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Background General practitioners ( GPs) play crucial roles in early detection of skin cancer. A pilot-study found a positive short-term effect of a 1-day dermatologic education programme on GPs' diagnostic competence. Objective To determine effects of a multifaceted intervention, including technical equipment and continuing feedback by a dermatologist, on GPs' diagnostic skills regarding skin cancer. Methods Randomized controlled trial with 78 GPs of the Canton of Zurich, Switzerland. Intervention: GPs in intervention group received a 1-day training, a Lumio© (magnifying glass with polarized light, 3Gen), a Nikon digital camera and - during 1 year - feedback on skin lesion pictures sent to the dermatologist. GPs in control group only received the 1-day training. Main outcome and measures: Primary outcome: structured assessment of GP's diagnostic skills in correctly diagnosing images of skin lesions regarding skin cancer. At baseline prior to intervention (T0), after the full-day training course in both groups (T1), and after 1 year of continuing feedback (T2) to the intervention group. Measures: Non-parametric unpaired (Wilcoxon-Mann-Whitney) tests were used to compare numbers of correctly classified skin lesions between both groups at T2 and for the change between T1 and T2. Results At T0, both groups classified a median of 23 skin lesions of the 36 images correctly. This value rose to 28 for both groups at T1 and fell to 24 for both groups at T2. No difference between control and intervention group at T2. Furthermore, we compared differences in the sum scores per GP between T1 and T2 for each group. Also in this comparison, no difference between control and intervention group was found. Conclusion and relevance No long-term effect of the multifaceted intervention was found on the competence to diagnose skin cancer by GPs. The positive short-term effect of the 1-day dermatologic education programme did not persist over 12 months. [ABSTRACT FROM AUTHOR]

We examined the gender difference in performance of open-water ultra-swimmers crossing the English Channel between 1875 and 2011. A total of 1606 swimmers (1120 males and 486 females) crossed the English Channel within a mean time of 809.6 ± 175.6 min. The overall female swim time of 796.3 ± 188.7 min was not different compared with the overall male swim time of 815.4 ± 169.4 min ( P > 0.05). The fastest male swim time ever of 417 min was 6.7% faster than the fastest female swim time ever with 445 min. The gender difference in performance of the top three times ever was 8.9 ± 2.3%. Over the last 36 years, the performance of the annual top three swimmers showed no changes for both females and males. The top three males (564.3 ± 63.8 min) were significantly faster than the top three females (602.1 ± 58.7 min; P < 0.01). The gender difference remained unchanged at 12.5 ± 9.6% over the years. To summarize, the top three male swimmers in the English Channel were ∼12% faster than the females in the last 36 years. It seems unlikely that female open-water ultra-swimmers will overtop males in the near future in the English Channel. [ABSTRACT FROM AUTHOR]

Most patients with diabetes are treated in primary care (PC). We performed a systematic review to assess the effect of single and combined interventions on cardiovascular risk factors (CVRFs) and glycated haemoglobin (HbA1c) levels in patients with diabetes in PC settings. We searched the MEDLINE database from January 1990 to October 2008. According to the Cochrane Effective Practice and Organization of Care Group (EPOC) criteria, (cluster-)randomized control studies and controlled before-and-after studies were selected and reviewed. Identified interventions were classified according to a modified EPOC intervention taxonomy. We included 68 studies. Forty-five studies evaluated the effect of any intervention on HbA1c. Seventeen studies presented a significant improvement in HbA1c. Nine out of 27 studies evaluating CVRFs [cholesterol, blood pressure (BP)] and HbA1c showed a significant improvement in at least two of these factors. Audit and feedback on performance, clinical decision support systems, multi-professional teams and patient education seemed to be successful strategies. The increasing evidence regarding the treatment of persons with chronic illnesses, summarized in the Chronic Care Model (CCM), is not reflected in most recent studies about diabetes treatment in PC. Most interventions still seem only partly adapted to the CCM. The methodological quality of many studies is still poor and often the pivotal outcomes, CVRFs and HbA1c, are not appropriately addressed. As a consequence, the potential of PC in the care of patients with diabetes may still be underestimated. [ABSTRACT FROM AUTHOR]

Aims: Diagnosis of inflammatory bowel disease (IBD) is often associated with a diagnostic delay. Although faecal calprotectin is a helpful screening tool, the widespread use in primary care (PC) may not be appropriate due to the low prevalence of IBD in this setting. To increase pretest probability for a positive calprotectin test, an 8-item questionnaire (CalproQuest) was tested for its feasibility and acceptability in PC., Methods: Population: PC patients with unspecific gastrointestinal complaints for at least 2 weeks. The CalproQuest consists of four major and four minor questions specific for IBD. It is considered positive if greater than or equal to two major or one major and two minor criteria are positive., Primary Outcome: feasibility of CalproQuest, secondary outcome: patient's acceptance of stool sampling., Results: Of 95 patients with a complete CalproQuest 52 (54.7%) were positive, 39 (41.1%) fulfilled two major and 13 (13.7%) one major and greater than or equal to two minor criteria. Twenty-seven general practitioners completed 83 (87.4%) questionnaires on feasibility which was assessed positive. Eighty-two patients (86.3%) completed questionnaires on acceptance which was high., Conclusion: The CalproQuest is a feasible instrument for assessing IBD in PC. Further prospective studies concerning validity and cost effectiveness of a combined use with the calprotectin test in this setting are necessary., (© 2018 John Wiley & Sons, Ltd.)

Background: General practitioners (GPs) play crucial roles in early detection of skin cancer. A pilot-study found a positive short-term effect of a 1-day dermatologic education programme on GPs' diagnostic competence., Objective: To determine effects of a multifaceted intervention, including technical equipment and continuing feedback by a dermatologist, on GPs' diagnostic skills regarding skin cancer., Methods: Randomized controlled trial with 78 GPs of the Canton of Zurich, Switzerland., Intervention: GPs in intervention group received a 1-day training, a Lumio (magnifying glass with polarized light, 3Gen), a Nikon digital camera and - during 1 year - feedback on skin lesion pictures sent to the dermatologist. GPs in control group only received the 1-day training., Primary Outcome: structured assessment of GP's diagnostic skills in correctly diagnosing images of skin lesions regarding skin cancer. At baseline prior to intervention (T0), after the full-day training course in both groups (T1), and after 1 year of continuing feedback (T2) to the intervention group., Measures: Non-parametric unpaired (Wilcoxon-Mann-Whitney) tests were used to compare numbers of correctly classified skin lesions between both groups at T2 and for the change between T1 and T2., Results: At T0, both groups classified a median of 23 skin lesions of the 36 images correctly. This value rose to 28 for both groups at T1 and fell to 24 for both groups at T2. No difference between control and intervention group at T2. Furthermore, we compared differences in the sum scores per GP between T1 and T2 for each group. Also in this comparison, no difference between control and intervention group was found., Conclusion and Relevance: No long-term effect of the multifaceted intervention was found on the competence to diagnose skin cancer by GPs. The positive short-term effect of the 1-day dermatologic education programme did not persist over 12 months., (© 2014 European Academy of Dermatology and Venereology.)

Rationale, Aim and Objective: To test feasibility and diagnostic accuracy of dermatologist's feedback based on digital images of skin lesions collected in Swiss primary care., Methods: This was a process analysis of a randomized controlled trial, conducted in 2011/2012. 30 of 78 general practitioners (GPs) were randomized to an intervention, which included dermatologist's feedback on digital images of skin lesions. Feedback was categorized into four categories: (1) no further investigation; (2) clinical observation; (3) biopsy; and (4) other. Histologic findings were allocated to the same categories. Feasibility was measured in the perspective of GPs concerning technical handling and of dermatologists as proportion of images usable for feedback. Diagnostic accuracy was measured as proportion of malignant histology of the first three feedback groups. No long-term data was collected., Results: 981 images of skin lesions were collected, two were not eligible due to low quality of images. The majority of GPs (77.8%) reported no problem with the procedure. 207 images were in feedback category 1, 353 in 2, 360 in 3 and 59 in 4. A total of 236 histologic tests were collected. Three cases in category 1 indicated malignancy (1 melanoma). 201 of category 3 received a biopsy, where in 91 (45.3%) malignancy was confirmed., Conclusion: Teledermatology with digital images taken in primary care was feasible from a GP and from a specialist perspective. However, diagnostic appropriateness regarding avoidance of specialist care and possible missed skin cancer raises concerns. These results therefore question a promotion of teledermatology in clinical routine., (© 2015 John Wiley & Sons, Ltd.)

Rationale, Aims and Objectives: The inappropriate use and overcrowding of emergency departments (EDs) by walk-in patients are well-known problems in many countries. The current study aimed to determine whether ambulatory walk-in patients could be treated more efficiently in a new hospital-integrated general practice (HGP) for emergency care services compared to a traditional ED., Methods: We conducted a pre-post comparison before and after the implementation of a new HGP. Participants were walk-in patients attending the ED of a city hospital in Zurich. Main outcome measures were differences in total process time, time intervals between stages of care and diagnostic resources used., Results: The median process time from admission to discharge was 120 minutes in the ED [interquartile range (IQR): 80-165] versus 60 minutes in the HGP (IQR: 40-90) (P < 0.001). The adjusted odds ratio of receiving any additional diagnostics was 1.86 (95% confidence interval 1.06-3.27; P = 0.032) for ED doctors versus general practitioners (GPs) when controlling for patients' age, sex and injury-related medical problems., Conclusion: The HGP is an efficient way to manage walk-in patients with regard to process time and utilization of additional diagnostic resources. The involvement of GPs in the HGPs should be considered as a promising model to overcome the inappropriate use of resources in EDs for walk-in patients who can be treated by ambulatory care., (© 2013 John Wiley & Sons, Ltd.)

Background: Switzerland lacks of national guidelines for the initial treatment of an acute coronary syndrome (ACS). ACS is not as frequent in an outpatient setting as in an emergency department; nevertheless, missing an ACS is associated with high morbidity and mortality. We wanted to observe actual infrastructure and performance based on case vignettes in outpatient general practitioners (GPs) and cardiologists (CAs); as a second outcome, we wanted to compare GPs to CAs., Methods: We conducted a postal vignette-based survey to investigate the management of outpatients presenting with acute chest pain by doctors in private practice. The use of troponin and cardiac stress testing for the evaluation of acute chest pain as well as referral practice and use of antiplatelet agents were assessed and compared between GPs and CAs., Results: There were 507 of the 571 respondents (response rate 39.7%) who were CAs (36) or GPs (471) and were included in the analysis. Whereas all CAs were equipped with electrocardiogram (ECG), cardiac stress testing and troponin assays, the majority of GPs had an ECG (97.8%) and applied troponin testing (76.3%), and 38.7% performed cardiac stress testing. The vast majority responded to directly refer a STEMI to the next catheter lab (87.7%), or in the case of a troponin-positive NSTEMI, to an inpatient ward (94.1%) with no difference between GPs and CAs. A majority of the GPs responded to use antiplatelet agents in the case of a STEMI (89.6%) and reported further workup with cardiac stress testing in the case of a troponin-negative acute chest pain (78.7%), which was lower compared to CAs who applied antiplatelet agents and cardiac stress testing in 100% and 97.0%., Conclusions: We could show that international guideline adherence in ACS of GPs is high and GPs perform as well as CAs. Nevertheless there is room for optimization in the antiplatelet therapy and the use of cardiac stress testing in a low-risk population. National guidelines for treatment of an ACS in an outpatient setting are indicated., (© 2012 John Wiley & Sons Ltd.)

Background: Several studies have assessed the effect of cost sharing on health service utilization (HSU), mostly in the USA. Results are heterogeneous, showing different effects. Whereas previous studies compared insurants within one health care system but different modes of insurance, we aimed at comparing two different health care systems in Europe: Germany and Switzerland. Furthermore, we assessed the impact of cost sharing depending on socio-demographic factors as well as health status., Methods: Two representative samples of 5197 Swiss insurants with and 5197 German insurants without cost sharing were used to assess the independent association between cost sharing and the use of outpatient care. To minimize confounding, we performed cross-sectional analyses between propensity score matched Swiss and German insurants. We investigated subgroups according to health and socio-economic status to assess a potential social gradient in HSU., Results: We found a significant association between health insurance scheme and the use of outpatient services. German insurants without cost sharing (visit rate: 4.8 per year) consulted a general practitioner or specialist more frequently than Swiss insurants with cost sharing (visit rate: 3.0 per year; P < 0.01). Subgroup analyses showed that vulnerable populations were differently affected by cost sharing. In the group of respondents with poor health and low socio-economic status, the cost-sharing effect was strongest., Conclusion: Cost-sharing models reduce HSU. The challenge is to create cost-sharing models which do not preclude vulnerable populations from seeking essential health care., (© 2011 Blackwell Publishing Ltd.)

Background: In Switzerland, there is a dearth of information on the extent to which patients with chronic illnesses receive care congruent with the Chronic Care Model (CCM). To drive quality improvement programmes, it is necessary to have practical assessment tools in the country's own language to evaluate the delivery of CCM activities., Methods: German translation and adaptation of the original Assessment of Chronic Illness Care (ACIC). We followed a sequential forward and backward translation approach. In a multidisciplinary committee review the original English version and the translations were compared, instructions and formats modified and cross-cultural equivalences verified. The second version was pre-tested and multidisciplinary group discussion led to the final version which aimed to create a comprehensive culturally adapted translation capturing the original idea of the items rather than a direct one to one translation., Results: Difficulties encountered during the translation process consisted in the difference of health care settings and health care organization in Switzerland and USA.The adapted German version was delivered to a managed care organization in the city of Zurich to test the initial use for diabetes care. The average ACIC subscale scores were: organization of the health care delivery system: mean (m) = 7.31 (SD = 0.79), community linkages: m = 3.78 (SD = 1.09), self-management support: m = 4.88 (SD = 1.21), decision support: m = 4.79 (SD = 1.16), delivery system design: m = 5.56 (SD = 1.28) and clinical information systems: m = 4.50 (SD = 2.69). Overall, the ACIC subscale scores were comparable with the scores of the original testing., Conclusion: After cultural adaptations the German version of the ACIC is applicable as a tool to guide quality improvement in chronic illness care in German speaking countries in Europe., (© 2010 Blackwell Publishing Ltd.)

Rationale, Aims and Objectives: To investigate the demand for traditional out-of-hours general practitioner (GP) emergency care in Switzerland including GPs' satisfaction and reasons for encounter (RFE)., Method: During a 2-month period (2009), a questionnaire-based, cross-sectional study was performed in GPs participating in the mandatory out-of-hours service in the city of Zurich, Switzerland. The number and mode of patient contacts were assessed to investigate the demand for GP care in traditional out-of-hours services. GPs and patient characteristics, including RFE according to the International Classification of Primary Care, were noted. Descriptive statistics and non-parametric tests were conducted., Results: Out of the 295 out-of-hours episodes during the study period, 148 (50%) duty periods were documented by a total of 93 GPs (75% men) with a mean (SD) age of 48.0 (6.2) years. The median (interquartile range) number of out-of-hours contacts was 5 (3-8) and the demand for home visits was significantly more common compared with practice and telephone consultations. A total of 112 different RFEs were responsible for the 382 documented patient contacts with fever accounting for the most common complaint (13.9%). Although 80% of GPs agreed to be satisfied overall with their profession as primary care provider, 57.6% among them were dissatisfied with the current out-of-hours service. Inappropriate payment and interference with their daily work in practice were most frequently reported., Conclusions: Our findings indicate that there is still strong patient demand for out-of-hours care with special need for home visits, suggesting that new organizational models such as integrating GPs into emergency care may not be an appropriate approach for all patients. Therefore, the ongoing reorganization of the out-of-hours-service in many health care systems has to be evaluated carefully in order not to miss important patient needs., (© 2010 Blackwell Publishing Ltd.)

Aims: Injection drug users are at high risk for chronic hepatitis C virus infection (CHC). Opioid maintenance treatment (OMT) offers a unique opportunity to screen for CHC. This study proposed the hypothesis that a general practitioner (GP) with special interest in addiction medicine can achieve CHC screening rates comparable to specialized centres and aimed to investigate determinants for a successful CHC case finding in a primary care setting., Design and Participants: Retrospective medical record analysis of 387 patients who received opioid maintenance therapy between 1 January 2002 and 31 May 2008 in a general practice in Zurich, Switzerland., Measurements: Successful CHC assessment was defined as performance of hepatitis C virus (HCV) serology with consecutive polymerase chain reaction-based RNA and genotype recordings. The association between screening success and patient characteristics was assessed using multiple logistic regression. findings: Median (interquartile range) age and duration of OMT of the 387 (268 males) patients was 38.5 (33.6-44.5) years and 34 (11.3-68.0) months, respectively. Fourteen patients (3.6%) denied HCV testing and informed consent about screening was missing in 13 patients (3.4%). In 327 of 360 patients (90.8%) with informed consent a successful CHC assessment has been performed. Screening for HCV antibodies was positive in 136 cases (41.6%) and in 86 of them (63.2%) a CHC was present. The duration of OMT was an independent determinant of a successful CHC assessment., Conclusions: In addicted patients a high CHC assessment rate in a primary care setting in Switzerland is feasible and opioid substitution provides an optimal framework.

Background: Osteoarthritis (OA) has a high prevalence in primary care. Patient satisfaction is an important indicator for the quality of care provided to OA patients. Little is known about satisfaction of patients with this condition in a primary care setting in Germany. The aim of the study was to assess current satisfaction of patients and reveal possible disease and quality of life related predictors., Methods/design: Seventy-five German GPs approached 1250 patients with OA consecutively. Sociodemographics, OA-specific quality of life (GERMAN-AIMS2-SF), co-morbidities and depression (using PHQ-9) were assessed. Patient satisfaction was measured by means of the European Task Force on Patient Evaluations of General Practice (EUROPEP) instrument. A stepwise linear regression analysis with the EUROPEP score as dependent variable controlled for the amount of GP visits was performed to assess predictors of satisfaction., Results: A total of 1021 OA patients returned the questionnaire. The adjusted R(2) of the final model was 0.270 (P < 0.001). The main predictors were the PHQ-9 score (beta = -0.372; P < 0.001), age (beta = -0.185; P < 0.001), living alone (beta = -0.209; P < 0.001) and number of co-morbidities (beta = -0.152; P < 0.001). The only disease-related factor which remained as predictor of patient satisfaction was duration of OA (beta = -0.105; P = 0.008)., Discussion: The finding that depression and social factors are more important for patient satisfaction with provided care than disease-related aspects suggests that these factors need to be considered carefully in treatment. This represents a big challenge within an increasingly specialized health care system. The General Practitioner as the regular and first-choice provider of health care seems to be the most appropriate instance who can accomplish this.

Objective: In patients with osteoarthritis (OA), moderate physical activity (PA) can reduce the progress of joint damage. PA is therefore an important target of in the non-surgical treatment of OA. To know about factors associated with PA can increase the success of interventions aiming at increasing PA. The aim of the study was to determine predictors of PA in patients suffering from OA to the hip or to the knee., Methods: In total, 1250 outpatients from 75 general practices were consecutively approached, 1021 returned questionnaires containing sociodemographic data, and short forms of the International Physical Activity Questionnaire (IPAQ), the Arthritis Impact Measurement Scale and the Patient Health Questionnaire to assess concomitant depression. A hierarchical stepwise multiple linear regression analysis with the IPAQ continuous score as dependent variable was performed., Results: Comparison of our findings with General population suggests that the overall PA of OA patients is decreased. Main predictors of PA were physical limitation to the lower body (beta = -0.179; P = 0.001), social contacts (P = -0.134; P < 0.001), pain (beta =-0.120; P = 0.001), age (beta = -0.110; P = 0.004) and the body mass index (beta =-0.043; P < 0.001)., Conclusion: The findings emphasize the influence of physical as well as psychosocial factors on PA of patients with OA and should help to tailor future interventions more appropriately. Further research is needed to determine if these tailored interventions will result in better compliance and in increased PA.

Objective: The chronic care model and the 5A approach have achieved widespread acceptance and reflect the core elements of patient-centred care in chronic diseases, including arthritis. Appropriate assessment tools are indispensable to assess whether provided care is in alignment with these evidence-based conceptual frameworks of care. The aim of this study was to examine the validity of a translated and culturally adapted version of the Patient Assessment of Chronic Illness Care (PACIC 5A) questionnaire among osteoarthritis (OA) patients., Methods: Of 300 administered questionnaires, 236 (78.6%) were returned. Established statistical approaches were used in order to assess psychometric properties. Test-retest reliability was tested in 75 randomly selected patients who received the questionnaire a second time after 2 weeks. The EUROPEP questionnaire was used in order to address external validity., Results: Scale internal consistency was confirmed with values ranging from 0.52 to 0.97 for Pearson's r. Internal consistency reliability was satisfying: Cronbach's alpha was 0.78 or higher for all scales. Test-retest reliability (intraclass correlation coefficient) exceeded 0.77. Correlations with the EUROPEP, which is not organized according to a conceptual approach to care, were only strong in corresponding scales., Conclusions: The PACIC 5A is a reliable and valid instrument to assess the congruency of care to the chronic care model of OA patients. Its use is encouraged in quality improvement projects but also in further research.