Neue „Choosing wisely“ Empfehlungen zu unangemessenen medizinischen Interventionen: Sicht von Schweizer Hausärzten

Aim: As part of the “Choosing wisely” campaign expert-driven recommendations of inappropriate interventions which lead to overdiagnosis and overtreatment are being published. The aim of our work was to describe an innovative method for developing recommendations together with general practitioners (GPs) and to compare the results with the “Choosing wisely” campaign lists as well as with the Swiss “Smarter medicine” shortlist. Methods: We asked 109 GPs who attended a medical education conference to form groups (of 5 to 7 GPs each) and develop three interventions that are relevant to their work and should be avoided. We then compared the most frequently suggested interventions with those of the “Choosing wisely” campaign list and the “Smarter medicine” campaign shortlist. Finally, we asked the Swiss Young GPs Association (JHaS) members for additional suggestions. Results: Five groups suggested avoidance of check-up examinations, especially in younger or asymptomatic individuals. Further unnecessary interventions, which were mentioned with similar frequency, included resting or exercise electrocardiography in asymptomatic individuals and cholesterol analysis in individuals older than 75 years, or statin therapy in primary prevention and/or high age. Four groups suggested avoiding arthroscopy or magnetic resonance imaging of the knee joint after an injury (in the absence of joint instability or blockade), and three groups recommended to avoid imaging diagnostic procedures in patients with unspecific headache (in the absence of red flags). There was no consistency between interventions of the GPs’ list and the list of the Swiss “Smarter medicine” official campaign. The interventions that were most frequently mentioned by the GPs are also present on the lists issued by are present on lists of medical societies that have joined the “Choosing wisely” campaign. The response rate from the Swiss Young GPs association members was impressively low. Conclusion: The perspective of users (GPs) is crucial for the development of lists of potentially inappropriate interventions. In order to enhance the degree of identification with and adherence to the recommendations. The interventions suggested in our study could lead to further recommendations on interventions to be avoided in primary care, ideally in collaboration with the “Smarter medicine” campaign. Empathic communication with patients about harms and benefits of potentially inappropriate interventions is crucial for the implementation of this policy

What interventions do general practitioners recommend avoiding? A nationwide survey from Switzerland

Background: To address low-value interventions in healthcare, “Choosing Wisely” campaigns provide recommendations of interventions to avoid (RIAs). These are usually developed by expert panels rather than general practitioners (GPs). The aim of our study was to develop RIAs for ambulatory general medicine based on the suggestions of GPs, with their involvement from the very beginning. Methods: This was a nationwide online Delphi survey among Swiss Society of General Internal Medicine members. In round one, each participant suggested two interventions perceived as particularly inappropriate. In round two, the 16 most frequent RIAs were rated by importance on a 0–100 scale and compared with “Choosing Wisely” lists. We calculated descriptive statistics for suggestions and importance ratings, and used regression models to search for associations with GP characteristics. Results: Response rates were 7.4% (538/7318) for round one and 18.2% (1357/7468) for round two. GPs provided 1074 suggestions. Out of the 16 most frequent RIAs, 13 corresponded to existing “Choosing Wisely” lists. The RIAs rated most important were: antibiotics in viral infections, unnecessarily duplicated tests and imaging in unspecific low back pain (means 88.5–91.7, standard deviations 18.6–19.9). None of the GPs’ characteristics were associated with any of the five highest rated RIAs except for working in a hospital setting. Conclusion: Most RIA suggestions from GPs were concordant with previously published recommendations of interventions to avoid, independently of GPs knowledge of these and reflecting their high clinical relevance. In addition, our study revealed some more relevant topics and may help to develop future “Choosing Wisely” recommendations, with the final goal to reduce low-value care

Impact of a deprescribing tool on the use of sedative hypnotics among older patients: study protocol for a cluster randomised controlled trial in Swiss primary care (the HYPE trial)

INTRODUCTION Benzodiazepines and other sedative hypnotics (BSH) are potentially inappropriate and harmful medications in older people due to their higher susceptibility for adverse drug events. BSH prescription rates are constantly high among elderly patients and even increase with higher age and comorbidity. Deprescribing BSH can be challenging both for healthcare providers and for patients for various reasons. Thus, physicians and patients may benefit from a supportive tool to facilitate BSH deprescribing in primary care consultations. This study intends to explore effectiveness, safety, acceptance and feasibility of such a tool. METHODS AND ANALYSIS In this prospective, cluster randomised, controlled, two-arm, double-blinded trial in the ambulatory primary care setting, we will include general practitioners (GPs) from German-speaking Switzerland and their BSH consuming patients aged 65 years or older, living at home or in nursing homes. GPs will be randomly assigned to either intervention or control group. In the intervention group, GPs will participate in a 1-hour online training on how to use a patient support tool (decision-making guidance plus tapering schedule and non-pharmaceutical alternative treatment suggestions for insomnia). The control group GPs will participate in a 1-hour online instruction about BSH epidemiology and sleep hygiene counselling. This minimal intervention aims to prevent unblinding of control group GPs without jeopardising their 'usual care'.The primary outcome will be the percentage of patients who change their BSH use (ie, stop, reduce or switch to a non-BSH insomnia treatment) within 6 months from the initial consultation. EXPECTED BENEFIT Based on the results of the study, we will learn how GPs and their patients benefit from a supportive tool that facilitates BSH deprescribing in primary care consultations. The study will emphasise on exploring barriers and facilitators to BSH deprescribing among patients and providers. Positive results given, the study will improve medication safety and the quality of care for patients with sleeping disorders. ETHICS AND DISSEMINATION The study has been approved by the Ethics Committee of the Canton of Zurich (KEK-ZH Ref no. 2023-00054, 4 April 2023). Informed consent will be sought from all participating GPs and patients. The results of the study will be publicly disseminated

Swiss GPs’ preferences for antidepressant treatment in mild depression : vignette-based quantitative analysis

Background: GPs frequently prescribe antidepressants in mild depression. The aim of this study was to examine, how often Swiss GPs recommend antidepressants in various clinical presentations of mild depression and which factors contribute to antidepressant treatment recommendations. Methods: We conducted an online survey among Swiss GPs with within-subject effect analysis. Alternating case vignettes described a typical female case of mild depression according to International Classification of Diseases, 10th edition criteria, with and without anxiety symptoms and sleep problems. GPs indicated for each vignette their preferred treatments (several recommendations were possible). Additionally, we assessed GP characteristics, attitudes towards depression treatments, and elements of clinical decision-making. Results: Altogether 178 GPs completed the survey. In the initial description of a case with mild depression, 11% (95%-CI: 7%-17%) of GPs recommended antidepressants. If anxiety symptoms were added to the same case, 29% (23%-36%) recommended antidepressants. If sleep problems were mentioned, 47% (40%-55%) recommended antidepressants, and if both sleep problems and anxiety symptoms were mentioned, 63% (56%-70%) recommended antidepressants. Several factors were independently associated with increased odds of recommending antidepressants, specifically more years of practical experience, an advanced training in psychosomatic and psychosocial medicine, self-dispensation, and a higher perceived effectiveness of antidepressants. By contrast, a higher perceived influence of patient characteristics and the use of clinical practice guidelines were associated with reduced odds of recommending antidepressants. Conclusions: Consistent with depression practice guidelines, Swiss GPs rarely recommended antidepressants in mild depression if no co-indications (i.e., sleep problems and anxiety symptoms) were depicted. However, presence of sleep problems and anxiety symptoms, many years of practical experience, overestimation of antidepressants’ effectiveness, self-dispensation, an advanced training in psychosomatic and psychosocial medicine, and non-use of clinical practice guidelines may independently lead to antidepressant over-prescribing

Medication Review and Enhanced Information Transfer at Discharge of Older Patients with Polypharmacy: a Cluster-Randomized Controlled Trial in Swiss Hospitals

Background: Medication safety in patients with polypharmacy at transitions of care is a focus of the current Third WHO Global Patient Safety Challenge. Medication review and communication between health care professionals are key targets to reduce medication-related harm. Objective: To study whether a hospital discharge intervention combining medication review with enhanced information transfer between hospital and primary care physicians can delay hospital readmission and impact health care utilization or other health-related outcomes of older inpatients with polypharmacy. Design: Cluster-randomized controlled trial in 21 Swiss hospitals between January 2019 and September 2020, with 6 months follow-up. Participants: Sixty-eight senior physicians and their blinded junior physicians included 609 patients ≥ 60 years taking ≥ 5 drugs. Interventions: Participating hospitals were randomized to either integrate a checklist-guided medication review and communication stimulus into their discharge processes, or follow usual discharge routines. Main measures: Primary outcome was time-to-first-readmission to any hospital within 6 months, analyzed using a shared frailty model. Secondary outcomes covered readmission rates, emergency department visits, other medical consultations, mortality, drug numbers, proportions of patients with potentially inappropriate medication, and the patients' quality of life. Key results: At admission, 609 patients (mean age 77.5 (SD 8.6) years, 49.4% female) took a mean of 9.6 (4.2) drugs per patient. Time-to-first-readmission did not differ significantly between study arms (adjusted hazard ratio 1.14 (intervention vs. control arm), 95% CI [0.75-1.71], p = 0.54), nor did the 30-day hospital readmission rates (6.7% [3.3-10.1%] vs. 7.0% [3.6-10.3%]). Overall, there were no clinically relevant differences between study arms at 1, 3, and 6 months after discharge. Conclusions: The combination of a structured medication review with enhanced information transfer neither delayed hospital readmission nor improved other health-related outcomes of older inpatients with polypharmacy. Our results may help researchers in balancing practicality versus stringency of similar hospital discharge interventions. Study registration: ISRCTN18427377, https://doi.org/10.1186/ISRCTN18427377. Keywords: communication; health care quality improvement; hospital medicine; medication safety; primary care

Shared decision making for men facing prostate cancer treatment: a systematic review of randomized controlled trials

Aims: To synthesize the empirical evidence on the effectiveness of shared decision making (SDM) compared to usual care for prostate cancer (PC) treatment. Methods and results: A systematic review of academic (MEDLINE, EMBASE, Cochrane Library, CINHAL, PsychINFO, and Scopus) and grey (clinicaltrials.gov, WHO trial search, meta-Register ISRCTN, Google Scholar, opengrey, and ohri.ca) literature, also identified from contacting authors and hand-searching bibliographies. We included randomized controlled trials (RCTs): 1) comparing SDM to usual care for decisions about PC treatment, 2) conducted in primary or specialized care, 3) fulfilling the key SDM features, and 4) reporting quantitative outcome data. Four RCTs from Canada (n=3) and the USA were included and comprised 1,065 randomized men, most (89.8%) of whom were in PC stage T1-T2. The studies reported 24 outcome measures. In 62.5% study estimates, SDM was similar to usual care at improving patient satisfaction and mood, and at reducing decisional conflict and decisional regret. In 37.5% study estimates, SDM significantly improved knowledge, perception of being informed and patient-perceived quality of life (QoL) at four weeks. There was a dearth of outcome data, particularly on the adherence to treatment and on patient-important and clinically relevant health outcomes such as symptoms and mortality. Conclusion: SDM may positively influence men’s knowledge and may have a positive but short-term effect on patient-perceived QoL. The (long-term) effects of SDM on patient-related outcomes for decisions about PC treatment are unclear. Future research needs consensus about the interventions and outcomes needed to evaluate SDM and should address the absence of evidence on health outcomes

Multimorbidity: can general practitioners identify the health conditions most important to their patients? Results from a national cross-sectional study in Switzerland

Faced with patients suffering from more than one chronic condition, or multimorbidity, general practitioners (GPs) must establish diagnostic and treatment priorities. Patients also set their own priorities to handle the everyday burdens associated with their multimorbidity and these may be different from the priorities established by their GP. A shared patient-GP agenda, driven by knowledge of each other's priorities, would seem central to managing patients with multimorbidity. We evaluated GPs' ability to identify the health condition most important to their patients. Data on 888 patients were collected as part of a cross-sectional Swiss study on multimorbidity in family medicine. For the main analyses on patients-GP agreement, data from 572 of these patients could be included. GPs were asked to identify the two conditions which their patient considered most important, and we tested whether either of them agreed with the condition mentioned as most important by the patient. In the main analysis, we studied the agreement rate between GPs and patients by grouping items medically-related into 46 groups of conditions. Socio-demographic and clinical variables were fitted into univariate and multivariate models. In 54.9% of cases, GPs were able to identify the health condition most important to the patient. In the multivariate model, the only variable significantly associated with patient-GP agreement was the number of chronic conditions: the higher the number of conditions, the less likely the agreement. GPs were able to correctly identify the health condition most important to their patients in half of the cases. It therefore seems important that GPs learn how to better adapt treatment targets and priorities by taking patients' perspectives into account

Determinants associated with deprivation in multimorbid patients in primary care-A cross-sectional study in Switzerland

Deprivation usually encompasses material, social, and health components. It has been shown to be associated with greater risks of developing chronic health conditions and of worse outcome in multimorbidity. The DipCare questionnaire, an instrument developed and validated in Switzerland for use in primary care, identifies patients subject to potentially higher levels of deprivation. To identifying determinants of the material, social, and health profiles associated with deprivation in a sample of multimorbid, primary care patients, and thus set priorities in screening for deprivation in this population. Secondary analysis from a nationwide cross-sectional study in Switzerland. A random sample of 886 adult patients suffering from at least three chronic health conditions. The outcomes of interest were the patients' levels of deprivation as measured using the DipCare questionnaire. Classification And Regression Tree analysis identified the independent variables that separated the examined population into groups with increasing deprivation scores. Finally, a sensitivity analysis (multivariate regression) confirmed the robustness of our results. Being aged under 64 years old was associated with higher overall, material, and health deprivation; being aged over 77 years old was associated with higher social deprivation. Other variables associated with deprivation were the level of education, marital status, and the presence of depression or chronic pain. Specific profiles, such as being younger, were associated with higher levels of overall, material, and health deprivation in multimorbid patients. In contrast, patients over 77 years old reported higher levels of social deprivation. Furthermore, chronic pain and depression added to the score for health deprivation. It is important that GPs consider the possibility of deprivation in these multimorbid patients and are able to identify it, both in order to encourage treatment adherence and limit any forgoing of care for financial reasons

Smoking Cessation Counselling: What Makes Her or Him a Good Counsellor? Can Counselling Technique Be Deduced to Other Important Lifestyle Counselling Competencies?

Smoking is a major health concern in both developed and developing countries. Smoking cessation counselling is of major importance for health care providers such as physicians, psychologists, nurses and many further therapeutic workers. We recently have demonstrated feasibility of a 4-hour “student-to-student course” (1 hour of scientific background and 3 hours of role plays and intervision) that provided knowledge, skills and attitude to smoking cessation counselling. A key question remains whether such knowledge, skills and attitude can be further deduced to key public health or lifestyle counselling areas like body weight management in overweight persons, management of addictions like alcohol and substance or situation (e.g., Internet and shopping) abuse, management of physical activity/exercise or lifestyle modification like workaholic lifestyle. The authors try to develop such a base for enabling patients to adapt healthier behaviour and give objectives for such counselling situations including the elaboration of clear therapeutic aims for counsellors