investigated whether regular exercise was protective against reduced heart rate variability (HRV), a clinically relevant predictor of cardiovascular morbidity and mortality, and whether adverse effects of obesity and weight gain on HRV were modified by regular exercise. Twenty-four-hour electrocardiograms were recorded in 1,712 randomly selected SAPALDIA participants aged ≥50, for whom BMI was assessed in the years 1991 and 2001-2003. Other examinations included an interview investigating health status (especially respiratory and cardiovascular health and health relevant behaviours including physical activity) and measurements of blood pressure, body height and weight. The association between regular physical activity and HRV and interactions with BMI and BMI change was assessed in multivariable linear regression analyses. Compared to sedentary obese subjects, SDNN (standard deviation of all RR intervals) was 14% (95% CI: 8-20%) higher in sedentary normal weight subjects; 19% (CI: 12-27%) higher in normal weight subjects exercising regularly ≥2h/week; and 19% (CI: 11-28%) higher in obese subjects exercising regularly ≥2h/week. Compared with sedentary subjects who gained weight, those who gained weight but did exercise regularly had a 13% higher SDNN (CI: 7-20%). Regular physical exercise has strong beneficial effects on cardiac autonomic nervous function and thus appears to offset the negative effect of obesity on HR

Prevalence of renal impairment and its association with cardiovascular risk factors in a general population: results of the Swiss SAPALDIA study

Background. Impaired renal function is evolving as an independent marker of the risk of cardiovascular morbidity and mortality. Little is known about the prevalence of impaired renal function and its relationship to cardiovascular risk factors in the Swiss general population. Methods. SAPALDIA comprises a random sample of the Swiss population established in 1991, originally to investigate the health effects of long-term exposure to air pollution. Participants were reassessed in 2002/3 and blood measurements were obtained (n = 6317). Renal function was estimated using the Cockcroft-Gault equation and the modified MDRD (four-component) equation incorporating age, race, gender and serum creatinine level. Results. The estimated prevalence of impaired renal function [estimated glomerular filtration rate <60 ml/min/1.73 m2] differed substantially between men and women, particularly at higher ages, and amounted to 13% [95% confidence interval (CI) 10-16%] and 36% (95% CI 32-40%) in men and women, respectively, of 65 years or older. Smoking, obesity, blood lipid levels, high systolic blood pressure and hyperuricaemia were all more common in men when compared with women. These cardiovascular risk factors were also associated independently with creatinine in both women and men. Women were less likely to receive cardiovascular drugs, in particular angiotensin-converting enzyme inhibitors and β-blockers, when compared with men of the same age. Conclusion. Moderate renal impairment seems to be prevalent in the general population, with an apparent excess in females which is not explained by conventional cardiovascular risk factors. The unexpected finding questions the validity of the prediction equations, in particular in female

Differences in Heart Rate Variability Associated with Long-Term Exposure to NO2

BACKGROUND: Heart rate variability (HRV), a measure of cardiac autonomic tone, has been associated with cardiovascular morbidity and mortality. Short-term studies have shown that subjects exposed to higher traffic-associated air pollutant levels have lower HRV. OBJECTIVE: Our objective was to investigate the effect of long-term exposure to nitrogen dioxide on HRV in the Swiss cohort Study on Air Pollution and Lung Diseases in Adults (SAPALDIA). METHODS: We recorded 24-hr electrocardiograms in randomly selected SAPALDIA participants >or= 50 years of age. Other examinations included an interview investigating health status and measurements of blood pressure, body height, and weight. Annual exposure to NO2 at the address of residence was predicted by hybrid models (i.e., a combination of dispersion predictions, land-use, and meteorologic parameters). We estimated the association between NO2 and HRV in multivariable linear regression models. Complete data for analyses were available for 1,408 subjects. RESULTS: For women, but not for men, each 10-microg/m3 increment in 1-year averaged NO2 level was associated with a decrement of 3% (95% CI, -4 to -1) for the standard deviation of all normal-to-normal RR intervals (SDNN), -6% (95% CI, -11 to -1) for nighttime low frequency (LF), and -5% (95% CI, -9 to 0) for nighttime LF/high-frequency (HF) ratio. We saw no significant effect for 24-hr total power (TP), HF, LF, or LF/HF or for nighttime SDNN, TP, or HF. In subjects with self-reported cardiovascular problems, SDNN decreased by 4% (95% CI, -8 to -1) per 10-microg/m3 increase in NO2. CONCLUSIONS: There is some evidence that long-term exposure to NO2 is associated with cardiac autonomic dysfunction in elderly women and in subjects with cardiovascular disease

Heart rate variability in the general population and its determining factors

Background: As the leading cause of mortality in Switzerland and many other developed countries, cardiovascular disease (CVD) is of high significance in public health: In 2003, CVD was the leading cause of death in Switzerland, accounting for 38% of adult deaths. Heart rate variability (HRV) is a subclinical electrophysiologic marker of cardiac autonomic control and lower HRV is associated with higher CVD morbidity and mortality. Thus altered HRV may signify autonomic dysregulation, and study of factors influencing HRV may inform epidemiologic and clinical evaluation of pathways ultimately leading to cardiac morbidity and mortality. Literature on HRV in the general population and its influencing factors is relatively scarce. Literature on HRV in the general population and its influencing factors is relatively scarce. Aims: This thesis presents normal values of HRV for the Swiss population and describes its determinants. As an example of an environmental risk factor, we study the influence of passive smoking on HRV and possible mechanisms. A further aim of the thesis is to describe the impact of obesity and a sedentary lifestyle as personal risk factors on HRV and to look at modification of the effect of obesity by physical exercise. Methods: Between 2001 and 2003, we measured time and frequency domain parameters of HRV in a random sample of the SAPALDIA (Swiss cohort study on Air Pollution and Lung Diseases in Adults) cohort participants aged 50 to 72 using digital 24-hour electrocardiogram recordings. Subjects with recordings of less than 18 hours, atrial fibrillation, recent anaesthesia or myocardial infarction or subjects taking digitalis were excluded, and recordings of insufficient quality discarded, leaving 1742 recordings for analyses. Health status and personal risk factors were assessed in a detailed interview. Blood pressure, height and weight as well as markers of cardiovascular health in the blood were measured. To assess effects of different risk factors on HRV, a structured multivariable linear regression was performed. To estimate percentiles of gender specific HRV parameters as a function of age, subjects with known risk factors (smoking, history of cardiovascular disease, high blood pressure, diabetes, medication) were excluded. In multivariable regression analyses, we determined the effect of environmental tobacco smoke on HRV, heart rate and blood pressure. We estimated the effect of physical activity and BMI on HRV in multivariable regression analyses and investigated the interaction between those two variables. Results: Taking into account the effects of age, lifestyle factors, variables of cardiovascular health, medication and cardiovascular risk factors in the blood, women had a lower HRV than men. The age dependent decline of HRV differed between the sexes. High blood pressure, current smoking, higher levels of uric acid, high-sensitive C-reactive protein and non-HDLcholesterol were independently associated with lower HRV. Non-smoking subjects exposed to tobacco smoke pollution at home or at work for more than 2 hours/day had lower HRV values than unexposed subjects. We also found a higher heart rate in exposed subjects and a tendency for higher diastolic blood pressure. Obese subjects exercising regularly 2 hours per week or more had higher HRV than their sedentary peers. Regardless of weight, the improvement of HRV was greatest for those who exercised regularly. Subjects having gained weight over the past 11 years who were exercising at least moderately had increased HRV values compared to subjects not exercising. Exercising regularly significantly modified the relation of obesity with HRV. Conclusions: HRV shows independent associations with a great variety of known personal and environmental cardiovascular risk factors. These findings help elucidate cardiac autonomic pathways through which factors such as passive smoke exposure and inactivity may adversely influence cardiac morbidity and mortality. As such, the findings strengthen scientific understanding of the etiology of cardiac disease, and may be useful in the development of public health strategies to protect and improve cardiovascular health