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

Inventory and perspectives of chronic disease management programs in Switzerland: an exploratory survey

Objective: To describe chronic disease management programs active in Switzerland in 2007, using an exploratory survey. <br><br> Methods: We searched the internet (Swiss official websites and Swiss web-pages, using Google), a medical electronic database (Medline), reference lists of pertinent articles, and contacted key informants. Programs met our operational definition of chronic disease management if their interventions targeted a chronic disease, included a multidisciplinary team (≥2 healthcare professionals), lasted at least six months, and had already been implemented and were active in December 2007. We developed an extraction grid and collected data pertaining to eight domains (patient population, intervention recipient, intervention content, delivery personnel, method of communication, intensity and complexity, environment, clinical outcomes). <br><br> Results: We identified seven programs fulfilling our operational definition of chronic disease management. Programs targeted patients with diabetes, hypertension, heart failure, obesity, psychosis and breast cancer. Interventions were multifaceted; all included education and half considered planned follow-ups. The recipients of the interventions were patients, and healthcare professionals involved were physicians, nurses, social workers, psychologists and case managers of various backgrounds. <br><br> Conclusions: In Switzerland, a country with universal healthcare insurance coverage and little incentive to develop new healthcare strategies, chronic disease management programs are scarce. For future developments, appropriate evaluations of existing programs, involvement of all healthcare stakeholders, strong leadership and political will are, at least, desirable

Use of Preventive Services of Overweight and Obese Europeans Aged 50-79Years

Background: Although frequent contacts with health care systems may represent more opportunities to receive preventive services, excess body weight has been linked to decreased access to preventive services and quality of care. Objective: The objective of the study is to examine whether obese and overweight, compared to normal weight persons, have different experiences of preventive care. Design: The study design is cross-sectional. Baseline data (2004) of a population-based survey conducted in 10 European countries. Participants: The participants were noninstitutionalized adults, 13,859, (50-79years) with body mass index (BMI) ≥18.5kg/m2, who answered the baseline and supplementary questionnaires (overall response rate of 51.3%) of the Survey of Health, Ageing and Retirement in Europe (SHARE). Measurements: BMI was divided into normal weight (BMI, 18.5-24.9kg/m2), overweight (BMI, 25.0-29.9kg/m2), and obesity (BMI >30kg/m2). Reported dependent variables were: influenza immunization, colorectal and breast cancer screening, discussion and recommendation about physical activity, and weight measurement. We performed multivariate logistic regressions, adjusting for age, sex, education, income, smoking, alcohol consumption, physical activity, and country. Results: Overweight and obesity were associated with higher odds of receiving influenza immunization but not with receipt of breast or colorectal cancer screening. Overweight and obese individuals mentioned more frequently that their general practitioner discussed physical activity or checked their weight, which was not explained by chronic diseases or the number of ambulatory care visits. Conclusions: These first data from SHARE did not suggest that overweight or obesity were associated with decreased use of preventive service

Factors associated with healthcare professionals' intent to stay in hospital: a comparison across five occupational categories

Objectives To identify factors associated with intent to stay in hospital among five different categories of healthcare professionals using an adapted version of the conceptual model of intent to stay (CMIS). Design A cross-sectional survey targeting Lausanne University Hospital employees performed in the fall of 2011. Multigroup structural equation modeling was used to test the adapted CMIS model among professional groups. Measures Satisfaction, self-fulfillment, workload, working conditions, burnout, overall job satisfaction, institutional identification and intent to stay. Participants Surveys of 3364 respondents: 494 physicians, 1228 nurses, 509 laboratory technicians, 935 administrative staff and 198 psycho-social workers. Results For all professional categories, self-fulfillment increased intent to stay (all β > 0.14, P 0.22, P < 0.05). Some factors were associated with specific professional categories: workload was associated with nurses' intent to stay (β = −0.15), and physicians' institutional identification mitigated the effect of burnout on intent to stay (β = −0.15 and β = 0.19). Conclusion Respondents' intent to stay in a position depended both on global and profession-specific factors. The identification of these factors may help in mapping interventions and retention plans at both a hospital level and professional groups' leve

Healthcare and preventive services utilization of elderly Europeans with depressive symptoms

BACKGROUND: Depressive symptoms are associated with increased healthcare utilization. However, it is unclear whether depressed individuals experience more or less frequent access to preventive services. Our goal was to investigate the association between depressive symptoms and both utilization of healthcare and preventive services. METHODS: Baseline self-reported data (2004) from non-institutionalized individuals aged &gt;/=50 years participating in the Survey of Health, Ageing, and Retirement in Europe (SHARE) were used. Of the 18,560 respondents to the baseline questionnaire, 13,580 answered the supplementary questionnaire, which included measures of preventive services. Healthcare utilization during the previous 12 months, including outpatient visits, medication, hospitalization, surgery, and home healthcare were assessed. Preventive service measures assessed the participation in influenza immunization and colorectal and breast cancer screening. Depression status was assessed with the EURO-D, a validated instrument for which a score &gt;3 defines clinically significant depressive symptoms. Logistic regressions were performed adjusting for age, gender, socioeconomic status, behavioral risk, chronic disease, disability, and country of residence. RESULTS: The estimated prevalence of depressive symptoms was 28.2%. Depressive symptoms were associated with significantly greater use of all healthcare domains but not preventive services, with the exception of colorectal cancer screening. Similar trends were found for each country of residence and for both genders. LIMITATIONS: It was not known whether medical tests were used for screening or diagnostic purposes. CONCLUSIONS: SHARE data suggest that patients with depressive symptoms are frequent users of healthcare but not preventive services. Low screening rates may reflect missed screening opportunities rather than a lack of screening opportunities

Les itinéraires cliniques sont-ils efficaces ? : revue Cochrane pour le praticien

Cet article présente les résultats de la revue systématique: Rotter T, Kinsman L, James E, et al. Clinical pathways : Effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No:CD006632. DOI:10.1002/14651858.CD006632.pub2. PMID: 20238347

Contrôle glycémique chez le diabétique de type 1 : quels objectifs ?

Le traitement recommandé du diabète de type 1 repose sur le contrôle glycémique strict, qui permet une diminution du risque de complications microvasculaires comparativement à un contrôle glycémique moins strict (conventionnel). L'effet du contrôle glycémique strict sur les complications macrovasculaires est moins clair. La question des objectifs glycémiques est ainsi sujette à débat. Alors qu'il n'y a pas eu de nouvelles études d'intervention concernant le diabète de type 1 chez les adultes depuis les années 1990, des études récentes concernant le diabète de type 2 ont montré l'absence de bénéfices sur le risque de complications, voire une augmentation de la mortalité en cas de contrôle glycémique très strict, comparativement à un contrôle moins strict. L'objectif de cette revue était de déterminer les avantages et inconvénients du contrôle glycémique strict dans le diabète de type 1

Ambulatory Healthcare Use Profiles of Patients With Diabetes and Their Association With Quality of Care: A Cross-Sectional Study

BACKGROUND: Despite the growing burden of diabetes worldwide, evidence regarding the optimal models of care to improve the quality of diabetes care remains equivocal. This study aimed to identify profiles of patients with distinct ambulatory care use patterns and to examine the association of these profiles with the quality of diabetes care. METHODS: We performed a cross-sectional study of the baseline data of 550 non-institutionalized adults included in a prospective, community-based, cohort study on diabetes care conducted in Switzerland. Clusters of participants with distinct patterns of ambulatory healthcare use were identified using discrete mixture models. To measure the quality of diabetes care, we used both processes of care indicators (eye and foot examination, microalbuminuria screening, blood cholesterol and glycated hemoglobin measurement [HbA1c], influenza immunization, blood pressure measurement, physical activity and diet advice) and outcome indicators (12-Item Short-Form Health Survey [SF-12], Audit of Diabetes-Dependent Quality of Life [ADDQoL], Patient Assessment of Chronic Illness Care [PACIC], Diabetes Self-Efficacy Scale, HbA1c value, and blood pressure <140/90 mmHg). For each profile of ambulatory healthcare use, we calculated adjusted probabilities of receiving processes of care and estimated adjusted outcomes of care using logistic and linear regression models, respectively. RESULTS: Four profiles of ambulatory healthcare use were identified: participants with more visits to the general practitioner [GP] than to the diabetologist and receiving concomitant podiatry care (“GP & podiatrist”, n=86); participants visiting almost exclusively their GP (“GP only”, n=195); participants with a substantially higher use of all ambulatory services (“High users”, n=96); and participants reporting more visits to the diabetologist and less visits to the GP than other profiles (“Diabetologist first”, n=173). Whereas participants belonging to the “GP only” profile were less likely to report most processes related to the quality of diabetes care, outcomes of care were relatively comparable across all ambulatory healthcare use profiles. CONCLUSIONS: Slight differences in quality of diabetes care appear across the four ambulatory healthcare use profiles identified in this study. Overall, however, results suggest that room for improvement exists in all profiles, and further investigation is necessary to determine whether individual characteristics (like diabetes-related factors) and/or healthcare factors contribute to the differences observed between profiles