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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 [ABSTRACT FROM AUTHOR]

Introduction: Helping smokers to quit is an important task of general practitioners (GPs). However, achieving tobacco abstinence is difficult, and smokers who fail may still want to improve their health in other ways. Therefore, Swiss GPs developed a multithematic coaching concept that encourages health behavior changes beyond smoking cessation alone.Aims and Methods: To compare the effectiveness of such coaching with state-of-the-art smoking cessation counseling, we conducted a pragmatic cluster-randomized two-arm trial with 56 GPs in German-speaking Switzerland and 149 of their cigarette smoking patients. GPs were instructed in either multithematic health coaching or smoking cessation counseling. After 12 months, we compared their patients' improvements in cigarette consumption, body weight, physical inactivity, alcohol consumption, stress, unhealthy diet, and a health behavior of their own choice, using hierarchical logistic regression models and Fisher's exact and t tests.Results: Over 95% of all participants achieved clinically relevant improvements in at least one health behavior, with no difference between study arms (health coaching vs. smoking cessation counseling: aOR = 1.21, 95% CI = [0.03-50.76]; and aOR = 1.78, 95% CI = [0.51-6.25] after non-responder imputation). Rates of clinically relevant improvements in the individual health behaviors did not differ between study arms either (they were most frequent in physical activity, achieved by 3 out of 4 patients), nor did the extent of the improvements.Conclusions: Multithematic health coaching and state-of-the art smoking cessation counseling were found to be comparable interventions, both in terms of smoking cessation success and, quite unexpectedly, their effects on other health behaviors.Implications: The findings of our study suggest that in general practice, multithematic health coaching is an effective smoking cessation intervention, and conversely, monothematic smoking cessation counseling also achieves the beneficial effects of a multithematic health behavior intervention. This opens up the possibility for GPs to support their smoking patients in improving their health behavior in additional and more flexible ways. [ABSTRACT FROM AUTHOR]

Background: Chronic conditions are a significant public health concern due to their rising prevalence, association with high mortality, and substantial healthcare costs. General practitioners play a crucial role in managing these conditions, and quality indicators are essential tools for assessing the quality of care. Electronic feedback reports incorporating quality indicator performance have shown promise in improving care quality. However, most studies have focused on single conditions or link feedback to financial incentives, which may not sustain long-term practice changes. This study aims to evaluate the effectiveness of a multi-condition electronic feedback reports on quality indicator performance in Swiss general practice without financial incentives. Methods: This randomized controlled trial involves general practitioners enrolled in the FIRE project, a database of electronic medical records from Swiss primary care. Participants are randomized to receive either a plain feedback report or a comprehensive quality indicator -specific feedback report bi-monthly for 12 months. The plain feedback report contains descriptive summaries of practice activities, while the quality indicator-specific feedback report includes performance data on 14 quality indicators across cardiovascular, endocrine, pulmonary, and renal domains. The quality indicators were selected in multi-step process involving review of the literature and clinical guidelines, domain expert consultations, and a panel discussion with general practitioners. The primary study objective is to compare the effectiveness of the quality indicator-specific feedback report and of the plain feedback report with respect to the performance of the selected quality indicators. Conclusion: The study addresses a critical gap by evaluating a multi-condition feedback report without financial incentives. Its findings can inform future health policies and strategies, in line with national and international initiatives that promote or even require the implementation of quality measurement activities in general practice. Trial registration: Trial registry: ISRCTN. Registration number: ISRCTN10637092, https://www.isrctn.com/ISRCTN10637092. Registered January 9, 2024. [ABSTRACT FROM AUTHOR]

Sample size calculations for trials with time-to-event outcomes are usually based on the assumption that an event – prototypically death in survival analysis – occurs only once per sample unit. However, events like changes in disease status or switches between treatment modalities may repeat over time. In trials with such outcomes, standard sample size formulae derived from the classical survival time models are not applicable. Instead, modeling the repeating transition events must precede the actual sample size calculation. Markov chains are an obvious choice to model transitions. Accordingly, in order to determine the sample size for a one-arm feasibility and acceptability study of a new drug intake route, we model switches of administration routes by a homogeneous finite-state, higher-order Markov chain. Assumptions about its transition matrix translate into multinomial distributions of the preferred administration routes at given points in time. From these distributions, the required sample size can then be calculated according to the study's specific question. In this manuscript, we first introduce the method for the case of drug intake preferences, before we briefly discuss how the proposed method can also be used for power-based sample size calculation in multi-arm trials. [ABSTRACT FROM AUTHOR]

Sex differences in cardiovascular prevention have been reported, yet the role of sex with regard to different modifiable risk factors such as low-density lipoprotein cholesterol (LDL-C), systolic blood pressure (BP), and glycated hemoglobin (HbA1c) in primary care settings is unclear. Therefore, we studied sex differences in assessment and measured values of LDL-C, BP, and HbA1c in primary and secondary cardiovascular prevention delivered by general practitioners. This cross-sectional study was based on electronic medical records of 59,092 primary care patients (51.9% women) aged 40–79 years in Switzerland. Multilevel regression was used to model associations of sex with assessment and measured values of LDL-C, BP, and HbA1c in 2018. In both primary and secondary prevention, women had lower LDL-C assessment rates (age-adjusted odds ratio (aOR) 0.71 [95% confidence interval (CI) 0.67 to 0.75] and 0.70 [CI 0.51 to 0.95]), and higher measured LDL-C values than men (age-adjusted difference 0.30 mmol/L [CI 0.25 to 0.35] and 0.28 mmol/L [CI 0.07 to 0.48]). Compared with men, women in primary prevention displayed lower BP and HbA1c assessment frequencies (aOR 0.77 [CI 0.73 to 0.81] and 0.76 [CI 0.71 to 0.80]) and measured values (age-adjusted difference -2.49 mmHg [CI -2.99 to -1.79] and -0.19% [CI -0.24 to -0.14]), while there was no sex difference in secondary prevention. Age-dependent increases in measured values of LDL-C, BP, and HbA1c were greater in women than men. Control of LDL-C in women in primary care should be improved to reduce sex-based inequalities in prevention of cardiovascular disease. [Display omitted] • Sex differences in cardiovascular risk management exist in primary care. • Women face poorer control of LDL-C than men in primary and secondary prevention. • BP and HbA1c assessment and values are lower in women than men in primary prevention. • BP and HbA1c assessment and values are similar between sexes in secondary prevention. • Improvements in LDL-C management in women are key to reduce sex-based inequalities. [ABSTRACT FROM AUTHOR]

Aims: To estimate the prevalence of chronic obstructive pulmonary disease (COPD) and related risk factors in people in opioid agonist treatment (OAT), to compare airflow limitation severity and age‐specific COPD prevalence rates with those in the general population, and to assess the OAT patients' willingness to adopt life‐style changes and to use therapeutic offers for COPD management. Design Cross‐sectional study in a random sample of OAT patients. Setting: Out‐patient centres for substance addiction medicine in Zurich, Switzerland. Participants: A total of 125 participants, recruited from November 2016 to April 2017 through invitation letters followed by phone or personal contact. Measurements Standardized questionnaires about drug use, smoking habits and medical history, completed during face‐to‐face interviews or from medical records. Spirometry without and—depending on the result—with bronchodilation. Findings Almost one‐third [30.3%; 95% confidence interval (CI) = 22.6–39.0%] of the 119 participants with valid spirometry tests were diagnosed with COPD. Among males aged 30–59 years, the age‐adjusted prevalence of at least moderate airflow limitation (GOLD grade ≥ 2) was 2.4 (95% CI = 1.3–4.4) times as high as in the ever‐smoking Swiss population in the same age group. Smoking tobacco (92.0%) and substance inhalation (cannabis = 97.6%, cocaine = 69.6%, heroin = 68.0%) were highly prevalent among all participants. The participants expressed considerable interest in life‐style changes and use of therapeutic offers for COPD management, with smoking cessation being least (20.2% of tobacco smokers interested) and pharmacological treatment to alleviate COPD symptoms most popular. Conclusions: In Switzerland, COPD prevalence and multiple risk factors for COPD appear to be high among people in OAT compared with the general population. Individuals in OAT appear to develop COPD at a younger average age compared with the general population and are open to life‐style changes and other COPD management approaches. [ABSTRACT FROM AUTHOR]

Background: Tobacco abuse is a frequent issue in general practitioners' (GPs') offices, with doctors playing a key role in promoting smoking cessation to their patients. However, not all smokers are ready and willing to give up smoking. Thus, a GP focusing on smoking cessation alone might waste the opportunity to improve his patient's health by supporting a change in another harmful behaviour pattern. The aim of this study is to determine whether multi-thematic coaching will lead to higher overall health benefits without resulting in a reduced rate of successful smoking cessations, compared with a monothematic smoking cessation approach.Methods: The study is designed as a two-armed, double-blinded, cluster-randomised trial. GPs will be randomly assigned to the intervention or control group. In the intervention group, GPs will undergo training in patient-centred coaching, shared decision-making and motivational interviewing. The control group will be trained in a state-of-the-art smoking cessation algorithm. GPs will approach adult cigarette-smoking patients and advise those included according to the GP's group affiliation. The primary outcome is the between-group difference in the proportion of participants who achieve a beneficial change in at least one of seven different health-related behavioural dimensions, 12 months post baseline. Secondary outcomes include smoking cessation rates and the patients' self-perceived smoking-related motivation, self-efficacy and planning behaviour. Additionally, covariates describing both GPs and patients will be collected before the start of the intervention, and process outcome measures in compliance with the RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) framework will be recorded during the ongoing study.Discussion: Tobacco consumption is still highly prevalent in the general population and often goes hand in hand with other behaviour patterns with adverse health effects. This study will add to the literature regarding effective strategies available to GPs to address unhealthy behaviour among their smoking patients beyond mere smoking cessation counselling. The study will also establish a basis for decisions about further promotion and dissemination of the coaching under study.Trial Registration: ISRCTN, ISRCTN38129107 . Registered on 2 October 2017. [ABSTRACT FROM AUTHOR]

Background: Digitalization and patient empowerment result in new requirements and challenges. In response, the module 'Clinical Telemedicine/e-Health' was implemented by the Faculty of Medicine of Zurich in 2008. The module was systematically evaluated to determine if the students would benefit from this course. In 2011, 2015, and 2016 further evaluations were performed. Method: In 2008 and 2009, students evaluated 16 statements. We calculated the combined mean value and medians for both evaluations. In 2011, the same evaluation was conducted, and the results were compared through U-test. In 2015, students were asked about the application and benefits of telemedicine; the answers were analyzed qualitatively and quantitatively. In 2016, the University of Zurich created an online survey which integrated three of the statements from the original evaluations. Results: Every mean value of the combined evaluations of 2008/2009, 2011, and 2016 achieved a score of over 4 on a 6-point scale. In 2011, and also again in 2016, the overall satisfaction and understanding of telemedicine as a supplement in traditional medical consultations increased as follows: 4.71 ± 0.74 versus 4.86 ± 0.93 versus 5.1 ± 1.5 and, respectively, 5.02 ± 0.96 versus 5.25 ± 0.81 versus 5.7 ± 0.6. In the 2015 evaluation, 93% of students indicated that they would use telemedicine for chronically ill and elderly patients. Conclusion: The positive assessment of the module indicates the successful introduction of the topics of telemedicine and e-health to medical students at the University of Zurich. Throughout the course, the students gained confidence and basic skills. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: In randomised controlled trials with only few randomisation units, treatment allocation may be challenging if balanced distributions of many covariates or baseline outcome measures are desired across all treatment groups. Both traditional approaches, stratified randomisation and allocation by minimisation, have their own limitations. A third method for achieving balance consists of randomly choosing from a preselected list of sufficiently balanced allocations. As with minimisation, this method requires that heterogeneity between treatment groups is measured by specified imbalance metrics. Although certain imbalance measures are more commonly used than others, to the author's knowledge there is no generally accepted "gold standard", neither for categorical and even less so for continuous variables.Methods: An intuitive and easily accessible web-based software tool was developed which allows for balancing multiple variables of different types and using various imbalance metrics. Different metrics were compared in a simulation study.Results: Using simulated data, it could be shown that for categorical variables, χ2-based imbalance measures seem to be viable alternatives to the established "quadratic imbalance" metric. For continuous variables, using the area between the empirical cumulative distribution functions or the largest difference in the three pairs of quartiles is recommended to measure imbalance. Another imbalance metric suggested in the literature for continuous variables, the (symmetrised) Kullback-Leibler divergence, should be used with caution.Conclusion: The Shiny Balancer offers the possibility to visually explore the balancing properties of several well established or newly suggested imbalance metrics, and its use is particularly advocated in clinical studies with few randomisation units, as it is typically the case in cluster randomised trials. [ABSTRACT FROM AUTHOR]

Background: Since 1999, the University Hospital Zurich (Switzerland) offers an e-mail based online consultation where patients can ask online doctors anonymous questions about individual health concerns. This study aimed at the characterization of the patient, the content of the question and the recommendations given specifically in the field of gastroenterology. Methods: In total, 3,489 inquiries were asked from July 2010 to December 2015. Based on the International Classification of Diseases ICD-10 and the Primary Care Code ICPC-2 252 (7.2%) inquiries were included in the retrospective qualitative study. The content of the requests was qualitatively evaluated by inductive categorization using a professional text analysis program (MAXQDA). Results: Of the users, 49.2% were male, 49.6% female. The mean age was 47.9 years. Main topics of the questions were bowel diseases in 29.8% (infectious in 6%, non-infectious in 7.1%, other bowel diseases in 16.7%). Most often patients suffered from abdominal pain (32.7%), diarrhea (22.7%), general weakness (22.7%) or epigastric pain (17.1%). Half (48.8%) of the questioners inquired about a second opinion while 25% asked for medical advice. The online doctors responded with detailed information about therapy (73.4%), explained a specific disease (63.9%) or provided decision support (13.9%). Most patients rated the clarity of the answer as good or very good (95.2%). Conclusion: An e-mail based teleconsultation in the field of gastroenterology can provide individual advice and empowers patients by improving their health literacy. Patients with bowel diseases have high expectations to obtain professional medical advice and need support in their decision-making process. [ABSTRACT FROM AUTHOR]

Increasing oncological treatment costs are a major global concern with the risk of entailing two-tiered health care. Among cost determining factors is the price of individual drugs. In recognition of the central role of this factor, we present a comprehensive overview of the development of monthly prices of oncological drugs introduced over the last 15 years in Switzerland. We identified all oncological drugs newly reimbursed by mandatory health insurance in 2005–2019, and searched public repositories for their package prices, indications with approval dates, and treatment regimens for the calculation of (indication-specific) monthly prices. We found 81 products covering 77 different substances (39.5% protein kinase inhibitors, 21.0% monoclonal antibodies). Most indications related to the topography "blood", followed by "lung and thorax" and "digestive tract". From 2005–2009 to 2015–2019, the median monthly product price over all distinct indications of all products decreased by 7.56% (CHF 5,699 [interquartile range 4,483–7,321] to CHF 5,268 [4,19–6,967]), whereas it increased by 73.7% for monoclonal antibodies. In December 2019, six products had monthly prices over CHF 10,000, all approved for hematological or dermatological cancers. Our analysis suggests that individual price developments of oncological drugs are presently not the major driver of rising cancer treatment costs. However, rising launch prices of some new, mostly hematological drugs are of concern and require continued monitoring. [ABSTRACT FROM AUTHOR]

Guidelines recommend initiation of statins depending on cardiovascular risk and low-density lipoprotein cholesterol (LDL-C) levels. In this retrospective cohort study, we aimed to assess guideline concordance of statin treatment decisions and to find determinants of undertreatment in Swiss primary care in the period 2016–2019. We drew on electronic medical records of 8060 statin-naive patients (50.0% female, median age 59 years) with available LDL-C levels and cardiovascular risk. Guideline concordance was assessed based on the recommendations of the European Society of Cardiology, and multilevel logistic regression was performed to find determinants of undertreatment. We found that statin treatment was initiated in 10.2% of patients during one year of follow up. Treatment decisions were classified as guideline-concordant in 63.0%, as undertreatment in 35.8% and as overtreatment in 1.2%. Among determinants of undertreatment were small deviation from LDL-C treatment thresholds (odds ratio per decrease by 1 mmol/L: 2.09 [95% confidence interval 1.87–2.35]), high compared with very high cardiovascular risk (1.64 [1.30–2.05]), female sex (1.31 [1.05–1.64]), and being treated by older general practitioners (per 10 year decrease: 0.74 [0.61–0.90]). In conclusion, undertreatment of patients at high or very high cardiovascular risk was common, but general practitioners considered cardiovascular risk and LDL-C in their treatment decisions. [ABSTRACT FROM AUTHOR]

Background: Research on individual general practitioner (GP) workload, e.g. in terms of consultation counts, is scarce. Accurate measures are desirable because GPs' consultation counts might be related to their work satisfaction and arguably, there is a limit to the number of consultations a GP can hold per day without jeopardizing quality of care. Moreover, understanding the association of consultation counts with GP characteristics is crucial given current trends in general practice, such as the increasing proportion of female GPs, part-time work and group practices. Aim: The aim of this study was to describe GPs' consultation counts and efficiency and to assess associations with GP and practice variables. Methods: In this retrospective observational study we used routine data in electronic medical records obtained from 245 Swiss GPs in 2018. We described GPs' daily consultation counts as well as their efficiencies (i.e. total consultation counts adjusted for part-time work) and used hierarchical linear models to find associations of the GPs' total consultation counts in 2018 with GP- and practice-level variables. Results: The median daily consultation count was 28 over all GPs and 33 for full-time working GPs. Total consultation counts increased non-linearly with part-time status, with high part-time working GPs (60%-90% of full-time) being equally or more efficient than full-time workers. Excluding part-time status in the regression resulted in higher consultation counts for male GPs working in single practices and with older patients, whereas part-time adjusted consultation counts were unaffected by GP gender and practice type. Conclusion: Female gender, part-time work in the range of 60%-90% of full-time, and working in group practices do not decrease GP efficiency. However, the challenge of recruiting sufficient numbers of GPs remains. [ABSTRACT FROM AUTHOR]